DR. BURKE, section editor for Journal Club, is chairman of the department of pediatrics at Saint Agnes Hospital, Baltimore. He is a contributing editor for <italic>Contemporary Pediatrics</italic>. He has nothing to disclose in regard to affiliations with

Michael G. Burke, MD

	Asking teenagers how often they have consumed alcohol in the past year provides a simple screen for those at risk for alcohol use disorder (AUD), a study in 1193 adolescents in rural Pennsylvania showed.

	Investigators provided participants, aged 12 to 20 years, with a tablet computer to collect data on past-year alcohol use and alcohol-related symptoms. The survey, which took from 3 to 6 minutes to complete, addressed age of first drink; how often the teenager used alcohol in the past 30 days and past 12 months; how many drinks he or she typically had on each occasion; greatest number of drinks in any 24-hour period; age of first binge; age when first “drunk”; and frequency of binge drinking in the past 30 days.

Next: New antibody eases hemophilia treatment

	In analyzing the collected data, investigators found that for teenagers aged 17 years or younger, consuming at least 1 standard drink 3 or more days in the past year identified them as at risk for AUD, according to criteria of the 

Diagnostic and Statistical Manual of Mental Disorders, 

). Specifically, among adolescents who met this 3-or-more-day threshold, 44% had AUD whereas those who reported fewer than 3 days of alcohol use rarely met AUD criteria (

The idea of using a single screening question to look for problem alcohol consumption in children and adolescents is not new, but changes in the American Psychiatric Association diagnostic criteria from 

 defined alcohol abuse and alcohol dependence, a separate more serious disorder. The 

 has combined the conditions into AUD with subcategories for severity. Teenagers aged 17 years or younger who report use of alcohol on 3 or more days in the past year are most likely to meet 

 criteria for AUD. In 18- to 20-year-olds, those who report alcohol use on 12 or more days were most likely to meet the definition. Use this screening question to decide whether or not you need to look further into your patient’s alcohol consumption. -Michael G Burke, MD

	 Ms Freedman is a freelance medical editor and writer in New Jersey. Dr Burke, section editor for Journal Club, is chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore, Maryland. The editors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

Articles

Asking teenagers how often they have consumed alcohol in the past year provides a simple screen for those at risk for alcohol use disorder (AUD), a study in 1193 adolescents in rural Pennsylvania showed.

Simple screen for alcohol use disorder

Given that college athletes are up to half as likely as their peers to smoke cigarettes, investigators explored whether varsity, club, and intramural athletes also are less likely than nonathletes to engage in waterpipe smoking. Using a waterpipe-hookah, narghile, arghile, or shisha-pipe-to smoke tobacco is an emerging trend among college students. 

Investigators analyzed 8,745 responses from an online survey about waterpipe and cigarette tobacco smoking and about participation in intramural, club, and varsity sports. The questions were part of the revised annual National College Health Assessment survey, which was completed by selected students from 8 universities in the South, Northeast, and Western regions of the United States.  

Overall, 2,576 (29.5%) male and female respondents reported ever trying waterpipe tobacco smoking; these respondents were significantly more likely to be younger, male, and not African American. Club sport participants and intramural participants were more likely than nonparticipants to have ever tried waterpipe smoking. Varsity sports participants, on the other hand, were no more likely than nonparticipants to have smoked tobacco from a waterpipe. The survey confirmed that club, intramural, and varsity sports participants all were less likely than their nonparticipating counterparts to have smoked cigarettes (Primack BA, et al. 

Research shows that many young people who would not consider smoking cigarettes see waterpipes as a safer and more acceptable alternative. They are not, however: The unfiltered smoke from 1 bowl of tobacco contains up to 46 times the tar content of 1 cigarette. And the water-cooling does nothing to decrease the addictive properties of nicotine. The American Lung Association reports that teens who use a waterpipe are 8 times more likely than their peers to smoke cigarettes. We need to warn our patients starting at an early age that smoke from a hookah is a danger to their health, and we need to encourage regulation of hookah bars and cafes in our communities.

Given that college athletes are up to half as likely as their peers to smoke cigarettes, investigators explored whether varsity, club, and intramural athletes also are less likely than nonathletes to engage in waterpipe smoking

Journal Club: College athletes at risk for waterpipe tobacco smoking

By studying whether colonization patterns of the major gas-forming coliforms differ in colicky infants and healthy controls, investigators in Turin, Italy, examined the hypothesis that colonic gas production and dismicrobism are implicated in infantile colic.  

Study patients were 80 exclusively breast-fed infants from 4 to 16 weeks of age: 41 had a diagnosis of colic, 39 did not.  

This study complements previous work by Savino et al that showed the benefit of probiotic modification of gut flora in colicky infants (

2007;119:e124-e130). It may be that poor gut flora is what is ailing at least some unhappy babies. 

