Family Meals: They Do Everyone Good

Patient Presentation
An 18-month-old male came to clinic for his health maintenance visit. His dietary history showed he drank ~45 ounces of milk a day mainly from a bottle that he was allowed to have during most of the day. His mother complained that he didn’t eat much solid food, and wouldn’t sit down to eat. She noted that she didn’t really stop to eat herself. She would just drive through a fast-food restaurant and eat in the car even if she was not pressed for time. “It’s just something I do,” she said. He was doing well with normal development. The past medical history showed a healthy male. The social history showed him living with his employed mother. There was maternal family support locally. The family did not receive governmental assistance and the mother felt she had adequate resources from her employment. The pertinent physical exam revealed a smiling male with normal vital signs and growth parameters in the 25-50%. His examination was normal including normal appearing teeth.

The diagnosis of a healthy male with inappropriate food intake and behaviors was made. The pediatrician counseled the mother to decrease the total milk intake to 16 ounces/day and to put this into a sippy-cup or regular cup. “Any other fluid he wants can be up to 4 ounces of juice a day or water. All of it should be in a cup. He also should not be walking around with the cup. If he fills up on fluid he won’t eat. He should have 3 meals and a couple of snacks a day and he needs to sit down whenever he eats or drinks. It really does only take a few minutes and you both can have a nice time together talking and eating. It’s also a good break for you during the day. Even if you do have some fast-food, you should eat it as a family, sitting down together. He’ll learn what is expected of him at the dinner table too.” The laboratory evaluation showed a low hemoglobin and hematocrit so he was started on elemental iron.

The patient’s clinical course at 3 month followup found the mother to be proud of having started some of the interventions. She reported that he was only using a sippy-cup and taking only 24 ounces of milk a day. “He cries so much for the milk that I give him more than I should,” she said. “We are sitting down more together though – at least for dinner and most of his snacks when I am with him. When we are at my mom’s house, we have started to have him sit with us for part of our dinner too,” she remarked.

Discussion
Family meals (FM) are “…occasions when food is eaten simultaneously in the same location by more than 1 family member.” Overall, more frequent family meals are protective for healthy physical and psychosocial functioning across socioeconomic status, race/ethnicity and gender. Why FMs have these protective effects (possibly related to family connectedness) is unclear and additional research is ongoing.

Factors associated with increased FMs include:

  • Increased parental education
  • Gender – adolescent boys report more FM than adolescent females
  • Race/ethnicity – Asian-Americans have more FM than whites who have more than African-Americans. Hispanics have more FMs.
  • Children’s ages – younger children have more FMs than older children and adolescents
  • Parenting style – mothers who are authoritative have more FMs

The ideal FM environment is one that is positive, without arguments if possible and encourages communication among the family members. There should be no television or other electronic devices (including phones) in the room. Quiet music can help to set a positive mood for the meal. FMs do not have to be long and can be as short as 20 minutes.

Barriers to FMs often cited are work and school/extracurricular schedules, lack of meal planning, not having a regular time set for meals, picky eaters, young children not able to sit through the meal, and family members being hungry at different times. Ways to overcome this include setting the expectations that FMs will occur and family members are expected to participate, making grocery lists, making meals ahead of time for use later, and use of time saving devices such as microwave ovens and slow-cookers. Additional ways to keep the FM a popular and daily event include keeping the conversation fun and light, involving the children in meal preparation and serving foods that the children enjoy. FMs also can expand the types of foods children enjoy and the FM should not turn into a short-order restaurant to prepare separate meals for each person’s tastes.

