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Evaluations of all Arabic speaking children age 3-9.0 years with significant speech delays or impairments, referred to a community based, child development center in the public health care system during a 5-year period were reviewed. Use of an inordinate degree of words and expressions in Fossha version of classical Arabic, mainly used in the media, children's literature and formalized venues, as well as in English, was highly associated with ASD, especially among those who were both more intelligent (IQ> 70), as well as older (greater than 4 years), (Pearson 7.29, Fisher 2-tailed test, p = 0.015). The use of "out of context" speech embedded in ordinary Arabic vernacular was associated with a higher degree of speech stereotypy (p < 0.001) among children with ASD, and unrelated statistically to the number of hours of screen viewing time, jargoning or associative speech. Idiosyncratic speech choices reflect neuro-linguistic mechanisms in social communication- impaired youngsters.

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INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) is a worldwide problem and treatment is controversial among physicians and parents. OBJECTIVES: To clarify the prescribing of methylphenidate to children in the center of Israel, the use and possible effect that gender, socioeconomic status (SES), ethnic and cultural characteristics play in the treatment of ADHD. METHODS: We assessed the prescription rate of methylphenidate in the years 2005, 2007 and 2011 in children and adolescents age 6-18 years provided from Sharon Shomron and Dan Petach Tikva Clalit Health Services pharmacies. RESULTS: Methylphenidate (MPH) prescriptions showed an increase in prevalence from 4.2% to 7.5% in the years 2007 to 2011, respectively. Jewish children were four times more likely to be prescribed MPH than Arab children, with significant discrepancies along SES and gender lines (p < .001). Higher socioeconomic status (SES) and male gender were associated with greater use of MPH. General pediatric prescription rates of MPH in all communities increased by 85%, compared with year 2007 statistics (p < .001). CONCLUSIONS: It is time to change policy. Efforts should be directed at over-treated and under-treated populations. DISCUSSION: Prescription patterns for MPH in children reflect diagnostic patterns of ADHD that appear to be heavily influenced by additive factors of SES, cultural attitudes and gender.

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BACKGROUND: Iron deficiency (ID) is a common nutritional deficiency. OBJECTIVES: To estimate the prevalence and causes of ID and iron deficiency anemia (IDA) and to report the iron status in Israeli Arab infants. METHODS: Data on iron status was taken from 410 infants, aged 9 to 15 months, who were randomly selected from 2400 infants born between 2005-2010. Hemoglobin (Hb) <11 g/dL, ferritin <12 µg/L and mean corpuscular volume (MCV) <70 fL were the criteria for establishing IDA, and ferritin<12 µg/L and MCV <70 fL for establishing ID. RESULTS: Of the 410 infants, 116 (28%) had Hb <11 g/dL, and 68 (17%) had MCV<70 fL. We were able to analyze the samples of 368 infants for ferritin: 27 (7%) had ferritin <12 µg/L. Iron deficiency anemia (Hb <11 g/dL and ferritin <12 µg/L) was diagnosed in 15/368 infants (4%).The IDA rate was 2% (10/368 infants) when the criteria of three factors (Hb <11 g/dL and ferritin <12 µg/L, MCV <70 fL) were used. Infants who were breastfed >6 months were significantly less prone to have anemia (P > 0.002) and infants who received >6 months of iron supplements were also less prone to have anemia (P < 0.05). CONCLUSIONS: Studies are needed for establishing valid cutoff points for diagnosing ID and IDA and for identifying the causes of the high rate of anemia in the absence of ID. Breastfeeding and iron preparation supplementation are recommended and the test of ferritin at one year of age could be considered.

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OBJECTIVE: To examine dispensing patterns of methylphenidate (MPH) to determine how socioeconomic status (SES), ethnocultural affiliation, and gender affect the medical treatment of ADHD. METHOD: We reviewed MPH prescription records for year 2011 of children aged 6 to 18, from regional pharmacies serving homogeneous neighborhoods. RESULTS: MPH prescriptions showed an increase in prevalence from 4.2% to 7.5% in the years 2007 to 2011, respectively. Jewish children were four times more likely to be prescribed MPH than Arab children, with significant discrepancies along SES and gender lines ( p < .001). Higher SES and male gender were associated with greater use of MPH. General pediatric prescription rates of MPH in all communities increased by 85%, compared with year 2007 statistics ( p < .001). CONCLUSION: Prescription patterns for MPH in children reflect diagnostic patterns of ADHD that appear to be heavily influenced by additive factors of SES, cultural attitudes, and gender. Dispensing data provide valuable information for targeting underserved groups and defining potential areas of abuse.

