bluuebunny/crossref_metadata_2025 huggingface dataset:
A Randomized, Clinical Trial of a Home Safety Intervention Based in an Emergency Department Setting
Authors: Posner Jill C. , Hawkins Linda A. , Garcia-Espana Felipe , Durbin Dennis R.
Published: August 2004

Objective. To assess the effectiveness of an emergency department (ED)-based home safety intervention on caregivers’ behaviors and practices related to home safety.

Methods. We conducted a randomized, clinical trial of 96 consecutive caregivers of children who were younger than 5 years and presented to an urban pediatric ED for evaluation of an acute unintentional injury sustained in the home. After completing a structured home safety questionnaire via face-to-face interview, caregivers were randomly assigned to receive either comprehensive home safety education and free safety devices or focused, injury-specific ED discharge instructions. Participants were contacted by telephone 2 months after the initial ED visit for repeat administration of the safety questionnaire. The pretest and posttest questionnaires were scored such that the accrual of points correlated with reporting of safer practices. Scores were then normalized to a 100-point scale. The overall safety score reflected performance on the entire questionnaire, and the 8 category safety scores reflected performance in single areas of home injury prevention (fire, burn, poison, near-drowning, aspiration, cuts/piercings, falls, and safety device use). The main outcome was degree of improvement in safety practices as assessed by improvement in safety scores.

Results. The intervention group demonstrated a significantly higher average overall safety score at follow-up than the control group (73.3% ± 8.4% vs 66.8% ±11.1) and significant improvements in poison, cut/piercing, and burns category scores. Caregivers in the intervention group also demonstrated greater improvement in reported use of the distributed safety devices.

Conclusions. This educational and device disbursement intervention was effective in improving the home safety practices of caregivers of young children. Moreover, the ED was used effectively to disseminate home injury prevention information.
Brain Perfusion in Children: Evolution With Age Assessed by Quantitative Perfusion Computed Tomography
Authors: Wintermark Max , Lepori Domenico , Cotting Jacques , Roulet Eliane , van Melle Guy , Meuli Reto , Maeder Philippe , Regli Luca , Verdun Francis R. , Deonna Thierry , Schnyder Pierre , Gudinchet François
Published: August 2004

Objective. The objective of this study was to assess the age-related variations of brain perfusion through quantitative cerebral perfusion computed tomography (CT) results in children without brain abnormality.

Methods. Brain perfusion CT examinations were performed in 77 children, aged 7 days to 18 years. These patients were admitted at our institution for both noncontrast and contrast-enhanced cerebral CT. Only children whose conventional cerebral CT and clinical/radiologic follow-up, including additional investigations, were normal were taken into account for this study (53 of 77).

Results. The average regional rCBF amounts to 40 (mL/100 g per minute) for the first 6 months of life, peaks at ∼130 (mL/100 g per minute) at ∼2 to 4 years of age, and finally stabilizes at ∼50 (mL/100 g per minute) at ∼7 to 8 years of age, with a small increase of rCBF values at ∼12 years of age. The rCBF in the gray matter averages 3 times that in the white matter, except for the first 6 months of life. The global CBF represents 10% to 20% of the global cardiac output for the first 6 months of life, peaks at ∼55% by 2 to 4 years of age, and finally stabilizes at ∼15% by 7 to 8 years of age. Specific age-related evolution patterns were identified in the different anatomic areas of the cerebral parenchyma, which could be related to the development of neuroanatomic structures and to the emergence of corresponding cognitive functions.

Conclusions. Quantitative perfusion CT characterization of brain perfusion shows specific age variations. Brain perfusion of each cortical area evolves according to a specific time course, in close correlation with the psychomotor development.
Anxiety, Depressive, and Posttraumatic Stress Disorders Among Mothers of Pediatric Survivors of Hematopoietic Stem Cell Transplantation
Authors: Manne Sharon , DuHamel Katherine , Ostroff Jamie , Parsons Susan , Martini D. Richard , Williams Sharon E. , Mee Laura , Sexson Sandra , Austin Jane , Difede Joanne , Rini Christine , Redd William H.
Published: August 2004

Objective. To examine the prevalence and predictors of anxiety, depression, and posttraumatic stress disorder among mothers of children who underwent hematopoietic stem cell transplantation (HSCT).

Methods. A total of 111 mothers of children who survived HSCT completed self-report measures of psychological functioning at the time of HSCT and self-report measures and a structured psychiatric interview 18 months after HSCT. Demographic data and medical data were also collected.

Results. Approximately 20% of mothers had clinically significant distress reactions. When subthreshold posttraumatic stress disorder was included, nearly one third of mothers met the criterion for persistent distress. Mothers with 1 of the 4 psychiatric diagnoses reported a significantly lower quality of life, suggesting that the diagnoses had an impact on their general quality of life. Mothers who had 1 of the 4 diagnoses at 18 months were younger and had higher anxiety and depressive symptoms at the time of HSCT.

