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Health of Infants and Children
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Health and Development of Children Older Than Age 2

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Keeping your kids safe during the summer

The National SAFE KIDS Campaign provides parents and children with safety tips and checklists to prevent accidental childhood injury — the number one killer of kids ages 14 and under. The non-profit organization stresses the importance of safety in the summer, when most injuries occur.

Because children have less supervision, more free time, and engage in more outdoor activities during the warmer months, they are more likely to get hurt. In fact, emergency room doctors call summer "trauma season." Injuries from car accidents, drownings, bike crashes, falls, and other hazards peak from May to August, with 42% of all unintended injury-related deaths occurring then. But there are ways to help prevent these tragedies.

In the pool:

  • Never leave kids alone when they're in or near the water
  • Place barriers around the pool to prevent access, use gate alarms, and be prepared in case of emergency.
  • Remember floatation devices for weak swimmers and for all kids when they go out on boats

In the yard:

  • Make sure your home playground is safe. Falls cause 60% of playground injuries so a safe surface is critical. Use wood chips or mulch instead of concrete, asphalt, or packed dirt.
  • In spite of extensive warnings from the American Academy of Pediatrics, half a million families buy trampolines each year. The injury rate is exceptionally high, second only to that of bicycles. Injuries include broken bones that often require surgery to repair; concussions and other head injuries; neck and spinal injuries; sprains, strains, and bruises; and cuts and scrapes.

On the go:

  • Everyone should wear helmets on bikes, scooters, inline skates, or skateboards. Studies on bicycle helmets have shown that they can reduce the risk of head injury by as much as 85%.
  • Teach your children the rules of the road so they'll be safe when riding or walking
  • If your kids will be walking at dawn or dusk, make sure they carry a flashlight and wear reflective clothing

For more safety tips and checklists, visit the SAFE KIDS Web site at www.safekids.org.

July 2002 Update

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Asthma Education Leads to Improvement in Children

Managing your child's asthma should include meeting with an asthma educator a few times, according to a follow-up study. Presented at the meeting of the American Academy of Allergy, Asthma, and Immunology, the study reports that after attending an interactive training program three times patients felt less worried about their asthma and had fewer asthma-induced awakenings during the night. Both patients and their caregivers, who also took part in the program, made better decisions about asthma care.

The 30 subjects, asthmatic children ages 6–12, underwent ACE IT! (Asthma Care Education: Intensive Training), an interactive, small-group education program. The sessions included a motivational talk by a teenage athlete with asthma and a pharmacist's discussion of medications. A nurse and asthma specialist also taught the participants about the clinical nature of asthma, environmental controls, relaxation techniques, and asthma action plans.

Researchers evaluated the children at the beginning and end of the training, after six months, and again a year later. After the courses, the number of patients reporting two or more nocturnal awakenings per month dropped from 9 to 5, and the number of symptom-free days also improved, from an average of 20 days per month to over 25 days per month.
The patients were more willing to use the tools available to them, such as medications and peak flow meters, devises that asthmatics breath into to help detect airway changes. They also worked harder to avoid things that triggered their asthma, such as pets or dust.

The researchers plan to continue tracking these 30 children to study the long-term effects on quality of life, morbidity, and cost of treatment. A previous study published in the Journal of Allergy and Clinical Immunology in 2000, found that the training program was much more effective than simply handing out educational materials.

May 2002 Update

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Hepatitis A Vaccine is Safe and Effective for Children

Hepatits A is a virus transmitted by contaminated food and is a common cause of inflammation of the liver (hepatitis). This illness may be associated with fever, yellowing of the skin and eyes (jaundice), loss of appetite, nausea, vomiting, and tiredness. In many parts of the world, hepatitis A is so common that almost every adult has been infected at some point in his or her life. A vaccine to protect against hepatitis A infection was licensed in the United States by the Food and Drug Administration in 1995 for individuals 2–12 years of age.

A recent study published in the Journal of the American Medical Association showed that the hepatitis A vaccine was highly effective in preventing hepatitis A outbreaks among a large group of children who received it. The study also found the vaccine to be quite safe. Out of the nearly 30,000 children who received the vaccine, no serious side effects were reported. Mild adverse reactions were reported in a small percentage of cases, including injection site reactions, fever, and rash.