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Iron-deficiency anemia (IDA) is a disease with worldwide prevalence. The prevalence of IDA and iron deficiency (ID) was ascertained by serum ferritin and mean corpuscular volume (MCV) levels in first graders in Taibe. A total of 1132 first graders were tested for the iron status between the years 1999 and 2004. Serum ferritin, hemoglobin (Hb), hematocrit, MCV, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and red and white blood cell counts were checked. Hb<11.5 g/dL, serum ferritin<12 µg/L, and MCV<75 fL were the criteria we chose for establishing IDA, and serum ferritin<12 µg/L and MCV<75 fL for establishing ID. Non-IDA was ascertained by a low Hb value, coupled with normal serum ferritin. The mean value of serum ferritin was 26.6±16.8 µg/L. Eighty-two (11.8%) children had low serum ferritin (<12 µg/L). The mean value of Hb was 12.3±0.8, and 80 (11.5%) of the children had low Hb. A correlation was found between hematological parameters and Hb. The prevalence of IDA, ID, and non-IDA was 2.2%, 11.8%, and 9.4%, respectively. No correlation was found between indices of anemia and demographic characteristics. Non-IDA and ID are prevalent in 5 to 6-year-old Arab children; however, IDA is surprisingly low. We need to look for other causes of anemia in this age group of the population.

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BACKGROUND: Childhood attention deficit hyperactivity disorder (ADHD) is a chronic health problem with significant risk for long-term morbidity in adulthood. OBJECTIVES: We examined long-term outcomes of ADHD in a population-based sample of childhood ADHD cases prospectively assessed as adults. METHODS: Long-term outcomes for 70 adults who were diagnosed with ADHD during childhood were examined and compared with data on the general population. RESULTS: Most subjects admitted to persistence of ADHD-related symptoms in adulthood, despite discontinuation of regular medical treatment and follow-up. Areas most severely affected by past and ongoing symptoms included driving performance and incidence of motor vehicle accidents, and rates of marriage stability over time. Relatively unaffected were occupational and academic achievements and military service. CONCLUSIONS: There is a need for outreach and better services for adults who were previously diagnosed with ADHD. This condition remains a marker of a certain degree of risk regarding marital stability, interpersonal relations and driving habits.

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OBJECTIVES: To describe the trend in the rate of consanguineous marriages among the Israeli Arab population and to identify factors associated with this custom shift in recent years. METHODS: The study was conducted between November 2009 and January 2010 in Family Health Centers. A questionnaire was presented to parents during routine visits to the center with their children. RESULTS: Information on 6,437 couples was collected. The rate of consanguineous marriages decreased from 35.8% among those married before 2000, to 28.2% among those married in 2000-2004, and to 24.0% among those married in 2005-2009 (P for trend <0.001). First cousin marriages were the most common type of consanguineous marriages in all the time periods. Consanguineous marriages were associated with consanguinity between the couples' parents (both husband and wife), a high consanguinity rate in the place of residence and younger age at marriage (wife). CONCLUSIONS: The rates of consanguineous marriages among Israeli Arabs are decreasing but still high. Because consanguineous marriages are widely acceptable, the role of public health professionals and primary care personnel is to provide comprehensive information about the potential genetic risks of consanguinity on offspring health and to increase the accessibility of premarital and preconception counseling services.

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BACKGROUND: Iron deficiency anaemia (IDA) is a common nutritional problem. OBJECTIVE: To determine the effect of nutritional education and supplemental iron administration on the prevalence of IDA in Arab infants. METHODS: Three hundred and ten infants were randomized alternately into two groups. Mothers (n = 143) in the control group received standard information on prevention of IDA and mothers in the intervention group (n = 144) received extensive information on the importance of an iron-rich diet. Data was scored regarding diet contents. Mothers in the intervention group were encouraged to give their children an iron polymaltose complex (IPC) preparation starting from age 4 months to 1 year. Compliance of receiving the medication was evaluated. The groups were compared for outcome by chi-square test. Main outcome measures were haemoglobin (Hb), mean corpuscular volume (MCV), and serum ferritin levels. RESULTS: Anaemia (Hb <11 g/dL) was recorded in 28% and 34% of the intervention and control groups, respectively (p = NS). There was no effect of infant or parental background factors on rate of anaemia. Frequency of anaemia was lower in infants who received ≥ 6 months of iron medication according to mothers' reports, and in infants breastfed for ≥ 6 months (p = 0.002). CONCLUSIONS: Questions were raised regarding the strategies of preventing IDA in infancy.