BLOOD PRESSURE IS ELEVATED IN CHILDREN WHO SNORE

Primary snoring appears to be an aspect of the dose-response relationship between sleep-disordered breathing and blood pressure (BP) measurements, according to a study conducted in youngsters from 6 to 13 years of age who were recruited from 13 Hong Kong schools.  

Parents of 466 children completed an obstructive sleep apnea (OSA) questionnaire that stratified their offspring as low or high risk for OSA. All children at high risk and a randomly selected sample of those at low risk underwent overnight polysomnography and ambulatory BP monitoring. Data for 190 children, limited to those who were prepubertal and of normal weight, were included in the final analysis. The limitations controlled for the potential confounding of obesity and pubertal growth, both of which are associated with elevated BP. Median age of the study patients was 10 years. 

Of the 190 children, 46 were found to snore, 56 did not snore (the controls), 62 had OSA with an apnea-hypopnea index of 1 to 3, and 26 had OSA with an apnea-hypopnea index of more than 3. Daytime and nighttime BP increased across the severity spectrum from no snoring to snoring and to increasing OSA severity. This relationship remained significant even after adjusting for age, sex, and body mass index. The dose-response trends for the patients with nighttime systolic and diastolic hypertension also were significant. The authors concluded that primary snoring could be the beginning of the severity spectrum of sleep-disordered breathing and that the condition therefore should no longer be considered entirely benign (Li AM et al. 

It makes sense that sleep-associated upper airway obstruction is a spectrum, rather than an all-or-nothing condition. These authors have helped define the lower end of this scale. In doing so, they may have changed how we think about the snoring child. 

Journal research looks at elevated BP in children who snore, leading treatments for lice and cause of colic.

Journal Club: Colic, snorers with high BP and lice killers

Are new assays useful for detecting TB?							

The test was positive in 17% of the study group, negative in 48%, and indeterminate in 35%. Analysis showed that age younger than 5 years and being immunocompromised were both independently associated with a higher probability of an indeterminate result. In children who were not immunocompromised, the likelihood of an indeterminate test result was inversely correlated with age, decreasing by 13% for each additional year of age (Haustein T et al: 

These tests are based on detection of interferon gamma production by mononuclear cells after exposure to antigens produced by M tuberculosis. They offer a potentially useful tool for making the often confusing diagnosis of both tuberculosis infection and disease. 

One advantage of these tests over the traditional tuberculin skin test is that bacille Calmette-Guérin and most nontuberculous mycobacteria do not generate the antigens necessary to cause a positive test. The tests now available include a positive control: In other words, if the control is not positive, the tested sample may be inadequate, or the patient may not be able to mount the appropriate response even in the presence of these TB antigens. These authors show that indeterminant tests such as these are more common in the youngest patients and in those with immune deficiency, the very patients who are most likely to develop TB disease after infection. 

The 2009 Red Book offers a clear explanation of the current role of these assays in detection of TB. As more information is obtained, that role will likely increase. -MB

Overall, 83% of the adults wanted the doctor to shake hands, and most did (70% of residents, 66% of attendings). Even more parents, 87%, wanted their physicians to address them by name, but only 14% of residents and 24% of attendings did so. Physicians did best in meeting expectations by introducing themselves at encounters, with 84% of residents and 93% of attendings extending this courtesy (Amer A et al 

Name tags for everyone. In 9% of encounters, physicians incorrectly addressed the parent by using the child's last name. I wonder how often physicians fail to call the parent by name so as to avoid this error. If that's the case, we need to display parents' names prominently on patient charts, on appointment lists, and in the hospitalized child's room. -MB

A review of three articles, about media exposure's link to increased BMI, a better test for tuberculosis, and how parents may be put off if you don't greet them properly.

Journal Club: TV, TB, and how to say hello

Novel sleep apnea treatment shows promise

Subjects in this study of treatment with nasal insufflation (TNI) were mostly obese boys ranging in age from 5 to 15 years. The children, some of whom had undergone adenotonsillectomy, were recruited from a sleep disorders center where they were recommended treatment with CPAP. Adherence was poor: half of the children reported using CPAP for fewer than four hours each night and for fewer than five days a week. 

TNI also improved oxygen stores and decreased arousals, which reduced occurrence of obstructive apnea from 11 to five events per hour. In most children, reduction in the apnea-hypopnea index on TNI was similar to that on CPAP, and comparable in children with and without adenotonsillectomy (McGinley B et al: 

				
			In 2008, Kheirandish-Gozal and colleagues published a study of nightly nasal steroid spray for treatment of children with mild OSA (

2008;122:e149). The current study looks at a different alternative treatment for a small group of children with more severe OSA (eight of 12 required this intervention despite prior adenotonsillectomy). Both interventions offer a "kinder, gentler" therapeutic approach for children along the spectrum of this condition.Consider nasal steroids before turning to surgery. If, after surgery, OSA doesn't improve, try TNI. Still no improvement? It's time for CPAP. 

