Clinical Updates of Interest to Providers
CHILD OVERWEIGHT AND OBESITY IN THE U.S. AND NEW MEXICO:
2007 DATA
The percentage of children aged 10-17 years considered to be overweight (Body Mass Index
(BMI) at 85th – 94th percentile) remained relatively stable between 2003 and 2007, but the
national prevalence of childhood obesity (BMI >94th percentile) grew significantly during the
same time period. This is according the National Children’s Health Study, which showed that
nearly one in three children is now overweight or obese. The study also demonstrated
marked disparities between the rates of overweight and obesity associated with
socioeconomic status, type of health insurance coverage, school outcomes and race.
Nationally, the percentage of overweight children held at about 15.5%. The number of obese
children, however, grew from 14.8% in 2003 to 16.4% in 2007. Nationally, the percentage of
children ages 10-17 years who are overweight or obese grew to 31.6% in 2007 from 30.6%
in 2003. In New Mexico, that percentage grew from 28.9% in 2003 (state rank: 21) to 32.7%
in 2007 (state rank: 33). States statistics vary widely; Utah and Minnesota have the lowest
rate of overweight and obesity (23%) whereas Mississippi has the highest (44%). The chart
shows how New Mexico’s children compare to national data and the changes that have
occurred since the 2003 study. You can read the entire study in Health Affairs 2010;29:347-56.
At Pediatrix Cardiology Associates, we have begun measuring the BMI and BMI percentile in
all patients ages 2 – 20 years who come to our Albuquerque office. We will note any BMI
>85th percentile in our correspondence to the referring physician in the hope that this
information will be used to appropriately modify dietary and life-style patterns in children who
are at risk.
United States New Mexico
2003 2007 2003 2007
% Overweight/Obese 10-17 years 30.6 31.6 28.9 32.7
State Rank 21 33
% Overweight/Obese:
<100% of Federal Poverty Level 39.8 44.8 46.1 46.8
>400% of Federal Poverty Level 22.9 22.2 18.6 15.2
Public (Gov’t) Insurance 39.6 43.2 37 43.5
Private Insurance 26.7 27.3 24.2 23.6
MOTOR AND SOCIAL DEVELOPMENT IN 6-MONTH-OLD INFANTS WITH
CONGENITAL HEART DISEASE
Early motor and social developmental impairment are well-known risk factors for later
psychopathology and learning disorders. Recent literature reviews report developmental
impairments in a significant number of children following the surgical repair of congenital heart
disease (CHD). Typically, the degree of impairment has varied directly with the complexity of
the CHD. An article from researchers at the University of Oslo in the March, 2010 issue of The
Journal of Pediatrics assessed whether the development of children with varying forms of CHD
differs from that of children without CHD at 6 months of age. A total of 236 children with CHD
were compared with 61,032 children from the Norwegian Mother and Child Cohort Study
conducted by the Norwegian Institute of Public Health. Diagnostic and treatment information
was retrieved from a nationwide CHD registry. Four groups of CHD were distinguished: mild (n
= 92), moderate (n = 50), severe (n = 70), and CHD with comorbidity (n = 24). At 6 months of
age, the children's mothers reported on motor and social development by using the Mother
and Child Questionnaire. After adjusting for confounders (ie, birth weight), severe CHD
increased the odds of gross motor impairment (odds ratio [OR], 3.78) and fine motor
impairment (OR, 2.04). CHD with co-morbidity (eg, intestinal malformations) increased the
odds of gross motor impairment (OR, 3.00), fine motor impairment (OR, 5.47), and social
impairment (OR, 3.43). The authors concluded that infants with severe CHD or CHD with
comorbidities have significantly increased odds of motor and social impairment which are
evident at 6 months of age.
POPULATION-BASED SUDDEN DEATH IN CHILDREN
Sudden death (SD) in children is a relatively uncommon but devastating problem. There are
few prospective population-based studies, and the annual incidence is poorly defined.