Should your child be immunized? In the United States, there actually are certain areas of the country with higher than average rates of hepatitis A. Speak with your child's pediatrician because the hepatitis A vaccine is currently recommended for:

  • Children living in areas with consistently higher rates of hepatitis A. This includes 11 states where the prevalence of hepatitis A is greater than twice the national average: Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington. (Routine vaccination can also be considered in six states where the prevalence of the disease is less than double but greater than the national average: Arkansas, Colorado, Texas, Missouri, Montana, and Wyoming.)
  • Children traveling to countries where the disease is highly prevalent. This includes all countries other than Canada, Japan, Australia, New Zealand, Scandinavia, and those in Western Europe.
  • Children with chronic liver disease or blood-clotting disorders.

April 2002 Update

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Immunizations for 2002

Vaccinations against childhood illnesses are arguably one of the most significant medical achievements of the twentieth century. One hundred years ago, approximately half of all children born in the United States died before the age of 5, many of them from diseases that today can be prevented by vaccines. With proper immunization, the number of cases of these diseases has been reduced dramatically.

Although no new vaccines have been added to the 2002 recommended childhood immunization schedule, this year's schedule highlights vaccines for pre-adolescents and "catch-up" vaccines for children who have fallen behind the currently recommended schedule.

In addition, due to unusual national shortages of the pneumococcal and diphtheria/tetanus/pertussis vaccines, the 2002 immunization schedule also includes a link to information from the Centers for Disease Control (CDC), which explains the necessary modifications to the recommended schedule for these vaccines. These vaccine shortages will hopefully only be temporary.

Please discuss your child's immunization history with the doctor to insure that his or her immunizations are up to date in accordance with the current 2002 Recommended Childhood Immunization Schedule, approved annually by the CDC, the American Academy of Pediatrics, and the American Academy of Family Physicians. For additional reliable and up-to-date information about vaccines and their importance, visit the National Immunization Program website at http://www.cdc.gov/nip or the American Academy of Pediatrics website at http://www.aap.org/.
April 2002 Update

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Obesity in Children is on the Rise

A recent study published in the Journal of the American Medical Association showed that American children are heavier now than ever before. In 1998, 12%, 21%, and 22% of Caucasion, African American, and Hispanic children, respectively, were classified as overweight. In fact, between 1986 and 1998, the prevalence of overweight children rose steadily among these groups.

The reason behind childhood obesity — that kids are taking in more calories than they're expending — is easy to understand. But diagnosing obesity is more complicated. It cannot be diagnosed simply by looking at someone because ideal body images differ among individuals, and different body shapes carry weight differently.

And changing lifestyles that create obesity may be even harder. Children are spending more time than ever watching television, playing video games, and surfing the Internet instead of being active. Their parents are busier than ever, too, making it harder to cook nutritious meals.

This is all problematic, as obesity is a risk factor for many health problems, both in childhood and later in life. Children who are overweight are more likely to develop high blood pressure, high cholesterol, and heart disease as adults than kids of normal weight. Long-term obesity also increases the risk of arthritis, heart disease, diabetes, and certain kinds of cancer.

So what can you do? First, talk with your child's doctor. Objective standards have been developed for defining and measuring obesity. He or she will use the body mass index (BMI), calculated from your child's weight and height, and compare it with national growth charts.

There are also tangible things parents can do to help prevent (and treat) obesity in their children as well as in themselves. Begin by establishing healthier eating habits and promoting a more active lifestyle. For example, you can plan daily family activities that involve exercise; limit television, computer, and video game use; eat meals together as a family whenever possible; and when eating out, choose lower fat items on the menu.
March 2002 Update

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Injuries From Infant Walkers

The American Academy of Pediatrics is recommending a ban on mobile baby walkers after recent studies have shown serious injury associated with their use.

Baby walkers are made for infants who are sitting up, but not yet walking on their own. Most of them are designed with a rigid base set on wheels. The infant sits in a cloth seat that supports his weight, yet allows his feet to be in contact with the floor. This design lets the child move around quickly and independently, without adult help.

Unfortunately, problems have developed. Infant walkers were responsible for 34 deaths from 1973 to 1998. Moreover, 8,800 children under 15 months of age were treated in emergency rooms in the United States in 1999 for injuries associated with walkers. About one quarter of these injuries resulted in fractures and head injuries. Injury rates related to infant walkers are higher than those associated with any other type of baby equipment.

Many dangers can arise while your baby is strapped into an infant walker. Walkers can tip over, tumble down the stairs, gain speed quickly, knock over baby gates, and make hazardous or poisonous items easier to reach. Studies have shown that injuries occur even with close adult supervision.

