Pediatrics

Girls Fare Worse with Concussions Than Do Boys

Female athletes who sustained concussions performed worse than male athletes, and reported more symptoms, according to new research from Michigan State University.

Certified athletic trainer Tracey Covassin, PhD, lead a 2-year study to determine the age and sex differences in concussion outcomes in athletes between the ages of 14 and 25 years of age. A total of 296 participants (203 male; 93 female) who had sustained concussions during the 2008–2009 and 2009–2010 academic years were compared to the results of nearly 2,000 athletes who had been tested at baseline using the online version of the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), a neurocognitive battery that tests memory, visual memory, visual processing speed and reaction time. Patients also completed the Post-Concussion Symptom Scale (PCSS) at baseline.

The ImPACT battery was administered again at 2, 7 and 14 days after sustaining a concussion, and a personal trainer assessed participants’ static and dynamic postural stability using the Balance Error Scoring System (BESS) at 1, 2 and 3 days post-concussion.

Results showed that female athletes performed worse than male athletes on visual memory (65.1% vs. 70.1%) and reported more symptoms (14.4% vs. 10.1%). High school athletes performed worse than college athletes on verbal (78.8% and 82.7%) and visual memory assessments (65.8% vs. 69.4%), and high school athletes continued to have verbal memory impairment 7 days after sustaining concussions, compared with college athletes, according to researchers. High school male athletes scored worse than college male athletes on the BESS (18.8% vs. 13%). However, college females scored worse than high school female athletes on the BESS (21.1% vs. 16.9%).

Most concussions occurred playing football (n=121), according to researchers, followed by women’s soccer (n=30).

A concussion was defined in the study as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces,” and met the following criteria:

• Presence of on-field signs such as posttraumatic amnesia, or loss of consciousness, and symptoms including dizziness, and headache as determined by a sports medicine professional.
• Decrease from baseline levels in at least one post-concussion neurocognitive score determined by reliable change estimates.
• Increase from baseline levels in post-concussion symptoms determined by reliable change estimates.

“The results of the current study suggest that age and sex should be considered when interpreting the results of symptom reports, [neurocognitive testing], and postural instability assessments following concussion,” the researchers wrote.

Covassin T. Am J Sports Med. 2012;doi:10.1177/0363546512444554. Disclosure: The National Operating Committee on Standards for Athletic Equipment funded this study.

Childhood Obesity Possibly Linked to Caesarean Delivery

Children delivered by caesarean section are twice as likely to become obese, compared to those delivered vaginally, according to recent study results.

“Almost one in three children in the US are delivered by caesarean section,” study researcher Susanna Huh, MD, told Pediatric Annals “If caesarean delivery is a risk factor for obesity, then this would be another reason to avoid caesarean sections that aren’t medically necessary.”

Huh, director of the Growth and Nutrition Program at Children’s Hospital in Boston, along with Harvard Medical School colleagues conducted a prospective pre-birth cohort study, titled “Project Viva,” that enrolled women in eastern Massachusetts during early pregnancy between 1999 and 2002. Modes of delivery were identified through electronic hospital records. The researchers included 1,255 children in the study, measuring body composition at 3 years of age.

Researchers assessed data from multivariable linear regression models to determine the relationship between caesarean deliveries and BMI scores. They also used multinomial logistic regression to assess the associations between caesarean section births, overweight and obesity. Children with a BMI less than the 85th percentile were used as the comparison group. The researchers adjusted for maternal age, race, ethnicity, education and BMI, as well as child age, sex and birth weight.

Results showed that 284 children (22.6%) were delivered by caesarean section. At 3 years of age, 15.7% of participants delivered by caesarean section were obese vs. 7.5% of participants born vaginally. Caesarean sections were associated with higher odds of obesity at 3 years of age (OR=2.10; 95% CI, 1.36–3.23), higher mean BMI z scores (0.2 units; 95% CI, 0.07–0.33) and higher sum of triceps and subscapular skinfold thickness (0.94 mm; 95% CI, 0.36–1.51).

The researchers said they were unable to examine the potential reasons underlying the relationship between caesarean section births and childhood obesity. However, they wrote that one possible explanation may be the differences in the composition of intestinal bacteria.

