March 2018 Briefing - Pediatrics

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Here are what the editors at HealthDay consider to be the most important developments in Pediatrics for March 2018. This roundup includes the latest research news from journal articles, as well as the FDA approvals and regulatory changes that are the most likely to affect clinical practice.

Receptivity to Tobacco Ads Linked to Progression to Use

FRIDAY, March 30, 2018 (HealthDay News) -- For adolescents, receptivity to tobacco advertising is associated with progression toward use, according to a study published online March 26 in JAMA Pediatrics.

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Childhood Irritability, Depressive Mood Linked to Suicidality Later

FRIDAY, March 30, 2018 (HealthDay News) -- Children with high irritability and depressive/anxious mood have increased suicidality risk during adolescence, according to a study published online March 28 in JAMA Psychiatry.

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Scale of Online Marketplace for Marijuana Increasing

THURSDAY, March 29, 2018 (HealthDay News) -- The scale of the online marketplace for marijuana increased from 2005 to 2017, according to a study published online March 22 in the American Journal of Preventive Medicine.

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Change in BMI During Puberty Tied to Later Heart Failure Risk

THURSDAY, March 29, 2018 (HealthDay News) -- Change in body mass index (BMI) to overweight during puberty significantly increases men's risk of heart failure later in life, according to a study published online March 12 in the Journal of Internal Medicine.

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Dining Out Linked to Phthalates Exposure in U.S. Population

THURSDAY, March 29, 2018 (HealthDay News) -- Among the U.S. population, dining out is associated with exposure to phthalates, according to a study published online March 28 in Environment International.

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Traumatic Brain Injury Rare for Children With Isolated Vomiting

THURSDAY, March 29, 2018 (HealthDay News) -- Children presenting with head injury with isolated vomiting rarely have clinically important traumatic brain injury (ci-TBI) or traumatic brain injury on computed tomography (TBI-CT), according to a study published online March 29 in Pediatrics.

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Novel Interstitium Has Been Identified in Human Tissues

THURSDAY, March 29, 2018 (HealthDay News) -- A previously unrecognized interstitium has been identified in human tissues, according to a study published online March 27 in Scientific Reports.

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Liquids in E-Cigarettes Are Heterogeneous, Frequently Toxic

WEDNESDAY, March 28, 2018 (HealthDay News) -- The e-liquids used in electronic cigarettes (e-cigarettes) are a heterogeneous group, and there is a positive correlation between the number of chemicals contained in the liquid and the likelihood of its toxicity, according to a study published online March 27 in PLOS Biology.

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Children With ASD, Younger Siblings Are Undervaccinated

WEDNESDAY, March 28, 2018 (HealthDay News) -- Compared with the general population, children with autism spectrum disorder (ASD) and their younger siblings are undervaccinated, according to a study published online March 26 in JAMA Pediatrics.

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EHR Usability Contributes to Possible Patient Harm Events

TUESDAY, March 27, 2018 (HealthDay News) -- Electronic health record (EHR) usability may contribute to possible patient harm events, according to a research letter published in the March 27 issue of the Journal of the American Medical Association.

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Parent-Child Book Reading Tied to Psychosocial Benefits

TUESDAY, March 27, 2018 (HealthDay News) -- Reading books together is associated with psychosocial benefits in both children and parents, according to a review published online March 27 in Pediatrics.

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Children's Hoverboard, Skateboard Injuries Are Similar

TUESDAY, March 27, 2018 (HealthDay News) -- Injury characteristics among hoverboard riders and skateboarders are similar, according to a study published online March 26 in Pediatrics.

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Educational Attainment Down With In Utero Exposure to AEDs

TUESDAY, March 27, 2018 (HealthDay News) -- Exposure to sodium valproate or a combination of antiepileptic drugs (AEDs) in utero is associated with worse attainment on national educational tests for 7-year-olds, according to a study published online March 26 in the Journal of Neurology, Neurosurgery & Psychiatry.

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Geographic, Social Variances Tied to Higher Drug-Related Mortality

TUESDAY, March 27, 2018 (HealthDay News) -- County-level economic and other social conditions explain the geographic disparities in overdose rates across the country, according to a study published online March 26 in the American Journal of Preventive Medicine.

