Psychologically Distressed Children More Likely To Be Involved In Bullying

Bullying by elementary school children was associated with increased odds of lacking a feeling of safety while at school, having lower academic achievement, and feeling sad most days, according to an article in the November issue of the Archives of Pediatrics and Adolescent Medicine, one of the JAMA/Archives journals.

According to background information in the article, "Bullying is defined as any repeated negative activity or aggression intended to harm or bother someone who is perceived by peers as being less physically or psychologically powerful than the aggressor(s)." In a 2000 survey of more than 15,000 U.S. students, researchers found the prevalence of bullying involvement among teens and preteens was approximately 30 percent. Concerns about the role of bullying in school violence, depression, and health concerns have grown over the past decade.

Gwen M. Glew, M.D., of the University of Washington, Seattle, and colleagues surveyed 3,530 third, fourth, and fifth grade students to determine prevalence of bullying and its association with attendance, academic achievement, suspension or expulsion, and self-reported feelings of sadness, safety and belonging. Students were classified as victims, bullies, bully-victims (those who were both victimized and bullied others), bystanders (children who did not bully others and were not bullied by others) and nonresponders.

Twenty-two percent of the children surveyed reported being involved in bullying, either as a victim, bully, or both. Six percent of the children reported being bullied "always," 14 percent said they bullied others, and two percent said they both bullied and were bullied. All three bullying-involved groups-either as a victim, bully or bully-victim-were significantly more likely than bystanders to feel unsafe at school. Among students who reported feeling as though they did not belong at school, their odds of being a victim were 4.1 times higher than those who felt they belonged at school; their odds of being a bully was 3.1 times higher than those saying they belonged. Bullies and victims were more likely than bystanders to feel sad most days. Both bullies and bully-victims were more likely to be male.

Antisocial Behavior in Children Associated with Gene Variant and Environmental Risk Factors

For children with attention deficit hyperactivity disorder (ADHD), possessing a variant of a gene involved in brain signaling may predict antisocial behavior and increase susceptibility to the effects of lower birth weight, according to a study in the November issue of the Archives of General Psychiatry, one of the JAMA/Archives journals.

Biological processes play a key role in the genesis of antisocial behavior with specific evidence of brain involvement and contribution of genetic and early environmental risk factors, including prenatal factors, according to background information in the article. Given the links between deficits in a brain region called the prefrontal cortical and antisocial behavior and between the enzyme catechol O-methyltranferase (COMT) and prefrontal cortical functioning, the authors suggest that a variant of the COMT gene might be associated with antisocial behavior.

Anita Thapar, M.D., of Cardiff University, Cardiff, Wales, and colleagues looked for the presence of a variant in the COMT gene in 240 British children, aged five to 14 years with ADHD or hyperkinetic disorder who are at high risk for early-onset antisocial behavior. The researchers used the children's birth weight as a marker for prenatal risk to determine the contribution of the environment to risk of developing symptoms of early-onset antisocial behavior.

The researchers found a significant association between the COMT variant and antisocial behavior; and between low birth weight and antisocial behavior. There was also a significant gene and environment (low birth weight) interaction associated with antisocial behavior.

Day Care Centers Safest Form of Childcare According to First National Comprehensive Study

Child care is quite safe overall, and child care fatalities are rarer than outside of paid care, according to sociologists Julia Wrigley and Joanna Dreby, City University of New York Graduate Center, who created a comprehensive database of child care failures, including fatalities, between 1985 and 2003. But they found that the fatality rate for children who receive child care in private homes is sixteen times higher than the fatality rate for children in child care centers. The study appears in the October issue of the American Sociological Review, published by the American Sociological Association.

While more than 8 million children are in paid child care every day, until now little has been known about their safety. Wrigley and Dreby analyzed reports of 1,362 fatalities (among 4,356 caregiving failures) from 1985 to 2003. The fatality data was gathered from media reports, legal cases, and state records. Three forms of child care were investigated: child care centers, nannies working in children's homes, and family day care providers working in their own homes.

"While accidents can happen anywhere, child care centers are almost 100% protective against children's deaths by violence. They are much safer than arrangements in private homes," explains Wrigley.

Infants are by far the most vulnerable children in care. Their fatality rate from both accidents and violence is nearly seven times higher than that of children from one to four. Equally striking are differences in infant fatality rates across types of care. The infant fatality rate in the care of nannies or family day care providers is more than seven times higher than that in centers.

Why are centers the safest form of child care?

Wrigley and Dreby conclude that centers are the safest form of child care because they afford children multiple forms of protection. Most importantly, staff members do not work alone. They have others watching them and helping them cope with fussy infants or whining toddlers. This helps them maintain their emotional control. It also helps identify and remove unstable or volatile workers. Center teachers also have more training than most caregivers in private homes and they are supervised by professionally-trained directors. Finally, centers control access by outsiders more effectively to keep out people who might pose risks.

These protections help reduce risks of accidental deaths, such as suffocation and drowning. But they are especially important in preventing violent deaths. Not a single shaken baby fatality was found in a child care center, while 203 were reported in arrangements in private homes. With little professional training, without supervisors or coworkers, and often paid very little for long hours of work, even some experienced caregivers can lose emotional control. Once children are past the toddler years, safety differences between centers and other forms of child care diminish.

Wrigley says, "Child care is quite safe overall, but it could be made safer. We need to recognize what a stressful and demanding job it is to look after young children. Improved safety will only come with more resources and closer regulation of care."

How can child care safety be improved?

• Recognize the safety advantages of centers and provide funding for the expansion of center care for the most vulnerable children, infants.

• Offer more training and support for caregivers working in private homes.

• Expand the resources for licensing and regulation so that "bad apples" in child care can be identified and excluded from the field.

• Collect safety data so that parents can choose care arrangements wisely and prevention strategies can be developed with full information.

Despite Vaccine Tetanus a Problem for Newborns in Remote Areas

With the target date for elimination of neonatal tetanus about to pass, the disease remains a major public health problem in remote areas of Africa and Asia, despite an international campaign to eliminate the often-fatal illness and despite having a vaccine that works.

Neonatal tetanus is common where infants' umbilical cords are cut with unsanitary instruments. The vaccine used to prevent tetanus in women of childbearing age and their newborns is effective, according a new systematic review of data.

The low performance of the vaccination campaign is "probably related to organizational and quality issues," according to a new systematic evidence review.

The authors located only two studies that met the quality criteria for the review, and both were conducted more than 25 years ago. Nevertheless, "these were reasonably good studies, quite large, both confirming that the vaccine was effective," says lead author Dr. Vittorio Demicheli, an Italian epidemiologist.

The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The reviewers identified two experimental studies involving 10,560 infants born to 95,704 immunized individuals in Colombia and Bangladesh. Conducted in the 1960s and 1970s respectively, the studies confirmed that two or more doses of the vaccine are highly effective in preventing deaths from neonatal tetanus.

In 1989, the World Health Organization and other groups launched an international vaccination campaign targeting women of childbearing age, who then pass immunity to their unborn children.

The goal of the campaign was to eliminate neonatal tetanus by 1995, a date that was eventually pushed back to 2005. Significant progress has been made, yet neonatal tetanus remains a major public health problem in 52 countries, according to WHO.

According to the review authors, it's possible that vaccines are not being stored properly, or that factors such as malaria preventatives, malnutrition or vitamin A deficiency are interfering with its effectiveness.

Organic Diets Lower Childrens Dietary Exposure to Common Agriculture Pesticides

A study led by an Emory University researcher concludes that an organic diet given to children provides a "dramatic and immediate protective effect" against exposures to two pesticides that are commonly used in U.S. agricultural production. The results were published on a recent online version of the scientific journal Environmental Health Perspectives (EHP). Over a fifteen-day period, Dr. Chensheng "Alex" Lu and his colleagues from Emory University, the University of Washington, and the Centers for Disease Control and Prevention specifically measured the exposure of two organophosphorus pesticides (OP), malathion and chlorpyrifos, in 23 elementary students in the Seattle area by testing their urine.

The participants, ages 3-11-years-old, were first monitored for three days on their conventional diets before the researchers substituted most of the children's conventional diets with organic food items for five consecutive days. The children were then re-introduced to their normal foods and monitored for an additional seven days.

"Immediately after substituting organic food items for the children's normal diets, the concentration of the organophosphorus pesticides found in their bodies decreased substantially to non-detectable levels until the conventional diets were re-introduced," says Dr. Lu, an assistant professor in the department of environmental and occupational health, Rollins School of Public Health, Emory University.

During the days when children consumed organic diets, most of their urine samples contained zero concentration for the malathion metabolite. However, once the children returned to their conventional diets, the average malathion metabolite concentration increased to 1.6 parts per billion with a concentration range from 5 to 263 parts per billion, Dr. Lu explains.

A similar trend was observed for chlorpyrifos. The average chlorpyrifos metabolite concentration increased from one part per billion during the organic diet days to six parts per billion when children consumed conventional food.

The researchers note that to ensure that any detectable change in dietary pesticide exposure would be attributable to the organic food rather than the change in diet, the substituted organic foods were items the children would have normally eaten as part of their conventional diet. Organic food items were substituted for the conventional diet of fresh fruits and vegetables, juices, processed fruits or vegetables (e.g. salsa), and wheat-based or corn-based products (i.e. pasta, cereal, popcorn, or chips).

Former research has linked organophosphorus pesticides to causes of neurological effects in animals and humans.

Number of Babies Born Prematurely Tops Historic Half Million Mark in U S

More than a half million babies were born too soon in the United States last year, according to preliminary data released today by the National Center for Health Statistics.