Existing retrospective death certificate–based studies suggest that the annual incidence of SD
in U.S. children ranges between 0.8 and 6.2 per 100,000 population. As part of the ongoing
Oregon Sudden Unexpected Death Study, the Oregon Health Sciences Center performed a
prospective, 3-year, community-wide, multiple-source evaluation of pediatric (0 – 17 years) SD
among the 660,486 residents of Multnomah County, Oregon (Heart Rhythm, Vol.6, Nov, 2009).
SD was defined as sudden unexpected collapse within 1 hour of symptom onset (witnessed),
or within 24 hours of being observed alive and symptom-free (unwitnessed). Subjects with a
non-cardiac terminal illness or SD associated with trauma, violent death, overdose, drowning,
or suicide were excluded. Thirty-three children (2.8% of the entire population) met criteria for
SD. The median age was 0.37 years, with an age range of 0.03–12.3 years. The pediatric SD
annual incidence was 1.7 per 100,000 total population or 7.5 per 100,000 children (ages 0 –
17). This compares to 60/100,000 for overall SCD among all ages. Of the SD victims, 25/33
were <1 year old and 23/25 met the criteria for SIDS. The other 2 were found to have
congenital heart disease (CHD) (interrupted aortic arch and VSD with LV noncompaction). Both
should have been detected by routine physical examination. Of the 8 children > 1 year old, 4
had a seizure disorder and 2 were found to have CHD (Ebstein’s + WPW and hypertrophic
cardiomyopathy). Information regarding the presenting rhythm was available in 22/33 (67%);
20/22 were found to be in asystole. In all likelihood, this does not represent the initial
malignant rhythm since SIDS cases, which represented the majority in this study, occurs at
times which result in a delay in emergency response. The authors concluded that SD in the
pediatric population is low (<3% of all SD), that the majority of cases are related to SIDS.
Children with CHD make up a significant proportion of this population.
TRICYCLIC ANTIDEPRESSANT (TCA) TOXICITY: STILL COMMON AFTER
ALL THESE YEARS
Case Presentation: A 16 year old girl presented to the emergency department with
somnolence, respiratory depression, hypotension, poor perfusion and tachycardia. A portion
of her ECG is shown.
Although she was originally thought to be in ventricular tachycardia, a history of purposeful
TCA (nortryptyline) overdose was obtained from a parent and the patient was appropriately
managed with ventilatory support, intravenous hydration and intravenous alkalinization with
sodium bicarbonate. Within a few hours, her ECG started to normalize and she made a full
recovery.
Discussion: TCAs inhibit the reuptake of serotonin and epinephrine, block cardiac sodium
channels and phase 3 cardiac potassium channels, increase anticholinergic activity and
produce peripheral vascular α-adrenergic blockade. In toxic concentrations, the effects include
sinus tachycardia, significant cardiac conduction abnormalities (increased PR and QRS
durations), prolonged QT interval, ST segment and T-wave changes, hypotension, altered
mentation, seizures and the possibility of malignant and potentially fatal cardiac arrhythmias.
The classic electrocardiogram shows sinus tachycardia with long PR interval, wide QRS
duration, prolonged QT interval (which is what the above ECG shows; this is not ventricular
tachycardia) and a ‘classic’ large R wave in AVR (see above). A QRS duration >100ms predicts
a higher risk for ventricular arrhythmias and seizures and demands immediate attention.
There is no antidote for TCA overdose. Treatment includes rapid alkalinization of the serum to
a pH > 7.45, which counteracts the sodium channel blocking effects and quickly normalizes the
ECG. Fluid resuscitation, assisted ventilation and sedation to prevent seizures are utilized as
needed. Correct ECG interpretation is essential, since inappropriate use of antiarrhythmics
can easily increase sodium channel blockade (worsen conduction) and further prolong the QT
interval, thereby facilitating severe ventricular arrhythmias.