Learning Point
Eating more frequent family meals has better physical and psychosocial outcomes for children including:

  • Increased/Improved
    • Consumption of good nutrition including appropriate calories, “… protein, fiber, calcium, iron, folate, and vitamins A, B-6, B-12, C and E….”, and increased servings of fruits, vegetables, grains and calcium-rich foods.
    • Healthy body weight
    • Body image perception
    • Self-esteem
    • Academic grade point averages, commitment to learning, language skills
    • Family relationships (e.g., perceived family support, communication, and parental involvement), and connectedness
    • Effective communication
  • Decreased
    • Consumption of poor nutrition including soda consumption and saturated fats
    • Disordered eating including less obesity and eating disorders
    • Alcohol and substance abuse (including tobacco and marijuana)
    • Depression and suicidal thoughts
    • Violent behavior

Questions for Further Discussion
1. How often do you personally have family meals?
2. How could you include family meal counseling into your preventative care discussions?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Family Issues and Child Nutrition.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Berge JM, Rowley S, Trofholz A, Hanson C, Rueter M, MacLehose RF, Neumark-Sztainer D. Childhood obesity and interpersonal dynamics during family meals. Pediatrics. 2014 Nov;134(5):923-32.

Martin-Biggers J, Spaccarotella K, Berhaupt-Glickstein A, Hongu N, Worobey J, Byrd-Bredbenner C. Come and get it! A discussion of family mealtime literature and factors affecting obesity risk. Adv Nutr. 2014 May 14;5(3):235-47.

Harrison ME, Norris ML, Obeid N, Fu M, Weinstangel H, Sampson M. Systematic review of the effects of family meal frequency on psychosocial outcomes in youth. Can Fam Physician. 2015 Feb;61(2):e96-106.

DeGrace BW, Foust RE, Sisson SB, Lora KR. Benefits of Family Meals for Children With Special Therapeutic and Behavioral Needs. Am J Occup Ther. 2016 May-Jun;70(3):7003350010p1-6.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Common are Herniated Disks in Children?

Patient Presentation
A 15-year-old female came to clinic with a history of lumbar pain for 2 weeks. She was a softball infielder and thought that the pain began after she had increased her training and had to slide into bases over a several day period. She said it was “just always there” and she described 4-6/10 for intensity. No specific movements or position made it worse or better. She had tried using heat and ice, massage and some increased rest at night but she still did not stop playing. Intermittent ibuprofen provided some relief. She denied any specific radiation of the pain into her legs, or bowel or bladder problems. The past medical history was positive for a sprained ankle. The family history was positive for a maternal grandmother with a herniated disk as an older woman. The review of systems was negative.

The pertinent physical exam showed a healthy female with normal growth parameters and vital signs. Her spine appeared normal. She had generalized stiffness and decreased flexibility in the lumbar spine. No specific flexion, extension, lateral movement or rotational movement of the spine increased the pain or elicited radicular symptoms. She did have a positive straight leg test on both sides but her hamstrings were also tight. She had no specific sensory changes in the lower extremities.

The diagnosis of low back pain that was most likely soft tissue in origin was made. Because it had not improved, and radiologic evaluation using plain radiographs were ordered and were normal. The patient’s clinical course showed she began rehabilitation with physical therapy. Unfortunately after another 2 weeks she continued to have pain and was referred to a sports medicine specialist. Magnetic resonance imaging at that time showed a protrusion of the L4-L5 disk. She was instructed to use high dose oral anti-inflammatory medication, rest and do monitored rehabilitation with the physical therapist. After another 2 weeks with some but not significant improvement she had a steroid injection after which she had pain relief. She continued to do her rehabilitation and slowly over the next 8 weeks she returned to her normal routine.

Discussion
Intervertebral disk herniation occurs at the same locations in pediatric patients as adults with L4-L5 and L5-S1 being the most common. Patients often (30-60% for lumbar disk patients) have a direct trauma or sports related injury that is identified before the onset of pain. There is also a group of morbidly obese patients who probably have degenerative disease. In adults and children, lumbar disk herniation is also seen with repetitive or excessive axial loading, poor conditioning, decreased range of motion and history of prior back injury. Disk herniation is caused by vertebral motion that causes increased intradisk pressure including axial compression, lumbar flexion and/or rotation.

