<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_432"
                     title="Short Needle May Short HBV Protection for Obese (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/Pediatrics/Vaccines/tb/18348?impressionId=1265806907397"
                     
      &lt;p&gt;Obese adolescents and young adults may not generate an adequate immune response to hepatitis B (HBV) vaccine because the needles used to vaccinate them are too short, a randomized study suggests.&lt;/p&gt;
&lt;p&gt;Immunization with a 1.5-inch needle was associated with 80% higher anti-HBV titers than a 1.0-inch needle, researchers reported online in &lt;em&gt;Pediatrics.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;The difference persisted in analyses performed to correct for imbalances in the study population.&lt;/p&gt;
&lt;p&gt;&quot;This supports the hypothesis that inadequate muscle penetration is responsible, at least in part, for lower immune response to HBV vaccine among obese adolescent and adult vaccine recipients,&quot; Amy Middleman, MD, of Baylor College of Medicine in Houston, and colleagues concluded.&lt;/p&gt;
&lt;p&gt;Several studies have shown that adolescents and adults with a higher body mass index (BMI) have lower antibody titers after HBV vaccination. The observations have taken on new significance, given that an increasing number of vaccines target a population that has a rising BMI, the authors wrote.&lt;/p&gt;
&lt;p&gt;Researchers hypothesize that standard-length needles do not penetrate through the deltoid fat and into the muscle of obese adolescents and adults. Because of its less abundant blood supply, adipose tissue may delay antigen presentation to B and T cells responsible for immune response, the authors continued.&lt;/p&gt;
&lt;p&gt;To test the hypothesis, Middleman and colleagues conducted a randomized, clinical trial involving adolescents and adults ages 14 to 24 with no prior exposure to HBV vaccine. Eligibility criteria included weight &amp;gt;90 kg for female patients and &amp;gt;120 kg for male patients.&lt;/p&gt;
&lt;p&gt;Patients were randomized to receive the HBV vaccine series with a standard one-inch needle or a 1.5-inch needle. Patients younger than 19 received 0.5-mL injections, and older patients received 1.0-mL injections.&lt;/p&gt;
&lt;p&gt;Investigators used a standardized injection procedure: insertion of the needle at a 90&amp;#176; angle to the deltoid muscle, leaving 2 to 3 mm of needle visible between the skin and the hub.&lt;/p&gt;
&lt;p&gt;Patients received three doses of vaccine at baseline, one month, and four months. Blood samples were obtained at baseline and two months after the final injection.&lt;/p&gt;
&lt;p&gt;The two groups did not differ significantly with respect to median age (21), BMI (~40), deltoid skinfold (41 mm), triceps skinfold (~40 mm), days between vaccine doses one and three (~135), and days from third vaccine dose to titer assessment (65).&lt;/p&gt;
&lt;p&gt;At the end of the study, 24 patients had completed the immunization protocol, 10 in the one-inch group and 14 in the 1.5-inch group.&lt;/p&gt;
&lt;p&gt;Patients vaccinated with a one-inch needle had a median antibody titer of 189.8 mIU/mL compared with 345.4 mIU/mL for patients vaccinated with the 1.5-inch needle (&lt;em&gt;P&lt;/em&gt;=0.03).&lt;/p&gt;
&lt;p&gt;The between-group difference remained significant in analyses that excluded an outlier from the 1.5-inch group (&lt;em&gt;P&lt;/em&gt;=0.047) and that excluded the only two male patients in the study (&lt;em&gt;P&lt;/em&gt;=0.035).&lt;/p&gt;
&lt;p&gt;&quot;As we continue to experience high rates of obesity in the U.S. and throughout the world, additional evidence-based research on optimizing the effective delivery of immunizations to adolescents and young adults will be critical,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;Following updated needle length recommendations will be a first step toward improving the health of our youth and young adults by preventing vaccine-preventable diseases.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by federal grants and awards. GlaxoSmithKline provided the vaccine.&lt;/p&gt;&lt;p&gt;The authors had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_391"
                     title="Rare Genetic Deletion Linked to Morbid Obesity (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Genetics/GeneralGenetics/tb/18286?impressionId=1265806907397"
                     
      &lt;p&gt;Missing sections of DNA may have a powerful impact on weight for a small segment of the population, researchers said.&lt;/p&gt;