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Complete Genome Sequence Can Be ID'd From Amniotic Fluid

TUESDAY, March 27, 2018 (HealthDay News) -- The complete genome sequence of fetuses can be elucidated from amniotic fluid, according to a study published online March 15 in Clinical Chemistry.

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Early Social Media Use May Harm Teen Girls' Well-Being

MONDAY, March 26, 2018 (HealthDay News) -- High levels of social media interaction in early adolescence may have negative implications for later well-being and happiness in girls, according to a study published online March 20 in BMC Public Health.

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Ethical Duties ID'd for Short-Term Global Health Experiences

MONDAY, March 26, 2018 (HealthDay News) -- In a position paper published online March 27 in the Annals of Internal Medicine, ethical obligations have been detailed for physicians participating in short-term global health experiences (STEGHs).

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2011 to 2015 Saw Increase in Suicide Rate for Youth in Utah

MONDAY, March 26, 2018 (HealthDay News) -- From 2011 to 2015, the unadjusted suicide rate among youth in Utah increased 136.2 percent, according to research published in the March 23 issue of the U.S. Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report.

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Sports Sponsorships Often Market Unhealthy Food and Drinks

MONDAY, March 26, 2018 (HealthDay News) -- Sports sponsorships frequently advertise unhealthy food and nonalcoholic beverages, according to a study published online March 26 in Pediatrics.

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Measles in Childhood Affects Airflow Obstruction in Midlife

FRIDAY, March 23, 2018 (HealthDay News) -- Childhood measles infection appears to compound the associations between smoking, current asthma, and post-bronchodilator airflow obstruction, according to a study published online March 20 in Respirology.

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Lean Approach May Help Tackle Burnout in Health Care Providers

FRIDAY, March 23, 2018 (HealthDay News) -- The Lean approach, which emphasizes reducing waste and improving customer value by focusing on the big picture, can be used to address physician burnout, according to a report published in Medical Economics.

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Neural Markers of Depression Resilience ID'd in Female Teens

FRIDAY, March 23, 2018 (HealthDay News) -- Adolescent females at high familial risk of depression who do not go on to develop depression have compensatory functional connectivity patterns in emotion regulatory networks, according to a study published online March 21 in JAMA Psychiatry.

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Unique Risks Associated With Texting Medical Orders

THURSDAY, March 22, 2018 (HealthDay News) -- Despite the popularity, convenience, and speed of texting medical orders, there are unique and alarming risks associated with the practice, according to a report published in Drug Topics.

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Vaccine-Derived Immune Protection Against Mumps Wanes

THURSDAY, March 22, 2018 (HealthDay News) -- Vaccine-derived immune protection against mumps wanes on average 27 years after vaccination, according to a study published online March 21 in Science Translational Medicine.

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Soy-Based Formula Tied to Reproductive Differences

THURSDAY, March 22, 2018 (HealthDay News) -- Infants given soy-based formula have reproductive system differences compared with those given cow-milk formula or breast milk, according to a study published online March 1 in the Journal of Clinical Endocrinology & Metabolism.

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CDC: Low Birthweight Rate Increased From 2014 to 2016

THURSDAY, March 22, 2018 (HealthDay News) -- From 2014 to 2016 there was an increase in the singleton low birthweight rate, which was mainly due to increases in the rate of moderately low birthweight, according to a March data brief published by the U.S. Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS).

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High-Flow O2 Therapy Feasible for Infants With Bronchiolitis

WEDNESDAY, March 21, 2018 (HealthDay News) -- High-flow oxygen therapy may be more effective than standard oxygen therapy in preventing care escalation among infants with bronchiolitis treated outside an intensive care unit, according to a study published in the March 22 issue of the New England Journal of Medicine.

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Most Schools Have Variety of Food Allergy Policies

WEDNESDAY, March 21, 2018 (HealthDay News) -- The vast majority of school nurses report staff training on anaphylaxis and epinephrine availability, though barriers to implementation of food allergy policies exist, according to a study published in the March issue of the Annals of Allergy, Asthma & Immunology.

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Adjuvant Long-Acting Muscarinic Antagonist Improves Asthma

WEDNESDAY, March 21, 2018 (HealthDay News) -- For patients with persistent asthma, the use of long-acting muscarinic antagonists (LAMAs) versus placebo as an adjunct to inhaled corticosteroids, and combined use of inhaled corticosteroids and long-acting β-agonists (LABAs), termed single maintenance and reliever therapy (SMART), are associated with a reduced risk of exacerbations, according to two reviews published online March 19 in the Journal of the American Medical Association.