Some parents think the walkers will help their child learn to walk sooner, but this has not been proven true. In fact, some studies suggest babies who use walkers actually learn to crawl and walk later than those without walker experience.

If you do choose to use an infant walker, despite this recent recommendation of the American Academy of Pediatrics, never leave your child unattended, even for a moment. Be sure to block off stairs in your home with gates. Remember, though, infants in walkers can travel at high enough speeds to knock gates over, so gates do not guarantee your baby's safety.

To be safe, avoid mobile infant walkers altogether. Stationary activity centers (such as exercise saucers or bouncer seats) which do not roll on wheels provide a safer environment in which your baby can develop and thrive.
November 2001 Update

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The Benefits of Surgery for Ear Infection are Unclear

Every year thousands of young children undergo surgery to alleviate chronic middle ear infections (otitis media). The demand for these procedures is driven by the concern that persistent bouts of ear infection will cause hearing loss and long-term effects on their child's speech and language development. However, the benefits of surgery are unclear — even after two recent new studies.

The most common operation involves inserting tubes through the eardrums to drain fluid that collects in the middle ear. Whether or not prompt implementation of this surgery actually protects against the development of infection was the subject of the first study in which 6,350 children were checked regularly for ear infections. By the age of 3, 429 of them were diagnosed with chronic ear infections. About half received the surgery as soon as possible, while the others waited up to nine months. The researchers found the children who had the surgery promptly had fewer subsequent ear problems than those who waited. But there was no significant difference in their speech, language, cognition or psychosocial development as measured by standardized tests and parental assessments. In fact the mean scores for all of the children fell with the average range for that age.

The second study examined hospital discharge records for children in Ontario to determine whether removing adenoids and/or tonsils at the same time as the insertion of tubes helped reduce the likelihood of subsequent ear problems. Of the 37,316 cases who received tubes, 28% also involved the removal of adenoids and/or tonsils. About one quarter of those who didn't undergo adjuvant surgery were re- hospitalized within two years after their initial surgery for subsequent ear problems. But those who did nearly halved their risk of re-hospitalization. Having both adenoids and tonsils out provided additional benefit.

So should children with chronic ear infections have tubes inserted, and should they also have their adenoids and tonsils taken out? Because of limitations in these and previous studies, we still don't know. More research is needed to weigh the long-term risks of hypothetical development impairment verses the not fully understood risk of the different surgeries.
August 2001 Update

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Study Shows Fish Consumption Protects Against Stroke, But FDA Suggests Pregnant Women Should Take Caution

A large study in the Journal of the American Medical Association (JAMA) recently showed that regularly eating fish might protect against ischemic stroke, which is the most common type of stroke. Numerous studies have already shown an association between fish consumption and a reduced risk of heart disease. But there is a caveat. The Food and Drug Administration (FDA) recently warned that pregnant women and women who are of childbearing age who may become pregnant, should avoid certain types of fish that contain high levels of mercury, which may be harmful to their unborn children.

Results of the Nurses' Health Study, published in the JAMA article, involved nearly 80,000 women. It showed that women who ate fish two to four times a week had a 48% lower risk of ischemic stroke — the kind caused by blood clots — than women who ate fish less than once per month. Even women who ate fish only once a week or less had a risk reduction, but it was not statistically significant. These results held true primarily among women who did not regularly take aspirin, which prevents the formation of blood clots. Omega-3 fatty acids, the protective substances found in fish, reduce levels of fats related to cardiovascular disease and help prevent blood clotting. Dark, oily fish such as mackerel, salmon, and sardines are a good source of omega-3 fatty acids.

Although pregnant women need not give up fish — and its beneficial health effects — altogether, they should be careful about what types of fish they eat. The FDA has advised that pregnant women and those who may become pregnant stop eating shark, swordfish, king mackerel, and tilefish. These large, long-living fish contain hazardous levels of methyl mercury, a form of mercury that can accumulate in a woman's body and affect the developing central nervous system of an unborn child. This can lead to babies with slower cognitive development. As an extra precaution, the FDA advised that nursing mothers and young children also avoid these fish. Mercury gets into both fresh and salt water through industrial pollution.

Some critics feel the FDA's mercury warnings are not strong enough. A report by the National Academy of Sciences suggested the exposure limits for mercury should be four times stricter.