Conclusions. A subset of mothers of children who survive HSCT may require psychological intervention. Mothers who are most at risk are younger and evidence anxiety and depressive symptoms at the time of transplantation.
Intracerebral Abscess in Children: Historical Trends at Children’s Hospital Boston
Authors: Goodkin Howard P. , Harper Marvin B. , Pomeroy Scott L.
Published: August 2004

Objectives. A previous study performed at Children’s Hospital Boston describing the natural history of intracerebral abscess between 1945 and 1980 demonstrated a decline in mortality after 1970. This current study examines the occurrence of intracerebral abscess at Children’s Hospital Boston between 1981 and 2000, inclusive, and compares the results with the previous study. Our objectives were to determine whether there had been a change in the predisposing factors, whether there were changes in the microbiology of intracerebral abscesses, and whether mortality rate had continued to decline.

Methods. To ensure that all occurrences of intracerebral abscess treated at Children’s Hospital Boston between 1981 and 2000 were identified, we searched 4 separately maintained databases for the keywords “brain” or “abscess” or the International Classification of Diseases, Ninth Revision code 324.x. This search yielded the names of 386 patients. Of these 386 patients, a solitary intracerebral abscess or multiple noncontiguous intracerebral abscesses could be confirmed in 54 patients on the basis of cranial imaging (computed tomography or magnetic resonance imaging) or autopsy reports. The complete retrospective review of the medical records of these 54 patients constitutes the basis for this study.

Results. Congenital heart disease was the most common predisposing factor during both eras. Compared with the previous era, important historical trends identified include a reduction in the number of abscesses that occurred in the settings of sinus or otitic infection (11% during 1981–2000 vs 26% during 1945–1980), an increase in number of intracranial abscesses in infants (18% vs 7%) and in the setting of immunosuppression (16% vs 1%), an increase in the number of children who were treated with antibiotics alone (22% vs 1%), a stable overall mortality rate (24% vs 27%), and the identification of Citrobacter and fungus as causes of intracranial abscess not observed during the previous era of 1945–1980. Citrobacter was observed only during the neonatal period. Fungi were the causative organisms predominantly in the setting of immunosuppression.

Conclusions. Intracerebral abscess in children continues to be associated with high rates of neurologic impairment and death. Because earlier detection may reduce morbidity and mortality, intracranial abscess should be considered when evaluating children with new-onset neurologic signs or symptoms, especially in children who have acute immunosuppression and disseminated fungal disease or fungemia.
Prescribing Therapy Services for Children with Motor Disabilities
Authors: Michaud Linda J. ,   Committee on Children With Disabilities
Published: August 2004

Pediatricians often are called on to prescribe physical, occupational, and speech-language therapy services for children with motor disabilities. This report defines the context in which rehabilitation therapies should be prescribed, emphasizing the evaluation and enhancement of the child's function and abilities and participation in age-appropriate life roles. The report encourages pediatricians to work with teams including the parents, child, teachers, therapists, and other physicians to ensure that their patients receive appropriate therapy services.
Association Between Evening Admissions and Higher Mortality Rates in the Pediatric Intensive Care Unit
Authors: Arias Yeseli , Taylor Douglas S. , Marcin James P.
Published: August 2004

Background. Previous research investigating the relationship between the time of admission and mortality rates has yielded inconsistent results and has not been conducted in the pediatric intensive care unit (PICU) patient population.

Objective. To determine whether an association between the time of admission (weekday versus weekend and daytime versus evening) and the risk of death exists among pediatric patients included in a cohort of children admitted to a national sample of PICUs.

Design/Methods. We analyzed retrospectively a cohort of consecutive admissions to 15 PICUs included in the Pediatric Intensive Care Unit Evaluations database. The odds of death were analyzed by using mixed-effects, multivariate, logistic regression, with clustering at the hospital level. The primary independent variables were admission to the PICU on a weekend and admission to the PICU during evening hours. The severity of illness was adjusted by using the Pediatric Risk of Mortality III probability of death score.

Patients. All 20 547 emergency PICU admissions made between May 1995 and December 2001 were included in the analyses.

Main Outcome Measures. The primary outcome was death within 48 hours after admission to the PICU.

Results. Pediatric patients admitted to the PICU during evening hours had higher odds of death (odds ratio [OR]: 1.28; 95% confidence interval [CI]: 1.00-1.62) than did those admitted during daytime hours. Subgroup analyses revealed higher odds of death among patients admitted with shock (OR: 4.09; 95% CI: 1.65–10.1), with congenital cardiovascular disease (OR: 3.90; 95% CI: 1.37–11.1), or after cardiac arrest (OR: 1.80; 95% CI: 1.04–3.13). There was no association between mortality rates and the day of admission (weekend admissions versus weekday admissions).

Conclusions. An increased risk of death exists for some pediatric patients admitted to the PICU during evening hours. It remains necessary to determine whether this finding results from differences in the structure of care, processes of care, or both.
Severe Acute Respiratory Syndrome Among Children
Authors: Leung Chi-wai , Kwan Yat-wah , Ko Po-wan , Chiu Susan S. , Loung Po-yee , Fong Nai-chung , Lee Lai-ping , Hui Yim-wo , Law Helen K.W. , Wong Wilfred H.S. , Chan Kwok-hung , Peiris J.S. Malik , Lim Wilina W.L. , Lau Yu-lung , Chiu Man-chun
Published: August 2004

Objective. To study the epidemiologic, clinical, laboratory, and radiologic features, prognostic indicators, and short-term to medium-term outcomes for children with severe acute respiratory syndrome (SARS) and to validate the performance characteristics of a clinical case definition, calculated with respect to SARS-associated coronavirus (SARS-CoV) seroconversion.

