JOURNAL CLUB

Commentaries By Michael G. Burke, MD

Does "TV turnoff" reduce aggression?

Although the relationship between exposure to aggression in the media and children's aggressive behavior has been documented, studies have not evaluated what interventions counteract these effects. To fill this void, investigators conducted a trial in matched third- and fourth-graders in two separate schools. In one school, children received an 18-lesson, six-month classroom curriculum to reduce television, videotape, and video game use. Lessons included self-monitoring and reporting of television, videotape, and video game use to motivate children to spend less time in these activities; a "TV turnoff" during which children were challenged not to engage in these activities for 10 days; and encouragement to follow a TV, videotape, and video game budget. Parent education also was provided. In the control school, children simply were assessed for aggressive behavior.

In both schools, assessment was performed before and after the six-month study period, using peer ratings of aggressive behaviors, playground observations of aggressive behavior by trained observers, and parent interviews. Children also were questioned about their perceptions of a "mean and scary world." Compared with controls, children in the intervention group had statistically significant decreases in peer ratings of aggression. Differences in observed physical aggression, parent reports of aggressive behavior, and perceptions of a mean and scary world were not statistically significant but favored the intervention group (Robinson TN et al: Arch Pediatr Adolesc Med 2001;105:17).

Commentary: I read this article the morning after the recent middle school shootings in California. It was a stark reminder of how important a concern childhood violence is to advocates for children, especially pediatricians. In a related editorial, James Garbarino, PhD, asks what causes violence among children and adolescents. He answers: "There is no cause, only the accumulation of risk factors." He emphasizes the complexity of social problems and the difficulty of isolating one of the many causes for social ills. Nonetheless, he encourages making incremental gains by addressing single risk factors, such as watching violence on TV. (Arch Pediatr Adolesc Med 2001;155:13).

Editor's note: See our May cover story on how violent video games affect children's health and what you can do about the problem.

Inhaled insulin an alternative to injection

A new study in adults suggests that preprandial inhaled insulin can be used as a substitute for preprandial insulin injections, with no loss of glycemic control. During the four-week baseline lead-in phase of the study, patients with type 1 diabetes mellitus were trained to follow a weight-maintenance diet and perform blood-glucose monitoring. During the 12-week treatment phase of the trial, 37 patients inhaled insulin three times a day before meals. In addition, they took long-acting insulin subcutaneously as a single bedtime injection. The 35 patients in the control group gave themselves an insulin injection two or three times daily, in keeping with their usual regimen. All patients monitored their blood glucose four times a day—before breakfast, lunch, and dinner and at bedtime, always before administering insulin. The response of HbA_1c to treatment did not differ between the two groups, nor did occurrence or severity of hypoglcemia. Meal glucose profiles at baseline and at the end of the study were not significantly different between groups, nor was pulmonary function, which was stable during the study period (Skyler JS et al: Lancet 2001;357:331).

Commentary: First proposed in the 1920s, this idea is not new. Pharmaceutical changes now provide more exact dosing and more uniform absorption, however. It may be that the time for this idea has come at last.

Cellular phones not tied to brain tumors

The hypothesis that hand-held cellular telephone use causes brain tumors is not supported by a new study. The investigation focused on 782 patients 18 years old or older who received care at hospitals in Boston, Phoenix, Ariz., and Pittsburgh, Pa., for tumors identified as glioma, intracranial meningioma, or acoustic neuroma. Controls were 799 patients admitted to the same hospitals for a variety of nonmalignant conditions. A research nurse interviewed each of the participants, or his or her proxy if the subject was too ill, functionally impaired, or had died, about use of hand-held cellular telephones. The nurse asked about first and last use, how long the subject had been a "regular" user (defined as two calls a week), how much time the subject typically spent on the phone each day, and the hand he or she usually used to hold the handset.

