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Translating Best Evidence into Best Care

EDITORS NOTE: Studies for this issue were identified using the Clinical Queries feature of PubMed, hand searching
JAMA Pediatrics and The Journal of Pediatrics, and from customized EvidenceUpdates alerts.
Jordan Hupert, MD

Physical tness is associated with enhanced

academic performance
Esteban-Cornejo, Tejero-Gonzalez CM, Martinez-Gomez
D1, del-Campo J, Gonzalez-Galo A, Padilla-Moledo, et al. Independent and combined influence of the components of
physical fitness on academic performance in youth. J Pediatr.
Question Among school-aged children, what is the association of physical fitness with academic performance?
Design Cross-sectional study.
Setting Schools in Cadiz and Madrid, Spain.
Participants Girls aged 6-18 years.
Intervention Cardiorespiratory capacity, motor ability, and
muscular strength assessment.
Outcomes Academic performance assessed through school
Main Results Cardiorespiratory capacity and motor ability
were independently associated with all academic variables,
even after adjustment for fitness and obesity indicators (all
P < .001).
Conclusions Cardiorespiratory capacity and motor ability,
both independently and combined, may have a beneficial influence on academic performance in youth.
Commentary There is growing interest in the relationship
between physical fitness and academic performance.1,2
Numerous confounding factors can affect this relationship,
such as sample size, and sampling methods and measurements. In this study, the authors analyzed this relationship after controlling for several confounding factors by using
objective fitness measures and standard academic scores in
a large sample of youth. This study adds to the current
consensus on the positive association between cardiorespiratory fitness and academic performance, further highlighting
the potential benefits of motor ability on academic performance. However, these findings should be interpreted with
caution, due to several limitations. This study could have
elaborated on the variance explained by all variables in the
regression models. Additionally, school/class level could
have been considered as a confounding factor, and the
cross-sectional design precluded causal inferences. The effect
of physical fitness on academic performance is still equivocal
given the lack of previous experimental and longitudinal
studies. Future studies should aim to isolate the effects of potential confounders (eg, socioeconomic status, motivation,
intelligent quotient, sleep habit) on academic performance.
In addition, multilevel analyses can distinguish factors oper206

ating at an individual level from those at a contextual level

(eg, school environment). Research also is needed to further
explore the reciprocal associations between physical fitness
and academic performance.
Li-Jung Chen, PhD
National Taiwan University of Sport
Taichung, Taiwan

1. Chen L-J, Fox KR, Ku P-W, Taun C-Y. Fitness change and subsequent academic performance in adolescents. J Sch Health 2013;83:631-8.
2. London RA, Castrechini S. A longitudinal examination of the link between youth physical fitness and academic performance. J Sch Health

High incidence of occult, serious injury in

possibly-abused infants presenting with isolated
Harper NS, Feldman KW, Sugar NF, Anderst JD, Lindberg
DM. Examining siblings to recognize abuse investigators.
Additional injuries in young infants with concern for abuse
and apparently isolated bruises. J Pediatr. 2014;165:383-8.
Question Among possibly-abused infants with apparently
isolated bruising, what is the incidence of occult, serious internal injury?
Design Prospectively planned secondary analysis of an observational study.
Setting 20 US child abuse investigation centers.
Participants Infants <6 months of age with apparently isolated bruising evaluated for possible physical abuse.
Intervention Radiologic, hematologic, and hepatic diagnostic testing.
Outcomes Additional injuries or bleeding disorders.
Main Results Overall, 73 of 146, (95% CI, 42%-58%) had at
least one additional serious injury. No bleeding disorders
were identified.
Conclusions Infants <6 months of age with bruising
prompting subspecialty consultation for abuse have a high
risk of additional serious injuries.
Commentary The evaluation of the infant with bruising,
without other overt evidence of physical abuse, is always a
challenge. Since the landmark article by Sugar et al highlighting that those who dont cruise, rarely bruise, there

Vol. 166, No. 1  January 2015

has been increasing focus on young infants.1 The importance
of investigating infants with apparently isolated bruises was
highlighted by Petska et al, where isolated bruising was the
first indication of abusive head trauma.2 The study by Harper
et al explored this issue in a highly selected cohortthose who
had already been referred to a child-abuse physician for
assessment (suggesting concern for abuse) with apparently
isolated bruising. Their aim was to identify the incidence of
occult injury. In the study by Harper et al, 50% had presumed
abuse. The extent of further investigation was high in this
cohort, 93.8% undergoing a skeletal survey and 91% neuroimaging. The yield also was high, with about 25% being
abnormal. Of note, facial bruising was strongly associated
with positive neuroimaging (OR 3.89, 95% CI, 1.19-14.09).
However, we were not told how many of these infants had
clinical signs or symptoms of neurological injury (eg, apnea,
seizures, altered consciousness, nor was reported the developmental stage of the infants). Fractures (the majority of which
[135/137] were clinically occult) were identified in 23.3%,
reiterating the need for skeletal surveys in young infants
with isolated bruises. Although no new coagulation disorders
were identified among the 103 infants undergoing investigation, the extent of investigation was not standardized, and
thus it is difficult to interpret this data. This large scale study
reiterates the need to conduct a full evaluation of infants <6
months of age with apparently isolated bruising, as the likelihood of identifying further occult injury is high.
Sabine Maguire, MBBCH, MRCPI, FRCPCH
Cardiff University School of Medicine
Cardiff, Wales, United Kingdom

1. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those
who dont cruise rarely bruise. Puget Sound Pediatric Research Network.
Arch Pediatr Adolesc Med 1999;153:399-403.
2. Petska HW, Sheets LK, Knox BL. Facial bruising as a precursor to abusive
head trauma. Clinical Pediatrics 2013;52:86-8.