Some 12.5 percent of all babies – about 508,000 – were born premature (less than 37 completed weeks gestation) in 2004, according to Preliminary Births for 2004: Infant and Maternal Health, which was released on the March of Dimes Third Annual National Prematurity Awareness Day.

"We were deeply saddened on Prematurity Awareness Day to learn these sobering statistics," said Dr. Jennifer L. Howse, president of the March of Dimes. "Prematurity has reached crisis proportions, and has become the number one killer of newborns. The health consequences for babies who survive can be devastating. We must renew our commitment today to raise public awareness about prematurity, and to mobilize the political will to act."

Each year, about 1 in 8 live births are premature. The latest statistics represent a nearly 2 percent increase over 2003 final data. The preterm birth rate has increased 33 percent since 1981, the first year the government began tracking premature birth rates. There's been an 18 percent increase since 1990, according to the report.

Prematurity is the leading cause of death in the first month of life, and those who survive often have serious lifelong health problems such as cerebral palsy, mental retardation, chronic lung disease, blindness, and hearing loss. As much as half of all neuro-developmental problems in children can be attributed to premature birth.

Also, more babies were born with low birthweight (less than 5.5 pounds) in 2004, according to the government report. The rate of low birthweight babies reached 8.1 percent, up from 7.9 percent in 2003, a nearly 16 percent increase since 1990.

Comforting Behavior Mistaken for Movement Disorder

The comforting behavior of thumb-sucking wouldn't land a 1-year-old girl in a neurologist's office, but the twisting and unusual movements of the comforting act of infantile masturbation can lead parents and physicians to believe a child is suffering from a movement disorder.

An article published in December's Pediatrics describes a dozen cases of young girls who were referred to pediatric movement disorder clinics between 1997 and 2002 for evaluation of paroxysmal (episodic) dystonic posturing, which is characterized by involuntary muscle contractions that force the body into adnormal movements and positions. Many of the children were subjected to invasive testing and medication before neurologists discovered the dystonic-like symptoms were actually normal muscle contractions that accompany masturbation.

"Masturbation is a normal human behavior. It's not harmful to anybody," said Jonathan W. Mink, M.D., Ph.D., Chiefof Child Neurology at the University of Rochester Medical Center's Golisano Children's Hospital at Strong, lead author of the article. "But these children have had invasive procedures and have been treated with medication because their doctors either hadn't witnessed the movements or didn't recognize the behavior."

Mink theorizes that the cases studied were all female because boys' masturbation is more recognizable because of the tendency to have direct hand contact with the genitals. Girls don't necessarily directly touch the genitals when masturbating. An episode may begin in a car seat or high chair where straps place pressure on the genital area. Many of the episodes come on when a child is tired or bored.

By viewing the episodes video-taped by parents, Mink was able to determine that the children were not having seizures nor were they suffering from paroxysmal dystonic posturing. One child was distracted out of the episode with the promise of a cookie. Another stopped to play with a toy truck. Children having seizures or with dystonia cannot respond or be distracted out of an episode. Mink recommends pediatricians and pediatric neurologists ask parents to video-tape the episodes before performing invasive and often expensive tests that could be unnecessary.

Mink also cautions pediatricians and parents against making any assumptions about what masturbation means for the child in the long run. Children stumble on masturbation on their own. Masturbation does not mean that a child has been sexually abused, Mink said.

Wheezing Prevalence Patterns Established by Age 6

Among children who exhibit asthma-like symptoms during preschool, researchers have found that patterns of wheeze prevalence and levels of lung function are established by age 6 and do not significantly change for at least 10 years. Their findings were reported in the second issue of the November 2005 American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society.

Fernando D. Martinez, M.D., of the Arizona Respiratory Center at the University of Arizona Health Sciences Center in Tucson, along with eight associates, studied 826 children based on the occurrence of "wheezing lower respiratory illnesses" before age 3 and active wheeze at age 6. Among this group, there were 425 "never wheezers," 164 "transient early wheezers," 113 "persistent wheezers" and 124 "late-onset wheezers."

The four types of pre-school wheeze that were used to classify the children were defined as based on either the presence or absence of at "least one physician-diagnosed wheezing 'lower respiratory illness' in the first 3 years of life," and at least "one episode of 'parent-reported wheeze' during the past year for the child at age 6."

During the follow-up on each child at ages 8, 11, 13 and 16 years, parents completed a questionnaire on the youngster's prevalence of wheeze (with or without a cold). Researchers characterized current wheeze at each age as either "no wheeze," "infrequent wheeze" (one to three episodes in the past year) or "frequent wheeze" (four or more episodes in the past year). The investigators also performed a pulmonary function test on each participant at age 11.

"There was no significant change in lung function among subjects within either of the three different wheezing groups or the non-wheezing group studied, relative to their peers, from age 6 to 16 years," said Dr. Martinez.

According to the authors, more than 75 percent of the "never" and "transient early wheezers" reported no wheezing between ages 8 and 16. Among the small proportion of children in those groups who reported wheezing, the researchers said that most had only infrequent episodes.

Parents Impressions of Neighborhood Safety Linked To Childrens Weight

Children who live in neighborhoods that their parents believe are unsafe are more likely to be overweight than those in neighborhoods perceived as safe, according to a study in the January issue of the Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.

Almost 16 percent of 6- to 11-year-old children in the United States are overweight, defined as having a body mass index (BMI) of greater than or equal to the 95th percentile of national norms for age and sex, according to background information in the article. Children who are African-American or Hispanic, who watch large amounts of television or who have parents with high BMIs are more likely to be overweight, but little is known about how a child's neighborhood affects his or her risks. Few previous studies have looked specifically at the relationship between neighborhood safety and children's risk of being overweight.

Julie C. Lumeng, M.D., of the University of Michigan, Ann Arbor, and colleagues collected data from 768 children and families participating in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, a study of families in 10 diverse regions of the United States. The parents completed questionnaires that assessed how safe they thought their neighborhoods were at the time their children were in first grade. The ratings were divided into quartiles, with the first quartile perceived as the least safe and the fourth as safest. Their children's height and weight were measured in the laboratory when they were 4 ½ years old and again the spring of their first-grade year in school, when their mean (average) age was 7. BMI was calculated by dividing their weight in kilograms by the square of their height in meters.

The researchers found that 17 percent of children living in the first quartile of neighborhoods perceived as least safe by their parents were overweight, compared with 10 percent in the second quartile, 13 percent in the third quartile and only 4 percent of children living in the fourth, safest quartile. This relationship was not affected by any other variables that the researchers measured, including the education levels or marital status of the children's mothers, racial or ethnic backgrounds or participation in after-school activities.

Viral Infection at Birth Linked to Cerebral Palsy

Neurotropic viruses and cerebral palsy: population based case-control study BMJ Online First

Exposure to certain viral infections shortly before and after birth (the perinatal period) is associated with cerebral palsy, finds a study published online by the BMJ today.

These findings support the theory that infections during this period can trigger brain damage and the development of cerebral palsy.

The study took place at the Adelaide Women's and Children's Hospital in Australia and involved 443 children with cerebral palsy and 883 control babies. All babies were born to white mothers between 1986 and 1999.

Blood samples taken within a few days of birth were used to test for the presence of neurotropic viruses (a group of viruses including herpes viruses, which can all cross the placenta and infect the fetus).

Exposure to viral infection was common in all newborn babies, especially in preterm babies, implying that infection before birth may also be linked to preterm delivery.

Herpes group B viruses were found more often in babies who were later diagnosed with cerebral palsy than in control babies. In fact, the risk of cerebral palsy was nearly doubled with exposure to herpes group B viruses.

Despite some limitations, this study shows that perinatal exposure to neurotropic viruses is associated with preterm delivery and cerebral palsy, say the authors. Future studies are planned to investigate the possible causes of this link, they conclude.

Children Threats To Pediatric Care

The year 2006 could be a seminal one for children's health-care coverage, according to Lucile Packard Children's Hospital chief-of-staff Harvey Cohen, MD, PhD. The proposed cuts to Medicaid, coupled with an ongoing push to enroll many of those children receiving state coverage into managed-care plans, threaten kids' access to specialty care.

"It is important that those of us who care for and about children realize that we are putting them at risk if we decide to decrease funding for their health or try to alter the current ways they receive care," said Cohen.

About 35 percent of Packard Children's patients are enrolled in Medicaid or a related state program, California's Healthy Families. If the new federal budget passes as currently written, millions of children covered by Medicaid could be required to pay as much as 20 percent of the cost of their care - up to 5 percent of the families' income - while simultaneously receiving less-comprehensive benefits. Many pediatric specialists also have grave concerns about the ability of managed-care plans to appropriately treat children with complex medical problems.

"Children's access to high-quality care is at risk, especially for those with chronic or life-threatening conditions," said Cohen. "These changes would make it more difficult for these children to see pediatric specialists, and they would instead be sent to adult specialists who don't know as much about children's illnesses."

Safe Medical Devices for Children

According to Food and Drug Administration (FDA), some 80,000 medical devices are marketed in the United States, ranging from those as simple as plastic tubing and baby bottle nipples to others as complex as pacemakers or cerebrospinal fluid shunts.

Although low-risk devices like plastic tubing need not be evaluated by FDA before going to market, between 55 percent and 60 percent of all devices are considered to be higher risk and require agency review before they can enter the market.

In this IOM study, sponsored by the FDA, the committee was charged with evaluating FDA's postmarket surveillance of medical devices used with children specifically.

The committee found that the FDA lacks effective procedures to monitor the status of safety studies of medical devices and recommended that Congress ensure that the agency establishes a reliable system to track these postmarket studies. The committee also recommended that the information collected by this system be made available to patients, health care providers, and researchers in a format that allows users to find studies that look at studies involving children.