Ever having used a hand-held cellular telephone was not significantly associated with the relative risk of glioma, meningioma, or acoustic neuroma. Neither was regularly using a hand-held cellular phone. Among regular users of hand-held cellular phones, those who began using cellular telephones years ago were at no greater risk than those who began using the phones more recently. Furthermore, the risk of any type of tumor did not increase significantly with increasing duration or frequency of use or total cumulative use. Finally, tumors did not develop disproportionately often on the side of the head on which the user typically held the phone (Inskip PD et al: N Engl J Med 2001;344:79).

Commentary: This is reassuring data about a theory that has raised significant concerns in the lay press. The authors suggest that further research is necessary to evaluate the risk of long-term exposure and delayed effects of cell phone-derived microwave radiation. Using that cellular phone driving 70 mph down the highway is probably the greater risk (N Engl J Med 1997;336:453).

Injury from falling TVs a significant problem

Children increasingly are being injured by a TV set that topples when the child tries to reach or climb it, and the injury often is severe enough to cause hospitalization and functional limitation. Investigators reviewed the charts of 183 children, 7 years old and younger, who were hospitalized for injuries caused by falling TV sets. More than half the children were boys, and more than three quarters were 1 to 4 years of age. The injury almost always occurred at the child's home or another private house. More than two thirds of injuries were to the head; fewer than half the children sustained injuries to more than one region of the body, with only two injuring the thoracic cavity. In about 70% of the children, injury was mild, but more than one quarter had moderate or critical injuries.

The injured children were hospitalized for an average of 3.3 days. About one third were admitted to the intensive care unit, and one fifth required one or more surgical interventions. About one quarter developed one or more functional limitations, usually in an activity of daily living, although neurologic and sensorial functions were impaired in some. Five children developed a problem with bladder or bowel control, or both.

Analysis of data from the National Pediatric Trauma Registry, from which this study was drawn, shows that injuries related to TV sets accounted for 0.30% of all unintentional blunt trauma among children as old as 7 years between 1988 and 1993, a rate that more than doubled to 0.63% between 1994 and 1999. In addition, although no child died from this type of injury in the earlier period, five fatalities were reported between 1994 and 1999. Investigators hypothesized that the rise in injuries may in part be caused by the increase in larger, heavier TV sets (DiScala C et al: Arch Pediatr Adolesc Med 2001;155:145).

Commentary: The authors point out that the increasing size of television screens and new technology have worsened the tendency of TVs to be front heavy and prone to tipping. They call for new safer designs in the future and, right now, use of caution and better securing of TVs.

Questionnaire targets TB test candidates

A tuberculosis risk assessment questionnaire developed by the New York City Department of Health (NYCDOH) in 1996 is a valid instrument for identifying children who should have tuberculin skin testing, an evaluation shows. Investigators administered the questionnaire to the caretakers of 2,920 children 1 to 18 years of age who visited an ambulatory clinic in the South Bronx, where, in 1996, the reported tuberculosis (TB) case rate was almost five times the national average. The risk assessment questions included the following:

• Has your child had any contact with a case of TB?

• Was any household member, including your child, born in or a visitor to areas where TB is common?

• Does your child have regular contact with adults at high risk for TB (that is, those who are HIV infected, homeless, or incarcerated or who use illicit drugs)?

• Does your child have HIV infection?

Any "Yes" response was considered a positive risk factor.

The questionnaire identified 413 children (14%) as having at least one risk factor for TB. Of those, 23 (5.6%) had a positive skin test, whereas only four (0.16%) of the 2,507 children without a risk factor had a positive result. Of those four, three (75%) were older than 11 years. Based on these results, the NYCDOH questionnaire had a sensitivity (probability of a positive questionnaire result in a child with a positive purified protein derivative [PPD] of tuberculin) of 85.2%, a specificity (probability of a negative questionnaire result in a child with a negative PPD) of 86.0%, and a negative predictive value (proportion of children with negative questionnaires who also had negative PPDs) of 99.8% (Ozuah PO et al: JAMA 2001;285:451).