Participants Children <24 months of age with a primary

diagnosis of viral bronchiolitis.
Intervention HS or NS.
Outcomes Hospital admission rate, length of stay for
admitted patients (LOS), and Respiratory Distress Assessment Instrument (RADI) score.
Main Results Admission rates in 3% of the HS group was
28.9% compared with 42.6% in the NS group, (number
needed to treat = 8; 95% CI, 5-23). LOS and RADI did not
differ between the groups.
Conclusions HS given to children with bronchiolitis in the
ED decreases hospital admissions.
Commentary This high-quality, relatively large RCT
demonstrated a significant effect of nebulized HS (up to
3 doses) in reducing the risk of hospital admission in infants with bronchiolitis presenting to the ED. In contrast,
another smaller RCT published in the same issue of JAMA
Pediatrics failed to find significant benefits of a single dose
of HS in similar patients.1 Inclusion of these two latest
RCTs in a recent Cochrane review showed a marginally
nonsignificant effect of HS on hospital admissions in an
ED setting (6 trials, risk ratio 0.77, 95% CI 0.58-1.02).2
However, the results were statistically significant when
the meta-analysis included only the 4 trials in which multiple ($2) doses were used (risk ratio 0.64, 95% CI 0.500.83). In patients hospitalized with bronchiolitis, the Cochrane review suggested that HS was associated with a significant mean reduction of 1.15 days in LOS.2 The trial by
Wu et al did not find a significant benefit of HS on LOS.
Another published RCT did not demonstrate an effect of
HS on LOS.3 Inconsistency of results across trials in hospitalized patients may be explained partially by variation
in diagnostic criteria, disease severity, treatment regimen
and/or outcome measures. Additional evidence is needed
to better define nebulized HS effects in both the ED and
in hospitalized patients with bronchiolitis.
Linjie Zhang, MD, PhD
Federal University of Rio Grande
Rio Grande, Brazil

Multiple-dose hypertonic saline decreases

bronchiolitis admissions
Wu S, Baker C, Lang ME, Schrager SM, Liley FF, Papa C.
Nebulized Hypertonic Saline for Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr. 2014;168:657-63.
Question Among infants with bronchiolitis, what is the therapeutic efficacy of hypertonic saline (HS), compared with
isotonic normal saline (NS), in reducing hospitalization
Design Randomized controlled trial (RCT).
Setting Emergency departments (ED) of 2 urban childrens
hospitals in California.

1. Florin TA, Shaw KN, Kittick M, Yakscoe S, Zorc JJ. Nebulized hypertonic
saline for bronchiolitis in the emergency department: a randomized clinical trial. JAMA Pediatr 2014;168:664-70.
2. Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database of Systematic Reviews. Issue 7. Art. No.: CD006458, http://dx.doi.
org/10.1002/14651858.CD006458.pub3; 2013.
3. Sharma BS, Gupta MK, Rafik SP. Hypertonic (3%) saline vs 0.93% saline
nebulization for acute viral bronchiolitis: a randomized controlled trial.
Indian Pediatr 2013;50:743-7.



Professional breastfeeding support enhances

breastfeeding continuation
Fu I1, Fong D, Heys M, Lee I, Sham A, Tarrant M. Professional breastfeeding support for first-time mothers: a multicentre cluster randomised controlled trial. BJOG. 2014 May
26. doi: 10.1111/1471-0528.12884.
Question Among breastfeeding women, what is the therapeutic efficacy of professional breastfeeding follow-up support, compared with standard care, in enhancing
breastfeeding continuation?
Design Randomized controlled trial.
Setting Three geographically distributed public hospitals in
Hong Kong, China.
Participants 722 primiparous breastfeeding mothers with
uncomplicated, full-term pregnancies.
Intervention (1) Standard postnatal maternity care; (2) standard care plus three in-hospital professional breastfeeding
support sessions; or (3) standard care plus weekly postdischarge breastfeeding telephone support for 4 weeks.
Outcomes Prevalence of any and/or exclusive breastfeeding
at 1, 2, and 3 months postpartum.
Main Results Compared with standard care only, participants receiving telephone support were significantly more
likely to continue any breastfeeding at: 1 month (76.2%
versus 67.3%; number needed to treat [NNT] 12, 95% CI
6-83); and 2 months: (58.6 versus 48.9%; NNT 10, 95% CI
6-60); and to be exclusively breastfeeding at 1 month:


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(28.4% versus 16.9%; NNT 9, 95% CI 6-23). There were no
other statistically significant relationships among the 3
Conclusions Professional breastfeeding telephone support
provided early in the postnatal period, and continued for
the first month postpartum, improves breastfeeding duration
among first-time mothers.
Commentary The findings of this study may be particularly
helpful for those who seek to support the breastfeeding efforts of women who are at higher risk for lower breastfeeding
rates. These groups include lower income mothers, younger
mothers, and mothers from certain racial/ethnic groups
such as African American. Organizations and medical providers who seek to support mothers after discharge from
the hospital face the challenge of costs and logistics. The
use of structured telephone calls to advise and support
mothers is an effective and less expensive way to give breastfeeding support. There may be greater success if more than
one of the interventions are combined and/or employing
newer technologies such as Facetime or Skype. These newer
technologies may add another dimension of telesupport
to mothers who need it, thereby decreasing breastfeeding
rate disparities.
Eric Walsh, MD, DrPH
Pasadena Public Health Department
Pasadena, California