Additionally, the committee found that it was difficult to reliably identify postmarket studies that considered pediatric issues or focused on children. The report recommends that the current 3-year limit on the length of studies ordered after a device is marketed be lifted for appropriate studies involving the effects of children's growth and development. Because children represent a small market for devices, imposing requirements on manufacturers to conduct studies examining their use in pediatric patients could inhibit the development of new equipment for children, the committee acknowledged.

Growing Pains

My son occasionally complains of pains in his arms and legs that are so severe he is almost in tears. He is very active so I am not sure if the pain is related to exercise or something more serious. How can I tell?

It's not uncommon to have 4 and 5-year-olds complain of painful arms and legs, and they may even describe bone pain. This usually occurs in the late evening, just before going to bed, or they may awake during the night with pain.

Several things could contribute to these complaints. If the child only complains immediately before being put to bed, this could be their attempt at putting off going to bed, or they may be trying to prolong the amount of time they have with their parent before going to bed. It's usually easy to identify this type of complaint and simple reassurance will usually suffice, but parents should be firm about the child's bedtime.

Of more concern is the child who consistently complains of aching legs or deep pain (bone pain). This pain is generally called growing pains in children between the age of 3 and 5, although there is no known physiological reason. Some experts think the pain is due to spurts of rapid growth involving bones and joints. These children wake up crying with pain, usually in their legs, and it is obvious they are uncomfortable. Parents can massage the legs, put their child in a hot bath or give the child acetaminophen to get rid of the pain. These painful episodes are often recurrent over several days or a week or so.

When It Comes to Babies Learning Language The Eyes Have It

Infants begin pulling off an amazing feat sometime in the final three months of their first year of life. They learn an important social interaction by following the gaze of an adult, a step that scientists believe gives babies a leg up on understanding language. University of Washington psychologists Rechele Brooks and Andrew Meltzoff have pinpointed this developmental step as beginning somewhere in the 10th or 11th month of life, and have found that infants who are advanced in gaze-following behavior before their first birthday understand nearly twice as many words when they are 18 months old.

Writing in the current issue of the journal Developmental Science, Brooks and Meltzoff provide further evidence for the importance of eyes in human social interactions and trace how gaze-following develops in infants. Three years ago they reported that 12- 14- and 18-month-old infants are much more likely to look at an object when a person turns toward it with open eyes rather than closed eyes.

"Our work shows that babies can look where an adult is looking but that it isn't easy, particularly at home where there are a lot of distractions," said Brooks, who is a research associate at the UW's Institute for Learning and Brain Sciences.

"We have found that at 9 months babies are beginning to do this by following the movement of the head. At 10 and 11 months they are following the head and the eyes. The eyes add important information and the babies are more consistently following the head when the eyes are open. It is as if a light is going off in their head. This is a clear shift and an important advance."

Brooks and Meltzoff refer to the behavior of a baby (or an adult) looking where another has just looked as "gaze-following." Psychologist have known for some time that among adults detecting the direction of another's glance is a crucial component of human social interaction.

"This line of research is important because following another person's line of sight is crucial for understanding the emotions of other people and, as we are now showing, learning about language," said Meltzoff, who is co-director of the institute and a professor of psychology.

The new study is part of an effort by UW researchers to understand the development of gaze-following in babies. To do this, they tested 96 normally developing infants. There were 32 infants at each of three ages, 9, 10 and 11 months. Equal numbers of boys and girls in each age group were randomly assigned to eyes open or shut conditions.

Each infant was seated in a parent's lap, across a small table from a researcher. Parents were instructed not to move their head or talk during the experiment. The researcher played with an infant before placing two identical toys on pedestals to the left and right of the table. Then the researcher resumed playing with the child before starting four head-turning trials. In the trials the researcher made eye contact with the infant before silently turning her head toward either the toy on the left or the one on the right. In the eyes-open condition, the researcher kept her eyes open and turned her head from the child to one of the toys for about seven seconds before turning back to the child. The procedure was the same in the eye-closed trials, except the researcher shut her eyes before turning toward one of the toys and didn't open them again until she was facing the infant.

In a follow-up interview when the infants were 18 months old, parents were asked to check off on a list how many words their child understood.

There were marked differences in the babies' ability to gaze-follow based on age. The 9-month-olds turned their heads toward a toy nearly as often in the closed-eyes condition as in the open-eyes conditions. However, the 10- and 11-month-olds looked at a toy significantly more often when the researchers turned with her eyes open than when she turned with her eyes closed.

About one-third of the infants in the open-eyes condition also made simultaneous sounds such as "ah" or "hmm" when they engaged in gaze-following. Babies at this age are unable to speak but can make very simple sounds. Typically developing babies experience a burst of language between 18 and 24 months of age.

In this study, the babies who simultaneously followed the eyes of the researcher and made vocalizations when they were 10 or 11 months old understood an average of 337 words at 18 months old while the other babies understood an average of 195 words.

"The sounds they are making are very simple, but some children are looking and making these sounds spontaneously," said Brooks. "They are creating a social interaction or a link. There seems to be something special about the vocalization when they are looking at the toy. They are using social information to pick out what we are focusing on. They can't vocalize words, but they are carefully watching where we are looking. We think they are using social information and getting a boost in figuring out the social and language world together."

"Although the babies are too young to talk to us, those individual babies who are most attuned to our eye gaze are the same babies who pick up language faster more than half a year later," said Meltzoff. "This is a fascinating connection between the social and linguistic world and suggests that language acquisition is supported by preverbal social interaction.

"To do this a baby has an important social regularity to master: follow mom's eyes and you can discover what she is talking about. This study shows that babies first master this social information between 10 and 11 months of age, and it may be no coincidence that there is a language explosion soon thereafter. It is as if babies have broken the code of what mom is talking about and words begin pouring out of the baby to the parents' delight," he said.

The UW researchers are following the same group of babies to see if gaze-following and vocalization at an early age predict increased language understanding and use at 24 and 30 months of age.

Botox Injections Help Children with Cerebral Palsy

Doctors at Duke Children's Hospital are treating the tight muscles caused by cerebral palsy with Botox injections. When given in combination with physical therapy, the shots help patients strengthen their weak muscles and restore normal movement.

The medication is injected into the muscles during an outpatient visit. Although anesthesia is not required for Botox injections, Duke pediatric neurologist Pedro Weisleder, M.D., Ph.D., teamed with Duke pediatric anesthesiologist Allison Ross, M.D., to develop a system for sedating children with inhaled anesthetics similar to the laughing gas used in many dental offices.

"Children don't take well to needles or painful procedures, and several parents asked if we could perform the injections under anesthesia to eliminate their child's pain," said Weisleder, an assistant professor of pediatric neurology at Duke University Medical Center. "The end result is that the procedure is painless and post-anesthesia recovery is rapid. It also allows me to give more accurate injections," he said. To identify the correct muscles for injection, Weisleder uses a special needle through which he can both electrically stimulate the muscles and deliver the medication.

The effects generally last about three months. During that time, patients work with a physical therapist to stretch and strengthen their weaker muscles. "Our goal is not to paralyze the muscles, it is to rebalance them around the joints," Weisleder said.

In cerebral palsy, the brain loses the ability to moderate the activity of contracting muscles. Muscles that produce contraction are stronger than those that produce extension, Weisleder said. Partially paralyzing the stronger muscles with botulinum toxin gives patients an opportunity to stretch and strengthen the weak muscles, he said. The long-term goal of the two components of the treatment – injections and physical therapy – is to achieve better muscle strength balance which may lead to restoring normal function, Weisleder said.

Cerebral palsy encompasses a group of physical and movement disorders that appear in the first few years of life. The muscle spasticity and tightness caused by the disorder make it difficult for people to perform fine motor tasks, such as writing, and causes problems with balance and walking. Though the disorder itself is not progressive, the consequences of the muscle spasms worsen over time, Weisleder said. Spasticity can interfere with daily activities and, in more severe cases, cause significant pain and snap joints out of alignment.

Genetic Profile of an Often Misdiagnosed Chronic Allergic Disease of Children

Though many parents may never have heard of it, a severe and chronic condition called eosinophilic esophagitis (EE) is recognized by doctors as an emerging health problem for children. A disease that was often misdiagnosed in the past, EE has been increasingly recognized in the United States, Europe, Canada and Japan in the last few years. Cases of the disease can be devastating since children who suffer from it may have a host of lifelong problems.

Now, an interdisciplinary team of scientists funded in part by the National Institute of Allergy and Infectious Diseases (NIAID) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), both components of the National Institutes of Health (NIH), has published a major advance in understanding Eosinophilic Esophagitis. In the February 2006 issue of the Journal of Clinical Investigation, the team reveals that a highly specific subset of human genes plays a role in this complicated disease.

"Understanding the genetic profile of a disease such as EE is an important first step towards developing new ways to diagnose and treat it," says NIAID Director Anthony S. Fauci, M.D.

In EE, the esophagus (the muscular tube that connects the end of the throat with the opening of the stomach) becomes inflamed - often, but not always, due to allergic reactions to food. This inflammation causes nausea, heartburn, vomiting and difficulty swallowing. In advanced cases, children may suffer from malnutrition, often require special liquid diets, and may need to have a feeding tube inserted in order to receive nourishment. Eosinophilic Esophagitis, first identified in 1977, has been increasingly recognized since the advent of diagnostic endoscopy, a procedure in which a flexible fiber-optic tube is inserted down the throat to directly image and biopsy the esophagus.