&lt;p&gt;Nearly all teens and adults found to have a particular deletion of roughly 30-genes on chromosome 16p11.2 were obese  --  most morbidly so  --  with a body mass index of at least 40 kg/m&lt;sup&gt;2&lt;/sup&gt;, Philippe Froguel, MD, PhD, of Imperial College London, and colleagues reported in &lt;em&gt;Nature&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;While the variant appeared to explain only a small proportion of morbid obesity  --  0.7% in the study population  --  it was never present in healthy, normal-weight controls.&lt;/p&gt;
&lt;p&gt;&quot;Although the recent rise in obesity in the developed world is down to an unhealthy environment, with an abundance of unhealthy food and many people taking very little exercise, the difference in the way people respond to this environment is often genetic,&quot; Froguel said in a prepared statement.&lt;/p&gt;
&lt;p&gt;But with further findings like these, it may be possible to identify such individuals through genetic testing, he said.&lt;/p&gt;
&lt;p&gt;If so, &quot;We can then offer them appropriate support and medical interventions, such as the option of weight-loss surgery, to improve their long-term health,&quot; Froguel declared.&lt;/p&gt;
&lt;p&gt;Although researchers speculate that one in 20 cases of obesity may have a genetic cause, the genetic component remains largely elusive.&lt;/p&gt;
&lt;p&gt;Even accounting for such a small fraction of cases, the newly discovered 16p11.2 variant would be the second most frequent known genetic cause of obesity, Froguel&apos;s group said.&lt;/p&gt;
&lt;p&gt;Extensive genome-wide association studies have linked numerous single nucleotide polymorphisms (SNPs) to obesity, but added all together they account for only a small fraction of the known heritable component, the researchers said.&lt;/p&gt;
&lt;p&gt;&quot;The &apos;common disease, common variant&apos; hypothesis is increasingly coming under challenge,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Their team first identified the genetic deletion in teen and adults with learning difficulties or delayed development.&lt;/p&gt;
&lt;p&gt;Because the 31 individuals who had the nearly identical deletions of at least 593 kilobases at chromosome 16p11.2 in one copy of their DNA all had a BMI of over 30 kg/m&lt;sup&gt;2&lt;/sup&gt;, the researchers decided to dig a little deeper.&lt;/p&gt;
&lt;p&gt;&quot;Cohorts with extreme phenotypes that include obesity may be enriched for rare but very potent risk variants,&quot; making them easier to discover, they wrote.&lt;/p&gt;
&lt;p&gt;So they undertook a case-control study among 312 patients at three centers in Britain and France who presented with congenital malformations, developmental delay, or both, in addition to obesity.&lt;/p&gt;
&lt;p&gt;The same deletions were seen in 2.9% of these individuals.&lt;/p&gt;
&lt;p&gt;The function of the missing genes are not well known, but some have previously been associated with delayed development, autism, and schizophrenia.&lt;/p&gt;
&lt;p&gt;Notably, though, the frequency of deletion of these genes in the obese case-control cohort was &quot;appreciably higher&quot; than the less than 1% seen in the autism and other studies that didn&apos;t include obesity as an inclusion criteria, the researchers said.&lt;/p&gt;
&lt;p&gt;A second independent survey of genetic data at eight cytogenetic centers in France, Switzerland, and Estonia turned up a 0.6% rate among 3,947 people with developmental delay, malformations, or both, but who were not selected for obesity (&lt;em&gt;P&lt;/em&gt;=0.00022 versus the cohort selected for obesity).&lt;/p&gt;
&lt;p&gt;Analysis of those with the missing genes revealed an age-dependent link to weight: All four teens and adults were obese. Children were often obese (four of 15) or overweight (two of 15). Children under 2 years all had normal weight.&lt;/p&gt;
&lt;p&gt;So to see whether the deletion was independent of neurodevelopmental problems, Froguel&apos;s group examined genome-wide association study data from general population cohorts totaling 11,856 individuals along with 2,772 from childhood obesity and adult morbid obesity case-control studies, 931 in an extreme early-onset obesity study, and 141 who had bariatric weight-loss surgery.&lt;/p&gt;
&lt;p&gt;All adult carriers of the deletion were obese with the exception of one who was apparently diabetic. Each of the seven children and adolescents who carried the variant had a BMI in the top 0.1% for their age and gender.&lt;/p&gt;
&lt;p&gt;None had any reported developmental or cognitive problems. Four had reported hyperphagia with excessive hunger and food intake.&lt;/p&gt;
&lt;p&gt;Altogether, the 16p11.2 deletions predicted 29.8-fold elevated risk of obesity (&lt;em&gt;P&lt;/em&gt;=0.00000058) and 43.0-fold elevated risk of morbid obesity (&lt;em&gt;P&lt;/em&gt;=0.000000064) compared with lean or normal weight.&lt;/p&gt;