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The Bedouin population in Israel is a semi-nomadic traditional patriarchal society. Consanguineous marriages are very common, contributing to high rates of congenital malformations and genetic diseases, resulting in high infant mortality. Data on consanguineous marriages among Bedouins in Israel are limited. This study examined the current prevalence of consanguineous marriages and their determinants among Israeli Bedouins. One thousand two hundred ninety Bedouin women who delivered in the maternity wards of the only hospital serving the Bedouin population were interviewed between November 2009 and January 2010. The prevalence of consanguineous marriages was 44.8 %. The most common type of spousal relationship was first cousins (65.7 % of all consanguineous marriages). The mean inbreeding coefficient was 0.0238. Factors significantly associated with consanguinity were less years of schooling (OR 0.94, 95 % CI (0.88-0.99), p = 0.02) and younger age at marriage of the wife (OR 0.90, 95 % CI (0.80-0.96), p = 0.0002). In conclusion, the rate of consanguineous marriages among Bedouins is very high, making this population at risk for congenital malformations and genetic diseases. Efforts should be directed at better education and provision of premarital and prenatal counseling on the health consequences of consanguineous marriages and the possibilities to lower those risks.

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We prospectively compared the efficacy and safety of iron deficiency anemia prophylaxis with iron gluconate (IG) or iron polymaltose complex (IPC) in healthy infants attending a community pediatric center. Participants were randomly assigned to receive one of the test drugs from age 4 to 6 months to age 12 months. Parents/guardians were given extensive information on iron-rich diets and anemia prevention. Main outcome measures were blood levels of hemoglobin, hematocrit, mean corpuscular volume, red blood cell distribution width, and serum iron, ferritin, and transferrin, in addition to adverse effects. One hundred five children completed the study: 53 in the IG group and 52 in the IPC group Mean hemoglobin levels at study end were significantly higher in the IG group (12.04±0.09 g/dL vs. 11.68±0.11, P<0.014). A hemoglobin level <11 g/dL was detected in 3 infants of the IG group, and in 10 infants of the IPC group (P<0.04). Adverse effects (spitting, vomiting, diarrhea, constipation, discolored teeth) were significantly more common in the IG group (47% vs. 25%, P>0.025). In conclusion, both oral IG and IPC prevent iron deficiency anemia in infants. Iron gluconate seems to be more effective but less tolerable.

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OBJECTIVE: To examine the 5-year outcome in a cohort of children with "growing pains" and the association with changes in pain threshold. STUDY DESIGN: Subjects were 44 children with growing pains studied previously, and controls were 38 pain-free children matched by sex and age. Current status of growing pains and other pain syndromes were assessed by parental questionnaires. Pain threshold was measured with a Fisher-type dolorimeter. Outcomes were correlated with the pain threshold. RESULTS: We examined 35/44 patients (80%) after 5 years. Eighteen patients (51%) experienced resolution of growing pains. In 14 of the 17 patients with persistent growing pains (83%), episodes were less frequent and milder. The prevalence of accompanying pain syndromes decreased from 20% to 14%. No patient developed fibromyalgia. Pain thresholds were similar in the entire growing pains cohort and healthy controls, but those with continued growing pains had significantly lower thresholds than controls (P <.05) and patients with resolved growing pains (P <.02). CONCLUSIONS: We confirm that growing pains has a benign prognosis and probably represents a pain amplification syndrome of early childhood.

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OBJECTIVES: The purpose of this work was to use the comprehensive computerized database of Clalit Health Services to analyze the prevalence and contributing factors of anemia among the population of Clalit Health Services-insured Israeli infants aged 9 to 18 months, characterized by ethnic sector. METHODS: This was a cross-sectional retrospective study for the year 2003 using the computerized database of Clalit Health Services for 34,512 infants aged 9 to 18 months insured by the Clalit Health Services sick fund. Children with abnormal white blood counts at the time of the hemoglobin test and with chronic diseases were excluded. The data were analyzed for age, infant hemoglobin level, ethnic origin, district distribution, type of clinic where the infant received treatment, the number of iron prescriptions dispensed to each child, and the mother's last hemoglobin level before giving birth. Anemia was defined as a hemoglobin level <105 g/L. RESULTS: The prevalence of anemia among Israeli infants is 15.5%. The prevalence is significantly higher in the non-Jewish population (22.5%) as compared with the Jewish population (10.5%). The lowest prevalence of anemia was found in pediatric health centers (10.7%). A significant correlation was found between the presence of anemia in infants and the presence of anemia found in their mothers. Infants with anemia used significantly less iron preparations. CONCLUSIONS: This study is one of the first studies to use a comprehensive computerized database to perform a population-based analysis of anemic infants. We found a considerable percentage of infants to be anemic and identified a specific population to be at high risk for anemia. We describe 2 factors that have the potential to be altered through intervention: improving compliance of iron intake and maternal anemia. Major national efforts should be made to minimize the prevalence of anemia, especially in the non-Jewish population, and to learn more about the causes of iron-deficiency anemia in this group. This study provides a base for an intervention study.

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Consanguineous marriages are associated with many problems, although the prevailing opinion is that the advantages outweigh the disadvantages. This explains why the custom is still extremely prevalent, particularly in Arab countries, India and small isolated communities. Among Israeli Arabs there has been a reduction in the rate of such marriages, although it is still sufficiently high to cause medical problems. Among Israeli Jews, the rate has always been much lower. Future goals are to expand the educational programs aimed at the Israeli Arab community and to promote the uptake of genetic counseling and prenatal testing where available in order to reduce the health problems even further. Ongoing research in order to identify specific genes will enable more conditions to be detectable early in pregnancy. We expect that the willingness of families to agree to termination of affected pregnancies will reduce the number of babies born with these conditions.

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OBJECTIVE: The most common cause of recurring childhood musculoskeletal pain is termed growing pains (GP). We hypothesized that GP may represent a local overuse syndrome and therefore may be associated with decreased bone speed of sound (SOS) measured by quantitative ultrasound (US). METHODS: We studied 39 children with GP. Bone SOS was measured by US in both mid-tibial and radius bones according to a validated protocol. Unpaired Student t test was used to compare patients and norms of healthy controls. RESULTS: Tibial SOS was significantly reduced in children with GP compared to controls (Z score -0.546 for boys and -0.891 for girls; p = 0.004, p < 0.001, respectively). Radius SOS was significantly reduced only in girls with GP (Z score -0.692, p = 0.006). No correlation was found between bone SOS and various demographic and clinical factors besides the child's ethnicity and body mass index. CONCLUSION: Bone SOS was significantly reduced in children with GP, especially in painful tibial regions. GP may represent a local overuse syndrome.

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PURPOSE: To evaluate the level of knowledge among adolescents about the issues associated with consanguinity, because consanguineous marriages are widely practiced among Arabs, and are associated with an increased incidence of congenital malformations. METHODS: We carried out a national survey among 2933 students aged 15-16 years within the Israeli Arab community. Variables considered were gender, religion, location of residence, parents' level of education, number of siblings, whether their parents' marriage was consanguineous, whether any family members had congenital malformations, and the respondents' religious beliefs and traditions. Association among those variables and the level of knowledge that were statistically significant by univariate analysis were also assessed in a multivariate model. RESULTS: One-quarter of the students (24.5%) demonstrated a high level of knowledge, whereas 29.7% had a moderate level and 45.8% a low level. Overall, 81.5% knew that consanguinity was associated with a high incidence of congenital malformations, although only half of these (50.0%) knew what congenital malformations were and which were associated with consanguinity. The variables significantly associated with a low level of knowledge were gender, level of parents' education, consanguinity between the students' parents, and extreme religious attitudes. CONCLUSIONS: Efforts to increase the knowledge of Israeli Arab adolescents about consanguinity should therefore be especially directed toward males with parents who have a lower level of education, with parents who are consanguineous, and who have extreme religious attitudes.

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AIM: To determine the reported antibiotic prescribing practices for upper respiratory tract infections in children among pediatricians and family physicians. METHODS: Regional survey of practicing pediatricians and family physicians and comparison of the survey responses of 81 physicians with the recently published recommendations of the Centers for Disease Control and Prevention. RESULTS: Whereas almost all the physicians agreed that a diagnosis of acute otitis media required documentation of middle ear effusion and acute illness, 28% of family physicians and 12% of pediatricians reported that they routinely prescribed antibiotics for children with bronchitis, even though this is not recommended. In this survey 39% of pediatricians and 47% of family physicians reported that they omitted laboratory testing for the diagnosis of group A streptococcal pharyngitis, and of those who submitted samples for testing, most reported that they prescribed antibiotics immediately without waiting for the results. Even though these recommendations state that sinus tenderness is rare in young children with sinusitis, more than 48% of the physicians believed that both this and the presence of purulent rhinitis were essential to confirm this diagnosis. While none of the pediatricians reported prescribing antibiotics for the common cold, 17% of the family physicians did so (p = 0.006). CONCLUSIONS: The reported prescribing practices of the physicians in this survey are not in line with the recommendations. Effective intervention is needed to encourage the judicious use of antibiotics in Israel.

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BACKGROUND: The infant mortality rate is a health status indicator. OBJECTIVES: To analyze the differences in infant mortality rates between Jews and Arabs in Israel between 1975 and 2000. METHODS: Data were used from the Central Bureau of Statistics and the Department of Mother, Child and Adolescent Health in the Ministry of Health. RESULTS: The IMR in 2000 was 8.6 per 1,000 live births in the Israeli Arab population as compared to 4.0 in the Jewish population. Between 1970 and 2000 the IMR decreased by 78% among Moslems, 82% among Druze, and 88% among Christians, as compared to 79% in the Jewish population. In 2000, in the Arab population, 40% of all infant deaths were caused by congenital malformations and 29% by prematurity, compared to 23% and 53%, respectively, in the Jewish population. Between 1970 and 2000 the rate of congenital malformations declined in both the Arab and Jewish populations. In the 1970s the rate was 1.4 times higher in the Arab community than in the Jewish community, and in 2000 it was 3.7 times higher. CONCLUSION: As in the Jewish population, the IMR in the Arab community has decreased over the years, although it is still much higher than that in the Jewish community. Much remains to be done to reduce the incidence of congenital malformations among Arabs, since this is the main cause of the high IMR in this population.

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Hemoglobin Taybe is an unstable alpha-chain hemoglobin variant caused by a deletion of a threonine residue at codon 38 or 39 of the alpha-1 globin chain. We describe preterm infant triplets born with hydrops fetalis and anemia who were found by DNA analysis to be homozygous for hemoglobin Taybe. All three infants developed intrauterine hemolytic anemia, which subsequently led to hydrops fetalis. To the best of our knowledge, this is the first description of hydrops fetalis associated with this hemoglobinopathy. We suggest that hemoglobin Taybe be considered in the differential diagnosis of hydrops fetalis and that known affected fetuses be carefully followed both antenatally and postnatally.

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Neural tube defects (NTDs) are severe congenital malformations and can be fatal. Intake of 0.4 mg folic in the periconceptional period reduces the risk of NTD by 50-70%. Consanguinity in the Arab population in Israel is a prevalent custom. The aim of this study was to assess the level of awareness regarding folic acid and its effect in the prevention of NTD among Arab Israeli women of childbearing age. We conducted a cross-sectional study. Of the 653 women (18-45 years) who were randomly selected for interview while visiting their family physician or well-baby clinic, 624 women completed the questionnaire. Fifty-three percent (n = 333) of the respondents had heard of folic acid; 14% (n = 89) were familiar with the protective effect of NTD and 3% (n = 18) had taken folic acid in the first months of pregnancy whereas none of them had used it in the preconception period. Highly educated women, women with one or two children, paramedics, and women of high socioeconomic status were more knowledgeable about the protective effects of folic acid (P < 0.001). Age and religion had no significant effect. An urgent need exists to improve the awareness of this population to the protective effect of folic acid. Daily supplementation and fertification of food with folic acid should be considered as the best way to improve the balance of folic acid in women of childbearing age of this special population (high prevalence of consanguinity).

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OBJECTIVE: To investigate whether children with recurrent musculoskeletal pain termed growing pains (GP) have lower pain thresholds than children without GP. METHODS: We measured the pain threshold of 44 children with GP and 46 controls. Pain thresholds were measured by use of a Fisher type dolorimeter with pressure applied to areas associated with increased tenderness in fibromyalgia (FM), control points, and anterior tibia, the usual region of pain in children with GP. Unpaired Student's t test and chi-square tests were used to compare the pain threshold and number of tender points in patients and controls. RESULTS: The pain threshold in characteristic tender points of FM, control points, and anterior tibia in the children with GP was significantly lower in children with GP (3.5 +/- 0.6 kg/cm2 in GP versus 4.0 +/- 0.7 in controls, p < 0.001, 3.8 +/- 0.7 versus 4.4 +/- 0.8, p = 0.005; 5.1 +/- 1.1 versus 5.9 +/- 1.5, p = 0.004). Children with GP had a significantly greater number of tender points in response to an applied pressure of 4 kg/cm2. CONCLUSION: Children with GP have more tender points and lower pain thresholds than children without GP indicating that GP may represent a variant of a noninflammatory pain syndrome in younger children.

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