While this controversy remains unresolved, the FDA encouraged pregnant women to continue to eat a variety of other fish, containing very low levels of mercury, as part of a balanced diet. Among other health benefits, the fatty acids in fish enhance brain development. According to the FDA, women can safely eat up to 12 ounces of fish per week. Fish that contain low levels of mercury include shellfish, canned fish, smaller ocean fish, and farm-raised fish. Women who eat fish caught by family or friends should contact their local health department for advice on the safety of fish from local waters.
May 2001 Update

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Children and Peanut Allergies

Children usually outgrow allergies to milk and eggs, but not to peanuts. In a recent study, researchers found that the majority of children with peanut allergies will have adverse reactions to accidental peanut exposure within five years. In addition, allergic reactions are likely to worsen over the years.

Researchers followed 83 children who were diagnosed with a peanut allergy before their 4th birthday. Of these children, 61 had initial non-life-threatening reactions, while 22 had potentially life-threatening reactions. After 5.9 years, they found that 50 of the 83 children had experienced a total of 115 adverse reactions to peanuts.

Most of the reactions increased in severity after the initial reaction. Of the children with initial non-life-threatening reactions who had additional reactions, 44% had at least one potentially life-threatening subsequent reaction. And of the 22 children who had initial life-threatening reactions followed by additional reactions, 71% had at least one additional life-threatening reaction.

In 12 of the original 83 children, the initial reaction occurred after touching, (not eating) peanuts, and they experienced only skin symptoms. Eight of these 12 had subsequent reactions, and all eight had at least one occurrence of respiratory or gastrointestinal symptoms. Children with only skin symptoms had significantly lower serum peanut-specific antibodies than those with other initial symptoms, but there was no "safe" antibody level below which subsequent reactions were only skin-specific.

Most children with peanut allergies accidentally ingest peanuts and this study showed that allergic reactions are likely to get progressively worse with each exposure. Children must be educated to avoid peanuts and foods containing peanuts. In addition, children should always have access to a self-injectable epinephrine kit that both parents and children should know how to use if the need arises.
February 2001 Update

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Early versus Later Orthodontic Treatment in Children

Which approach works best for children who need orthodontic care: early two-phase treatment (which begins when a child still has all or most of his or her "baby" teeth) or later single-phase treatment (which is implemented when most, or all, of the permanent teeth are in)? Proponents of early two-phase orthodontic treatment argue that it is better able to modify the patient's skeletal growth and improve the patient's self-esteem. They also believe this approach achieves a better and more stable result and reduces the need for extensive therapy later. A University of North Carolina study, however, reports early two-phase orthodontic treatment is not necessarily superior to later single-phase treatment, nor does it always achieve all the goals some orthodontists claim it does.

Most people do not have perfect teeth, however, malocclusion is a condition where the jaws are misaligned. In very severe forms of malocclusion, the misalignment may interfere with the ability to speak or eat. The children in the North Carolina trial did not have such extreme misalignment. These children were determined to have moderate-to-severe Class II malocclusion. Children with a Class II malocclusion have some jaw misalignment. In addition, teeth may be crowded, abnormally spaced, or misaligned. This type of malocclusion can also involve upper teeth that protrude excessively or front teeth that do not meet. Malocclusion usually becomes apparent between ages 6 and 14, when the teeth and jaw are growing and often runs in families.

In this study, researchers randomly assigned children who still had most of their baby teeth to one of three groups: headgear treatment (fixed-appliance therapy), bionator therapy (removable-appliance therapy), or to an observational group that received no treatment. Seventy-five percent of the children in both the headgear and bionator therapy groups showed improvement in jaw alignment (although there was significant variation across all three groups).

The second phase of the study was to see whether the improvements achieved in the first phase of the study truly represented long-term results. Once the children's permanent teeth came in, study investigators randomly assigned members of all three groups to receive fixed-appliance therapy. Researchers discovered that the skeletal changes resulting from early treatment did not last. In addition, skeletal relationships, as well as the relationship between the upper and lower jaws, did not differ significantly between the groups that received the early two-phase treatment and the group that received later single-phase treatment. Neither the length of treatment nor the severity of the malocclusion was an important influence on the end result. Individual skeletal growth patterns, however, did play an important role.

One of the conclusions from this study is that the success of Class II correction does not depend on when treatment begins as long as it begins while the child is still growing. If the criterion for success of Class II correction is a better, more stable result, the later single-phase treatment would be preferable because treatment time is shorter. However, if the criteria for success include better self-esteem, then it may be preferable to start treatment earlier. It is important to keep in mind that early treatment is not the only way to correct malocclusion. A Class II correction can be achieved early or later with equally beneficial results. Other studies have been conducted that support these findings among children with more severe occlusions and other orthodontic problems.

