BackgroundCurrent guidelines for nutritional rehabilitation in hospitalized restrictive eating disorder patients recommend a cautious approach to refeeding. Several studies suggest that higher calorie diets may be safe and effective, but have traditionally excluded severely malnourished patients. The goal of this study was to evaluate the safety of a higher calorie nutritional rehabilitation protocol (NRP) in a broad sample of inpatients with restrictive eating disorders, including those who were severely malnourished.MethodsA retrospective chart review was conducted among eating disorder inpatients between January 2015 and March 2016. Patients were started on a lower calorie diet (≤1500 kcals/day) or higher calorie diet (≥1500 kcals/day). Calorie prescription on admission was based on physician clinical judgement. The sample included patients aged 8–20 years with any DSM-5 restrictive eating disorder. Those who were severely malnourished (<75% expected body weight [EBW]) or required tube feeding during admission were included. Multivariable regression models were used to determine whether level of nutritional rehabilitation was associated with hypophosphatemia, hypomagnesemia, or hypokalemia.ResultsThe sample included 87 patients; mean age was 14.4 years (S.D. 32.7); 29% were <75% EBW. The majority (75.8%) was started on higher calorie diets (mean 1781 kcal/day). Controlling for rate of calorie change, initial %EBW, age, race/ethnicity, insurance, diagnosis, and NG/NJ tube placement, higher calorie diets were not associated with hypophosphatemia, hypomagnesemia, or hypokalemia on admission or within the first 72 h. Increased risk of hypophosphatemia on admission was associated with lower baseline %EBW.ConclusionA higher calorie NRP was tolerated in this broad population of inpatients with restrictive eating disorders. Lower %EBW on admission was a more important predictor of hypophosphatemia than initial calorie level. Larger studies are required to demonstrate the safety of higher calorie diets in severely malnourished patients.

The American Academy of Pediatrics California Chapter 3 created a 20-minute training video targeting barriers to strong provider recommendation of the human papillomavirus (HPV) vaccine. The video included clinical vignettes featuring pediatricians modeling counseling techniques with vaccine-hesitant families. Ninety-six multidisciplinary providers (including pediatric residents) at 6 sites viewed the video and completed baseline and posttest questionnaires assessing their vaccine knowledge, attitudes toward vaccination, and comfort with skills needed to facilitate vaccination. Following the intervention, providers had substantial and statistically significant (P < .05) improvements in multiple areas assessed, particularly knowledge of the burden of HPV-related disease in males and changes in vaccine response with age; likelihood of “strongly agreeing” that vaccination should not be delayed beyond preadolescence and that HPV vaccine is safe; and feeling “very comfortable” counseling vaccine-hesitant parents and facilitating vaccine completion. This cost-effective and easily disseminated training modality shows promise in increasing provider comfort with HPV vaccine counseling.

Hyponatremia is a common electrolyte abnormality among children and adults. Visual disturbance associated with hyponatremia has been described in the past; however, all of these cases presented primarily with other classical signs and symptoms of hyponatremia, such as seizures, gastrointestinal upset, lethargy, or headache. We present a child who developed blindness on post-operative day #6 after resection of a brain tumour. Computed tomography of the head showed no new bleed, mass lesion, edema, or occipital lobe pathology. Laboratory evaluation revealed acute hyponatremia (115 mmol/L). No other obvious symptoms of hyponatremia were present prior to its identification. As her hyponatremia was gradually corrected, her blindness completely resolved. This is the first reported patient with acute hyponatremia to present primarily with blindness; a ?precondition? of chronically increased intracranial pressure (first hit) compounded by acute hyponatremia (second hit) may have induced reversible visual loss. Checking electrolytes should be the standard of care for neurosurgical patients with acute visual disturbance or other unexplained symptoms. It is a simple measure that quickly identifies a dangerous but reversible condition.

Seven states in the United States and the District of Columbia have legalized the recreational use of marijuana. The push for legalizing recreational marijuana is rapidly gathering momentum; 4 of the 7 states legalized recreational marijuana use in November 2016, and the Canadian federal government has announced its intent to do the same by 2018.Supporters of legalizing use argue that it will lead to increased regulatory capacity, which can restrict its sale to minors while permitting adults to use small amounts without fear of legal consequence. However, critics raise concerns that legalization will promote more permissive attitudes toward marijuana among minors, which may increase their rates of use. In a 2017 study, adolescents in states that had legalized recreational marijuana had lower perceptions of harm associated with marijuana use and higher past-month use compared with prelegalization rates. 1 These trends appeared to be more pronounced in regions that experienced a larger increase in marijuana commercialization and advertising over the study period. 1 It is unclear whether legalizing recreational use of marijuana itself promotes more lenient approaches toward marijuana or if a preexisting culture of permissive attitudes is the impetus for legalizing recreational use. However, 10% of non-marijuana using high school students state that they intend to initiate use specifically if and when marijuana becomes legal, 2 suggesting that legalizing the use of marijuana does influence adolescent behavior.With increased marijuana use comes the potential for increased adverse health outcomes among young people. Evidence is mounting that early and frequent marijuana use is not only associated with psychosis but also with long-term neurocognitive changes, including learning difficulties, memory problems, and a higher lifetime risk of schizophrenia. 3 Additional danger is likely to arise from more adolescents driving under the influence of marijuana, a phenomenon that is increasing in frequency in the postlegalization era. 4 An increase in use among young adults is also likely to lead to increased unintentional marijuana ingestions among their children. For example, Colorado legalized recreational use in 2009. In the years prior, there were no reported cases of toddler marijuana ingestion within the state. However, between 2009 and 2015, 81 cases of unintentional toddler marijuana ingestion were reported, with 13 of 62 (21%) requiring inpatient admission and 9 of 62 (15%) needing admission to intensive care units. 5 In our changing legal environment, pediatric physicians must revisit their approach to screening adolescents and young adults for marijuana use and initiating conversations about its associated health consequences. However, there are numerous challenges in