Methods. Children <18 years of age, from a single-site outbreak, who satisfied a clinical case definition for SARS, with subsequent serologic confirmation, were treated according to a standard protocol and prospectively monitored.

Results. Forty-four children were included. The median age was 12 years. Forty-two children (95.5%) demonstrated an epidemiologic link. Fever, cough, malaise, coryza, sputum production, headache, myalgia, lymphopenia, and elevated lactate dehydrogenase levels were common presenting features. Radiographic findings were nonspecific, but high-resolution computed tomography of the thorax was an early diagnostic aid. A specific reverse transcription-polymerase chain reaction assay for SARS-CoV yielded positive results for <50% of children. Of 9 children who developed hypoxemia, 8 were treated with methylprednisolone. Of 5 children who received intensive care, 3 required assisted ventilation. All children recovered, and serious adverse events in response to treatment were not observed. The outcomes at 3 to 6 months after disease onset, including exercise tolerance, pulmonary functions, and psychologic status, were favorable. An age of >12 years was associated with methylprednisolone therapy for severe illness. After exclusion of the only infant, an age of >12 years was associated with oxygen requirements. Sore throat, high neutrophil count at presentation, and peak neutrophilia were independent factors predicting severe illness. The clinical case definition demonstrated good sensitivity, specificity, and positive and negative predictive values (97.8%, 92.7%, 88%, and 98.7%, respectively) for diagnostic accuracy.

Conclusions. Children are susceptible to SARS-CoV infection. Teenagers resemble adults with respect to disease progression and may develop severe illness. The short-term to medium-term outcomes are good. Sore throat and initial and peak neutrophilia seem to be predictors of severe illness. Our clinical case definition performed well in the epidemic.
Effects of Growth Hormone Treatment on Body Proportions and Final Height Among Small Children With X-Linked Hypophosphatemic Rickets
Authors: Haffner Dieter , Nissel Richard , Wühl Elke , Mehls Otto
Published: August 2004

Background. X-linked hypophosphatemic rickets (XLH) is characterized by rickets, disproportionate short stature, and impaired renal phosphate reabsorption and vitamin D metabolism. Despite oral phosphate and vitamin D treatment, most children with XLH demonstrate reduced adult height.

Objective. To determine the beneficial effects of recombinant human growth hormone (rhGH) therapy on body proportions and adult height among patients with XLH.

Methods. Three initially prepubertal short children (age, 9.4–12.9 years) with XLH were treated with rhGH for 3.1 to 6.3 years until adult height was attained.

Results. rhGH treatment led to sustained increases in standardized height for all children. The median adult height was 0.9 SD (range: 0.5–1.3 SD) greater than that at the initiation of rhGH treatment and exceeded the predicted adult height by 6.2 cm (range: 5.3–9.8 cm). However, longitudinal growth of the trunk was stimulated more than leg growth. During rhGH treatment, the standardized sitting height increased by 1.6 SD (range: 1.1–2.7 SD), compared with baseline values. In contrast, the median subischial leg length did not change consistently (median change: 0.3 SD; range: −0.1 to 0.6 SD).

Conclusion. The increase in final height after rhGH treatment is of potential benefit for children with XLH. However, the exaggeration of disproportionate truncal growth observed for our prepubertal patients is a potential negative effect of treatment and should be confirmed with additional studies.
Air Pollution and Sudden Infant Death Syndrome
Authors: Dales Robert , Burnett Richard T. , Smith-Doiron Marc , Stieb David M. , Brook Jeffrey R.
Published: August 2004

Background. Sudden infant death syndrome (SIDS) affects ∼1 in 1000 live births and is the most common cause of infant death after the perinatal period.

Objective. To determine the influence of air pollution on the incidence of SIDS.

Methods. Time-series analyses were performed to compare the daily mortality rates for SIDS and the daily air pollution concentrations in each of 12 Canadian cities during the period of 1984-1999. Serial autocorrelation was controlled for by city, and then the city-specific estimates were pooled. Increased daily rates of SIDS were associated with increases, on the previous day, in the levels of sulfur dioxide (SO2), nitrogen dioxide (NO2), and carbon monoxide but not ozone or fine particles measured every sixth day. Effects persisted despite adjustments for season alone or the combination of daily mean temperature, relative humidity, and changes in barometric pressure for NO2 and SO2 but not carbon monoxide.

Results. Increases in both SO2 and NO2, equivalent to their interquartile ranges, were associated with a 17.72% increase in SIDS incidence.

Conclusion. Ambient SO2 and NO2 may be important risk factors for SIDS.
Legalization of Marijuana: Potential Impact on Youth
Authors: Joffe Alain , Yancy W. Samuel ,   the Committee on Substance Abuse and Committee on Adolescence
Published: August 2004

This technical report provides historical perspectives and comparisons of various approaches to the legal status of marijuana to aid in forming public policy. Information on the impact that decriminalization and legalization of marijuana could have on adolescents, in addition to concerns surrounding medicinal use of marijuana, are also addressed in this report. Recommendations are included in the accompanying policy statement.
Cystic Fibrosis on the Internet: A Survey of Site Adherence to AMA Guidelines
Authors: Anselmo Mark A. , Lash Katherine M. , Stieb Elisabeth S. , Haver Kenan E.
Published: August 2004

Objectives. The Internet permits unprecedented and mostly unrestricted access to medical knowledge; however, concerns exist regarding viewer privacy, accountability of authorship, accuracy of information, and patient safety. To address these issues, the American Medical Association (AMA) has developed guidelines concerning web site content and visitor rights. Cystic fibrosis (CF) is the most common genetically inherited lethal disease in North America. Many Internet sites that provide information on CF have been developed, although adherence to validated guidelines for online health information is not required. The purpose of this study was to assess systematically web sites with content pertaining to CF for adherence to the published AMA guidelines.

Methods. The search term “cystic fibrosis” was entered into a commonly used search engine (Google), and the first 100 eligible sites were reviewed. Each site was examined for adherence to the AMA Guidelines for Medical and Health Information Sites on the Internet using a series of adapted questions. There were 15 questions divided into the following main categories: 1) site structure and viewer privacy, 2) author accountability, 3) scientific citation, and 4) patient safety. The number of positives for each question was tabulated.

Results. With respect to site structure, fewer than half (45%) of the reviewed sites indicated a date of last revision. Only 11 (11%) carried an explicit privacy policy. A responsible author or group was listed in only 43 (43%) of 100 sites. Presented data regarding CF was supported by references, sources, or expert review in only 38 (38%) of 100 sites. A medical disclaimer noting that information provided does not substitute for evaluation by a health care team was evident in only 37 (37%) sites.

Conclusions. The majority of easily accessible CF informational web sites do not adhere to guidelines published by the AMA. Patients and families who use the Internet as a CF information resource should examine the web sites carefully and be familiar with the guidelines established by the AMA. Personal information is not protected, and few sites provide explicit privacy guarantees. Finally, CF care teams should inquire about Internet use by patients and families and be prepared to discuss findings from the Internet to heighten patient safety and awareness.
Endotoxin Exposure and Eczema in the First Year of Life
Authors: Phipatanakul Wanda , Celedón Juan C. , Raby Benjamin A. , Litonjua Augusto A. , Milton Donald K. , Sredl Diane , Weiss Scott T. , Gold Diane R.
Published: August 2004

Objective. Exposure to endotoxin in early life has been proposed as a factor that may protect against the development of allergic diseases such as eczema. The objective of this study was to examine the relation between endotoxin exposure in early life and eczema in the first year of life in children with parental history of asthma or allergies.

Methods. This study used a prospective birth cohort study of 498 children who had a history of allergy or asthma in at least 1 parent and lived in metropolitan Boston. A subset of 401 living rooms had house dust samples adequate for analysis of endotoxin.

Results. In multivariate analyses adjusting for gender, income, and season of birth, endotoxin levels in the living room at 2 to 3 months of age was inversely associated with physician- or nurse-diagnosed eczema in the first year of life (odds ratio [OR] for each quartile increment: 0.76; 95% confidence interval [CI]: 0.61-0.96). Exposure to a dog in the home at age 2 to 3 months was also inversely associated with eczema in the first year of life, but the CI widened when endotoxin was included in the multivariate model (OR: 0.54; 95% CI: 0.27-1.09). Other variables associated with eczema in the first year of life included paternal history of eczema (OR: 1.91; 95% CI: 1.03-3.55) and maternal specific immunoglobulin E positivity to ≥1 allergen (OR: 1.61; 95% CI: 1.01-2.56).

Conclusions. Among children with parental history of asthma or allergies, exposure to high levels of endotoxin in early life may be protective against eczema in the first year of life. In these children, paternal history of eczema and maternal sensitization to at least 1 allergen are associated with an increased risk of eczema in the first year of life.
Spectrum Bias of a Rapid Antigen Detection Test for Group A β-Hemolytic Streptococcal Pharyngitis in a Pediatric Population
Authors: Hall Matthew C. , Kieke Burney , Gonzales Ralph , Belongia Edward A.
Published: August 2004

Background. Rapid antigen detection testing (RADT) is often performed for diagnosis of group A β-hemolytic streptococcal (GABHS) pharyngitis among children. Among adults, the sensitivity of this test varies on the basis of disease severity (spectrum bias). A similar phenomenon may occur when this test is used in a pediatric population, which may affect the need for culture confirmation of all negative RADT results.

Objectives. To assess the performance of a clinical scoring system and to determine whether RADT spectrum bias is present among children who are evaluated for GABHS pharyngitis.

Methods. Laboratory and clinical records for a consecutive series of pediatric patients who underwent RADT at the Marshfield Clinic between January 2002 and March 2002 were reviewed retrospectively. Patients were stratified according to the number of clinical features present by using modified Centor criteria, ie, history of fever, absence of cough, presence of pharyngeal exudates, and cervical lymphadenopathy. The sensitivity of the RADT was defined as the number of patients with positive RADT results divided by the number of patients with either positive RADT results or negative RADT results but positive throat culture results.

Results. RADT results were positive for 117 of 561 children (21%), and culture results were positive for 35 of 444 children (8%) with negative RADT results. The overall prevalence of GABHS pharyngitis was 27% (95% confidence interval: 23–31%). The prevalence of GABHS pharyngitis was 18% among patients with 0 Centor criteria, 16% among those with 1 criterion, 32% among those with 2 criteria, and 50% among those with 3 or 4 criteria. Spectrum bias was present, inasmuch as RADT sensitivity increased with Centor scores, ie, 47% sensitivity among children with 0 Centor criteria, 65% among those with 1 criterion, 82% among those with 2 criteria, and 90% among those with 3 or 4 criteria.

Conclusions. The sensitivity of RADT for GABHS pharyngitis is not a fixed value but varies with the severity of disease. However, even among pediatric patients with ≥3 Centor criteria for GABHS pharyngitis, the sensitivity of RADT is still too low to support the use of RADT without culture confirmation of negative results.
Research on Prevention of Bilirubin-Induced Brain Injury and Kernicterus: National Institute of Child Health and Human Development Conference Executive Summary
Authors: Blackmon Lillian R. , Fanaroff Avroy A. , Raju Tonse N. K.
Published: August 2004

In July 2003, the National Institute of Child Health and Human Development convened a conference, “Research on Prevention of Bilirubin-Induced Brain Injury and Kernicterus: Bench-to-Bedside.” This article will provide a summary of presentations and discussions from this conference. The summary will focus on the identified knowledge gaps in 5 areas related to bilirubin-induced brain injury and kernicterus: 1) neurobiology and neuroimaging; 2) epidemiology and issues of clinical management; 3) methodologies for assessing clinical jaundice and direct and noninvasive measurement of serum bilirubin and hemolysis; 4) therapies for management of neonatal hyperbilirubinemia; and 5) public health surveillance and systems-based approaches to prevention.
Early Infant Multivitamin Supplementation Is Associated With Increased Risk for Food Allergy and Asthma
Authors: Milner Joshua D. , Stein Daniel M. , McCarter Robert , Moon Rachel Y.
Published: August 2004

Objective. Dietary vitamins have potent immunomodulating effects in vitro. Individual vitamins have been shown to skew T cells toward either T-helper 1 or T-helper 2 phenotypic classes, suggesting that they may participate in inflammatory or allergic disease. With the exception of antioxidant protection, there has been little study on the effect of early vitamin supplementation on the subsequent risk for asthma and allergic disease. The objective of this study was to determine whether early vitamin supplementation during infancy affects the risk for asthma and allergic disease during early childhood.

Methods. Cohort data were analyzed from the National Center for Health Statistics 1988 National Maternal-Infant Health Survey, which followed pregnant women and their newborns, and the 1991 Longitudinal Follow-up of the same patients, which measured health and disease outcomes. Patients were stratified by race and breastfeeding status. Factors that are known to be associated with alteration of risk for asthma or food allergies were identified using univariate logistic regression. Those factors were then analyzed in multivariate logistic regression models. Early vitamin supplementation was defined as vitamin use within the first 6 months.

Results. There were >8000 total patients in the study. The overall incidence of asthma was 10.5% and of food allergy was 4.9%. In univariate analysis, male gender, smoker in the household, child care, prematurity (<37 weeks), being black, no history of breastfeeding, lower income, and lower education were associated with higher risk for asthma. Child care, higher levels of education, income, and history of breastfeeding were associated with a higher risk for food allergies. In multivariate logistic analyses, a history of vitamin use within the first 6 months of life was associated with a higher risk for asthma in black infants (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.04–1.56). Early vitamin use was also associated with a higher risk for food allergies in the exclusively formula-fed population (OR: 1.63; 95% CI: 1.21–2.20). Vitamin use at 3 years of age was associated with increased risk for food allergies but not asthma in both breastfed (OR: 1.62; 95% CI: 1.19–2.21) and exclusively formula-fed infants (OR: 1.39; 95% CI: 1.03–1.88).

Conclusions. Early vitamin supplementation is associated with increased risk for asthma in black children and food allergies in exclusively formula-fed children. Additional study is warranted to examine which components most strongly contribute to this risk.
Meconium Obstruction in the Very Low Birth Weight Premature Infant
Authors: Garza-Cox Sanjuanita , Keeney Susan E. , Angel Carlos A. , Thompson Lauree L. , Swischuk Leonard E.
Published: August 2004

Meconium obstruction of prematurity is a distinct clinical condition that occurs in very low birth weight infants, predisposing them to intestinal perforation and a prolonged hospitalization if not diagnosed and treated promptly. We report a series of 21 infants, including 2 detailed case reports, whose clinical course is indicative of meconium obstruction of prematurity. Specific risk factors are identified along with descriptions of clinical and radiologic findings, disease course, treatment, and outcome. Meconium obstruction of prematurity was more common in infants with a maternal history of pregnancy-induced or chronic hypertension, suggesting the possibility of decreased intestinal perfusion prenatally. Inspissated meconium was located most frequently in the distal ileum, making this disease process difficult to treat. Gastrografin enemas were safe, diagnostic, and therapeutic. Delay in diagnosis and treatment was associated with perforation and delay in institution of enteral feeds.
Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
Authors:   Subcommittee on Hyperbilirubinemia
Published: August 2004

Jaundice occurs in most newborn infants. Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus. The focus of this guideline is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment. Although kernicterus should almost always be preventable, cases continue to occur. These guidelines provide a framework for the prevention and management of hyperbilirubinemia in newborn infants of 35 or more weeks of gestation. In every infant, we recommend that clinicians 1) promote and support successful breastfeeding; 2) perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia; 3) provide early and focused follow-up based on the risk assessment; and 4) when indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia and, possibly, bilirubin encephalopathy (kernicterus).
Clinical Assessment of Pediatric Obstructive Sleep Apnea
Authors: Goldstein Nira A. , Pugazhendhi Vasanthi , Rao Sudha M. , Weedon Jeremy , Campbell Thomas F. , Goldman Andrew C. , Post J. Christopher , Rao Madu
Published: August 2004

Objective. To determine whether children with a clinical assessment suggestive of obstructive sleep apnea (OSA) but with negative polysomnography (PSG) have improvement in their clinical assessment score after tonsillectomy and adenoidectomy (T&A) as compared with similar children who do not undergo surgery.

Methods. In a prospective, randomized, investigator-blinded, controlled trial, 59 otherwise healthy children (mean age: 6.3 years [3.0]; 31 boys, 28 girls) with a clinical diagnosis of OSA (clinical assessment score ≥40) were recruited from the pediatric otolaryngology and pediatric pulmonary private offices and clinics of a tertiary care, academic medical center. A standardized assessment was performed on all patients, including history, physical examination, voice recording, tape recording of breathing during sleep, lateral neck radiograph, echocardiogram, and PSG. A clinical assessment score was assigned. Children with positive PSG (n = 27) were scheduled for T&A, whereas children with negative PSG (n = 29) were randomized to T&A (n = 15) or no surgery (n = 14). Children were reassessed in an identical manner at a planned 6-month follow-up.

Results. Follow-up was available for 21 patients with positive PSG, 11 patients with negative PSG randomized to T&A, and 9 nonsurgery patients. In the randomized subjects, the median reduction in clinical assessment score was 49 (range: 32–61) for the T&A patients as compared with 8 (range: −9 to 29) for the nonsurgery patients. Nine (82%) of the T&A patients were asymptomatic (clinical assessment score <20) compared with 2 (22%) of the nonsurgery patients.

Conclusion. Children with a positive clinical assessment of OSA but negative PSG have significant improvement after T&A as compared with observation alone, thus validating the clinician’s role in diagnosing upper airway obstruction.
Proactive Management Promotes Outcome in Extremely Preterm Infants: A Population-Based Comparison of Two Perinatal Management Strategies
Authors: Håkansson Stellan , Farooqi Aijaz , Holmgren Per Åke , Serenius Fredrik , Högberg Ulf
Published: August 2004

Objective. There is a need for evidence-based knowledge regarding perinatal management in extreme prematurity. The benefit of a proactive attitude versus a more selective one is controversial. The objective of the present study was to analyze perinatal practices and infant outcome in extreme prematurity in relation to different management policies in the North (proactive) and South of Sweden.

Methods. A population-based, retrospective, cohort study design was used. Data in the Swedish Medical Birth Register (MBR) from 1985 to 1999 were analyzed according to region of birth and gestational age (22 weeks + 0 days to 27 weeks + 6 days). A total of 3 602 live-born infants were included (North = 1040, South = 2562). Survival was defined as being alive at 1 year. Morbidity in survivors, based on discharge diagnoses of major morbidity during the first year of life, was described by linking the MBR to the Hospital Discharge Register.

Results. In infants with a gestational age of 22 to 25 weeks, the proactive policy was significantly associated with 1) increased incidence of live births, 2) higher degree of centralized management, 3) higher frequency of caesarean section, 4) fewer infants with low Apgar score (<4) at 1 and 5 minutes, 5) fewer infants dead within 24 hours, and 6) increased number of infants alive at 1 year. There were no indications of increased morbidity in survivors of the proactive management during the first year of life, and the proportion of survivors without denoted morbidity was larger.

Conclusion. In infants with a gestational age of 22 to 25 weeks, a proactive perinatal strategy increases the number of live births and improves the infant’s postnatal condition and survival without evidence of increasing morbidity in survivors up to 1 year of age.
Health Services Use and Health Care Expenditures for Children With Disabilities
Authors: Newacheck Paul W. , Inkelas Moira , Kim Sue E.
Published: August 2004

Objective. To examine health care utilization and expenditure patterns for children with disabilities.

Methods. Secondary data analysis was conducted of the 1999 and 2000 editions of the Medical Expenditure Panel Survey (MEPS), a nationally representative survey conducted in 5 rounds by household interview. Two years of MEPS data were combined in this analysis to improve the precision of estimates. Disability was defined by the presence of a limitation in age-appropriate social role activities, such as school or play, or receipt of specialized services through the early intervention or special education programs. The survey sample included 13 792 children younger than 18 years. The overall response rate was 65.5%.

Results. Our findings demonstrate that the 7.3% of US children with disabilities used many more services than their counterparts without disabilities in 1999–2000. The largest differences in utilization were for hospital days (464 vs 55 days per 1000), nonphysician professional visits (3.0 vs 0.6), and home health provider days (3.8 vs 0.04). As a result of their greater use, children with disabilities also had much higher health care expenditures ($2669 vs $676) and higher out-of-pocket expenditures ($297 vs $189). We also found that the distributions of total and out-of-pocket expenses were highly skewed, with a small fraction of the disabled population accounting for a large proportion of expenditures: the upper decile accounted for 65% of total health care expenses and 85% of all out-of-pocket expenses for the population with disabilities. Health insurance was found to convey significant protection against financially burdensome expenses. However, even after controlling for insurance status, low-income families experienced greater financial burdens than higher income families.

Conclusions. The skewed distribution of out-of-pocket expenses found in this and earlier studies indicates that the financial burden of childhood disability continues to be shared unevenly by families. Low-income families are especially vulnerable to burdensome out-of-pocket expenses. Additional efforts are needed to protect these high-risk families.
Use of Antivenin to Treat Priapism After a Black Widow Spider Bite
Authors: Hoover Nancy G. , Fortenberry James D.
Published: August 2004

Black widow spider envenomation (BWSE) is commonly associated with severe abdominal pain, muscle cramping, and hypertension. Treatment is primarily symptomatic with the use of opiates and benzodiazepines. Priapism is a complication of BWSE that has only rarely been reported. We describe a 17-month-old male who developed priapism after known BWSE. His priapism did not respond to opiates or benzodiazepines, and he was treated with black widow spider antivenin. Complete detumescence followed within several hours. The patient required no additional opiates for pain and was discharged from the hospital the following day. The patient's rapid improvement after antivenin suggests its efficacy in treating BWSE-associated priapism.
Family Reports of Care Denials for Children Enrolled in TennCare
Authors: Valet Robert S. , Kutny Diane F. , Hickson Gerald B. , Cooper William O.
Published: August 2004

Objective. Twenty-three million people, accounting for >58% of Medicaid enrollees, are enrolled in Medicaid managed care programs. Although the expectation of management in Medicaid managed care programs necessitates restrictions in use of some services sought by patients and families, the circumstances surrounding care denial and related access problems in vulnerable populations of children have not been studied. The objective of this study was to identify experiences with care denial reported by families in TennCare, Tennessee's managed care program for Medicaid enrollees and uninsured.

Methods. Primary caregivers for 399 children who were enrolled in TennCare and presented for care at 21 pediatric and family medicine sites throughout Tennessee participated in a face-to-face interview.

Results. Of the 399 caregivers who participated in the study, 146 (36.6%) reported that their child experienced denial of care in the previous 12 months at a physician's office (12.5% of those interviewed), dentist's office (13.8%), or pharmacy (20.0%). For denial of any 1 type of care, families of children with chronic conditions (multivariable odds ratio [OR]: 2.05; 95% confidence interval [CI]: 1.41–2.99) and those whose parents had >12 years of education (OR: 1.80; CI: 1.21–2.70) were more likely to report denial of care; families of black children were less likely to report denial than white children (OR: 0.34; CI: 0.20–0.56). Content analysis of caregiver perceptions identified provider concerns about reimbursement as a factor in denials. Of the children who could not be seen by a physician, caregivers perceived that 12.2% became sicker as a result of the delay in care; 16.3% reported an emergency department visit after the denial.

Conclusions. More than one third of TennCare families reported denials of care for their children in the previous year, and factors surrounding these denials were identified. Given the large number of Americans who receive health care through Medicaid managed care programs like TennCare, more research is needed to understand the implications of denied care for children and families who are enrolled in these programs.
Effect of Dextromethorphan, Diphenhydramine, and Placebo on Nocturnal Cough and Sleep Quality for Coughing Children and Their Parents
Authors: Paul Ian M. , Yoder Katharine E. , Crowell Kathryn R. , Shaffer Michele L. , McMillan Heidi S. , Carlson Lisa C. , Dilworth Deborah A. , Berlin Cheston M.
Published: August 2004

Objectives. To determine whether the commonly used over-the-counter medications dextromethorphan and diphenhydramine are superior to placebo for the treatment of nocturnal cough and sleep difficulty associated with upper respiratory infections and to determine whether parents have improved sleep quality when their children receive the medications when compared with placebo.

Methods. Parents of 100 children with upper respiratory infections were questioned to assess the frequency, severity, and bothersome nature of the nocturnal cough. Their answers were recorded on 2 consecutive days, initially on the day of presentation, when no medication had been given the previous evening, and then again on the subsequent day, when either medication or placebo was given before bedtime. Sleep quality for both the child and the parent were also assessed for both nights.

Results. For the entire cohort, all outcomes were significantly improved on the second night of the study when either medication or placebo was given. However, neither diphenhydramine nor dextromethorphan produced a superior benefit when compared with placebo for any of the outcomes studied. Insomnia was reported more frequently in those who were given dextromethorphan, and drowsiness was reported more commonly in those who were given diphenhydramine.

