Larissa Hirsch, MD

Hypercholesterolemia, atherosclerosis, and coronary artery disease are ever-growing problems in our society. While these “adult” medical issues rarely concerned pediatricians in the past, it is now well recognized that these troublesome processes begin in childhood. In 2008, the American Academy of Pediatrics (AAP) called on pediatric providers to screen for high cholesterol levels in children and teens who had a family member with coronary artery disease before age 55 years; a parent with a history of hypercholesterolemia; an unknown family history; or risk factors, such as obesity and hypertension.

 However, a recent study by Ritchie and colleagues

 indicates that this selective screening may be missing affected children.

To determine how well the current screening guidelines identify children with hypercholesterolemia, Ritchie and colleagues

 analyzed data from more than 20,000 children involved in the Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project from September 2003 until April 2008. The CARDIAC Project has offered universal cholesterol screening to all fifth-grade students in public schools in West Virginia since 2000. The authors included children with a fasting lipid profile-consisting of total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, and low-density lipoprotein (LDL) cholesterol-and a completed family history questionnaire. They excluded children who had incomplete data.



Many youths who do not meet screening criteria have high LDL levels.

 Of the children whose data were analyzed, 71.4% would be screened based on the current guidelines. Of those, 8.3% had an LDL level of 130 mg/dL or higher, and 1.2% had an LDL level of 160 mg/dL or higher. Of the children who did not meet the screening criteria, 9.5% had an LDL of 130 mg/dL or higher, and 1.7% had an LDL level of 160 mg/dL or higher. The current AAP guidelines recommend pharmacologic therapy for children older than 8 years with risk factors, such as a positive family history or obesity, when LDL levels are persistently above 160 mg/dL, despite diet changes. For children without risk factors, pharmacologic treatment is recommended for persistent LDL levels above 190 mg/dL, with diet therapy. If pharmacologic therapy is considered for all children with an LDL level above 160 mg/dL, Ritchie and colleagues found that a third of these children would have been missed with the current screening guidelines. Those who do not require drug therapy may be in need of other treatment, such as close follow-up, lifestyle changes, and lipid evaluation of other family members.

The authors state that this study was conducted in a community where the prevalence of heart disease and childhood obesity, as well as uninsured person, is high. Many of the children’s parents and grandparents may be too young to have had problems detected yet, or may not have had testing with fasting lipid profiles. However, this is likely the case in many communities.



Encourage testing of family members of at-risk children.

 While universal cholesterol screening is a large undertaking, the Ritchie study indicates that it may be necessary in order to appropriately identify at-risk children and teens. If we can catch hypercholesterolemia at an early stage, and treat it with lifestyle changes and close follow-up, we may be able to prevent future problems from coronary artery disease and atherosclerosis. In the short term, we can encourage the family members of these children to be tested and treated, if necessary, before a catastrophic event occurs.

 Daniels SR, Greer FR and the Committee on Nutrition. Lipid screening and cardiovascular health in childhood. 

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;122/1/198#SEC10

 Ritchie SK, Murphy EC, Ice C, et al. Universal versus targeted blood cholesterol screening among youth: the CARDIAC project. 

Articles

Hypercholesterolemia, atherosclerosis, and coronary artery disease are ever-growing problems in our society. While these “adult” medical issues rarely concerned pediatricians in the past, it is now well recognized that these troublesome processes begin in childhood.

Cardiovascular Disease Screening Misses At-Risk Youth

The importance of vaccination has been well proved over the years for both individuals and the community as a whole. According to the 2004 to 2006 National Immunization Survey sponsored by the CDC, about 80% of children in the United States are up-to-date (UTD) with their immunizations, a rate that although respectable still leaves room for improvement.

 indicates that patient-held vaccination records can potentially improve immunization rates. To determine whether patient-held records correlate with immunization rates, McElligott and Darden analyzed data from the National Immunization Survey.