Historically, part of the reason why the disease has been misdiagnosed is that its symptoms are very similar to those of acid reflux disease. However similar the two diseases are in terms of symptoms, their underlying physiology is vastly different. Drugs on the market for treating acid reflux do not abate the symptoms of Eosinophilic Esophagitis, which is not caused by production of stomach acid, but likely by inflammation in the esophagus resulting from the abnormal accumulation of immune cells know as eosinophils - hence its name eosinophilic esophagitis. Eosinophils are white blood cells that contain inflammatory chemicals, highly reactive proteins, destructive enzymes, toxins, muscle contractors and signaling molecules that can guide immune defenses to the site of infection.

At the Cincinnati Children's Hospital Medical Center, Professor of Pediatrics Marc E. Rothenberg, M.D., Ph.D., has seen patients with EE for a number of years and pursued clinical and laboratory research on the disease as well. To better understand the disease, Dr. Rothenberg and his colleagues examined the gene expression in tissue samples taken directly from the esophagus of individuals with EE as well as from people without the disease. These individuals were selected to represent a diverse sample with respect to age, sex and disease state. Dr. Rothenberg and his colleagues found that a particular set of 574 genes were expressed differently in people with EE from people without the illness.

This transcript signature, as they call it, yielded some surprising findings; it was largely the same for every person with Eosinophilic Esophagitis, regardless of age and whether or not these people had food allergies. This transcript signature was quite distinct from the signature observed in patients with acid reflux disease, thus allowing the two diseases to be easily discriminated. Although EE is more common in males than in females, the genes expressed in the esophagus did not vary dramatically between males and females with EE. Of the 574 genes, the investigators found that the expression of one gene in particular, termed eotaxin-3, was elevated in people with EE compared to people without the disease - at up to more than 100-fold greater amounts in EE than controls. eotaxin-3, a factor released from certain cells and tissues, acts to attract circulating eosinophils, yet no one had previously observed that the local levels of eotaxin-3 correlated directly with the number of eosinophils in the esophagus.

Extremely Low Birth Weight Infants Appear To Be Reaching Functional Outcomes

The majority of extremely low-birth-weight infants appear to be attaining similar levels of education, employment and independence as young adults, compared with normal birth-weight infants, according to a study in the February 8 issue of JAMA.

Despite the recent dramatic improvements in survival, extremely low-birth-weight (ELBW, weighing less than 2.2 lbs.) and very low-birth-weight (VLBW, weighing less than 3.3 lbs.) children and adolescents remain disadvantaged on many measures of cognition, academic achievement, behavior, and social adaptation, according to background information in the article. Survivors from the early postneonatal intensive care era have only now reached young adulthood. Although some aspects of longer-term outcomes on VLBW young adults have been reported in a few studies, details of certain functional outcomes of former ELBW infants at young adulthood are unknown.

Saroj Saigal, M.D., F.R.C.P.C., of McMaster University, Ontario, Canada and colleagues conducted a study to determine the outcomes at young adulthood of former ELBW infants in comparison to a group of normal birth-weight (NBW) children, recruited at age 8 years. Measures of successful transition to adulthood included educational attainment, student and/or worker role, independent living, getting married, and parenthood. The study included 166 ELBW participants who weighed 1.1 to 2.2 lbs. at birth (1977-1982) and 145 sociodemographically comparable NBW participants assessed at young adulthood (22-25 years). Participants were administered questionnaires between January 1, 2002, and April 30, 2004.

The proportion of participants who graduated from high school was similar (82 percent vs. 87 percent). Overall, no statistically significant differences were observed in the education achieved to date. A substantial proportion of both groups were still pursuing postsecondary education (32 percent vs. 33 percent). No significant differences were observed in employment/school status; 48 percent ELBW vs. 57 percent NBW young adults were permanently employed. No significant differences were found in the proportion living independently, married/cohabiting, or who were parents. The age of attainment of the above markers was similar for both groups.

Backpack Safety

My 5-year-old wears a heavily loaded backpack to school and I am concerned this is going to affect his posture. How much weight should he carry and how can I tell if his backpack is starting to affect him physically?

It's amazing what children in school think they must carry with them and have available at all times. This includes textbooks (which seem to get bigger and bigger), school supplies (which must be tailored to meet each class's specifications) and the child's personal items such as MP3 players, etc. Backpacks have become the most popular and perhaps the most practical way for children and teenagers to manage all of their necessary school belongings. If used within a reasonable context, backpacks are a sensible way for children to transport their necessities.

The concept of the backpack is that by wearing the pack on the back with shoulder support, the weight is distributed to some of the body's strongest muscles. If children wear backpacks improperly or consistently put too much weight in their backpack, they can certainly injure their muscles and joints. They may begin to complain of back, shoulder and neck pain and you may actually begin to see some changes in the child's posture. The American Academy of Pediatrics (AAP) has established some guidelines that can be helpful. These include:

• Have your child select a backpack that fits him in size. It's a good idea to try on the backpack at the store, before you purchase it. Backpacks should always be lightweight and not add more weight.

• The backpack should be designed so that weight can be evenly distributed across the back. Padding to the back side of the pack increases comfort.

• The child should always wear both shoulder straps and avoid slinging the pack over one shoulder. Straps should fit snuggly and the pack should rest two inches above the waist.

• Shoulder straps should be wide and padded to allow proper distribution of weight. An added waist strap can help distribute the weight and keep the backpack from shifting from side to side.

• Do not put too much weight in the individual backpack. A rule of thumb should be that the pack never weighs more than 10 to 20 percent of the child's body weight. A 60-pound child should not carry a backpack that weighs more than 10 to 12 pounds.

• Encourage children to maintain a school locker they can visit at different times during the day, so they can swap books according to their class schedule.

• Discuss guidelines about backpacks with your school. Children should be allowed to stop at their lockers throughout the day. Some attention should be paid to the actual textbooks and material the children are required to have. Another important note about backpacks is that parents should know what kind of backpack is allowed in school. Concern about security and unacceptable items such as knives, guns, etc., have prompted some schools to implement rules that only allow backpacks with clear sides so the contents are visible.

With the above suggestions in place, parents should routinely observe their child's posture and the amount, weight and type of material being carried in backpacks. If your child complains of back pain or you notice a difference in posture, they should be evaluated by your pediatrician. Even though the child's back pain is most likely due to his backpack, there are other causes of back pain that should be detected early. If your child does not use the backpack for a week, pain and posture changes should stop. If there is no way to avoid an overly heavy backpack, some other solution such as a rolling backpack or keeping a set of books at home should be considered.

New Childhood Vaccine Available for Parents to Consider

There's a new kid on the childhood immunization block this year -- the hepatitis A vaccine. Because it is new, some parents may be left with two key questions: Should I have my child vaccinated against hepatitis A and if so, will my insurance cover the cost?

Hepatitis A is one of five hepatitis viruses, lettered A through E. Hepatitis E and D are very rare. Hepatitis C and B come from blood contact and hepatitis B also can be transmitted sexually. Children already are routinely vaccinated against hepatitis B. The hepatitis A vaccination became part of the recommended childhood immunization schedule with the start of 2006.

First, here's some background on the disease. According to John Messmer, associate of professor of family and community medicine at Penn State Milton S. Hershey Medical Center, people who contract hepatitis A usually recover from it, but recovery can take months and may require hospitalization. About 1 percent of cases develop severe or "fulminant" hepatitis with a fatality rate of up to 50 percent.

Hepatitis A is contracted from contaminated food or water or by contact with an infected person and is found only in humans. Although it is associated with poor sanitation, in the United States about 11,000 cases were reported in 2001 out of a probable total of about 45,000 occurrences. About one-third of the U.S. population has had hepatitis A.

The good news is that hepatitis A is preventable. Beginning in 1995, hepatitis A vaccine was administered to high-risk populations and children older than age 2 in states with the highest incidence of hepatitis A. It worked so well that it now is recommended for all children starting at age 1 since children under age 1 have some protection from maternal antibodies.

The vaccine is quite safe. Two doses are given six months apart, but more than 97 percent immunity is present after one dose. It also is highly recommended for people traveling to Africa, Asia, the Caribbean, Mexico, Central and South America, Eastern Europe, the Mediterranean and the Middle East and for those living in endemic areas, people who work in day-care centers or group homes, food handlers and people who engage in unsafe sexual practices.

Insurance companies likely will pay for the vaccine for children. Hepatitis A vaccine is part of the approved immunization schedule for children of employees participating in the Penn State Hershey Medical Center health-care benefits plan - check the prevention schedule for age and frequency guidelines.

How To Treat Children Exposed to Chemicals Used in Bioterrorist Attacks

The Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) released The Decontamination of Children: Preparedness and Response for Hospital Emergency Departments, a 27-minute video that trains emergency responders and hospital emergency department staff to decontaminate children after being exposed to hazardous chemicals during a bioterrorist attack or other disaster.

This video provides a step-by-step demonstration of the decontamination process in real time and trains clinicians about the nuances of treating infants and children, who require special attention during decontamination procedures. For example, children may be frightened not only by the emergency situation itself, but also may be afraid to undergo decontamination without their parents; children also take longer to go through the decontamination process than adults.

"This video provides a valuable and straightforward overview for first responders and hospital emergency personnel on decontaminating infants, children, and parents who have been exposed to dangerous chemical agents," said AHRQ Director Carolyn M. Clancy, M.D. "I hope this will be a valuable tool for those taking care of children, who will be one of our most vulnerable populations during a bioterrorist attack or other emergency."

Morphine and Topical Anesthesia Found Effective in Treating Procedure Related Pain in Newborn Infants

Intravenous morphine used alone or with topical tetracaine effectively reduced levels of pain in preterm newborn infants undergoing central line insertion procedures, according to a study in the February 15 issue of JAMA.