&lt;p&gt;By extrapolation, the researchers extrapolated that about 0.4% of all morbidly obese cases are attributable to an inherited 16p11.2 deletion, with 0.3% arising from a de novo deletion in the same genetic region.&lt;/p&gt;
&lt;p&gt;&quot;Although they may be heterogeneous in nature, these deletions are highly likely to be the causal variants,&quot; they wrote.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by &quot;Le Conseil Regional Nord Pas de Calais/FEDER&quot; along with various governmental and industry supporters for the various component studies.&lt;/p&gt;&lt;p&gt;The researchers reported no financial conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_355"
                     title="Obesity Delays Puberty in Boys (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Pediatrics/Obesity/tb/18235?impressionId=1265806907397"
                     
      &lt;p&gt;Unlike overweight girls, who tend to enter puberty early, overweight and obese boys in the U.S. may begin puberty later than thin boys, according to one of the first longitudinal studies of weight and timing of puberty in males.&lt;/p&gt;
&lt;p&gt;At 11.5 years, boys with the highest body mass index (mean BMI z score=1.84) were 165% more likely to be prepubertal than the thinnest boys (95% CI 1.05 to 6.61; &lt;em&gt;P&lt;/em&gt;=0.04), researchers reported online in the Feb. 1 &lt;em&gt;Archives of Pediatrics and Adolescent Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This longitudinal study provides further evidence that higher BMI during early and middle childhood is not associated with earlier pubertal onset in boys, contrary to what is seen in girls,&quot; Joyce M. Lee, MD, MPH, of the University of Michigan, and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;In fact, higher BMI in earlier childhood may be associated with and precede later onset of puberty among a population-based sample of U.S. boys.&quot;&lt;/p&gt;
&lt;p&gt;Rates of obesity among American girls and boys have nearly tripled since the 1960s, prompting concerns about the effect of excess weight on growth and development. Most research has focused on obese girls, who appear to reach puberty earlier than thin girls. A recent cross-sectional study suggested that, unlike their female counterparts, overweight boys may develop later.&lt;/p&gt;
&lt;p&gt;To further explore this relationship, Lee and colleagues analyzed the records of 401 boys from diverse socioeconomic backgrounds in ten regions of the U.S., using data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. The participants were full-term, only children born in 1991.&lt;/p&gt;
&lt;p&gt;The data included height and weight measurements of the children from ages 2 to 12 years and a visual assessment of whether the children had begun puberty, using Tanner genitalia staging, at 9.5, 10.5, and 11.5 years. Boys were defined as prepubertal if they were Tanner stage 1 at 11.5 years old and were otherwise categorized as pubertal.&lt;/p&gt;
&lt;p&gt;Among the participants, 14.4% were overweight (BMI &amp;#8805; 85th and &amp;lt;95th percentiles) and 19.4% were obese (BMI&amp;#8805;95th percentile) at age 11.5. Overall, 49 boys (12.2%) were prepubertal at age 11.5 years by Tanner genitalia staging.&lt;/p&gt;
&lt;p&gt;The authors wrote that their findings have important implications for understanding sex differences in physiological mechanisms of puberty.&lt;/p&gt;
&lt;p&gt;They noted that puberty is regulated by the gonadotropin-releasing hormone axis for both girls and boys, but it&apos;s unclear why such different associations between body fat and the timing of pubertal onset would exist between the sexes.&lt;/p&gt;
&lt;p&gt;&quot;Given the recent childhood obesity epidemic, additional studies are needed to further investigate the epidemiological link between body fat and pubertal initiation and progression in boys as well as the physiological mechanisms responsible,&quot; they concluded.&lt;/p&gt;
&lt;p&gt;The authors were unable to analyze the data based on race, because most of the children in the study were white. They also noted that BMI is a surrogate measure of overall body fat, and that study has found that the relationship between body fat and BMI varies depending on race. They also recommended that future studies use multiple methods of determining whether children have entered puberty.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the National Institute of Child Health and Human Development and the American Heart Association.&lt;/p&gt;&lt;p&gt;The authors reported no financial conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_261"
                     title="Scrubbing Away Germs Can Backfire on Backsides (CME/CE)"
                     score="0.002"
                     href="http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/tb/18121?impressionId=1265806907397"
                     
      Rashes from toilet seats are once again afflicting American children, and the rare condition is often misdiagnosed, which may delay proper treatment.&lt;br&gt;
&lt;br&gt;That&apos;s the conclusion from a report based of five-cases of toilet-seat contact dermatitis investigated by researchers at Johns Hopkins University School of Medicine and reported in the Jan. 25 issue of &lt;em&gt;Pediatrics&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;While toilet-seat dermatitis is commonly thought to result from allergies to wooden seats, the report concludes that another source is plastic toilet seats cleaned with harsh detergents.&lt;/p&gt;
&lt;p&gt;&quot;This case series and previous reports have documented that toilet-seat dermatitis is much more common than previously recognized in the U.S. and around the world,&quot; Bernard A. Cohen, MD, and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;Furthermore, the incidence of this condition is rising in North America because of a resurgent popularity of exotic-wood toilet seats and frequent use of detergents that contain highly irritant/sensitizing compounds such as quaternary ammonium compounds, phenol, formaldehyde, etc. in public restrooms.&quot;&lt;/p&gt;
&lt;p&gt;Of the cases analyzed by the authors, two occurred in the U.S. and the other three occurred in India.&lt;/p&gt;
&lt;p&gt;Both U.S. cases were girls, a 6-year-old who had a rash for over two years before it was correctly diagnosed and a 10-year-old whose rash lasted for a year. In both cases, the rashes seemed to worsen during the school year when the girls were using school restrooms. The younger girl&apos;s dermatitis twice became infected with methicillin-resistant &lt;em&gt;Staphylococcus aureus &lt;/em&gt;and required treatment with antibiotics.&lt;/p&gt;
&lt;p&gt;After doctors determined the rashes were the result of contact with toilet seats and instructed the girls to use toilet-seat covers and apply moisturizers and topical steroids to the affected areas, the eruptions cleared up within a few weeks.&lt;/p&gt;
&lt;p&gt;The cases in India included a 14-month old boy and two girls, 12 and 10.&lt;/p&gt;
&lt;p&gt;The boy and the 12-year-old girl were both initially misdiagnosed with ringworm and unsuccessfully treated with clotrimazole cream. The other girl was unsuccessfully treated with ayurvedic and homeopathic topical medications before doctors diagnosed toilet-seat dermatitis. Two of the children were instructed to use soaps that only exacerbated the problem.&lt;/p&gt;
&lt;p&gt;In all three cases, the rashes cleared up with some combination of topical steroids, using toilet-seat covers, replacing the household toilet seat, and limiting time on the toilet.&lt;/p&gt;
&lt;p&gt;The authors distinguished between two types of toilet-seat dermatitis: allergic contact dermatitis, the better described form of the condition, in which a patient develops allergy to wooden toilet seats, and irritant contact dermatitis, in which the rashes result from contact with harsh detergents used on plastic toilet seats.&lt;/p&gt;
&lt;p&gt;They noted that detergents used in public restrooms and in hospitals are potentially more irritating to the skin than those used at home and that alkaline detergents are more likely to cause skin irritation than acidic detergents, because they perturb the body&apos;s natural acidic environment.&lt;/p&gt;
&lt;p&gt;Toilet-seat dermatitis was first identified as an external skin rash in 1927. Exposure to wooden toilet seats and associated varnish, lacquers, and paints led to sensitization and development of an allergic contact dermatitis.&lt;/p&gt;
&lt;p&gt;The condition nearly disappeared in the U.S. in 1980s and 1990s, after public facilities and homeowners in the U.S. changed from wooden to plastic toilet seats and sanitary seat covers became readily available.&lt;/p&gt;
&lt;p&gt;However, in recent years the number of cases has grown as a result of homeowners installing toilet seats made of exotic woods and the increased use of harsh toilet seat detergents.&lt;/p&gt;
&lt;p&gt;Most reports have focused on adults with rashes, but little previous attention has focused on the condition in children. &quot;In this case series we describe toilet-seat contact dermatitis in children and underscore a typical history and physical findings that we hope will aid clinicians in recognizing this disease,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;It is important to underscore that regular use of toilet-seat covers is the key to success in treatment,&quot; the authors wrote. &quot;Such seat covers can be purchased at any major retailer such as Walmart or online.&lt;/p&gt;