A BETTER WAY FOR DETECTING STIS IN SUSPECTED SEXUAL ABUSE?

Culture, which requires collection of urogenital, oral, and/or anal swabs, is the current forensic standard. Based on results of the current study, investigators suggest that NAATs on urine, with confirmation, are adequate for use as a new forensic standard for diagnosis of these organisms in cases of suspected sexual abuse.  

   Investigators found that the sensitivity of vaginal culture for 

 was 39% in all children studied and 20% in prepubertal female children (age range of subjects was 0 to 13). In contrast, the sensitivities of urine and vaginal swab NAATs were 100% and 85%, respectively, in all female children for detection of 

 detection, culture sensitivity was 75% in all female children and 100% in prepubertal female children, whereas urine and vaginal swab NAAT sensitivities were 88% in all children and 100% in prepubertal female children. None of the male children tested positive for either organism by any test.  

Because investigators observed no false positives in their test results, they concluded that positive predictive values for all tests were 100% (Black CM et al: 

				
				If you are the physician evaluating a child for possible sexual abuse, you need to know both the science and the law of this topic. It may be that NAAT is a more sensitive test for sexually transmitted infections (STIs) in sexually abused children. But until the legal system in your community views these tests as valid, you may need both culture and a polymerase chain reaction assay. The authors point out that nucleic acid screening of urine eliminates the need for more traumatic urogenital swabs. NAATs have not been validated for use on rectal or pharyngeal specimens, however. In cases of possible sexual abuse, the authors (and the 2009 AAP Red Book Committee) also recommend confirmation of positive urine NAATs with a second study that assays other nucleic acids chains from the same organism. 

Journal abstracts and commentary on articles abotu fighting sleep apnea, a less invasive way to test for STIs after possible sexual assault, and colic's relation to maternal depression.

Journal Club: Sleep apnea, sexual abuse testing, and colic

New tool simplifies hypertension screening

To develop their table, authors used the lower limit of height (5th percentile) in the abnormal blood pressure range (≥90th percentile) for a given gender and age. Also, if the 90th percentile was ≥120 mm Hg for systolic blood pressure or ≥80 mm Hg for diastolic blood pressure, they used 120/80 mm Hg instead because the Fourth Report considers either of these figures at least prehypertensive (Kaelber DC et al: 

(Look for a Q&A and podcast in October's 

 with the author of the simplified BP norms.)

In 2007, members of this same group of investigators published data from a review of medical records from over 14,000 children 3 to 18 years old (Hansen ML et al: JAMA 2007;298:874). Of note, 507 (3.6%) of the children had medical record evidence of hypertension or prehypertension, but 74% went undiagnosed. The problem was not that BPs went unmeasured; only 6% of health maintenance visits failed to document it. Instead, the problem may have been that providers did not recognize that the documented BPs were abnormal. This failure is not hard to understand as BP norms for children are adjusted for gender, age, and height percentile. 

In the current article, the authors propose using a vastly simpler set of BP norms for screening. Children who fail the screen would be checked against the height-adjusted norms. In this second step, a few BP screens would be found to be false positives, but the chart is designed to provide 100% sensitivity (no false negatives). This method makes a lot of sense, especially for BP measurements done in a setting where height measurements are not available.  -MB 

Investigators presented 1,409 10-year-old boys and girls with a questionnaire that included figure drawings of  boys and girls of different body sizes, ranging from thin to obese. Participants were asked to choose positive and negative adjectives that applied to the three body types. They chose from a list of 21 adjectives, such as kind, good, sloppy, stupid, and hard working. Each child rated both sexes.  

The children were generally positive in their judgment of average body size, with fewer than 10% attributing negative stereotypes to it. Rather, the obese figure tended to be characterized by negative adjectives-slow, lazy, lonely, and different. Almost 60% of respondents reported relatively more negative than positive adjectives for obese figures, compared with 36% of respondents for thin figures and only 3% for average figures. The participants' own body sizes did not seem to influence their judgments on the figures' body size, though socioeconomic (SES) level did. Children at a high SES level were more likely than those of a lower level to have more negative than positive attitudes about obesity (Hansson LM et al: 

I find this a little disheartening, especially because even obese children described obese figures more negatively. Changing these attitudes would require a new approach by marketers, the media, parents, teachers, and the children's peers.  -MB 

Reviews of three pediatric articles: a quicker way to evaluate a child's blood pressure, giving parents a choice of oral or IV fluids for their kids, and a study on early weight-based stereotyping.