About 10 percent to 15 percent of newborns require prolonged hospitalization for conditions such as preterm birth, birth defects, and sepsis (a blood stream infection). As part of their medical care, they are often exposed to multiple invasive procedures that may be painful. There is accumulating evidence that untreated procedural pain in newborns leads to long-term changes in pain sensitivity, according to background information in the article. The effectiveness of local or systemic analgesics (pain relievers) to minimize pain in newborns during certain procedures is not clear.

Anna Taddio, Ph.D., of the Hospital for Sick Children and University of Toronto, and colleagues studied the relative efficacy and safety of topical local anesthesia (tetracaine) and intravenous opioid analgesia (morphine), used alone or in combination, for management of pain in newborns undergoing the insertion of a central venous catheter. The randomized, double-blind, controlled trial, conducted between October 2000 and July 2005, included 132 ventilated newborns (average gestational age, 30.6 weeks at study entry). Prior to catheter insertion, the newborns were randomly assigned to receive tetracaine (n = 42), morphine (n = 38), or both (n = 31); a separate nonrandomized group of 21 neonates receiving neither tetracaine nor morphine was used as a control group.

The researchers determined pain scores by measuring the proportion of time newborns displayed facial grimacing (brow bulge) during different phases of the procedure (skin preparation, needle puncture, and recovery).

The authors found that the combination of morphine (opioid analgesia) and tetracaine (local anesthesia) was more effective than either local anesthesia alone or no analgesia in reducing the pain of catheter placement, but similar in effectiveness to opioid analgesia alone. Local anesthesia alone, however, was not consistently different from no analgesia, suggesting that it was a weak analgesic.

"We hypothesize that morphine was more effective than tetracaine because morphine reduced the sensory input derived from multiple phases of the procedure that differed in both the location and degree of invasiveness, whereas tetracaine decreased sensation from the needle puncture site," they write.

Healthy Preterm Infants Show Reduced Lung Function

Tests of healthy preterm infants younger than 12 weeks of age show prematurity to be independently associated with reduced lung function. Predictors of this reduced expiratory flow during the first months of life include male sex, low gestational age and increased weight gain.

The results appear in the second issue for February 2006 of the American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society.

Marcus H. Jones, M.D., Ph.D., of the Department of Pediatrics at the Hospital São Lucas in Porto Alegre, Brazil, and four associates examined 62 preterm infants who had no significant neonatal respiratory disease. They also tested 27 full-term infants as controls.

Both the preterm and full-term groups included more females than males.

"There was a noticeable reduction in expiratory flows in the preterm groups compared with control infants and reference values," said Dr. Jones.

Using a model that adjusts for differences in body size, the investigators found male sex and lower gestational age significantly and independently associated with reduced flows in the preterm group.

"The increased risk of wheezing, chronic cough and hospital readmissions early in life suggests that some degree of airway obstruction is present even in preterm infants without neonatal respiratory distress," said Dr. Jones.

The researchers defined "healthy preterm infants" as those who had not required significant ventilatory support after birth and had not suffered prior lower respiratory infections. A minority of the premature infants in the study cohort required supplemental oxygen in the first two days of life.

"This study demonstrates an independent effect of gestational age on expiratory flows," said Dr. Jones. "There is up to a 7 percent increase per week of gestation. It also reinforces the hypothesis that prematurity alone has an important role in the development of persistent airway obstruction."

He added that lower expiratory flows in boys have also been observed in other lung function studies on full-term infants.

"However, in our sample, after adjusting for length, gestational age and weight, flows were up to 30 percent lower in males, a greater effect than previously reported in full-term infants," said Dr. Jones. "One could speculate, from the magnitude of lung function loss, that the described disadvantage of male infants in relation to respiratory disorders is heightened by prematurity. This might contribute to the increased neonatal morbidity and mortality related to respiratory illness for preterm male infants."

They also noted that in full-term and preterm infants, exposure to cigarette smoke while in the womb was not associated with lower air flows in their sample. "This absence of association was unexpected and may reflect the limitation of self-reported smoking among mothers and possible misclassification," Dr. Jones explained.

The investigators concluded that understanding the mechanisms associated with lower expiratory flow in preterm infants, particularly in the first year of life, could have potential implications for the prevention of respiratory diseases in this age group.

Children with Heart Defects Found to Benefit from Exercise

A small but compelling pilot study indicates that many children with serious congenital heart disease, who are typically urged to restrict their activity, can improve their cardiovascular function and exercise capacity through a cardiac rehabilitation program. Fifteen of 16 children participating in a 12-week rehabilitation program at Children's Hospital Boston showed significant gains in heart function, researchers report in the December Pediatrics.

Congenital heart defects affect about 8 in 1000 newborns. Due to advances in care, more and more children with these defects are surviving. Many have diminished exercise capacity after the defects are repaired, and some of this reduction is caused by a lack of activity, says Jonathan Rhodes, MD, a cardiologist at Children's who led the study.

"These kids haven't exercised much. They've been told by coaches, doctors, parents and teachers, 'Oh, you can't exercise,'" Rhodes says. "Cardiac rehabilitation is not a component of most pediatric cardiology programs."

The study enrolled 19 children, aged 8 to 17, who had congenital heart disease severe enough to consider restricting their activity and showed reduced cardiac function on exercise testing. None had findings on exercise testing that might raise a concern about the safety of rehabilitation, such as arrhythmias or chest pain. However, all 16 children who completed the program had undergone heart surgery or a nonsurgical procedure in the past, and 11 of 16 had only one functional ventricle, or pumping chamber. "This was a sick group," says Rhodes.

The 12-week program consisted of twice-weekly, hour-long sessions combining stretching, aerobics, and light weight/resistance exercises. Activities were tailored to the children's interests, and included dance, calisthenics, kick boxing and jump rope. Balls, music, games like "capture the flag" and relay races, and age-appropriate prizes were used to keep the kids motivated, and sessions were moved outdoors when weather permitted.

"One game they particularly enjoyed was 'punch the doctor,'" says Rhodes, referring to a game in which children threw punches at pieces of matting. "A lot of the kids were timid in the beginning, but they were really moving by the end. Being with other kids with heart disease who had never exercised helped melt away a lot of their anxiety. It was quite a metamorphosis."

Heart rate was checked before each session, and 2 to 3 times during the session. For safety, a pulse oximeter and external defibrillator were available on site, but were never needed.

At the end of the program, 15 of 16 children had significantly improved peak work rate, peak oxygen consumption, or both: their hearts were pumping more blood with each beat, and their muscles were using more oxygen. Improvements were as high as 20 percent on some parameters of function. There were no adverse events.

A Better Screening Test for Infant Iron Deficiency

A unique blood test detects iron deficiency in infants earlier and more accurately than the commonly used hemoglobin screening test, according to a study in the August 24/31 issue of the Journal of the American Medical Association. Iron deficiency is estimated to affect nearly 10 percent of American children one to two years of age. Early detection and treatment are critical because iron deficiency can impair infant mental development, possibly permanently, even before it progresses to anemia (clinically identified as a low hemoglobin level).

The study, done at Children's Hospital Boston, is the first to compare the test, called CHr, with the standard hemoglobin test as a screen for iron deficiency in infants. Hemoglobin is the iron-containing, oxygen-carrying molecule in red blood cells; the CHr test measures the hemoglobin content of reticulocytes, or immature red blood cells, whereas the standard hemoglobin test is based on the entire population of red blood cells. Because reticulocytes are present in the bloodstream for only 24 to 48 hours, as compared with several months for mature red blood cells, measuring the reticulocyte hemoglobin content (i.e., CHr) provides a more timely indication of iron status, the investigators say.

In this study, 200 healthy infants 9 to 12 months of age underwent both tests, as well as a transferrin saturation test, which is the "gold standard" test for iron deficiency but is impractical for routine screening. Using the optimal CHr cutoff value (established as 27.5 picograms), CHr correctly identified 83 percent of the iron-deficient infants, compared with only 26 percent identified by the current screening standard (a hemoglobin level less than 11 grams/deciliter).

"Our findings are important because, while iron deficiency can be readily treated, practitioners haven't had a simple, reliable and practical screening test to detect it early enough. Now they might," said Henry Bernstein, DO, Associate Chief, General Pediatrics, Children's Hospital Boston and the principal investigator of the study. "This study shows that CHr can be used to detect iron deficiency earlier and more accurately than standard hemoglobin screening. Once confirmed in larger, multicenter studies, these findings could change our preferred screening practices for the early detection of iron deficiency." He added that the CHr test is simple, requires no extra tubes of blood to be drawn and involves no additional cost.

"There is mounting evidence that iron deficiency in infants can cause permanent neurocognitive deficits, even before it has progressed to the point of causing anemia," said lead investigator Christina Ullrich, MD, a fellow in pediatric hematology and oncology at Children's Hospital Boston and the Dana-Farber Cancer Institute. "The ability of the CHr test to identify more infants, at an earlier stage of iron deficiency, makes it a better choice for screening than the current hemoglobin test."

Iron deficiency is the most common nutritional deficiency in the world. Infants and toddlers are especially susceptible because of their rapid growth, increased demands for iron, and variable dietary intake. The deficiency progresses in three stages: 1) depletion of the body's iron stores; 2) deficiency, in which hemoglobin synthesis is impaired, resulting in a fall in CHr; and 3) anemia, in which red-blood-cell hemoglobin is below normal for a person's age. Iron deficiency is usually readily treated with dietary iron supplementation.

Under current guidelines, children are first screened with the hemoglobin test at nine to 12 months of age. However, iron deficiency can exist for some time before causing anemia. There are other tests that can diagnose iron deficiency in the absence of anemia, but they are impractical for routine clinical screening. Thus, current screening practices miss iron deficiency in non-anemic infants in whom adverse consequences may be developing.