&lt;p&gt;As an alternative, newspaper cutouts could be used to provide barrier protection. Although it is possible to develop an allergy to toilet-seat covers, none have been reported thus far in the literature.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors reported no sources of funding or financial conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_229"
                     title="Abnormal Lipid Levels Common in Teens"
                     score="-0"
                     href="http://www.medpagetoday.com/Cardiology/Dyslipidemia/tb/18084?impressionId=1265806907397"
                     
      &lt;p&gt;One in five American adolescents has unhealthy cholesterol and triglyceride levels, suggesting that targeted screening of youths would be a good idea, CDC researchers said.&lt;/p&gt;
&lt;p&gt;Data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2006 indicated that 20.3% (95% CI 18.0% to 22.8%) of participants 12 to 19 years old had higher-than-normal levels of LDL cholesterol or triglycerides, or low levels of HDL cholesterol, according to Ashleigh L. May and colleagues at the CDC&apos;s National Center for Chronic Disease Prevention and Health Promotion.&lt;/p&gt;
&lt;p&gt;They also found that about a third of American youths would be candidates for lipid screening on the basis of body mass index (BMI) value, under guidelines from the American Academy of Pediatrics.&lt;/p&gt;
&lt;p&gt;Their findings, based on blood tests in 3,125 young NHANES participants, were published in the Jan. 22 issue of &lt;em&gt;Morbidity and Mortality Weekly Report&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;High LDL cholesterol was defined as at least 130 mg/dL. High triglyceride levels were 150 mg/dL or above. HDL cholesterol of 35 mg/dL or below was considered low. These applied equally across age groups.&lt;/p&gt;
&lt;p&gt;Here is the overall prevalence of each individual lipid abnormality: &lt;ul&gt; &lt;li&gt;High LDL: 7.6% (95% CI 6.2% to 9.3%)&lt;/li&gt; &lt;li&gt;Low HDL: 7.6% (95% CI 6.3% to 9.2%)&lt;/li&gt; &lt;li&gt;High triglycerides: 10.2% (95% CI 8.4% to 12.2%)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Those 18 to 19 years old were much more likely to have these abnormalities than younger adolescents: some 28.8% of participants in this age group had at least one, compared with 16.5% to 18.4% of those 17 and younger (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05).&lt;/p&gt;
&lt;p&gt;Prevalence of lipid abnormalities was also more common among white youths (22.4%) than among black (14.6%) and Hispanic (18.6%) participants (&lt;em&gt;P&lt;/em&gt;&amp;#8804;0.05 for both groups versus whites). Girls were somewhat less likely than boys to have one or more abnormalities (prevalence ratio 0.7, 95% CI 0.5 to 0.9).&lt;/p&gt;
&lt;p&gt;Not surprisingly, overweight and obese youths were much more likely than those of normal weight to have unhealthy lipid levels.&lt;/p&gt;
&lt;p&gt;Some 43% of obese adolescents had at least one abnormality, as did 22% of those considered overweight for their age and height. Both were significantly higher than the 14.2% of normal-weight participants with abnormal lipid levels.&lt;/p&gt;
&lt;p&gt;&quot;Based solely on their BMI, 32% of all youths would be candidates for lipid screening,&quot; May and colleagues wrote.&lt;/p&gt;
&lt;p&gt;An unsigned commentary by &lt;em&gt;MMWR&lt;/em&gt;&apos;s editors noted that &quot;untreated abnormal lipid levels in childhood and adolescence are linked to increased risk for cardiovascular disease in adulthood,&quot; but they stopped short of endorsing routine lipid testing for adolescents.&lt;/p&gt;
&lt;p&gt;The American Academy of Pediatrics recommends screening youths with specific risk factors such as overweight and family history. The U.S. Preventive Services Task Force looked at the screening issue in 2007 and decided not to recommend for or against routine screening.&lt;/p&gt;
&lt;p&gt;The &lt;em&gt;MMWR&lt;/em&gt; editors suggested a strategy in line with the pediatrics group&apos;s recommendation. &quot;Targeted screening of youths for abnormal lipid levels can identify those youths who might benefit from interventions that reduce the risk for CVD,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;Based on the findings in this study, clinicians should be aware of lipid screening guidelines and recommended interventions for children and youths who are overweight or obese,&quot; the editors added.&lt;/p&gt;
&lt;p&gt;Such interventions include behavior and nutrition counseling and, if lipid levels remain abnormal, drug treatment.&lt;/p&gt;
&lt;p&gt;But the editors pointed out that fewer than 1% of NHANES participants included in the current study &quot;had lipid levels high enough to warrant drug therapy according to AAP guidelines.&quot;&lt;/p&gt;

    </recommendedItem>
</recommendedContent>