Presentation is usually acute low back pain and/or lower extremity radiculopathy. Pediatric patients often will have less specific descriptions of the pain or complain of other symptoms which leads to longer duration before diagnosis. Disk disease is also uncommon therefore other common causes of back pain are usually sought first. A differential diagnosis of back pain can be found here. “Less than 10% of children presenting with low back pain have disk herniation as the cause, and less than half of those children require surgery.” Causes of back pain that are associated with back extension on physical examination include spondylolysis or spondylolisthesis, and slipped vertebral epiphysis. Problems associated with back flexion on physical examination include disk herniation, apophyseal injuries of the vertebral end plates, Scheuermann disease and Schmorl nodes.

Most patients with a herniated disk will have symptoms with a straight leg raising test and about ~33% will also have a positive crossed straight leg raising test. The straight leg test is considered positive if leg pain (not back pain) radiates below the knee. A reactive scoliosis is also common in pediatric patients with bending toward the contralateral side in an attempt to open up the affected intervertebral space and decrease pressure on the affected nerve. This scoliosis usually resolves with treatment. Patients also often present with generalized stiffness and compensatory gait abnormalities that usually improve with treatment. The bowel and bladder are usually not affected.

Bowel and/or bladder dysinnervation or other progressive neurological deficits, debilitating pain and non-relief with conservative treatment are causes for surgical intervention. Conservative treatment usually includes rest, physical therapy to improve mobilization, flexibility and strength, and anti-inflammatory medication. Pediatric patients with disk herniation f2007 unfortunately respond less well than adults to conservative treatment and are more likely to require operative treatment. This is felt to be because pediatric disks are more elastic and have a higher water content than adults who often have more dried out or degenerative disks. Because of the elasticity operative management also can be more difficult to perform. Open procedures are usually performed and not endoscopic procedures or chemonucleolysis. Surgical treatment has good short term prognosis but 20-30% of patients may require repeated surgical treatment later in life. Plain radiographs of the spine will rule out other causes of back pain such as various fractures and malalignment. Magnetic resonance imaging is the choice for disk disease as it helps to evaluate the soft tissue and neural constituents.

Learning Point
Although intervertebral disk herniation is common in adults, it is relatively uncommon in children. Of patients with disk herniation in various case series, it occurs 0.4%-15.4% in pediatric patient with ~5% being cited often. It is even more infrequent in patients < 10 years of age, but increases in the adolescent population. Gender predominance depends on the study. A positive family history has been reported as a risk factor with presumed weak connective tissue or developing degenerative changes at an earlier age being the proposed explanation.

Questions for Further Discussion
1. What spinal levels correspond to dermatomes in the anterior leg?
2. What spinal levels correspond to dermatomes in the posterior leg?
3. What are indications for referral to a sports medicine specialist?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Herniated Disk and Spine Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Slotkin JR, Mislow JM, Day AL, Proctor MR. Pediatric disk disease.
Neurosurg Clin N Am. 2007. Oct;18(4):659-67.

Tsutsumi S, Yasumoto Y, Ito M. Idiopathic intervertebral disk calcification in childhood: a case report and review of literature. Childs Nerv Syst. 2011 Jul;27(7):1045-51.

Lavelle WF, Bianco A, Mason R, Betz RR, Albanese SA. Pediatric disk herniation. J Am Acad Orthop Surg. 2011 Nov;19(11):649-56.

Ho C, Chang S, Fulkerson D, Smith J. Children presenting with calcified disc herniation: a self-limiting process. J Radiol Case Rep. 2012 Oct;6(10):11-9.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Causes Hyperphosphatemia?