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Blueprint Being Developed to Address Physician Burnout

WEDNESDAY, March 21, 2018 (HealthDay News) -- A new, three-pronged approach is being applied to develop a blueprint for addressing physician burnout, according to a report published in Medical Economics.

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USPSTF Recommends Skin Cancer Counseling for Fair-Skinned Youth

TUESDAY, March 20, 2018 (HealthDay News) -- The U.S Preventive Services Task Force recommends counseling to prevent skin cancer for fair-skinned children and young adults, while selective counseling is recommended for adults aged over 24 years. These findings form the basis of a final recommendation statement published in the March 20 issue of the Journal of the American Medical Association.

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Personal Health Info Found in Recycling at Five Hospitals

TUESDAY, March 20, 2018 (HealthDay News) -- A considerable amount of personal health information (PHI) and personally identifiable information (PII) was found in the recycling at five Canadian teaching hospitals, according to a research letter published in the March 20 issue of the Journal of the American Medical Association.

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Teen Cancer Survivors Have Strong Social Networks

TUESDAY, March 20, 2018 (HealthDay News) -- Survivors of adolescent and young adult (AYA) cancer often have stronger social networks than their non-cancer peers, according to a study published online March 8 in Cancer.

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In-Flight Transmission of Respiratory Diseases Low

TUESDAY, March 20, 2018 (HealthDay News) -- The probability of direct transmission of respiratory diseases is low for passengers on transcontinental U.S. flights not seated in close proximity to an infectious passenger, according to a study published online March 19 in the Proceedings of the National Academy of Sciences.

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Decision Characteristics Impact Decision Making in NICU

TUESDAY, March 20, 2018 (HealthDay News) -- For parents with an infant in the neonatal intensive care unit (NICU), preferences for parent-centered decision making are positively associated with decisions that involve big-picture goals and have the potential to harm the infant, according to a study published online March 19 in JAMA Pediatrics.

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Prior Authorization Negatively Impacts Clinical Outcomes

MONDAY, March 19, 2018 (HealthDay News) -- The burdens associated with prior authorization (PA) are high and include a negative impact on clinical outcomes, reported by 92 percent of physicians, according to the results of a survey conducted for the American Medical Association (AMA).

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Survey

Risk of Secondary ADHD Higher After Childhood TBI

MONDAY, March 19, 2018 (HealthDay News) -- Children with early childhood traumatic brain injury (TBI) have increased risk of secondary attention-deficit/hyperactivity disorder (SADHD), according to a study published online March 19 in JAMA Pediatrics.

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Risk of Suicide Up for Teens, Young Adults After Self-Harm

MONDAY, March 19, 2018 (HealthDay News) -- Adolescents and young adults have increased risk of suicide after nonfatal self-harm, according to a study published online March 19 in Pediatrics.

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Costs Up for Neonates With Vocal Fold Motion Impairment

MONDAY, March 19, 2018 (HealthDay News) -- For neonates undergoing congenital heart surgery (CHS), vocal fold motion impairment (VFMI) is associated with increased costs due to increased post-procedure length of stay (PPLOS), according to a study published online March 15 in JAMA Otolaryngology-Head & Neck Surgery.

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Oseltamivir Not Linked to Suicide Risk in Pediatric Patients

FRIDAY, March 16, 2018 (HealthDay News) -- Oseltamivir does not appear to be associated with suicide risk in pediatric patients, according to a study published in the March/April issue of the Annals of Family Medicine.

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2013 to 2016 Saw No Change in Antibiotic Prescribing Practices

FRIDAY, March 16, 2018 (HealthDay News) -- From 2013 to 2016, annual national outpatient antibiotic prescribing practices remained unchanged, according to a study published online Feb. 27 in Infection Control & Hospital Epidemiology.

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Peer-to-Peer Program Tied to Improved Depression Awareness

FRIDAY, March 16, 2018 (HealthDay News) -- A peer-to-peer depression awareness program is associated with improved knowledge and attitudes about depression among high school students, according to a study published online March 1 in Psychiatric Services.