Is Your Childs Pediatrician Boardcertified

U-M studies find 78 percent of U.S. hospitals don't require board certification for initial privileging; only 41 percent of health plans use it for credentialing of physicians

Most parents assume that their child's pediatrician is board certified, giving them the peace of mind that the physician has the knowledge, skill and experience to offer the highest quality of care in the field.

But many of those pediatricians practicing at hospitals or associated with health plans may, in fact, not be certified or may not have taken the proper steps for recertification, according to researchers at the University of Michigan Health System.

Results from two studies appearing in the Feb. 22 issue of the Journal of the American Medical Association (JAMA) show that 78 percent of U.S. hospitals don't require board certification to grant pediatricians initial privileging, or permission to practice in the hospital, and only 41 percent of health plans require general pediatricians to be board certified at any time during their association with the plan.

"In a time when patient safety and physician competency is of great concern to the public, we were surprised to find that more hospitals and health plans were not requiring current board certification of their physicians," says lead author for the two studies Gary L. Freed, M.D., MPH, chief of the Division of General Pediatrics and director of the Child Health Evaluation and Research (CHEAR) Unit at the U-M Health System. "Many hospitals report they require physicians to be board certified, but our study found approximately half of the hospitals in America and nearly half of the health plans do not have a specific time frame in which their physicians must achieve recertification."

Previously, once physicians received board certification, it remained valid for their entire medical career. But in 1987, the American Board of Pediatrics (ABP) began issuing time-limited certificates to ensure pediatricians remained competent and knowledgeable in their fields. This process requires recertification every seven years for a physician to maintain his certification status.

With limited information available about hospitals' and health plans' requirements for certification and recertification of their physicians, Freed and his colleagues set out to conduct two separate studies to determine hospitals' use of board certification for privileging, and the credentialing policies of health plans related to certification. Both studies used telephone surveys to gather information.

Study: Hospital privileging and board certification/recertification
Of the 159 nationally representative hospitals that participated in the study, 78 percent said that they did not require board certification at the time of initial privileging for their general pediatricians.

While 70 percent did require certification to be completed at some point by their pediatricians, about half of the hospitals did not have a specific time frame in which certification or recertification must be completed. And only 43 percent required their pediatric subspecialists to achieve subspecialty certification within a designated time frame.

With only 45 percent of hospitals requiring general pediatricians with time-limited certificates to recertify, Freed says hospitals are missing an opportunity to provide a measure of quality assurance to patients and their families.

"Certification and recertification provide hospitals with a wonderful opportunity to increase the public's trust in the care provided in their institutions," notes Freed, the Percy and Mary Murphy Professor of Pediatrics and Child Health Delivery at the U-M Medical School. "However, many institutions may view recertification as a burden to their physicians, when instead it should serve as a valuable quality assessment tool in their privileging process."

Study: Credentialing policies of health plans and use of board certification
The most significant finding of this study is that only 41 percent of health plans require their credentialed general pediatricians to be board certified, says Freed.

The remaining 59 percent never require certification of their general pediatricians. Health plan credentialing of physicians is designed to be a systematic approach to collection, review and verification of a physician's professional qualifications.

However, of the 174 plans examined in the study, 90 percent do not require general pediatricians to be board certified at the time of initial credentialing, Only 40 percent require subspecialists to become board certified in their subspecialty at some point during their association with the plan.

Of likely surprise to both patients and insurers is that 77 percent of plans say they still allow their pediatric subspecialists to bill as a subspecialist, even if their certification has expired. While 42 percent of the plans reported requiring recertification for general pediatricians, less than half have a specific time frame in which recertification must occur.

"The credentialing process is designed to aid health plans in choosing competent physicians for the care of their members, and the lack of use of board certification is a significant issue for the plans and the public,"says Freed. "No one would want to fly in airplane with a pilot who hasn't gone through regular training and assessment, and the public should expect no less from their health care providers. Parents have the right to have high expectations for the physicians they have entrusted with their child's care."

Pediatricians Play Key Role in Disasters

Recent acts of terrorism and disasters have heightened society's recognition of the need for emergency preparedness. Children are especially vulnerable during times of disaster and as part of the network of health responders, pediatricians need to be able to answer parents' concerns, recognize signs of possible exposure to weapons of terror, understand first-line response to such attacks and sufficiently participate in disaster planning to ensure that the unique needs of children are addressed.

A newly revised policy statement and technical report from the American Academy of Pediatrics (AAP) both titled, "The Pediatrician and Disaster Preparedness," provide guidance to pediatricians on how to prepare themselves, their patients and their practices for terrorism and disaster events. The policy encourages pediatricians to discuss issues related to family emergency preparedness as part of anticipatory guidance, and suggests providing families with information on creating a family emergency plan, as well as parents discussing the plan with their children and practicing the plan.

The policy also recommends that pediatricians:

• institute office and home disaster plans;

• participate in community or hospital disaster planning, including drills and exercises;

• work with schools and child care centers in developing disaster plans;

• serve a key role in identifying cases of illness after a chemical, biological or radiological release;

• in addition to the above, provide surveillance for unusual rates of infectious disease that may occur;

• ensure that the mental health needs of children and their families are being addressed and, when needed, provide appropriate referral for mental health services.

The policy points out that hospitals and communities must consider the needs of children in all aspects of emergency and disaster preparedness, and in all hazard plans. That includes appropriate types and numbers of pediatric-trained staff, equipment, medications and decontamination equipment. Hospitals must be prepared to handle circumstances in which patients will be cared for as a family unit and children will not be able to be separated from adults, such as in a quarantine situation.

Because children are often not considered in government and community activities surrounding disaster plans, the policy stresses that pediatricians are essential advocates for children. Grassroots advocacy by pediatricians can include efforts to ensure legislation and funding to support an emphasis on children in disaster planning at every level.

The Problems Facing Pediatric Health Care

By some measures, the United States provides great health care. But for many children, especially ethnic minorities, good health care is the exception. The spring issue of Stanford Medicine explores successes and failures in pediatric care. At the root of the special report's findings is the fact that in the United States - and throughout the world - adults' health problems get more attention than kids'.

Among the offerings:

• An analysis of the hidden competition for U.S. health-care resources. It's adults vs. kids - and the adults have the upper hand.

• A feature on the place of children's hospitals in society. These bastions of pediatric health care stand on shaky ground.

• A report from the unhealthiest place on the planet for children: sub-Saharan Africa.

• A bioethicist's answer to the question: How old do you have to be to make your own health-care decisions?

• An article on what happens when medical miracles grow up, focusing on a cancer survivor and a young woman with cystic fibrosis.

• An account of Hurricane Katrina and its aftermath from eyewitnesses at Children's Hospital New Orleans.

• A feature on associate professor of pediatrics Ching Wang's quest to cure the most deadly genetic disease of newborn children - spinal muscular atrophy.

The issue also includes a profile of medical school alumnus Njoroge Mungai, a Kenyan political leader (now retired) who held several top posts in the nation's first post-colonial government.

Children and Unintentional Swallowing of Medicines

Majority of Incidents Occur in the Home

Keeping medications out of the easy grasp of children four and younger in the home is a significant health issue in the United States because they are more likely to be hospitalized for unintentionally swallowing medications than other causes of unintentional injury, according to the Centers for Disease Control and Prevention (CDC) in a report released today.

From 2001-2003, an estimated 53,500 children four years and younger were treated in hospital emergency departments each year after swallowing medications not intended for them or given in error. Almost three-fourths of these children were one to two years old and 75 percent of the incidents occurred in the home. The report also indicated that children four and younger who are treated for medication exposure in the emergency room are nearly four times more likely to be hospitalized or transferred to specialized care than for other unintentional injuries.

National estimates for this study were based upon data from 3,600 sample cases from U.S. hospitals. About 40 percent of the ingestions involved common over-the-counter drugs like acetaminophen, cold and cough medications, non-steroid anti-inflammatory medications, antihistamines, and vitamins. Prescription drugs accounted for most of the remaining medication ingestions. The types of medications most commonly leading to hospitalization or transfer to specialized care were anti-seizure medications, calcium channel blockers, anti-depressants, and oral diabetes medications.

Although specific information about how these incidents occurred was available for only about 15 percent of the cases, in most of these cases medications were not properly stored in their original containers, according to Dr. Dan Budnitz, one of the CDC study authors.

"Emergency room reports often do not provide detailed information on the circumstances surrounding the incidents," said Budnitz, "But the information available suggests that it's important to keep medications out of sight and reach of young children."

Unintentional incidents involving medication by young children can also result in death; while not part of this study, information from death certificates in 2002 indicated that 35 children ages four years and younger died of poisoning after swallowing medications. Also, over 550,000 incidents involving medications are reported each year for children under age six. For these reasons parents and others who are responsible for supervising children should remain vigilant in protecting children from inadvertent access to medications. Here are several prevention recommendations:

• Store all medications in secured cabinets and out of reach of children. When possible, keep the medicines in their original containers. If medicines are transferred to other containers, be extra vigilant to ensure children do not have access to them. If you store medicines in your purse or a pill box, make sure that children do not have access.

• Discard all unused medicines by flushing down the toilet.
  Avoid taking medicines in front of children, because they tend to imitate adults. Do not call any medicine "candy."

• Make sure your visitors do not leave their medicines where children can easily find them.

• Post the poison control number 1-800-222-1222 on or near every phone at home.

• Put it in your speed dial on your mobile phone.

Spring Break Safety Tips

Spring break is a great time for the family to get away from the cold, dark days of winter and have some fun in the sun. Keep your family safe while on your trip by following these tips from the American Academy of Pediatrics (AAP).

Sun Safety for Babies

• Babies under 6 months of age should be kept out of direct sunlight. Move your baby to the shade under a tree, umbrella or stroller canopy.