This telephone survey included households with children aged 19 to 35 months. During the telephone interview, demographic and vaccination information were collected for all children in the house. The survey asked parents if they had a patient-held vaccination record available for the child in question. Additional information, such as race, maternal education, number of children in the home, poverty status, number of providers who gave the child vaccines, and language spoken, was also collected. Immunization data were gathered directly from the vaccine providers for those children. The authors used the vaccine provider’s records for UTD status; however, they excluded pneumococcal conjugate vaccine, influenza vaccine, and varicella-zoster vaccine from their analysis.

Vaccination rates improved when patients held records.

 The authors found that 40.8% of parents had their child’s vaccination record available. With all variables controlled for, children whose parents had the record available were 62% more likely to be UTD in their immunizations. Vaccination status fluctuated by all of the variables collected; however, presence of a record correlated with increased immunization for each variable.

Some of the greatest differences appeared to be in groups at highest risk for incomplete immunization status, such as those with multiple health care providers or low maternal education. Improved vaccination status with the presence of a patient-held record could be the result of many factors. These may include increased parental awareness of immunizations and improved communication among multiple providers. For patients who have their vaccination records, any visit (sick visits or trips to the emergency department) could be an opportunity to update their vaccine status.

McElligott and Darden state that their study was limited because of the difficulty in determining whether the improvement in immunization status was a result of record possession or whether both the improved immunization status and the record possession are related to a third factor, such as organizational skills. Another limitation was that the National Immunization Survey did not ask whether records were previously provided and lost or whether they were not provided by the practice used. In addition, the survey did not assess the accuracy of the records held by parents. Despite these limitations, the McElligott and Darden study highlights an easy-to-implement method that could significantly improve immunization rates.

Patient-held records also stress importance of vaccination.

 Practitioners can use the patient-held records to emphasize the importance of vaccination in several ways. They can ask to see the vaccination record at each visit, review the immunization status with the family, update the record as needed, and remind the family to bring the record for visits with other health care providers and for trips to the emergency department.

 McElligott JT, Darden PM. Are patient-held vaccination records associatedwith improved vaccination coverage rates? 

An Easy Way to Improve Immunization Rates: Turn Patients Into Record Holders

The frequent visits that pediatricians have with infants are bittersweet. While they are wonderful opportunities to form lasting relationships with families, they are also times when babies suffer through the necessary pain of multiple immunizations. Researchers have examined interventions to reduce this pain; several studies have focused on the effects of sweet oral solutions. Sucrose and glucose oral solutions have been proved to effectively provide analgesia to newborns undergoing painful procedures; however, these sweet solutions have not been studied as extensively in older infants or in infants receiving immunizations.

 recently conducted a systematic review and meta-analysis to determine whether sweet solutions have a role in reducing the pain of immunizations in infants aged 1 to 12 months. They examined results from 14 randomized controlled trials that met their inclusion criteria. Each study used glucose or sucrose solutions of varying concentrations as well as some form of pain outcome measure. Sucrose concentrations ranged from 12% to 75%, glucose concentrations from 30% to 40%; one study applied topical anesthetic cream along with the administration of an oral glucose solution. Volumes of solutions also varied. Most of the studies offered less than 2 mL; however, one study provided 10 mL of a sucrose solution. The pain measures used included outcomes such as cry duration, cry intensity, pain scale scores, parental preference, and physiologic factors (eg, heart rate).

Crying, other pain measures reduced with use of sweet solutions.

 The majority of studies showed a reduction in crying and pain scores during or after immunizations when a sucrose or glucose solution was given instead of a placebo or no treatment. Many studies found reduction in pain with certain pain measures and not others. It appears that higher concentrations of either glucose or sucrose solutions were more effective than lower concentrations. Using a meta-analysis design, the authors found a small but statistically significant reduction in the proportion of crying times and in the incidence and duration of crying.

 note that findings of the studies were difficult to compare and interpret because of the variable factors measured. In addition to variations in solution concentration, solution volume, and outcome measures among the studies, some studies included other interventions, such as maternal holding or distraction and the use of topical anesthetic cream. The authors also did not take into consideration the type of immunizations being given or the order in which they were injected.

Dose, timing of administration need clarification.