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Age-Appropriate Safety Seats for Young Children Can Significantly Reduce Risk for Serious Injury

Studies have shown that when it comes to child car safety, any restraint is better than none. But new research illustrates, for the first time, that choosing the appropriate restraining device — child safety seats for children under age 4 and booster seats for children ages 4 and older rather than seat belts — can significantly further reduce your child's risk of injury.

Researchers from The Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine studied insurance reports of car crashes involving children ages 2 through 5, then followed up with telephone interviews of the driver of the accident vehicle and the parents of the children involved in the crash. The investigators found that, compared to children in child safety seats or booster seats, children wearing seat belts at the time of the crash were 3.5 times more likely to suffer a significant injury. Significant injuries were defined to include internal organ injuries and most fractures, among other things. In addition, children wearing seat belts were 4.2 times more likely to have a significant head injury, such as a concussion or more severe brain injury, than children wearing age-appropriate restraints.

You can use the following criteria to improve your child's safety. Children who are at least one year old and weigh more than 20 pounds should be placed in a forward-facing child safety seat in the rear of the vehicle. Children who are at least 4 years old and weigh 40 pounds or more should ride in a belt-positioning booster seat that uses the vehicle's lap and shoulder belts. Your child is ready to use the vehicle's lap and shoulder belts when the lap belt rests low and snug across the hips and the shoulder belt doesn't cross the face or the neck.

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Adderall vs. Methylphenidate (Ritalin) for Attention Deficit Hyperactivity Disorder

The most commonly prescribed medication for children with attention deficit hyperactivity disorder (ADHD) is methylphenidate (for example, Ritalin). However, its effects may be short-lived and some children do not respond to it at all. Researchers at the State University of New York at Buffalo recently compared the effectiveness (and effects of) methylphenidate (MPH) with another drug, Adderall, in 21 children with ADHD between the ages of 6 and 12 years old. The results from this small study showed that a single morning dose of Adderall resulted in the same changes in behavior throughout the school day as MPH taken twice a day. A single dose of MPH in the morning appeared less effective than taking MPH twice a day or taking one dose of Adderall, and its effects wore off by early to mid-afternoon.

Adderall may offer a good alternative for children when a two-dose per day regimen is a problem. This study was conducted in the context of an intensive summer treatment program that included behavioral elements as well. More research is needed to compare these medications and dosing options in a regular school setting.

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Tobacco Smoke Can Trigger Childhood Asthma

A new study further highlights the need to eliminate children's exposure to tobacco smoke. After evaluating a random sampling of about 40,000 children between the ages 6 and 7 and 13 and 14, researchers in Italy determined exposure to the secondhand smoke of at least one parent increased a child's relative risk of asthma.

The children's parents were surveyed about their smoking habits and the respiratory health of their children. Children in both age groups who were exposed to secondhand smoke from both parents were more likely to have asthma. Having a mother who smokes was a slightly stronger predictor than having a father who smokes.

These results bolster previous research that has linked exposure to secondhand smoke in the home to childhood asthma. Restricting smoking to outside the home doesn't seem to help either. A 1997 study in California found that even if their parents smoked outside, children hospitalized for acute asthma took longer to recover when discharged than children whose parents did not smoke. Tobacco smoke clings to hair and clothes fibers, so even if the activity itself takes place away from child, the child can still be exposed to secondhand smoke.

For more information about asthma, see page 505 of the Family Health Guide. For tips on how to quit smoking, see page 57.

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Carbonated Beverages and the Risk of Bone Fractures in Teenaged Girls

Osteoporosis, or the loss of bone density, is usually thought of as a geriatric condition. But the disease may have its roots in adolescence as bone mass reaches its peak level. Factors that affect the accumulation of bone mass during this time can increase the risk of bone fractures and osteoporosis. In this context, teenaged girls may be jeopardizing their current and future health by drinking too many carbonated beverages.

Past results indicate that consumption of carbonated beverages is associated with bone fractures among teenaged girls. A recent cross-sectional study involving 460 9th- and 10th-grade girls confirmed these findings. The teenagers completed a questionnaire describing their physical activities and personal and behavioral habits. Researchers analyzed the results to determine an association between consumption of carbonated beverages and bone fractures.

Of the girls surveyed, 80% drank carbonated beverages, and nearly two-thirds of the girls drank cola. One-fifth of the girls reported having had bone fractures. Analysis showed that the risk of bone fracture in girls who drink carbonated beverages is three times that of girls who do not. The risk is highest, seven times greater, among
physically active girls who drink both cola and noncola.