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Risk of Post-Tonsillectomy Complications Up for Under-3s

FRIDAY, March 16, 2018 (HealthDay News) -- Children aged younger than 3 years seem to have increased risk of complications following tonsillectomy compared with children aged 3 years or older, according to a study published online March 15 in JAMA Otolaryngology-Head & Neck Surgery.

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Burn Deaths Down From 1989 to 2017 in the United States

THURSDAY, March 15, 2018 (HealthDay News) -- Burn injury survival has dramatically increased over the past 30 years, according to a study published online March 9 in the Journal of the American College of Surgeons.

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Prevalence of Sunburn 34.2 Percent in U.S. in 2015

THURSDAY, March 15, 2018 (HealthDay News) -- The prevalence of sunburn was 34.2 percent in 2015, and sunburn prevalence was higher in non-Hispanic whites, younger age groups, and those with sun-sensitive skin, according to a study published online March 14 in JAMA Dermatology.

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Review: Virtual Reality Distracts From Pain of Medical Procedures

THURSDAY, March 15, 2018 (HealthDay News) -- Virtual reality (VR) appears to be an effective distraction intervention to relieve pain and distress during various medical procedures, according to a review published online Feb. 26 in The Clinical Journal of Pain.

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More Harms Than Benefits for E-Cigarettes at Population Level

THURSDAY, March 15, 2018 (HealthDay News) -- Electronic cigarettes (e-cigarettes) are associated with more harm than benefit on a population level, according to a study published online March 14 in PLOS ONE.

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Fewer SIDS Cases Result From Genetic Heart Disease Causes

THURSDAY, March 15, 2018 (HealthDay News) -- Genetic heart diseases (GHDs) cause fewer cases of sudden infant death syndrome (SIDS) than previously thought, according to a study published in the March 20 issue of the Journal of the American College of Cardiology.

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Many Teens Using Tobacco Don't Self-Identify As Users

THURSDAY, March 15, 2018 (HealthDay News) -- Many adolescent users of one or more specific tobacco product type do not self-identify as tobacco users, according to a study published online March 12 in Pediatrics.

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Zika-Tied Birth Defects in 7 Percent of Infected Pregnant Women

WEDNESDAY, March 14, 2018 (HealthDay News) -- Seven percent of pregnant women with symptomatic Zika virus (ZIKV) infection have birth defects possibly associated with ZIKV infection, according to a study published in the March 15 issue of the New England Journal of Medicine.

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Novel Pediatric Appendicitis Risk Calculator Accurately IDs Risk

WEDNESDAY, March 14, 2018 (HealthDay News) -- The pediatric appendicitis risk calculator (pARC) accurately quantifies the risk for appendicitis in a validation cohort of patients with acute abdominal pain, according to a study published online March 13 in Pediatrics.

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Drug Copayments Often Exceed Prescription Drug Costs

WEDNESDAY, March 14, 2018 (HealthDay News) -- Drug copayments frequently exceed prescription drug costs, with overpayments affecting 23 percent of all prescriptions, according to a research letter published in the March 13 issue of the Journal of the American Medical Association.

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Bundled Intervention May Improve HPV Vaccination Rates

WEDNESDAY, March 14, 2018 (HealthDay News) -- A bundled intervention comprising quality improvement (QI) training plus provider prompts, communication skills training, and performance feedback may improve human papillomavirus (HPV) vaccination rates in pediatric clinics, according to a study published online March 14 in Pediatrics.

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Improved Glycemic Control With Surgical Tx of Obesity in Teens

WEDNESDAY, March 14, 2018 (HealthDay News) -- Surgical treatment of severe obesity in adolescents with type 2 diabetes is associated with better glycemic control and weight reduction than medical therapy, according to a study published online March 12 in JAMA Pediatrics.

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U.S. Spends Twice As Much for Similar Health Care Utilization

TUESDAY, March 13, 2018 (HealthDay News) -- Spending on health care is much higher in the United States than other high-income countries, but utilization rates are similar, according to a study published in the March 13 issue of the Journal of the American Medical Association.

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Opioid Receipt Up for Teens With Mental Health Conditions

TUESDAY, March 13, 2018 (HealthDay News) -- Adolescents with pre-existing mental health conditions and treatments are more likely to receive any opioid and to transition to long-term opioid therapy, according to a study published online March 12 in JAMA Pediatrics.