 Although the results of the Harrison study are encouraging, further research is needed before pediatricians can routinely provide sweet solutions with immunizations. With clarification of the solution volume and concentration and the timing of its administration, we may soon have an effective method of making immunizations a little less painful for all involved.

1. Harrison D, Stevens B, Bueno M, et al. Efficacy of sweet solutions foranalgesia in infants between 1 and 12 months of age: a systematic review. 

The frequent visits that pediatricians have with infants are bittersweet. While they are wonderful opportunities to form lasting relationships with families, they are also times when babies suffer through the necessary pain of multiple immunizations.

“Sweet” Solution for the Pain of Vaccinations

It can be difficult for pediatricians to discuss sexual activity with preadolescent patients, especially those who seem young and inexperienced. However, a recent study in 

 suggests that there is a real need for early discussions of sexual activity and sexually transmitted infections (STIs). This study, as well as one in 

Archives of Pediatric and Adolescent Medicine

 indicates also that testing for STIs in sexually active adolescents should be done early and frequently-including in patients who are asymptomatic.

Forhan and colleagues analyzed data from 838 girls aged 14 to 19 years; the data were collected by the CDC in the National Health and Nutrition Examination Survey 2003-2004. Participants were interviewed, examined, and tested for chlamydial infection, gonorrhea, infection with herpes simplex virus type 2, trichomoniasis, and human papillomavirus (HPV) infection. Testing was conducted for 23 high-risk HPV strains as well as HPV types 6 and 11 (which cause most genital warts).

Sexual histories were obtained by computer-assisted audio self-interview. In the interview, "sex" was defined as oral, vaginal, or anal. The investigators considered as sexually experienced any participant who answered affirmatively when asked if she had ever had sex.

 Although results for all 5 of the STI tests were available for only 70% of the participants, at least 1 test result was available for 96%. Even with this incomplete data set, 24.1% of participants were found to have at least one STI. Of those who were sexually experienced, 37.7% had at least 1 STI. The infection identified most frequently was HPV infection, followed by chlamydial infection.

The prevalence of STIs increased with age, from 14.1% in 14- to 15-year-olds to 33.8% in 18- to 19-year-olds. The prevalence was higher among non-Hispanic black participants than among those who were non-Hispanic white or Mexican American. STI prevalence increased with time since first sexual experience and with lifetime number of partners. However, even those participants with less than 1 year of sexual experience or only 1 lifetime partner had significant infection rates (19.2% and 19.7%, respectively).

 state that their study was limited by the fact that sexual history data were self-reported, as well as by some gaps in their records. They did not investigate syphilis or HIV prevalence and did not test for all strains of HPV. In addition, laboratory data were missing for many participants, with more test results missing in those who were younger and sexually inexperienced.

Despite these limitations, the Forhan study revealed an impressive prevalence of STIs in adolescent girls, including in girls who had only recently become sexually active and in those with only 1 lifetime partner. Tu and colleagues

 found that among the adolescents in their study, the mean age at first intercourse was 14.2 years; they also found that 25% of urban adolescents have their first chlamydial infection within 1 year of having intercourse.

Early, frequent STI testing also important.

 These studies emphasize the importance of early discussions of sexual activity and STI prevention, as well as the importance of early and frequent STI testing, especially testing for 

 The study findings should also bolster our support for HPV vaccination of girls while young enough that they are still likely to be sexually inexperienced. By opening our eyes to the realities of adolescent sexual activity, we can hopefully prevent, identify, and treat infections before permanent damage is done.

 Forhan SE, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. 

 Tu W, Batteiger BE, Wiehe S, et al. Time from first intercourse to first sexually transmitted infection diagnosis among adolescent women. 

New data underscore importance of discussing sex, STIs sooner rather than later.

Larissa Hirsch, MD

Articles

Cardiovascular Disease Screening Misses At-Risk Youth

An Easy Way to Improve Immunization Rates: Turn Patients Into Record Holders

“Sweet” Solution for the Pain of Vaccinations

When to Start Talking About Sex? Earlier Than You May Think!