Patient Presentation
A 6-month-old male came to the floor of a regional children’s hospital after being transferred from a local emergency room because of abdominal distention. The local emergency room physicans had contacted a local pediatrician who ordered an enema for the patient. The patient received the enema but had no fecal return. He continued to have abdominal distention and the decision to transfer him was made. Upon arrival at the children’s hospital the patient had bradycardia and a respiratory arrest. After intubation his heart rate increased to normal and he had spontaneous respirations. In the pediatric intensive care unit the pertinent physical exam showed a temperature of 99.8°F, heart rate of 128, respiratory rate of 22, blood pressure of 104/62 with a capillary refill of 3-4 seconds and pale color. He had a grossly distended abdomen without bowel sounds. He had a normal heart rate and sounds. His lungs were clear. He also had intermittent extremity spasms especially of his hands and feet. The pertinent laboratory evaluation at that time showed a glucose of 23 mg/dl, ionized calcium of 1.3 (normal 4.5-5.6 mg/dl), total calcium of 7.4 (normal 9.0-10.5 mg/dl), phosphorous of 28 (normal 3-4.5 mg/dl) and magnesium of 1.9 (normal 1.8-3.0 mg/dl). The differential diagnosis at that time included sepsis with ileus, volvulus, appendicitis with perforation (unlikely due to age), pseudoobstruction, bowel perforation, and metabolic abnormalities. The past medical history that became available later revealed a term infant who stooled around birth but had problems with constipation. A previous rectal biopsy had shown ganglion cells and his neonatal screening test was normal including for cystic fibrosis. He had been treated with oral polyethylene glycol and occasional enemas for constipation. The family history was negative for genetic, metabolic, neurologic or gastrointestinal problems. He was treated for presumed sepsis and hypocalcemia, hypoglycemia, and hyperphosphatemia with aggressive hydration, calcium gluconate, ampicillin, gentamycin and metronidazole, and rectal irrigation.

His clinical course over the next 24 hours, showed having tetany episodes that improved with additional calcium, but eventually his hypocalcemia, hypoglycemia and hyperphoshatemia all resolved. His blood cultures later grew Enterococcus species as a cause of his sepsis. He unfortunately had an ileal perforation that required an ileostomy. During surgery there was normal bowel anatomic alignment and biopsy of various bowel segments showed ganglion cells in all biopsies. Cystic fibrosis and other testing for severe ileus with perforation was being pursued. The tetany and metabolic problems were felt to be caused by the retention of a phosphate-based enema with resulting hyperphosphatemia and hypocalcemia which caused cardiac irritability and cardiopulmonary arrest.

Case Image
Figure 120 – Supine view of the abdomen reveals multiple dilated loops of bowel without evidence of rectal gas. The findings were felt to be compatible with a distal bowel obstruction.

Discussion
Constipation is a common problem in general pediatrics and its causes are numerous. It can cause acute and recurrent abdominal pain and is a cause of abdominal distention. Patients who are young, whose presentations are other than routine or who had complications should be invested for underlying causes of their constipation. This patient had undergone some evaluations in the past for constipation but because of the presentation of sepsis a more rigorous evaluation was undertaken. The differential diagnoses of the following can be found here: constipation, acute abdominal pain, recurrent abdominal pain, and abdominal distention.

Hyperphosphatemia caused by retention of oral phosphate containing medications and hypertonic sodium phosphate enemas are known causes of hyperphosphatemia. Phosphate-containing medications are used because the hyperosmolarity draws fluid into the intestinal lumen which stimulates peristalsis. Usually the phosphate and fluid are then evacuated. However, the phosphate can be absorbed, particularly if there is lack of bowel integrity, with resulting hyperphosphatemia. With rising concentrations of phosphate, calcium is bound causing hypocalcemia both extracellualrly and intracellularly. Hyperphosphatemia also inhibits Vitamin D hydroxylation and inhibits reabsorption of calcium in the bone. While hypocalcemia is the most common secondary problem due to hyperphosphatemia, hypokalemia, hypomagnesemia and hypoglycemia can also occur. Phosphate toxicity is treated by increasing urinary excretion, phosphate binders (such as aluminum hydroxide) and dialysis.

Hypocalcemia is associated with neuromuscular problems including irritability, poor feeding, emesis, paresthesia, muscle cramps (tetany) seizures, prolongation of the QT interval and cardiac arrhythmias. Chvostek’s sign occurs when tapping on the facial nerve causes facial muscle movement. It is common in hypocalcemia but can also be seen in hypomagnesemia, normal individuals, and patients with migraines or epilepsy. Trousseau’s sign occurs when a blood pressure cuff is inflated around the arm at a pressure greater than systolic pressure for 3 minutes and induces a spasm of the hand and forearm. This also occurs with hypocalcemia. Acidosis and hypoproteinemia tend to protect patients from secondary hypocalcemia problems by increasing the ionized fraction of serum calcium. Hypocalcemia is treated by giving calcium by judicious infusions with either calcium gluconate or calcium chloride. A differential diagnosis of hypercalcemia can be reviewed here.