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Bronchial Thermoplasty Can Improve Severe Asthmatic Cough

TUESDAY, March 13, 2018 (HealthDay News) -- Bronchial thermoplasty can treat severe asthmatic cough that is unresponsive to conventional therapies, according to a case report published online March 13 in the Annals of Internal Medicine.

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Three-Pronged Approach Can Improve Physician Engagement

MONDAY, March 12, 2018 (HealthDay News) -- The three-pronged approach implemented by one practice successfully improved physician engagement, according to an article published in Medical Economics.

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Childhood Maltreatment, Bullying Seem to Up Teen Pregnancy Risk

MONDAY, March 12, 2018 (HealthDay News) -- Higher teen pregnancy among sexual minorities is partially explained by childhood maltreatment and bullying, according to a study published online March 12 in Pediatrics.

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Over 5,100 Noncongenital Zika Cases Reported in U.S. in 2016

MONDAY, March 12, 2018 (HealthDay News) -- A total of 5,168 noncongenital Zika virus disease cases were reported from U.S. states and the District of Columbia in 2016, with 95 percent of cases identified in travelers returning from Zika virus-affected areas, according to research published in the March 9 issue of the U.S. Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report.

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Doctors Facing Challenge to Help Needy While Protecting Practices

FRIDAY, March 9, 2018 (HealthDay News) -- Physicians are increasingly being challenged to protect their practice finances while helping patients without insurance, according to an article published in Medical Economics.

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Sustained Collaboration Meets Needs for Bladder Exstrophy

FRIDAY, March 9, 2018 (HealthDay News) -- International collaboration focused on treating bladder exstrophy-epispadias complex (BE) and penopubic epispadias (PE) in India is associated with acceptable outcomes, according to a study published online March 7 in JAMA Surgery.

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Current Tobacco Smoke Exposure Doesn't Obstruct Peds Airflow

THURSDAY, March 8, 2018 (HealthDay News) -- Current tobacco smoke exposure (TSE) is not associated with airflow obstruction among school-aged children, while prenatal smoking is associated with airflow obstruction in children with asthma, according to a study published in the March issue of CHEST.

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Maternal Use of TDF Doesn't Further Reduce HBV Transmission

THURSDAY, March 8, 2018 (HealthDay News) -- Maternal use of tenofovir disoproxil fumarate (TDF) in addition to administration of hepatitis B immune globulin and hepatitis B vaccine to infants born to hepatitis B e antigen (HBeAg)-positive pregnant women does not further lower the rate of hepatitis B virus transmission, according to a study published in the March 8 issue of the New England Journal of Medicine.

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FDA Approves Mechanical Heart Valve for Newborns

WEDNESDAY, March 7, 2018 (HealthDay News) -- The U.S. Food and Drug Administration has approved the world's smallest mechanical heart valve, designed to be used in newborns and other young infants with heart defects.

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Vaccine Exposure in First 23 Months Has No Adverse Impact

WEDNESDAY, March 7, 2018 (HealthDay News) -- The estimated cumulative vaccine antigen exposure through age 23 months does not differ significantly for children with versus those without hospital visits for infectious diseases not targeted by vaccines from age 24 to 47 months, according to a study published in the March 6 issue of the Journal of the American Medical Association.

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Minorities Face Worse Prognosis and Complications in T1DM

TUESDAY, March 6, 2018 (HealthDay News) -- Compared to whites, blacks and Hispanics have increased markers of poor prognosis of type 1 diabetes at diagnosis and three years afterward, according to a study published online March 1 in Diabetes Care.

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Parental Dieting Pressure Linked to Long-Term Harm

TUESDAY, March 6, 2018 (HealthDay News) -- Exposure to parent encouragement to diet as an adolescent is tied to long-term harmful weight-related and emotional health outcomes and appears to be transmitted to the next generation, according to a study published online March 6 in Pediatrics.

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HPV Vaccine Intervention Tied to Increased Vaccination

TUESDAY, March 6, 2018 (HealthDay News) -- For adolescents, a health care professional human papillomavirus (HPV) vaccine communication intervention is associated with improved HPV vaccine series initiation and completion, according to a study published online March 5 in JAMA Pediatrics.