The results suggest a strong association between consumption of carbonated beverages and bone fractures in teenaged girls, but the researchers caution that a cause and effect relationship cannot be assumed. Despite that, they have a few theories that may explain the association. Laboratory research has shown that the high phosphorous concentration in cola can cause bone loss that may lead to a greater risk of bone fractures. Another plausible theory is that the consumption of carbonated beverages takes the place of consumption of milk, an important source of calcium. Low calcium intake can increase the risk of osteoporosis. Between 1970 and 1997, the consumption of carbonated beverages increased by 118% per capita in the United States, while milk consumption declined 23%.

The study, however, did not include questions concerning the amounts of milk and carbonated beverages consumed. Long-term studies that include these factors may help to assess the effect of milk and carbonated beverage consumption. Also, the use of bone density measurements may demonstrate a cause and effect relationship between carbonated beverage consumption and bone fractures. Research is necessary to determine how carbonated beverages may lead to bone fractures among physically active girls. Despite the need for further studies, the current body of evidence suggests that education on the health impact of carbonated beverage consumption may be a possible way to promote optimal bone development in teenaged girls and prevent osteoporosis.

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Is Your Child at High Risk for Knee Osteoarthritis?

Are the teen years too early to start taking steps to prevent osteoarthritis of the knee? Apparently not, according to the Johns Hopkins Precursors Study. This study followed a group of 1,337 (mostly white male) medical students for an average of 36 years. All participants were asked at the outset if they had suffered a knee injury. Most who had did so while playing a sport (a few had sustained their knee injuries in a car crash, though one suspects that number would be higher if the study were conducted today). Over the course of the study, it became clear that the participants who had sustained a knee injury in their adolescence or young adulthood (the average age at the time of injury was 16) were three times as likely to suffer from knee osteoarthritis by middle age as those who hadn’t.

Nowadays, with more and more adolescents of both sexes playing sports at younger and younger ages, it makes sense to be aware of the potential health risks that are involved later in life. Parents may think that their child’s knee injury, once healed, is no longer a problem, but this research suggests that adolescents and young adults who have experienced a traumatic injury to the knee make up a high-risk group and should be considering ways to try to prevent osteoarthritis. Prevention can involve using the proper sports equipment correctly and under safe conditions, temporarily modifying high-impact exercise, and, in the future, perhaps early intervention drug therapy. The adolescent and young adult years are not too early to consider one’s future health.

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Guidelines for Diagnosis and Evaluation of Children with ADHD

Attention deficit hyperactivity disorder (ADHD) affects 7–10% of children, making it the most common neurobehavioral disorder among children. Over the past decade, the number of prescriptions for stimulant medication to treat ADHD in children has ballooned, creating fears of over-diagnosis. Surveys show a lack of uniform criteria for diagnosis of ADHD and variations in the amount of stimulants prescribed by physicians. In an effort to develop a standard national framework for diagnosis and evaluation of ADHD in children of 6 to 12 years of age, the American Academy of Pediatrics formed a committee to review the existing literature and develop consistent guidelines.

The committee recommends that primary care clinicians evaluate for ADHD children who are inattentive, hyperactive, impulsive, academic underachievers, and those who have behavioral problems. Because these symptoms are rarely obvious in a clinical setting, parents or other caregivers who notice these problems should inform the child’s physician. When parents don’t bring up these concerns, physicians should inquire about the symptoms of ADHD.

According to the guidelines, a diagnosis of ADHD requires that a child meet the specific criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. These involve displaying numerous symptoms of inattention, hyperactivity, and impulsivity in at least two settings. By completing ADHD-specific questionnaires, parents or caregivers and classroom teachers must provide evidence of the core symptoms of the disorder, duration of symptoms, the degree of functional impairment, and associated conditions. According to the guidelines, nonspecific questionnaires are not adequate for the diagnosis of children with ADHD. The guidelines recommend that evaluation for ADHD also include an assessment for coexisting conditions such as conduct and oppositional defiant disorder, mood disorders, anxiety disorders, and learning disabilities. Coexisting conditions affect roughly one-third of children with ADHD. Recommendations do not include the use of brain imaging, EEG, and thyroid hormone screens as diagnostic tests for ADHD.

These guidelines provide a starting point for clinicians in the assessment of ADHD in children of 6 to 12 years of age. Further research is necessary to develop guidelines for other age ranges.

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