Learning Point

Phosphate is mainly regulated by parathyroid hormone and dietary/gastrointestinal intake. Therefore hyperphosphatemia occurs primarily because of disregulation to these systems.
The differential diagnosis of hyperphosphatemia includes:

  • Phosphate containing medications and bisphosphonates
  • Renal failure – acute or chronic
  • Hypoparathyroidism
  • Vitamin D toxicity
  • Tumor lysis syndrome
  • Tissue necrosis
  • Rhabdomyolysis
  • Hyperostosis
  • Familial tumoral calcinosis
  • Pseudohyperphosphatemia
  • Acromegaly

Questions for Further Discussion
1. What causes changes in magnesium?
2. What causes changes in potassium?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Fluid and Electrolyte Balance and Minerals.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Oxnard SC, O’Bell J, Grupe WE. Severe tetany in an azotemic child related to a sodium phosphate enema. Pediatrics. 1974 Jan;53(1):105-6.

Hebbar K, Fortenberry JD, Parks JS. Severe hypocalcemic tetany and respiratory failure in an infant given oral phosphate soda. Pediatr Emerg Care. 2006 Feb;22(2):118-20.

Domico MB1, Huynh V, Anand SK, Mink R. Severe hyperphosphatemia and hypocalcemic tetany after oral laxative administration in a 3-month-old infant. Pediatrics. 2006 Nov;118(5):e1580-3. Epub 2006 Sep 25.

Stubbs JR, Yu ASL. Overview of the causes and treatment of hypophatemia. UpToDate. (rev. 7/6/2015, cited 6/27/16).

Hasan ZU, Absamara R, Ahmed M. Chvostek’s Sign in Paediatric Practice. Current Pediatric Reviews, 2014:10;194-97.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Effective is Oseltamivir?

Patient Presentation
A 2-year-old male came to clinic with a 24 hour history of fever to 102-103°, rhinorrhea, cough and what his parents believe were muscle aches. There was no nausea, emesis or rash. He was drinking but not eating solid foods and was urinating well. He had received acetaminophen for his fever and discomfort with symptomatic relief. He had received a seasonal influenza vaccine 3 months prior to the visit. Influenza was circulating in the community and he had a known exposure to influenza at his daycare. Additionally there was a 2-month old sibling at home. The past medical history was positive for 3 otitis media episodes in the past.

The pertinent physical exam showed a tired, sick appearing male. His temperature was 38.5°C. His respiratory rate was 36 without increased work of breathing. His oxygen saturation was 95% on room air. The rest of his vital signs were normal with growth parameters in the 75-95%. He had copious clear rhinorrhea and tearing with some mild conjunctival injection. His mouth and ears were normal. His lungs were clear. There were no rashes. He complained of muscle aches with palpation of his arms and legs but did not appear to have any joint involvement. The rest of his examination was normal. The diagnosis of presumed influenza was made. He was started on oseltamivir for treatment. His parents had also received a seasonal influenza vaccine and they contacted their own physicians and received prophylactic oseltamivir. At followup for a health maintenance visit for the sibling the following week, the mother said that the infant did not develop influenza.

Discussion
Oseltamivir (Tamiflu®) is an oral neuraminidase inhibitor of influenza viruses types A and B. It first came on the market in Switzerland in 1999 and currently is used around the world along with other neuraminidase inhibitors to treat seasonal and pandemic influenza.