“Differences in child intestinal flora according to mode of delivery have been noted in the first year of life, a period of dramatic changes in number and diversity of gut microbes as well as rapid growth,” they wrote. “Most, but not all studies, suggest that infants delivered by caesarean section have higher stool quantities of members of the Firmicutes group, or lower quantities of the Bacteroidetes group.” Huh said she and her research team speculated that these differences in bacteria quantities may influence a child’s body composition.

Another possibility, the researchers wrote, could involve the routine use of perioperative antibiotic prophylaxis during caesarean deliveries, which could change the composition of neonatal intestinal flora and, therefore, lead to the development of obesity. The researchers added that further research is needed to confirm these findings and explore the link between caesarean section births and childhood obesity.

Huh SY. Arch Dis Child. 2012;doi:10.1136/archdischild-2011-301141. Disclosure: The researchers report no relevant financial disclosures.

Newborn Screening Not Fool-Proof

Despite uniform newborn screening standards that can lead to early intervention and reduced health care costs, improvement is still needed, according to a recent report in the Morbidity and Mortality Weekly Report.

“Laboratory gaps and opportunities center on detection of multiple conditions using a single test, expansion of automation to reduce testing costs and extension of new molecular methods to all disorders,” the Centers for Disease Control and Prevention (CDC) researchers wrote.

The report warned practitioners not to assume that every newborn who is screened will receive optimal service and care. “Short-term follow-up and management of children with disorders and long-term follow-up activities within the entire newborn screening system are central to realizing the promise of newborn screening.”

For more on newborn screening, refer to this month’s Healthy Baby column.

CDC. MMWR. 2012;61(21):390–393. Disclosure: The researchers report no relevant financial disclosures.

Omega-3 Fatty Acids May Be Helpful for Children with Tourette’s

Omega-3 fatty acids may reduce of tic-related impairment for some children with Tourette’s syndrome, but they do not reduce tics themselves, according to recent study results.

Researchers from the New York University School of Medicine conducted a double blind, placebo-controlled clinical trial of omega-3 fatty acids in pediatric Tourette’s syndrome.

Thirty-three children and adolescents in the New York metropolitan area aged 6 to 18 years with Tourette’s syndrome were randomly assigned, double blind, to omega-3 fatty acids or placebo for 20 weeks. Omega-3 fatty acids consisted of combined eicosapentaenoic and docosahexaenoic acids, with olive oil as the placebo. All participants were evaluated by a board-certified child and adolescent psychiatrist, and investigators, participants and parents were masked to treatment assignment.

Results showed that although participants treated with omega-3 fatty acids did not have significantly higher response rates or lower mean scores on the Yale Global Tic Severity Scale (YGTSS) vs. the placebo group (53% vs. 38%; 15.6 ± 1.6 vs. 17.1 ± 1.6), there were significantly more participants on omega-3 fatty acids considered responders on the YGTSS-Global (53% vs. 31%) and YGTSS-Impairment (59% vs. 25%) scales. Mean YGTSS-Impairment scores were significantly lower in the omega-3 fatty acids group compared with the placebo group (P=.04). Omega-3 fatty acids did not significantly affect obsessive-compulsive, depressive and anxiety symptoms in participants, according to the researchers.

The mean improvement on the TGTSS-Tic scores for the omega-3 fatty acids arm of the study was 26%, consistent with other Tourette’s syndrome randomized controlled trials with risperidone (Risperdal, Janssen Pharmaceuticals) and guanfacine (Intuniv, Shire), according to the researchers.

“Our study indicates that [omega-3 fatty acid] supplementation is tolerable for children and adolescents with [Tourette’s syndrome] and may be a rational consideration, especially for patients who experience high levels of impairment and/or do not obtain satisfactory results from currently established medications.”

Gabbay V. Pediatrics. 2012;doi:10.1542/peds.2011-3384. Disclosure: The researchers report no relevant financial disclosures.

Pregnant Teens at Higher Risk for Physical Abuse

Teenage girls who become pregnant are especially at risk for physical abuse, postpartum depression, and stress, according to Dawn Kingston, RN, BSc, MSc, PhD, of the University of Manitoba in Winnipeg, Canada.

“One of the most striking findings in this study was the high prevalence of physical abuse reported by adolescents. Our data indicate that physical abuse is a common experience among pregnant adolescents,” Kingston and colleagues wrote. “They are likely to experience multiple forms of abuse, and that while most women who reported abuse indicated their partners were the source of abuse, adolescents also reported high rates of abuse by family members.”

The researchers used the Canadian Maternity Experiences Survey to study differences in maternity experiences, knowledge and behaviors among 6,421 pregnant young women. Cohorts were grouped by age: 15 to 19 years; 20 to 24 years; and 25 years and older.

The women in the younger group were more likely to experience postpartum depression and significant stress. Although adolescents reported that they felt their health was not optimal, both adolescents and young adults said they thought the health of their infant was suboptimal.

Kingston and colleagues also reported that the women who became pregnant early in life were less likely to take folic acid supplements and were late in obtaining prenatal care. The women in the younger group were also more likely to be engaged in poor prenatal health behaviors, such as smoking cigarettes and using drugs. Although adolescents and young adults had fewer cesarean sections than adult women, they were less likely to breast-feed their infants. If they chose to breast-feed, it was for a shorter duration than their older counterparts.

Kingston D. Pediatrics. 2012;129:1228–1237. Disclosure: Dr. Kingston reports no relevant financial disclosures.

Loud Music Associated with Traditional Health-Risk Behaviors

Listening to loud music through earphones and at high-decibel concerts has been linked to certain health-risk behaviors in adolescents, according to new research.

Ineke Vogel, PhD, and colleagues from the Netherlands studied 944 Dutch students, aged 15 to 25 years, who completed questionnaires about their music listening habits, as well as other health risk behaviors in the previous 4 weeks, including daily cigarette smoking, binge drinking, cannabis use, hard drug use (cocaine, Ecstasy, amphetamines and heroin), and unprotected sex. Risky music listening was defined in the study as listening for 56 hours per week to a music level of 80 decibels (dB) or higher.

The researchers estimated that 30.4% of the participants exceeded the revised safety threshold for personal audio player use; and 48.1% exceeded the threshold at live pop concerts and discotheques. Those who listened to loud music through headphones reported more cannabis use during the previous 4 weeks. Participants exposed to sound levels exceeding the revised safety threshold at live pop concerts and discotheques used cannabis less often during the previous 4 weeks but were more often binge drinkers and reported inconsistent condom use during sexual intercourse.

Results also showed that 5.5% of participants had used hard drugs in the past 4 weeks, 33.2% participated in binge drinking and 37.5% reported inconsistent use of condoms during sexual intercourse. With the exception for hard drug use, all health-risk behaviors were significantly correlated with each other, according to the researchers.

“As with more traditional risk behaviors such as substance use and unsafe sexual intercourse, of which adverse health consequences have been recognized as important public health issues, risky music-listening behaviors pose a threat to young peoples’ future health,” the researchers wrote.

Vogel I. Pediatrics. 2012;doi:10.1542/peds.2011-1948. Disclosure: The researchers report no relevant financial disclosures.

Check List ☑

For patients and their families planning on visiting the London 2012 Olympic Games — or on traveling anywhere overseas this summer — the CDC has released its guidelines for safe health practices when vacationing abroad.

• ☑ Make sure all routine vaccinations are up to date. MMRV is especially necessary for any Europe-bound travelers, due to the measles outbreak there in 2011.

• ☑ Be sure medical insurance coverage extends beyond the United States. Consider purchasing medical travel insurance to cover unexpected health services.

• ☑ Become familiar with how to access local health services. If traveling in London, for example, emergency medical care service is reached by dialing 999 or 112 (not 911).

• ☑ Know enough of the local vernacular to facilitate getting necessary medical advice or care. For example, urgent medical care facilities in the UK are called Accident and Emergency Departments, or A&Es.

• ☑ Register with the Department of State’s Smart Traveler Enrollment Program (STEP). This free service can assist Americans in the event of an emergency abroad: ( http://step.state.gov/step).

Centers for Disease Control and Prevention. London 2012 Olympic and Paralympic Games. Available at http://wwwnc.cdc.gov/travel/news-announcements/london-2012-olympic-and-paralympic-games.htm. Accessed June 11, 2012.