Commentary: In the 2000 Red Book, the AAP's Committee on Infectious Diseases suggests that "All children need routine health care evaluations that include an assessment of their risk of exposure to tuberculosis. Only children deemed to have increased risk of contact with persons with contagious tuberculosis or those with suspected tuberculosis disease should be considered for a tuberculin skin test." This questionnaire may be a good tool for determining, even before you see the child, who is at risk and needs a TB skin test.

Also of note

Change in heart rate characteristics is early sign of sepsis. A new study shows that increasingly abnormal heart rate characteristics (HRCs) precede by up to 24 hours the abrupt clinical deterioration that prompts physicians to obtain blood cultures and start antibiotics for suspected sepsis. During a nearly two-year period, investigators prospectively studied infants who were at high risk of sepsis after their admission to a neonatal intensive care unit. The infants were divided into two groups: those with proven sepsis (culture positive) and those with sepsis-like illness (culture negative). Investigators measured novel characteristics—moments and percentiles—of normalized heart rate time series for five days before and three days after sepsis illness, sepsis-like illness, or, in controls, a random time. Culture-positive and culture-negative patients had similar HRC and clinical scores, including a significant rise in the Score for Neonatal Acute Physiology, in the 24 hours before abrupt deterioration. Analysis showed that during this period, HRC and clinical scores independently added information that distinguished infants with sepsis and sepsis-like illness from control patients. These findings suggest that monitoring these parameters in infants at risk of sepsis and sepsis-like illness might lead to earlier diagnosis and more effective therapy (Griffin MP et al: Pediatrics 2001; 107:97).

Web support for teens with CF shows promise. Teenagers with cystic fibrosis (CF) who agreed to participate in an experimental electronic support group visited the interactive World Wide Web site an average of four times a month. They particularly enjoyed sections of the site that described their peers and that allowed them to socialize. More than half of participants e-mailed each other at least once a week, and 77% e-mailed peers at least every other week. Although participants often accessed sections of the site with information about CF, scores on a quiz of participants' general knowledge of CF did not differ at the beginning and end of the study. By the time the project concluded, however, participants had gained an understanding of the limitations on their knowledge of their disease. (Johnson KB et al: Pediatrics 2001; 107[2]:e24).

DR. BURKE, Section Editor for Journal Club, is Chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore. He is a Contributing Editor for Contemporary Pediatrics.

CLINICAL TIP

Patient photos: Twice as nice

When I started a new practice, I decided to take photos of all the patients and their families and make collages to hang on the bulletin boards that decorate the exam rooms and waiting area. By chance, I got duplicates of all the families' pictures at a two-for-one sale and gave the extras out at the next visit. Everyone was thrilled. I work with an indigent population and family photos are not high on their priority list.

For patients who didn't return often, we put the extra copy in the chart. When the parents called, it was an unexpected pleasure to have a picture of the family in the file. I could see parent and child while I was on the phone and knew exactly to whom I was speaking.

Chrystal de Freitas, MD
Encinitas, Cal.

Nursemaid's elbow? Sneaking up on the diagnosis

When I evaluate a patient for possible nursemaid's elbow, I always examine the "good" arm first. A child with an elbow injury is usually very scared and often cries at any attempt to manipulate the painful arm. Go through a series of flexions, extensions, and contortions of the uninjured arm in a way that conveys that you know what you are doing and are not trying to cause pain.

When you get around to examining the injured arm, keep in mind that the most specific sign of radial head subluxation is pain on supination of the forearm. Make sure you do this part of the exam last! Gentle palpation of the hand, wrist, shoulder, and even the elbow should not elicit any pain as long as you do not move the elbow joint. By this point, the child will either trust you or think you are crazy. Then, go for the gold. If supination ruins your new-found relationship with the patient, you still have your diagnosis.

Randy J. Goldstein, MD
El Paso, Tex.

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by e-mail (Molly.Frederick@medec.com), please include your mailing address.

 

Michael Burke. Pediatric Journal Club. Contemporary Pediatrics 2001;4:16.