CHILD OVERWEIGHT AND OBESITY IN THE U.S. AND NEW MEXICO:
2007 DATA
The percentage of children aged 10-17 years considered to be overweight (Body Mass Index
(BMI) at 85th – 94th percentile) remained relatively stable between 2003 and 2007, but the
national prevalence of childhood obesity (BMI >94th percentile) grew significantly during the
same time period. This is according the National Children’s Health Study, which showed that
nearly one in three children is now overweight or obese. The study also demonstrated
marked disparities between the rates of overweight and obesity associated with
socioeconomic status, type of health insurance coverage, school outcomes and race.
Nationally, the percentage of overweight children held at about 15.5%. The number of obese
children, however, grew from 14.8% in 2003 to 16.4% in 2007. Nationally, the percentage of
children ages 10-17 years who are overweight or obese grew to 31.6% in 2007 from 30.6%
in 2003. In New Mexico, that percentage grew from 28.9% in 2003 (state rank: 21) to 32.7%
in 2007 (state rank: 33). States statistics vary widely; Utah and Minnesota have the lowest
rate of overweight and obesity (23%) whereas Mississippi has the highest (44%). The chart
shows how New Mexico’s children compare to national data and the changes that have
occurred since the 2003 study. You can read the entire study in Health Affairs 2010;29:347-56.
At Pediatrix Cardiology Associates, we have begun measuring the BMI and BMI percentile in
all patients ages 2 – 20 years who come to our Albuquerque office. We will note any BMI
>85th percentile in our correspondence to the referring physician in the hope that this
information will be used to appropriately modify dietary and life-style patterns in children who
are at risk.
United States New Mexico
2003 2007 2003 2007
% Overweight/Obese 10-17 years 30.6 31.6 28.9 32.7
State Rank 21 33
% Overweight/Obese:
<100% of Federal Poverty Level 39.8 44.8 46.1 46.8
>400% of Federal Poverty Level 22.9 22.2 18.6 15.2
Public (Gov’t) Insurance 39.6 43.2 37 43.5
Private Insurance 26.7 27.3 24.2 23.6
MOTOR AND SOCIAL DEVELOPMENT IN 6-MONTH-OLD INFANTS WITH
CONGENITAL HEART DISEASE
Early motor and social developmental impairment are well-known risk factors for later
psychopathology and learning disorders. Recent literature reviews report developmental
impairments in a significant number of children following the surgical repair of congenital heart
disease (CHD). Typically, the degree of impairment has varied directly with the complexity of
the CHD. An article from researchers at the University of Oslo in the March, 2010 issue of The
Journal of Pediatrics assessed whether the development of children with varying forms of CHD
differs from that of children without CHD at 6 months of age. A total of 236 children with CHD
were compared with 61,032 children from the Norwegian Mother and Child Cohort Study
conducted by the Norwegian Institute of Public Health. Diagnostic and treatment information
was retrieved from a nationwide CHD registry. Four groups of CHD were distinguished: mild (n
= 92), moderate (n = 50), severe (n = 70), and CHD with comorbidity (n = 24). At 6 months of
age, the children's mothers reported on motor and social development by using the Mother
and Child Questionnaire. After adjusting for confounders (ie, birth weight), severe CHD
increased the odds of gross motor impairment (odds ratio [OR], 3.78) and fine motor
impairment (OR, 2.04). CHD with co-morbidity (eg, intestinal malformations) increased the
odds of gross motor impairment (OR, 3.00), fine motor impairment (OR, 5.47), and social
impairment (OR, 3.43). The authors concluded that infants with severe CHD or CHD with
comorbidities have significantly increased odds of motor and social impairment which are
evident at 6 months of age.
POPULATION-BASED SUDDEN DEATH IN CHILDREN
Sudden death (SD) in children is a relatively uncommon but devastating problem. There are
few prospective population-based studies, and the annual incidence is poorly defined.
Existing retrospective death certificate–based studies suggest that the annual incidence of SD
in U.S. children ranges between 0.8 and 6.2 per 100,000 population. As part of the ongoing
Oregon Sudden Unexpected Death Study, the Oregon Health Sciences Center performed a
prospective, 3-year, community-wide, multiple-source evaluation of pediatric (0 – 17 years) SD
among the 660,486 residents of Multnomah County, Oregon (Heart Rhythm, Vol.6, Nov, 2009).
SD was defined as sudden unexpected collapse within 1 hour of symptom onset (witnessed),
or within 24 hours of being observed alive and symptom-free (unwitnessed). Subjects with a
non-cardiac terminal illness or SD associated with trauma, violent death, overdose, drowning,
or suicide were excluded. Thirty-three children (2.8% of the entire population) met criteria for
SD. The median age was 0.37 years, with an age range of 0.03–12.3 years. The pediatric SD
annual incidence was 1.7 per 100,000 total population or 7.5 per 100,000 children (ages 0 –
17). This compares to 60/100,000 for overall SCD among all ages. Of the SD victims, 25/33
were <1 year old and 23/25 met the criteria for SIDS. The other 2 were found to have
congenital heart disease (CHD) (interrupted aortic arch and VSD with LV noncompaction). Both
should have been detected by routine physical examination. Of the 8 children > 1 year old, 4
had a seizure disorder and 2 were found to have CHD (Ebstein’s + WPW and hypertrophic
cardiomyopathy). Information regarding the presenting rhythm was available in 22/33 (67%);
20/22 were found to be in asystole. In all likelihood, this does not represent the initial
malignant rhythm since SIDS cases, which represented the majority in this study, occurs at
times which result in a delay in emergency response. The authors concluded that SD in the
pediatric population is low (<3% of all SD), that the majority of cases are related to SIDS.
Children with CHD make up a significant proportion of this population.
TRICYCLIC ANTIDEPRESSANT (TCA) TOXICITY: STILL COMMON AFTER
ALL THESE YEARS
Case Presentation: A 16 year old girl presented to the emergency department with
somnolence, respiratory depression, hypotension, poor perfusion and tachycardia. A portion
of her ECG is shown.
Although she was originally thought to be in ventricular tachycardia, a history of purposeful
TCA (nortryptyline) overdose was obtained from a parent and the patient was appropriately
managed with ventilatory support, intravenous hydration and intravenous alkalinization with
sodium bicarbonate. Within a few hours, her ECG started to normalize and she made a full
recovery.
Discussion: TCAs inhibit the reuptake of serotonin and epinephrine, block cardiac sodium
channels and phase 3 cardiac potassium channels, increase anticholinergic activity and
produce peripheral vascular α-adrenergic blockade. In toxic concentrations, the effects include
sinus tachycardia, significant cardiac conduction abnormalities (increased PR and QRS
durations), prolonged QT interval, ST segment and T-wave changes, hypotension, altered
mentation, seizures and the possibility of malignant and potentially fatal cardiac arrhythmias.
The classic electrocardiogram shows sinus tachycardia with long PR interval, wide QRS
duration, prolonged QT interval (which is what the above ECG shows; this is not ventricular
tachycardia) and a ‘classic’ large R wave in AVR (see above). A QRS duration >100ms predicts
a higher risk for ventricular arrhythmias and seizures and demands immediate attention.
There is no antidote for TCA overdose. Treatment includes rapid alkalinization of the serum to
a pH > 7.45, which counteracts the sodium channel blocking effects and quickly normalizes the
ECG. Fluid resuscitation, assisted ventilation and sedation to prevent seizures are utilized as
needed. Correct ECG interpretation is essential, since inappropriate use of antiarrhythmics
can easily increase sodium channel blockade (worsen conduction) and further prolong the QT
interval, thereby facilitating severe ventricular arrhythmias.
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| PEDIATRIX CARDIOLOGY ASSOCIATES OF NEW MEXICO |