• Dress babies in lightweight clothing that covers the arms and legs, and use brimmed hats.

Sun Safety for Kids

• Choose sunscreen that is made for children, preferably waterproof. Before covering your child, test the sunscreen on your child's back for a reaction. Apply carefully around the eyes, avoiding eyelids. If a rash develops, talk to your pediatrician.

• Select clothes made of tightly woven fabrics. Cotton clothing is both cool and protective.

• When using a cap with a bill, make sure the bill is facing forward to shield your child's face. Sunglasses with UV protection are also a good idea for protecting your child's eyes.

• If your child gets sunburn that results in blistering, pain or fever, contact your pediatrician.

Sun Safety for the Family

• The sun's rays are the strongest between 10 a.m. and 4 p.m. Try to keep out of the sun during those hours.

• The sun's damaging UV rays can bounce back from sand, snow or concrete; so be particularly careful of these areas.

• Most of the sun's rays can come through the clouds on an overcast day; so use sun protection even on cloudy days.

• When choosing a sunscreen, look for the words "broad-spectrum" on the label - it means that the sunscreen will screen out both ultraviolet B (UVB) and ultraviolet A (UVA) rays. Choose a water-resistant or waterproof sunscreen and reapply every two hours.

• Zinc oxide, a very effective sunblock, can be used as extra protection on the nose, cheeks, tops of the ears and on the shoulders.

• Use a sun protection factor (SPF) of at least 15.

• Rub sunscreen in well, making sure to cover all exposed areas, especially the face, nose, ears, feet and hands, and even the backs of the knees.

• Put on sunscreen 30 minutes before going outdoors - it needs time to work on the skin.

• Sunscreens should be used for sun protection and not as a reason to stay in the sun longer.

Beach Tips*

• Drink plenty of water, non-carbonated and non-alcoholic drinks, even if you do not feel thirsty.

• Stay within the designated swimming area and ideally within the visibility of a lifeguard.

• Never swim alone.

• Be aware of rip currents. If you should get caught in a current, don't try to swim against it. Swim parallel to shore until clear of the current.

• Seek shelter in case of storm. Get out of the water. Get off the beach in case of lightning.

• Watch out for traffic - some beaches allow cars.

Headache Sleep Problems Connected in Children

Mayo Clinic researchers have found that frequent headaches in children appear to be associated with sleep problems. More than two-thirds of children studied who suffer from chronic daily headache also experience sleep disturbance, especially delay in sleep onset. For children with episodic headaches, one-fifth had sleep problems. The findings will be presented this week at the 24th Annual Conference on Sleep Disorders in Infancy and Childhood in Rancho Mirage, Calif.

"What's novel in our study is the finding that a high percentage of patients with headache have sleep disturbance," says Kenneth Mack, M.D., Ph.D., pediatric neurologist specializing in headache and the senior study investigator. "The number of patients who have headaches and also sleep disturbance surprised us. They also have the same sleep disturbance: a delay in sleep onset."

The researchers undertook this study to scientifically study their observation in the clinic that many children suffer from both headaches and sleep problems.

"We've continually seen that children with headaches are poor sleepers and that they're fatigued because they have poor sleep," says Dr. Mack. "We've known that when people don't get enough sleep they get more headaches, but we'd not appreciated the frequency of sleep disturbance with chronic daily headache."

The study involved a retrospective chart review of 100 children ages 6 to 17 with chronic daily headache - headache present 15 or more days a month for three months or more - and 100 children in the same age category with episodic headache - headache that occurs with less frequency than chronic daily headache. In addition to sleep onset delay, sleep problems found in children studied included awakening during the night or too early in the morning, or not feeling refreshed after sleep.

The investigators do not yet know which problem comes first - sleep problems or headache. In some children sleep problems come first, and in others, headache is first. "They feed on each other: sleep problems make the headaches worse, and the headaches make the sleep problems worse," says Dr. Mack. "Also, the worse the headaches, the more likely children are to have sleep problems, and vice versa. They could have a common cause, or one problem could be an early sign of the other."

Treatment must be simultaneous for both conditions, using medicine and non-medicine approaches, says Dr. Mack. "It's going to be hard to control the headaches till you get the sleep problems under control either with medication or non-medication treatment," he says.

Key non-medication treatments include attention to maintaining routine in the child's schedule and developing good sleep hygiene, according to Lenora Lehwald, M.D., Mayo Clinic neurology resident and study investigator. "Educating the patient and family on things like good sleep habits may in and of itself help to improve the sleep quality and thus the headaches in the long run," she says.

Dr. Lehwald explains that good sleep hygiene for children involves what seem to be very basic and simple practices in the evening routine. "A child should use his bedroom for just the types of activities that would be sedating and relaxing," she says. "TVs, video games - things that are exciting and get the child interested, motivated and activated - should not be in the bedroom. Also, it's important for children to have a routine for calming down and preparing for sleep the last hour they plan to be awake. They should choose activities that make them drowsy, like reading."

If a child with both headache and sleep problems requires medicine, Dr. Mack prefers migraine medication that also helps with sleep issues.

Addressing sleep problems in children who have episodic headache may also avert the child's transition to chronic daily headache, according to Dr. Lehwald. Children who develop chronic daily headache typically have had episodic headache.

Age is one factor that puts children at risk for headache. Teenagers have the highest level of risk, according to Dr. Mack, which may be partly due to a higher stress level for teens than for younger children. He also notes that a typical teen needs about 9.5 hours of sleep per night, more than most teens get. Family history of headache, time of year and stress level also appear to impact headache risk, say the researchers.

"Fall, when children start school, is a stressful time for children, and it's very much a time when they will experience more headache," says Dr. Lehwald. "As school lets up in the summer, they seem to have more headache-free time. So, that's a good indicator that stress has an impact on the frequency and severity of children's headaches."

From 10 to 20 percent of children have episodic headache. Chronic daily headache occurs in up to 4 percent of girls and up to 2 percent of boys.

Emergency Departments Score Poorly in Child Saving Drills

A mock-drill study conducted in a third of North Carolina's hospital emergency departments (EDs) revealed that nearly all failed to properly stabilize seriously injured children during trauma simulations, according to a team of researchers at the Johns Hopkins Children's Center and Duke University Medical Center. Simulations were conducted in 35 of North Carolina's 106 EDs. Of the 35 EDs in the study, five were designated trauma centers (out of a total of 11 in the state of North Carolina) and 30 were located in community hospitals. A report on the research team's findings, which state that their results probably apply to hospitals nationwide, is published in the March issue of Pediatrics.

Although the researchers caution that observations during mock codes do not necessarily represent performance in an actual health emergency, the study's results do suggest that hospital EDs are not fully prepared to deal with pediatric emergencies, according to lead author Elizabeth A. Hunt, M.D., M.P.H., assistant professor of anesthesiology and critical care Medicine at Johns Hopkins.

Hunt and colleagues staged mock codes using life-size child mannequins. They presented each ED team with a vignette describing the patient's symptoms, appearance and vital signs. Researchers then observed and rated the team's performance on 44 stabilization tasks, such as evaluating an airway, administering fluids and ordering appropriate tests.

None of the departments performed flawlessly, Hunt says, and while mistakes were ubiquitous, certain failures were more worrisome than others. For example, of the 35 EDs studied, 34 failed to administer dextrose properly to a child in hypoglycemic shock (a life-threatening, sharp drop in blood sugar). Also, 34 of 35 failed to correctly warm a hypothermic child.

Thirty-one of the 35 also failed to order proper administration of IV fluids, and personnel in 24 out of 35 either did not try or failed to access a child's bloodstream through a bone, a critical alternate avenue for rapidly delivering fluids and medicines to sick children whose veins may have constricted due to hypothermia or blood loss.

Researchers said they were surprised to find that emergency medicine staff failed to follow safe patient transport procedures. Only 12 of the 35 hospitals prepared appropriate medications, monitoring equipment and personnel needed to transport a child safely within the hospital. The observation adds new insight to why transportation within the hospital is a high-risk time for patients, Hunt says.

Despite the failures, Hunt says, departments successfully handled many of the 44 mock code tasks well, including:

• Calling appropriate members for assistance

• Assessing the airway

• Initiating bag-mask ventilation

• Ordering appropriate imaging tests

• Assessing initial vital signs

"There is no definitive evidence to say whether performance during simulation reflects performance during actual events," Hunt says. "However, this study gives us very specific targets for attempting to improve stabilization procedures for children." For example, Hunt suggests that hospitals conduct periodic drills to look for recurrent patterns that identify areas most vulnerable to error.

Healthcare Tips for One Year Olds

As the Comer Children's Hospital at the University of Chicago celebrates its first year, we have put together 10 tips for your child's healthcare as he or she turns one. These recommendations were developed with Dr. Joel Schwab and other leading pediatricians at Comer Children's Hospital.

Please note they are only guidelines. Please refer individual questions and concerns to your own child's pediatrician.

Immunizations: Immunizations are important to protect your child from many infectious diseases. Check with your child's physician to make sure they are up-to-date and get the vaccines that are scheduled for after your child's first birthday, such as DPT (Diphtheria, Tetanus and Pertussis), MMR (Measles, Mumps, and Rubella), Varicella (Chicken Pox), Pneumococcus, Polio and Haemophilus influenza.

Safety: As your child begins to walk, it's essential to child proof your home so they can continue to test out their independence in a safe manner. Place safety gates around stairs and windows to prevent falls, cover electric outlets with plastic caps, hide all wires and cords, and remove poisonous cleaning products from cabinets that are accessible. A one-year-old child must always be supervised.

