Copyright © 2007 Massachusetts Medical Society. All rights reserved.

NO EASY ANSWER TO CONTROLLING CALORIC INTAKE FROM “SUPER-SIZED” MEALS

Changing how fast food is served did not affect total calorie consumption.

About 75% of adolescents eat fast food at least once a week, and research suggests that the large portion sizes and rapid eating pace associated with fast food might bypass the body’s satiety cues. Investigators at Children’s Hospital Boston examined the effect of portion size and eating rate on energy intake in 18 adolescents (age range, 13–17; BMI >80th percentile).

Before consuming the baseline assessment meal (chicken nuggets, French fries, cola), adolescents were told that they could eat as much or as little of the food served as they liked and that refills were readily available. Participants were randomized to receive the same food during three subsequent sessions (with amounts based on 125% of their baseline consumption) either all at once, all at once but portioned into four servings, or portioned into four servings served individually every 15 minutes.

During the baseline meal, adolescents consumed a mean of 1383 calories. Mean calorie consumption did not differ significantly during the three eating conditions (about 1300 calories). Calories consumed during each meal represented about 50% of total daily energy expenditures.

Comment

Who knew that 10 chicken nuggets, a large order of fries, and a 20-ounce cola contains 1220 calories? The authors conclude that teaching portion control and recommending slower eating rates are unlikely to help control caloric intake at fast-food restaurants; altering the nutritional composition of fast foods might be more effective.

Alain Joffe, MD, MPH, FAAP

Published in Journal Watch Pediatrics and Adolescent Medicine June 27, 2007

Ebbeling CB, et al. Altering portion sizes and eating rate to attenuate gorging during a fast food meal: effects on energy intake. Pediatrics 2007;119:869–75.

LAB SCREENING IN CHILDREN WITH SUSPECTED INFLAMMATORY BOWEL DISEASE

When clinical suspicion is high, normal screening lab values have limited value.

Primary care clinicians often perform screening laboratory tests when they suspect that a child might have inflammatory bowel disease (IBD). Investigators evaluated the screening utility of hemoglobin values, platelet counts, erythrocyte sedimentation rate (ESR), and albumin levels using prospectively collected data from a multisite registry of 526 children (mean age, 11.6 years) who were newly diagnosed with IBD (392 with Crohn disease; 134 with ulcerative colitis).

All four tests were normal in 30% of children with mild disease (21% of patients with Crohn disease and 54% of those with ulcerative colitis), compared with only 4% of children with moderate or severe IBD. Of the four tests, ESR was the least likely to be normal (defined as <20 mm/hour), regardless of disease severity. For example, among children with moderate or severe IBD, 18% had normal ESRs, 24% had normal hemoglobin levels, 43% had normal platelet counts, and 50% had normal albumin levels. Hematochezia was the most common presenting feature in children with mild IBD.

Comment

These results indicate that the four IBD screening tests assessed have limited value. I wish the authors had performed more sophisticated analyses, such as calculating sensitivity for different combinations of laboratory values, because early identification of children with IBD is important. The authors note that new laboratory markers, such as antibodies against neutrophils or microbial antigens, and antiglycan antibodies, might hold greater promise.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine June 13, 2007

Mack DR, et al. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics 2007;119:1113–9.

DOES ADENOTONSILLECTOMY IMPROVE CHILDREN’S BEHAVIOR?

Parents report that children have better sleep, breathing, and quality of life but not better behavior, after adenotonsillectomy.

Many children with obstructive sleep apnea (OSA) undergo adenotonsillectomy to relieve respiratory and sleep-related symptoms. Research shows that the procedure also might change neurobehavioral sequelae linked to OSA. In a retrospective study of children (age range, 2–17 years) who were referred for polysomnography to evaluate for possible OSA, investigators in Canada and Australia compared clinical and behavioral outcomes in 86 children who underwent adenotonsillectomy and 52 who did not undergo the procedure.

Parents completed a questionnaire about changes in their child’s quality of life, sleep, and breathing an average of 3.5 years after adenotonsillectomy or polysomnography if surgery was not performed. The questionnaire included the Conners’ Parent Rating Scale-Revised (CPRS-R) to assess for neurobehavioral change.

Parents of children who underwent adenotonsillectomy were significantly more likely than parents of children who did not undergo the procedure to report improvements in daytime breathing (61% vs. 10%), sleep breathing (92% vs. 20%), loudness of snoring (91% vs. 25%), excessive daytime sleepiness (48% vs. 18%), and quality of life (74% vs. 10%). There were no significant differences between groups in rates of improvement in concentration, school performance, and intellectual or developmental progress. No significant differences in short-term or long-term improvements were found between groups for any CPRS-R subscales (oppositional, cognitive/inattention, hyperactivity, ADHD index). Results were similar when the time from adenotonsillectomy/polysomnography to parental reporting was <3.5 years and ⩾3.5 years.

Comment

Although other studies have shown that adenotonsillectomy can improve behavior and cognition in children with OSA, this retrospective study suggests that, from the parents’ point of view, adenotonsillectomy does not change their children’s behavior. However, the authors note that adenotonsillectomy might improve neurobehavioral outcomes among certain subgroups of children with sleep-disordered breathing, such as those already diagnosed with ADHD. In any case, pediatricians can counsel parents of children with OSA undergoing adenotonsillectomy to expect improvements in breathing and sleep but not necessarily behavior.

Cornelius W. Van Niel, MD

Published in Journal Watch Pediatrics and Adolescent Medicine July 3, 2007

Constantin E, et al. Adenotonsillectomy improves sleep, breathing, and quality of life but not behavior. J Pediatr 2007;150:540–6.

MIDSTREAM URINE SAMPLES IN CHILDREN: CLEAN FIRST, THEN COLLECT

Cleaning the perineum or genitals before obtaining a midstream urine sample was associated with lower rates of bacterial contamination.

In several adult studies, contamination rates were similar for midstream clean-catch and non–clean-catch urine samples. In a randomized trial, researchers compared perineal or genital cleaning (retracting the foreskin for noncircumcised boys or spreading the labia for girls, and wiping with gauze and liquid soap) with no cleaning before collection of midstream urine samples in 350 toilet-trained children (age range, 2–18 years; 60% girls) who provided samples for an emergency department medical assessment. Younger children were assisted by their parents.

Contaminated samples (<100,000 colony-forming units/mL of a single organism or a mix of 2 or more organisms) were significantly less common in children in the clean-catch group than in controls (7.8% vs. 23.9%). Positive urinalyses (leukocyte esterase, nitrites, or both on dipstick or ⩾5 white blood cells/high-powered field on microscopy) also were less common in the clean-catch group than in the control group (20.6% vs. 36.8%). The positive predictive value of a positive urinalysis for identifying urinary tract infection was significantly higher in the clean-catch group than in the non–clean-catch group (40.5% vs. 12.7%).

Comment

The evidence from this well-designed study is clear — before obtaining a midstream urine sample in children, the perineum or genitals should be cleaned.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine June 20, 2007

Vaillancourt S, et al. To clean or not to clean: effect on contamination rates in midstream urine collections in toilet-trained children. Pediatrics 2007;119:e1288–93. (http://dx.doi.org/10.1542/peds.2006-2392)