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Quintupled Glucocorticoid Dose No Help in Pediatric Asthma

TUESDAY, March 6, 2018 (HealthDay News) -- Quintupling the dose of inhaled glucocorticoids seems not to be effective for preventing exacerbations among children with asthma, while quadrupling the dose may be beneficial for adolescents and adults, according to two studies published online March 3 in the New England Journal of Medicine.

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Strong State Firearm Policies, Lower Firearm Suicide Rate Tied

MONDAY, March 5, 2018 (HealthDay News) -- Strong state firearm policies are associated with lower firearm suicide rates and lower homicide rates, according to a study published online March 5 in JAMA Internal Medicine.

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Pediatric Opioid-Related Hospital, ICU Admissions on the Rise

MONDAY, March 5, 2018 (HealthDay News) -- Nationally, the rate of hospitalization and pediatric intensive care unit (PICU) admission for opioid ingestions increased from 2004 to 2015, according to a study published online March 5 in Pediatrics.

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Excretion of Volatile Organic Compounds Up in Teen E-Smokers

MONDAY, March 5, 2018 (HealthDay News) -- Adolescents smoking electronic-cigarettes (e-cigarettes) only have significantly higher excretion of volatile organic chemical compounds than non-smokers, although the levels are lower than among those using cigarettes in addition to e-cigarettes, according to a study published online March 5 in Pediatrics.

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Global Costs of Diabetes Will Continue Rising Through 2030

MONDAY, March 5, 2018 (HealthDay News) -- The global costs of diabetes are high and will increase substantially by 2030, according to a study published online Feb. 23 in Diabetes Care.

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Pediatric Otolaryngology Practice Continues to Evolve

MONDAY, March 5, 2018 (HealthDay News) -- The pediatric otolaryngology (ORL) specialty has evolved over the past decade, with a notable decline in involvement in facial plastic and reconstructive surgery, according to a study published online Feb. 22 in JAMA Otolaryngology-Head & Neck Surgery.

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Domperidone Tied to Modest Increase in Breast Milk Supply

MONDAY, March 5, 2018 (HealthDay News) -- Domperidone is well tolerated and effective in producing a moderate short-term increase in expressed breast milk volume among mothers of preterm infants, according to a review published online Feb. 22 in BJOG: An International Journal of Obstetrics and Gynaecology.

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High Prevalence of Hearing Loss Seen After Infant Heart Surgery

FRIDAY, March 2, 2018 (HealthDay News) -- The prevalence of hearing loss in preschool children who had heart surgery in infancy may be above 20 percent, according to a study published in the January issue of The Journal of Pediatrics.

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Poor Outcomes Common With Childhood Anorexia Nervosa

FRIDAY, March 2, 2018 (HealthDay News) -- Anorexia nervosa (AN) that develops before age 14 often leads to unfavorable outcomes, according to a study published online Feb. 16 in the International Journal of Eating Disorders.

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Pregnant Women May Engage in Warm Exercise for Short Times

FRIDAY, March 2, 2018 (HealthDay News) -- Pregnant women can safely exercise in warm weather or sit in hot baths or saunas for a short period of time without risking critical elevations in core temperature, according to a review published online March 1 in the British Journal of Sports Medicine.

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Risk of Mental Health Visits Up in Childhood Cancer Survivors

FRIDAY, March 2, 2018 (HealthDay News) -- Survivors of adolescent cancer have higher rates of adverse mental health outcomes than the general population, according to a study published online Feb. 22 in Cancer.

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Nearly All Disadvantaged Urban Teens Exposed to Smoke

THURSDAY, March 1, 2018 (HealthDay News) -- Urine screening for tobacco-specific biomarkers shows that nearly all economically disadvantaged urban adolescents are exposed to tobacco smoke, including secondhand smoke (SHS), according to a study published online Feb. 23 in Cancer Epidemiology, Biomarkers & Prevention.

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Exposure to Metformin In Utero Ups Risk of Being Overweight

THURSDAY, March 1, 2018 (HealthDay News) -- Children exposed to metformin in utero have an increased risk of being overweight at age 4 years, according to research published online Feb. 27 in the Journal of Clinical Endocrinology and Metabolism.

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Diet-Treated Chronic Illness May Lead to Disordered Eating

THURSDAY, March 1, 2018 (HealthDay News) -- Interventions for diet-treated chronic illnesses may increase the risk for disordered eating in children, according to a review published online Feb. 22 in the International Journal of Eating Disorders.

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