Oral hygiene: As your child is now developing teeth, make sure they are getting sufficient amounts of fluoride that helps prevent cavities through either tap or bottled water that contains fluoride. Not all bottled water contains fluoride and some water filters can also eliminate fluoride. Also avoid early childhood cavities by not allowing your child to take a bottle to nap or sleep that contains liquids that have sugar in them. If your child insists on taking a bottle, fill it with water instead of sugary liquids. Get in the habit of brushing your child's teeth with a small amount of toothpaste. Your child's first dental appointment should be between the first and second birthday.

Car seats: If your child is one year old and weighs more than 20 pounds, you may turn the car seat around to face forward.

Shoes: With your child either walking or nearing that milestone, think about buying shoes to protect them from injury as they take their first steps. When buying shoes, be practical, and remember they should be soft, wide and inexpensive, as you will be replacing them early and often. Shoes are not necessary to learn to walk and high tops are preferable because they stay on their feet better.

Healthy diet: With your child eating more solid foods, it's important to pay attention to quantity and quality. Avoid high-fat, high sugar, low-nutrition foods, such as chips, pop, and fruit juices. Focus on healthier alternatives, such as fruits and vegetables. Also, it is not too early to begin regulating portions and allowing the child to determine when they are full.

Outdoor care: Your child will be going outside more, so protect them with an appropriate sun block. Apply the sunscreen before they actually get in the sun. Number 15 SPF is sufficient and should be applied at four-hour intervals. With a child's fair skin, make them wear hats and sunglasses when outside, especially during the peak hours of damage from 10 a.m. to 4 p.m. Apply an appropriate child-safe, non-toxic insect repellent as well. While DEET formulas up to 30 percent are safe for toddlers, there are also non-DEET formulations available (Cutters Advance/Picaridin) that protect against mosquitoes. Directions on the containers must be followed.

Interaction: Parents should help their child's development by maintaining significant interaction with them on a daily basis. Talking, reading, singing to and playing with your child enhance their mental, emotional and social development.

Don't compare: Try not to compare your child's progress with another's as no two children develop alike. Look to see if they are gaining skills and growing their language and socialization talents, including pronouncing simple words, like "mama" and "dada" and being interactive and responsive.

Discipline: Set limits for your children that are appropriate for their age. Timeouts, distractions and being consistent are important ways to enhance good behavior and children should be praised when they do well.

Scientists Provide New Evidence for Cellular Cause of SIDS

University of Chicago researchers and colleagues have found strong support that a disturbance of a specific neurochemical can lead to sudden infant death syndrome, the primary cause of death before age 1 in the United States. Approximately 3,000 infants die each year from SIDS, according to the Centers for Disease Control and Prevention.

In the March 8, 2006, issue of the Journal of Neuroscience, researchers describe what happens during hypoxia when levels of the hormone serotonin are disturbed in pacemaker cells - the specific group of neurons they previously showed to be responsible for gasping, which resets the normal breathing pattern for babies. Scientists found that normal serotonin levels are needed in these respiratory pacemakers to induce gasping and ignite auto-resuscitation.

"This confirms our previous studies," said Jan-Marino Ramirez, one of the authors of the study and professor of organismal biology and anatomy. "Now we've just better defined the players in the system."

In a paper published last year in the journal Neuron, Ramirez's work found that sodium-driven pacemaker cells controlled gasping. This work in tissue slices was confirmed in a study published last month by University of Bristol researchers who found the same results in rats.

Scientists knew that sudden infant death syndrome (SIDS) victims had disturbed levels of serotonin in areas critical for respiration. Since serotonin regulates the sodium channels in pacemaker cells, Ramirez's research team examined more closely serotonin levels in sodium-driven pacemaker neurons in the breathing center.

When researchers removed serotonin from these pacemaker cells, the gasping drastically decreased, from typically about 20 gasps to just two or three gasps - not enough for the baby to awaken.

"It indicates that if there's a problem with serotonin, the gasping is gone," Ramirez said. "And when these children don't gasp, they don't wake up."

According to the researcher, when the body senses a lack of oxygen, it shuts down most of the cellular respiratory network and focuses its energy on gasping, which is modulated solely by sodium-driven pacemaker neurons. If that specific neuron is blocked, for whatever reason, the body cannot gasp.

This means there may be nothing wrong with a baby's breathing under normal conditions, but if the baby goes into hypoxia from a blocked airway or because the baby sleeps on its tummy and does not receive sufficient oxygen, the child needs the sodium-driven pacemakers in order to gasp, which wakes the baby and initiates movement or crying.

"Gasping is an important arousal or auto-resuscitation mechanism," Ramirez said. It resets a baby's normal breathing rhythm and also alerts the baby as well as the mother that something is wrong.

"During normal breathing, it's a complicated network. However, the network becomes more vulnerable to situations like hypoxia, because under these conditions, respiration relies on only one group of pacemakers that become the critical drivers of [breathing] rhythm," Ramirez said.

Disturbed serotonin levels are also implicated in many psychiatric conditions, such as depression, bipolar disorder and attention deficit disorder. According to Ramirez, adults suffering with these types of conditions may be survivors of sudden infant death syndrome.

Ramirez and his colleagues now are looking more closely at the effects of different levels of serotonin, as well as the hormone norepinephrine, and exactly how much of each is necessary to keep auto-resuscitation in tact.

Gene Variation Increases SIDS Risk in African Americans

About five percent of deaths from SIDS (sudden infant death syndrome) in African Americans can be traced to defects in one gene, and half of those deaths result from a common genetic variation that increases an infant's risk of developing an abnormal heart rhythm during times of environmental stress, a research team based at the University of Chicago reports in the February 2006, issue of the Journal of Clinical Investigation.

Children with two copies of the common genetic variation have a 24-fold increased risk of sudden death as infants. One out of nine African Americans carries one copy of the common variant. One copy does not appear to increase risk for infants.

"The common polymorphism alone does not cause SIDS," said Steven Goldstein, MD, PhD, professor and chairman of pediatrics at the University of Chicago and director of the study. "Our findings suggest, however, that it renders infants vulnerable to environmental challenges--such as a long pause in respiration--that are tolerated by children without the mutation."

"The hope," he added, "is that findings like this may one day allow us to intervene. We might screen to identify children at high risk and teach parents how to lessen the likelihood of secondary challenges. We have already begun to evaluate drugs that may mitigate the risk."

SIDS--the sudden and unanticipated death of an infant with no detectable lethal disorder--is the leading cause of infant deaths in the United States, representing nearly one-third of deaths between one month and one year of age. African Americans have three times greater risk of SIDS than Caucasians and six times the risk of Hispanics or Asians, suggesting an important role for genetics.

The researchers studied the genes in tissue collected from 133 African American infants with a diagnosis of SIDS after autopsy. They compared results with tissue samples from 1,056 African American adults with no known health problems.

Their search focused on abnormalities in a gene called SCN5A, which has been associated with abnormal heart rhythms. Overall, the team found common and rare changes in this gene in five percent of SIDS deaths in African Americans. One specific variation, known as Y1103, was known to confer an eight-fold risk of cardiac arrhythmia in African American adults with one copy.

In this study, the researchers found that having two copies of Y1103 was more common in infants who died from SIDS than in controls. Three out of the 133 African American SIDS cases (2.3 percent) had two copies of Y1103, compared to only one individual out of 1,056 controls (0.1 percent). Four other SIDS cases had other damaging mutations in one copy of the gene.

How, they asked, might this variation contribute to SIDS?

The SCN5A gene codes for a sodium channel, a pore found in cardiac muscle cells that controls the passage of sodium ions in and out of the cell.

"This seemed like a good candidate for a genetic difference that could contribute to SIDS," said Goldstein, "but we had no clear idea how it increased risk since the Y1103 variant did not affect channel operation under normal conditions."

Cellular activity, particularly that of nerve and muscle cells, is controlled by the flow of ions like sodium and potassium. A change in an ion channel, if it disrupts ion flow, can alter the cell's activity. So Goldstein's team concentrated on how Y1103 might change a cell's behavior.

On first look, it made no difference. Cells with the normal or Y1103 channels "were found to function indistinguishably," the authors wrote. But SIDS is not purely genetic; it appears to require multiple "hits," some from altered genes and some from the environment.

The environment's role was demonstrated by the "Back to Sleep" campaign, begun in 1994, which cut the prevalence of SIDS in half by teaching parents to put babies to sleep lying on their backs. The campaign was based, in part, on the assumption that babies sleeping on their bellies had more spells of interrupted breathing or apnea.

One of the immediate consequences of apnea is a slight increase in acid levels inside oxygen-hungry muscle cells. When the researchers compared cells with the Y1103 mutation against normal cells in a slightly more acidic environment, the cells with the abnormal channels began to misbehave.

In normal cells, these sodium channels are closed at rest. In response to electrical signals they open briefly, allowing ions to flow though, then rapidly close again. When the pH falls, however, the mutant sodium ion channels tended to pop back open, delaying the cells' recovery after a burst of activity. In the heart, changes like this are known to increase the risk for abnormal rhythms and sudden death.

Fortunately, a drug called mexiletine, used to treat patients with arrhythmias, blocks late re-openings of sodium channels at low levels that do not interfere with normal function. Goldstein and colleagues found that the drug restored normal function in cells with two copies of the Y1103 channels even under acid conditions.

Although, the authors note, this study supports a role of Y1103 in SIDS, and the previous use of mexiletine by patients with arrhythmias "suggests a strategy for prophylactic therapy," they stress that their results "need to be replicated and the risks and benefits of treatment assessed" before screening programs are designed or drugs given to infants at risk to prevent SIDS.

Repetition of the findings would "lead us to consider genetic screening in African Americans in at least three situations," they add: "Infants with acute life-threatening events, siblings of SIDS victims, and couples that experience infertility or fetal demise."