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In our sample of inner-city children with asthma, obese children used more medicine, wheezed more, and a greater proportion had unscheduled ED visits than the nonobese children.

OBJECTIVE. The proliferation of policy statements from the American Academy of Pediatrics presents pediatricians with an increasing amount of health advice to deliver, yet no quantitative estimates of pediatric health advice expectations exist in the literature. The objective of this study was to quantify and characterize verbal health advice that pediatricians are expected to deliver to patients/guardians. METHODS. The authors read and coded the 344 American Academy of Pediatrics policy statements that are contained in the American Academy of Pediatrics' Pediatric Clinical Practice Guidelines and Policies, Third Edition, and identified 57 policies that contained health advice directives that are broadly relevant to pediatric practice. We extracted the individual advice text to a database in which we also coded its date of issue, its theme, and whether (1) it was duplicated in another policy, (2) a screening question was required to identify a target population for the advice, (3) handouts or other aids to delivering the advice were referenced in the policy itself, or (4) the text of the statement referred to evidence of the effectiveness of office-based delivery of the advice. RESULTS. These 57 policies were found to contain 192 discrete health advice directives that pediatricians are expected to deliver to patients/guardians. Seven (4%) of these directives originated before 1993, and 185 (96%) were created from 1993 to 2002. After removal of the 30 (16%) duplicates, safety advice composed 67%, media use composed 12%, substance abuse composed 5%, environmental health hazards composed 4%, development/emotional health composed 4%, sexuality and pregnancy composed 3%, nutrition composed 2%, and miscellaneous composed 3%. In 41% of the directives, a screening question was required to identify the target population for the advice. Aids to delivering advice were referenced in 20% of the policies. In no policy statements did the text refer to evidence that office-based counseling was an effective method to achieve the desired health or behavioral outcome. CONCLUSIONS. We examined the American Academy of Pediatrics policy statements and found 162 different verbal health advice directives on which pediatricians should counsel parents and patients throughout childhood. The expectation that delivery of all of this advice can be achieved is unrealistic. Moreover, none of the reviewed statements were found to include an evidence-based discussion of the efficacy of the suggested advice. In light of these findings, we suggest that committees should consider both the feasibility and the evidence of efficacy of office-based health advice when generating future policy statements.

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The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, effectively reduce coronary morbidity and mortality in high-risk adults. They are also some of the most widely prescribed medications in the United States. Their use in pediatrics, however, remains circumscribed. In this article we review the cholesterol hypothesis and focus on the knowledge base of the use of statins in adults and children. We pay particular attention to the known effects of statins in primary and secondary prevention of cardiovascular events. The toxicities of statins and their limitations in pediatrics are then considered. The use of statins in conjunction with noninvasive modalities of assessing atherosclerotic burden are also reviewed. Finally, we suggest methods to advance the use of statins in childhood that introduce their potential benefits to those individuals at highest risk for future events.

Objectives After completing this article, readers should be able to:1. Describe the development of atherosclerotic plaque. 2. Discuss the two-pronged approach to addressing pediatric hypercholesterolemia advocated by the National Cholesterol Education Program and the American Academy of Pediatrics. 3. Describe the criteria for using lipid-lowering medication in children. 4. List risk factors for coronary artery disease that should be addressed in pediatric patients. IntroductionDespite significant declines in death rates from heart disease in recent years, this continues to be the leading cause of death in the United States. In 1999, heart disease was responsible for more than 30% of all deaths, with ischemic heart disease representing 65% of this total. With improved mortality rates of coronary artery disease (CAD) has come greater understanding of how atherosclerosis arises and may be prevented. This review summarizes recent findings regarding the development of cardiovascular disease and alerts pediatricians to how they can screen patients for precursors of CAD. It provides primary and secondary prevention strategies to manage risk factors when they are detected and directs readers to sources that include detailed guidelines for the risk factors that are discussed. Current Understanding of AtherosclerosisCentral to an appreciation of childhood risk factors for adult heart disease is an understanding of how the principal feature of coronary artery disease-the atherosclerotic plaque-develops. Rather than a simple accumulation of cholesterol on the intimal surface of vessel walls, the atherosclerotic plaque represents the culmination of a complex series of events involving inflammatory mediators, macrophages, and activated T lymphocytes in addition to circulating lipoproteins.The sequence begins when low-density lipoprotein (LDL) particles, those composites of lipid and protein designed to transport cholesterol from the liver and intestine to other organs, accumulate beneath the endothelial layer of the arterial wall. There, the central lipid portion of the LDL particle undergoes oxidation, and the proteins on the surface of the particle undergo glycation. These reactions stimulate endothelial and smooth muscle cells to elaborate chemical signals that attract and activate circulating monocytes and T lymphocytes. Activated monocytes and lymphocytes amplify the initial immune response, and in particular, as monocytes mature into macrophages, these cells express specific receptors that allow them to engulf the excess LDL. The resulting lipid-laden macrophages or foam cells combine with activated T cells to form a fatty streak, the initial atherosclerotic element, on the intimal surface of the coronary artery.As endothelial cells, macrophages, and T cells continue to secrete inflammatory mediators, smooth muscle cells from the intima are induced to migrate to the site to cover the luminal surface of the fatty streak. These cells secrete a collagen matrix that forms a fibrous cap or plaque that walls off the underlyin...

A highly competitive infant formula market has resulted in direct-to-consumer marketing intended to promote the sale of modified formulas that claim to ameliorate common infant feeding problems. The claims associated with these marketing campaigns are not evaluated with reference to clinical evidence by the Food and Drug Administration. We aimed to describe the language of claims made on formula labels and compare it with the evidence in systematic reviews. Of the 22 product labels we identified, 13 product labels included claims about colic and gastrointestinal symptoms. There is insufficient evidence to support the claims that removing or reducing lactose, using hydrolyzed or soy protein or adding pre-/probiotics to formula benefits infants with fussiness, gas, or colic yet claims like "soy for fussiness and gas" encourage parents who perceive their infants to be fussy to purchase modified formula. Increased regulation of infant formula claims is warranted.

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