Conclusions. Diphenhydramine and dextromethorphan are not superior to placebo in providing nocturnal symptom relief for children with cough and sleep difficulty as a result of an upper respiratory infection. Furthermore, the medications given to children do not result in improved quality of sleep for their parents when compared with placebo. Each clinician should consider these findings, the potential for adverse effects, and the individual and cumulative costs of the drugs before recommending them to families.
Beneficial Effects of Continuous Subcutaneous Insulin Infusion and Flexible Multiple Daily Insulin Regimen Using Insulin Glargine in Type 1 Diabetes
Authors: Alemzadeh Ramin , Ellis James N. , Holzum Mary K. , Parton Elaine A. , Wyatt David T.
Published: August 2004

Objective. The aim of this study was to evaluate the metabolic effects of continuous subcutaneous insulin infusion (CSII) with flexible multiple daily insulin (FMDI; premeal lispro + bedtime glargine) therapy as determined by glycosylated hemoglobin (HbA 1c), body mass index (BMI), and hypoglycemic episodes in a group of patients who made the transition from multiple daily insulin (premeal lispro + bid ultralente) to either CSII or FMDI therapy.

Methods. Data from 40 (27 female and 13 male) patients (10.1–17.8 years of age) who were on CSII and 40 age- and gender-matched (27 female and 13 male) patients (10.3–17.3 years of age) who were on FMDI were collected during regularly scheduled visits at a similar frequency over a 1-year period.

Results. The total daily insulin dose did not change in CSII (0.97 ± 0.24 vs 0.91 ± 0.22 U/kg) and FMDI (0.98 ± 0.21 vs 0.97 ± 0.21 U/kg) patients, whereas the bolus:basal insulin ratio was significantly increased in both CSII (1.01 ± 0.43 vs 1.32 ± 0.52) and FMDI (1.07 ± 0.0.41 vs 1.29 ± 0.47) patients. The total cohort of CSII patients showed a decrease in HbA1c from 8.4 ± 1.0% to 7.8 ± 0.8%, whereas the FMDI cohort did not show a significant change in HbA1c (8.5 ± 1.1% to 8.2 ± 0.9%). However, 40% of the CSII group and 22.5% of the FMDI group showed ≥1.0% improvement in HbA1c. Also, a similar number of patients in CSII (52.5%; 8.0 ± 1.1 to 7.2 ± 0.5%) and FMDI (47.5%; 8.0 ± 0.5% to 7.5 ± 0.4%) maintained or achieved target HbA1c values <8.0%. The BMI increased significantly in the CSII group (21.6 ± 3.2 vs 23.0 ± 3.0 kg/m2) but did not change in the FMDI group (21.9 ± 3.9 vs 22.6 ± 3.8 kg/m2). There was a significant reduction in the rate of severe hypoglycemia (events/100 patient-years) in both cohorts: 20.6 to 8.2 in the CSII and 18.8 to 7.5 in the FMDI. Similarly, the rate of moderate hypoglycemia decreased in both CSII (68.3–35.4) and FMDI (56.3–30.4).

Conclusions. CSII therapy resulted in a significant improvement in HbA 1c in the entire group, whereas FMDI therapy improved HbA1c in only a subgroup of patients. However, almost half of the patients in each of the treatment groups maintained or achieved target glycemic control. Both CSII and FMDI treatment groups demonstrated a decreased rate of hypoglycemia without an abnormal increase in BMI. Although the design of this study does not allow direct comparison of the metabolic effects of CSII and FMDI therapies, both regimens seem to be superior to basal ultralente and lispro multiple daily insulin regimen and offer desirable therapeutic alternatives in pediatric diabetes care.
Triage of the Pediatric Patient in the Emergency Department: Are We All in Agreement?
Authors: Maldonado Theresa , Avner Jeffrey R.
Published: August 2004

Objective. To compare triage categorization as a measure of perceived patient acuity on presentation to the emergency department by pediatric emergency medicine (PEM) attending physicians, nurses, and pediatric residents with their general emergency medicine (GEM) counterparts.

Methods. A questionnaire that contained 12 pediatric triage scenarios was sent to all PEM attending physicians, triage-trained nurses, and pediatric residents and their GEM counterparts at a large urban hospital with separate pediatric and general emergency departments. Participants were asked to use a 3-tier triage system (emergent, urgent, nonurgent) to assign a triage level for each patient scenario.

Results. The response rate was 99%. The κ level of agreement was highest (.39) among the PEM physicians. Significantly more GEM attending physicians triaged the following scenarios at a higher acuity level as compared with PEM attending physicians with a trend toward emergent triage: simple febrile seizure, 50% (95% confidence interval [CI]: 30%–70%) versus 7.7% (95% CI: 1%–34%); 18-month-old with fever and bumps on lips, 21% (95% CI: 9%–43%) versus 0% (95% CI: 0%–23%); and 15-month-old well-appearing child with high fever, 50% (95% CI: 30%–70%) versus 7.7% (95% CI: 1%–34%). Significant differences were found between GEM and PEM triage-trained nurses only in the 15-month-old high fever scenario and between GEM and pediatric residents in the 15-month-old high fever scenario, the 18-month-old with fever and bumps on lips scenario, and a fever/limp scenario.

Conclusions. The level of agreement of triage assignment within each group was only fair. GEM participants and PEM participants agreed on most scenarios. However, GEM participants were more likely to triage children with certain febrile illnesses at higher acuity levels as compared with their PEM counterparts.