Oseltamivir is easily absorbed from the gastrointestinal tract, and circulates to the liver where it is converted to its active metabolite oseltamivir carboxylate (OC). In adults approximately 75% of the oral medication is converted and it then travels to the upper and lower respiratory tracts. Unchanged oseltamivir is eliminated in the urine. OC “inhibits the conserved active site of the neuraminidase enzymes that are present as major surface antigens on all types of influenza viruses. As neuraminidase is essential for the release of progency virions from infected cells, inhibiting this enzyme limits the duration and severity of the infection.” OC half-life is about 1-2 hours and the maximal concentrations occur ~ 3-4 hours after administration. Children < 12 years of age clear OC faster than teenagers and adults resulting in a lower drug exposure.

Oseltamivir is approved for use for treatment of uncomplicated influenza especially for those at increased risk such as infants, pregnant women and those with chronic cardiac, respiratory or metabolic problems, for severe or progressive influenza, and for those that are immunosuppressed. It can also be used for post-exposure prophylaxis. Oseltamivir can be used more than once during the season and has been used for seasonal prophylaxis particularly in institutional settings such as nursing homes. If resistance to oseltamivir is known (such as the H275Y mutation in season H1N1 viral strains) then other neuraminidase inhibitors such as zanamivir are recommended.

The most common side effects in children are nausea and vomiting. Neuropsychiatric symptoms that have been reported with use of oseltamivir include mental status changes, agitation, anxiety, confusion, delusions, hallucinations and nightmares. It is not clear why these symptoms may occur as oseltamivir does not cross the blood-brain barrier to any appreciable extent.

One study estimated the cost-effectiveness of different treatment strategies using oseltamivir for uncomplicated seasonal influenza in unimmunized patients 1-17 years. Empirically treatment was more cost effective than testing and then treating. Both empiric treatment or testing and then treating were more cost effective than no treatment. However, the cost effectiveness was very sensitive to the prevalence of oseltamivir-resistant strains that are circulating.

Of course, oseltamivir is not a substitution for receiving the seasonal influenza vaccine. Treatment recommendations or prophylaxis are always changing because of the changes in the influenza virus and its epidemiology. Health professionals should follow current recommendations from public health authorities.

Learning Point
The burden of influenza is often not apparent to many individuals. In the United States, up to 20% of the population develop influenza each year, deaths occur in 36,000-49,000 people, and ~250,000 require hospitalizations for complications such as pneumonia. Some strains have higher morbidity and mortality. For example, children and young adults had higher morbidity and mortality during the 2009-2010 H1N1 pandemic. The Avian H5N1 strain are more virulent than seasonal strains and have mortality rates >50%.

A 2014 Cochrane Review of the effectiveness of oseltamivir treatment included 107 clinical studies and 73 trials and found:

For treatment of symptomatic patients, time to first symptom alleviation was reduced by 16.8 hours or from 7 to 6.3 days. In children the reduction was 29 hours. There was no change for asthmatic children. In children there was no significant effect on hospitalizations. There also were no significant reduction in serious complications or in hospitalizations, but there are problems with the data because of lack of diagnostic definitions. Oseltamivir did reduce the risk of symptomatic influenza for individuals or households for those who used it for prophylaxis.

Questions for Further Discussion
1. What is the cost of oseltamivir in your local area?
2. What other neuraminidase inhibitors do you have available in your local area?
3. What is the rate of season influenza vaccination in your own practice?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Flu and Flu Shot.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Smith JR, Rayner CR, Donner B, et. al. Oseltamivir in seasonal, pandemic, and avian influenza: a comprehensive review of 10-years clinical experience. Adv Ther. 2011 Nov;28(11):927-59.

Lavelle TA, Uyeki TM, Prosser LA. Cost-effectiveness of oseltamivir treatment for children with uncomplicated seasonal influenza. J Pediatr. 2012 Jan;160(1):67-73.e6.

Jefferson T, Jones MA, Doshi P, et. al. Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children. Cochrane Database Syst Rev. 2014 Apr 10;4:CD008965.

Centers for Disease Control. Estimating Seasonal Influenza-Associated Deaths in the United States: CDC Study Confirms Variability of Flu.
Available from the Internet at http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm (rev. 3/18/16, cited 5/24/16).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital