bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of Plasma Human Immunodeficiency Virus RNA and CD4+ T Lymphocytes on Growth Measurements of Hemophilic Boys and Adolescents
Authors: Hilgartner Margaret W. , Donfield Sharyne M. , Lynn Henry S. , Hoots W. Keith , Gomperts Edward D. , Daar Eric S. , Chernoff David , Pearson Sunny K. ,   the Hemophilia Growth and Development Study
Published: August 2004

Objective.

The investigation examined the associations of plasma human immunodeficiency virus (HIV) RNA and CD4+ T lymphocytes with height, weight, skeletal maturation, testosterone levels, and height velocity for hemophilic children and adolescents with HIV infection in the Hemophilia Growth and Development Study.

Study Design.

Two hundred seven participants were evaluated over 7 years.

Results.

A threefold increment in baseline plasma HIV RNA was associated with a 0.98-cm decrease in height and a 1.67-kg decrease in weight; 100-cells/μL decrements in baseline CD4+ were associated with a 2.51-cm decrease in height and a 3.83-kg decrease in weight. Participants with high plasma HIV RNA (>3125 copies/mL) experienced significant delay in achieving maximum height velocity and lower maximum velocity compared with those with low viral load. The high CD4+ (>243)/low plasma HIV RNA group had earlier age at maximum height velocity compared with the other 3 groups and higher maximum height velocity compared with the low CD4+/high plasma HIV RNA and low CD4+/low plasma HIV RNA groups. Decrements in CD4+ were associated with decreases in bone age and testosterone level.

Conclusions.

CD4+ and HIV RNA were important in predicting growth outcomes.
Obstructive Nephropathy in Children: Long-Term Progression After Relief of Posterior Urethral Valve
Authors: Roth Karl S. , Carter W. Hans , Chan James C. M.
Published: August 2004

Background.

Approximately one third of children with end-stage renal disease have the illness because of urinary tract malformations, obstructive uropathy, and hypoplasia/dysplasia. The significant drop in infant mortality from obstructive uropathies in recent decades, attributable to prenatal diagnosis with renal ultrasonography and coordinated surgical and medical care, necessitated a reevaluation of the long-term outcome.

Methods.

To that end, we examined the long-term progression of obstructive nephropathy after neonatal relief of posterior urethral valves in our center over a span of 21 years, with diagnosis and care being provided by the same pediatric and urology team.

Results.

The 10 consecutive cases of posterior urethral valves represented 7% of all patients with congenital malformative uropathies seen over this period. The following procedures were performed: primary valve ablation (90%) and vesicostomy (40%). Seventy percent of patients progressed to end-stage renal disease over a (mean ± standard error of the mean) follow-up of 11.3 ± 2.1 years. The linear plot of the log of the inverse of serum creatinine versus time suggested unrelenting progression. The rate of progression was rapid after serum creatinine exceeded 5 mg/dL but the rate was slow and steady from serum creatinine of 1.5 to 5 mg/dL.

Conclusions.

To test the effect of a therapeutic intervention to ameliorate the rate of progression, this steady and prolonged progression of 0.5 mg/dL per year between serum creatinine concentration of 1.5 to 5 mg/dL would seem the optimal study.
Lice, Nits, and School Policy
Authors: Williams L. Keoki , Reichert Amanda , MacKenzie William R. , Hightower Allen W. , Blake Paul A.
Published: August 2004

Background.

The epidemiology of head lice infestation is poorly understood. Many schools treat all children with nits as though they are contagious. Children with nits but no lice are often removed from school until they are treated and all visible nits are removed.

Objective.

To investigate the probability that children with nits alone will become infested with lice.

Design.

Prospective cohort study.

Setting.

Two metropolitan Atlanta elementary schools.

Participants.

A total of 1729 children were screened for head lice. Twenty-eight children (1.6%) had lice, whereas 63 (3.6%) had nits without lice. Fifty of the 63 children (79%) with nits alone completed follow-up.

Outcome Measure.

Conversion (ie, becoming infested with lice) within 14 days after initial screening.

Results.

Nine of 50 children (18.0%) followed for nits alone converted. Although children who converted did not have significantly more nits than did nonconverters, having nits near the scalp was a risk factor for conversion. Seven of 22 children (31.8%) with ≥5 nits within one fourth inch of the scalp converted, compared with 2 of 28 children (7.1%) with fewer (relative risk: 4.45; 95% confidence interval: 1.03–19.35). This risk remained statistically significant after separately stratifying for sex, recent treatment, and total number of nits.

Conclusions.

Although having ≥5 nits within one fourth inch of the scalp was a risk factor for conversion, most children with nits alone did not become infested. Policies requiring exclusion from school and treatment for all children with nits alone are likely excessive. Instead, these children may benefit from repeated examination to exclude the presence of crawling lice.lice, pediculus, lice infestations, pediatrics, school.
Developing Language Skills of Cocaine-Exposed Infants
Authors: Singer Lynn T. , Arendt Robert , Minnes Sonia , Salvator Ann , Siegel A. Carol , Lewis Barbara A.
Published: August 2004

Objective.

To assess whether there is an association of level of fetal cocaine exposure to developmental precursors of speech-language skills at 1 year of age, after controlling for confounding factors.

Design.

In a prospective, longitudinal, quasi-experimental, matched cohort design, 3 cocaine exposure groups were defined by maternal self-report and infant meconium assay: nonexposure (n = 131), heavier exposure (n = 66), >the 75th percentile for maternal self-report and >the 70th percentile of benzoylecgonine concentration, and all others as lighter exposure (n = 68). At 1 year of age, the Preschool Language Scale-3 was administered by examiners unaware of infant drug status.

Results.

Independent of confounding drug, medical, and environmental factors, more heavily exposed infants had lower auditory comprehension scores than nonexposed infants and lower total language scores than lighter and nonexposed infants. More heavily exposed infants were also more likely to be classified as mildly delayed by total language score than nonexposed infants. There were positive linear relationships between the concentration of benzoylecgonine in meconium and all outcomes and between maternal report of severity of prenatal cocaine use with poorer auditory comprehension indicating a relationship between amount of exposure and poorer outcomes.

Conclusions.

This study documents significant behavioral teratogenic effects of fetal cocaine exposure on attentional abilities underlying auditory comprehension skills considered to be precursors of receptive language. Pediatricians are in a unique position to monitor early development of cocaine-exposed infants and make timely referrals for intervention.
The Effect of Late Doses on the Achievement of Seroprotection and Antibody Titer Levels With Hepatitis B Immunization Among Adolescents
Authors: Middleman Amy B. , Kozinetz Claudia A. , Robertson Laura M. , DuRant Robert H. , Emans S. Jean
Published: August 2004

Objective.

To determine the effect of varying dosing schedules and predictor variables on the seroprotection rates and geometric mean titer levels resulting from the hepatitis B vaccination series among adolescents.

Methods.

Adolescents received the hepatitis B vaccination series at varying schedules according to their natural adherence patterns. Data collected included participants' medication use; chronic illness; use of cigarettes, alcohol, and marijuana; age; race/ethnicity; and body mass index. Participants' dates of vaccinations were recorded and titer levels for hepatitis B surface antibody were drawn ∼12 and 24 months after study enrollment. The data for 498 participants were analyzed using χ2 tests, Student t tests, logistic regression models, and analysis of variance.

Results.

Seroprotection rates among adolescents were not affected by late vaccinations. The only factors affecting the achievement of seroprotection ∼12 and 24 months after the first vaccination were body mass index and the number of immunizations received. Increased time between doses 1 and 2 and doses 2 and 3 showed a trend toward correlating with increasing titer levels.

Conclusions.

Although adolescents at risk of acquiring hepatitis B should receive the hepatitis B vaccination series in a timely fashion, late doses are not detrimental, and may be beneficial, to achieving high antibody levels against the hepatitis B virus.
High-Flow Nasal Cannulae in the Management of Apnea of Prematurity: A Comparison With Conventional Nasal Continuous Positive Airway Pressure
Authors: Sreenan Con , Lemke Robert P. , Hudson-Mason Ann , Osiovich Horacio
Published: August 2004

Apnea of prematurity (AOP) is frequently managed with nasal continuous positive airway pressure (NCPAP). Nasal cannula (NC) are used at low flows (<0.5 L/min) to deliver supplemental oxygen to neonates. A number of centers use high-flow nasal cannula (HFNC) in the management of AOP without measuring the positive distending pressure (PDP) generated.

Objective. To determine the NC flow required to generate PDP equal to that provided by NCPAP at 6 cm H2O and to assess the effectiveness of HFNC as compared NCPAP in the management of AOP.

Method. Forty premature infants, gestation 28.7 ± 0.4 weeks (mean ± standard error of mean), postconceptual age at study 30.3 ± 0.6 weeks, birth weight 1256 ± 66 g, study weight 1260 ± 63 g who were being managed with conventional NCPAP for at least 24 hours for clinically significant apnea of prematurity, were enrolled in a trial of ventilator-generated conventional NCPAP versus infant NC at flows of up to 2.5 L/min. End expiratory esophageal pressure was measured on NCPAP and on NC, and the gas flow on NC was adjusted to generate an end expiratory esophageal pressure equal to that measured on NCPAP. Two 6-hour periods were continuously recorded and the data were stored on computer.

Results. The flow required to generate a comparable PDP with NC varied with the infant's weight and was represented by the equation: flow (L/min) = 0.92 + 0.68x, x = weight in kg,R = 0.72. There was no difference in the frequency and duration of apnea, bradycardia or desaturation per recording between the 2 systems.

Conclusion. NC at flows of 1 to 2.5 L/min can deliver PDP in premature neonates. HFNC is as effective as NCPAP in the management of AOP.
Invasive Group A Streptococcal Infection and Nonsteroidal Antiinflammatory Drug Use Among Children With Primary Varicella
Authors: Lesko Samuel M. , O'Brien Katherine L. , Schwartz Benjamin , Vezina Richard , Mitchell Allen A.
Published: August 2004

Objectives.

To test the hypothesis that nonsteroidal antiinflammatory drug use increases the risk of necrotizing soft tissue infections and, secondarily, all invasive group A streptococcal (GAS) infections in children with primary varicella infection.

Methods.

We conducted a prospective, multicenter case-control study among children <19 years old. Cases were children hospitalized with primary varicella complicated by invasive GAS infection or necrotizing soft tissue infection identified by a network of 45 pediatric infectious disease specialists located throughout the United States. Controls were children with uncomplicated primary varicella residing in the same communities as the cases. Data on medical history, clinical features of the varicella infection, signs and symptoms of infectious complications, and medication use were collected by structured telephone interviews. Univariate and multivariate matched odds ratios were calculated using conditional logistic regression.

Results.

Between June 1996 and September 1998, 52 cases of invasive GAS infection, including 21 with necrotizing soft tissue infection, and 172 controls with uncomplicated primary varicella were enrolled. Risk of invasive GAS infection was increased among children who were nonwhite (multivariate odds ratio [OR] 3.8, 95% confidence interval [CI]: 1.4–11), living in low-income households (OR 5.1, 95% CI: 1.7–15), exposed to varicella at home (OR 6.4, 95% CI: 2.6–16), or had a persistent high fever (OR 9.6, 95% CI: 2.8–33). Antipyretic regimen was associated with several measures of varicella illness severity among the controls. The risk of necrotizing soft tissue infection was not associated with the use of ibuprofen before the development of signs or symptoms of this complication (OR 1.3, 95% CI: 0.33–5.3). Risk of any invasive GAS infection was increased among children who had received ibuprofen (OR 3.9, 95% CI: 1.3–12), but not acetaminophen (OR 1.2, 95% CI: 0.50–3.0). However, there was no evidence of increasing risk with increasing duration of ibuprofen use. Subgroup analyses revealed that the risk of invasive GAS infection was increased only among children who had received both acetaminophen and ibuprofen.

Conclusions.

These data do not support the hypothesis that nonsteroidal antiinflammatory drugs, or ibuprofen in particular, increase the risk of necrotizing GAS infections. A statistically significant association was observed between nonnecrotizing invasive GAS infection and ibuprofen use; however, because of potential confounding, the meaning of this unexpected result is unclear. Nonetheless, these data suggest that parents use ibuprofen or ibuprofen together with acetaminophen to treat high fever and severe illness, which seems to identify children at high risk for invasive GAS infection.
Detecting Suicide Risk in a Pediatric Emergency Department: Development of a Brief Screening Tool
Authors: Horowitz Lisa M. , Wang Philip S. , Koocher Gerald P. , Burr Barbara H. , Smith Mary Fallon , Klavon Susan , Cleary Paul D.
Published: August 2004

Objective.

To develop a brief screening tool that will allow emergency department (ED) staff to rapidly and accurately detect suicide risk in child and adolescent patients.

Design.

Cross-sectional survey.

Participants.

One hundred forty-four children and adolescents, mean age of 13.6 years, presenting to an urban university teaching hospital pediatric ED for primarily psychiatric reasons.

Data Collection.

As part of a quality improvement initiative, we developed a 14-item screening survey (the Risk of Suicide Questionnaire [RSQ]) that was administered by a triage nurse to all pediatric mental health patients on admission to the ED. All patients were subsequently administered the 30-item Suicide Ideation Questionnaire (SIQ) by a mental health clinician, which served as the criterion standard assessment of suicidality. Other information collected included demographic and clinical characteristics.

Main Outcome Measures.

Sensitivity, specificity, positive predictive value, negative predictive value (NPV), and area under the receiver operating characteristic curve for responses to individual and combinations of RSQ items, relative to determinations of suicidality by the criterion standard SIQ.

Results.

Four of the items from the RSQ had a predictive c statistic of 0.87, a sensitivity of 0.98, and a NPV of 0.97. Little improvement in predictive ability was obtained by including other RSQ items (c statistic for the most predictive 4-item model = 0.87; cstatistic for the model containing all 14 items = 0.90). Among all possible combinations of 4 RSQ items, the combination of items inquiring about current suicidal behavior, past suicidal ideation, past self-destructive behavior, and current stressors yielded the highest sensitivity (0.98), NPV (0.97), and c statistic (0.87), as assessed by the criterion standard SIQ.

Conclusions.

A brief 4-item screening tool can be used by nonmental health clinicians to accurately detect suicidality in children and adolescents who visit an ED. Early and accurate identification of suicidality is a critical first step that could lead to better treatment and improved health outcomes for children and adolescents with mental health concerns.
Ethics and Immunization Policy: Promoting Dialogue to Sustain Consensus
Authors: Feudtner Chris , Marcuse Edgar K.
Published: August 2004

The societal consensus that has supported the United States' universal childhood immunization programs for the past 50 years shows signs of eroding. This article proposes a systematic approach to evaluate immunization policy options. Through a unifying framework that combines epidemiologic, economic, and ethical concerns, this approach promotes a clearer understanding of underlying issues and inherent tradeoffs between alternative policies. Such a systematic examination of policy options could facilitate the public dialogue necessary to continually recreate a broad consensus on immunization practices and enable us to choose policies most in accord with our fundamental values.
A Family Cluster of Streptococcal Toxic Shock Syndrome in Children: Clinical Implication and Epidemiological Investigation
Authors: Huang Yhu-Chering , Hsueh Po-Ren , Lin Tzou-Yien , Yan Dah-Chin , Hsia Shao-Hsuan
Published: August 2004

Background.

Most invasive group A streptococcal (GAS) disease occurs sporadically. Reports of family clusters of these infections are scanty, and most invasive disease occurs in adults. We describe a family cluster of streptococcal toxic shock syndrome (STSS) involving 3 children and present the results of an epidemiologic investigation.

Patients and Methods.

During a 16-day period, 3 children in a family developed STSS with an interval of 7 and 9 days, respectively, between the onset of disease. Cases 2 and 3 had GAS isolated from blood culture. Case 2 was fatal. Pharyngeal culture survey of the family members and schoolchildren was conducted. Antibiogram, serotyping, detection of exotoxin genes, and random amplified polymorphic DNA patterns of the disease strains and survey strains were examined.

Results.

One of 15 family members sampled—the sister of the index case—and 7 (5.6%) of 125 schoolchildren sampled had GAS isolated from pharyngeal cultures. Of the 10 strains examined, 2 isolates from the patients, 1 from the sister of index case, and 2 from the classmates of case 2 (the fatal case) had an identical pattern of both genotype and phenotype.

Conclusion.

We describe a family cluster of STSS involving 3 children caused by a single clone and provide additional data regarding invasive GAS infection subsequent to household contact. Additional studies should be conducted in conjunction with surveillance to define better the magnitude of risk in household contacts and to identify settings in which subsequent infections may occur.
Glutaric Acidemia, Type I, Missed by Newborn Screening in an Infant With Dystonia Following Promethazine Administration
Authors: Smith Wendy E. , Millington David S. , Koeberl Dwight D. , Lesser Philip S.
Published: August 2004

We report a child initially diagnosed with promethazine-induced dystonia despite a lack of response to diphenhydramine therapy. On further evaluation, the child was diagnosed with glutaric acidemia, type I (GA-I), an autosomal recessive inborn error of metabolism caused by the deficiency of glutaryl-CoA dehydrogenase. The characteristic clinical feature of GA-I is an acute encephalopathic and neurologic crisis typically occurring during a catabolic state. Despite slow improvement, many patients do not fully recover from a neurologic crisis, and residual neurologic morbidity can be significant. Although newborn screening using tandem mass spectrometry is expected to enable presymptomatic diagnosis of GA-I, this patient was not detected by newborn screening with tandem mass spectrometry. Therefore, a high suspicion of GA-I must be maintained in the evaluation of childhood dystonia, even when newborn screening results are reportedly normal.
Implementation Principles and Strategies for the State Children's Health Insurance Program
Authors:   Committee on Child Health Financing
Published: August 2004

This policy statement presents principles and implementation and evaluation strategies recommended for the State Children's Health Insurance Program (SCHIP). The statement summarizes the current status of SCHIP, the needs of uninsured children, and the potential benefits of SCHIP programs. Principles and recommended strategies include expanding eligibility, maximizing funding, providing comprehensive benefits, including pediatricians in program design and evaluation, providing adequate reimbursement and access to pediatricians, ensuring choices for families and pediatricians, and establishing simple administrative procedures.
Career Planning for Pediatric Residents
Authors: Abelson Herbert T. , Blewett Laurel , Tunnessen Walter W.
Published: August 2004

After having made decisions about college, medical school, and specialty training, some residents may delay consideration of their future career in pediatrics. Others, having decided what path they will pursue, are not clear as to what steps need to be taken to ensure that they approach their choice armed with the most appropriate and accurate information.

Residents seek career choice information from various sources. For many, the resources may not be able to provide as complete information in all facets of career decision-making.

An Internet accessible site for career planning for pediatric residents has been developed (www.ucch.org/residency/CareerPlanning.html). The advantages, beyond ease of access by all residents, are many, particularly the power of links to other Internet resources. In addition, a website provides the ability to rapidly update and add information, which is not feasible in printed form. career planning, pediatric residents, jobs, private practice, pediatric specialties.
Worldwide Timing of Growth Faltering: Implications for Nutritional Interventions
Authors: Shrimpton Roger , Victora Cesar G. , de Onis Mercedes , Lima Rosângela Costa , Blössner Monika , Clugston Graeme
Published: August 2004

Objective.

It is widely assumed that growth faltering starts at around 3 months of age, but there has been no systematic assessment of its timing using representative national datasets from a variety of countries.

Methodology.

The World Health OrganizationGlobal Database on Child Growth and Malnutritionincludes the results of 39 nationally representative datasets from recent surveys in developing countries. Based on these data, meanz scores of weight for age, length/height for age, and weight for length/height were compared with the National Center for Health Statistics and Cambridge growth references, for children younger than 60 months.

Results.

Mean weights start to falter at about 3 months of age and decline rapidly until about 12 months, with a markedly slower decline until about 18 to 19 months and a catch-up pattern after that. Growth faltering in weight for length/height is restricted to the first 15 months of life, followed by rapid improvement. For length/height for age, the global mean is surprisingly close to National Center for Health Statistics and Cambridge references at birth, but faltering starts immediately afterward, lasting well into the third year.

Conclusions.

These findings highlight the need for prenatal and early life interventions to prevent growth failure.
Technical Report: The Pediatrician's Role in the Diagnosis and Management of Autistic Spectrum Disorder in Children
Authors:   Committee on Children With Disabilities
Published: August 2004

Autism and its milder variants are not rare. Most pediatricians will have the opportunity to provide a medical home for a child with autism. This technical report serves to complement and expand on the information in the accompanying policy statement to increase the pediatrician's fund of knowledge and comfort level in caring for children with autism. In so doing, it is anticipated that earlier diagnosis and referral for appropriate intervention will be possible and that this will, in turn, have a positive effect on long-term outcomes for children with autism and their families.
Mortality Risk in Children With Epilepsy: The Dutch Study of Epilepsy in Childhood
Authors: Callenbach Petra M. C. , Westendorp Rudi G. J. , Geerts Ada T. , Arts Willem Frans M. , Peeters Els A. J. , van Donselaar Cees A. , Peters A. C.  Boudewyn , Stroink Hans , Brouwer Oebele F.
Published: August 2004

Objective.

Long-term follow-up studies of patients with epilepsy have revealed an increased mortality risk compared with the general population. Mortality of children who have epilepsy in modern times is as yet unknown. Therefore, the objective of this study was to determine mortality of children who have epilepsy in comparison with the general population.

Methods.

Between August 1988 and August 1992, 472 children, aged 1 month to 16 years, who presented in 1 of the participating hospitals with 2 or more newly diagnosed unprovoked seizures or at least 1 status epilepticus were enrolled in the study. All children were followed for 5 years or until death. The number of deaths observed during follow-up was compared with the expected number of deaths in the same age group in the general population in the Netherlands.

Results.

Nine children died during follow-up, amounting to a mortality rate of 3.8/1000 person-years, which is sevenfold higher than expected (95% confidence interval = 2.4–11.5). No deaths were observed among the 328 children who had epilepsy of nonsymptomatic cause. All deceased children had epilepsy that was caused by a static or progressive neurologic disorder (mortality risk = 22.9; 95% confidence interval = 7.9–37.9). None of them died from sudden unexpected and unexplained death of epilepsy.

Conclusions.

In our cohort, we found no indication that children who have nonsymptomatic epilepsy have an increased mortality risk compared with the general population, whereas children who have symptomatic epilepsy have a 20-fold increased mortality risk. These data provide guidance for counseling parents of children who have epilepsy.
Bacteremia, Central Catheters, and Neonates: When to Pull the Line
Authors: Benjamin Daniel K. , Miller William , Garges Harmony , Benjamin Daniel K. , McKinney Ross E. , Cotton Michael , Fisher Randall G. , Alexander Kenneth A.
Published: August 2004

Objectives.

Physicians who treat neonates who become bacteremic while dependent on central venous catheters face a serious and common dilemma. We sought 1) to evaluate the relationship between central venous catheter removal and outcome in bacteremic neonates, 2) to determine species of bacteria that are associated with an increased risk of infectious complications if the central catheter is not removed promptly, and 3) to provide evidence-based recommendations for central catheter management.

Method.

A retrospective cohort study of all neonates who had central venous access and developed bacteremia between July 1, 1995, and July 31, 1999, was conducted in the Duke University neonatal intensive care unit.

Results.

The outcome for patients in whom the central catheter was not removed within 24 hours of organism identification was significantly worse (odds ratio = 9.8) than it was for those whose catheters were removed promptly. For patients who were infected withStaphylococcus aureus or with nonenteric Gram-negative rods, delayed removal of the central catheter was associated with complicated bacteremia. Catheter sterilization was attempted in 27 neonates who were infected with enteric Gram-negative rods; only 10 of these infants retained their catheters without infection-related complications. Infants who had 4 consecutive blood cultures that were positive for coagulase-negative staphylococcus (CoNS) were at significantly increased risk for end-organ damage and death, compared with infants who had 3 or fewer positive blood culture for CoNS (odds ratio = 29.58).

Conclusions.

Bacteremic infants experienced fewer infection-related complications when the central catheter was removed promptly. One positive blood culture for Saureus or a Gram-negative rod warrants central line removal in a neonate. Clinicians who are faced with a neonate who has 1 positive culture for CoNS may attempt medical management without central catheter removal, but documentation of subsequent negative blood cultures is crucial. Once a neonate has 3 positive blood cultures for CoNS, the central catheter should be removed.central line, neonate, bacteremia, bacteria, umbilical catheter, Broviac, percutaneous.
Randomized Trial Comparing the Efficacy of a Novel Manual Breast Pump With a Standard Electric Breast Pump in Mothers Who Delivered Preterm Infants
Authors: Fewtrell Mary S. , Lucas Penny , Collier Sharon , Singhal Atul , Ahluwalia Jagjit S. , Lucas Alan
Published: August 2004

Objective.

The benefits of human milk for preterm infants are widely recognized, yet technological advances in milk expression have been slow. We compared the efficacy of a standard electric pump (EP; Egnell) used in 94% of United Kingdom neonatal units with a novel manual pump (MP; Avent ISIS) designed to operate more physiologically by simulating the infant's compressive action on the areola during breastfeeding.

Methods.

We randomized 145 women who delivered infants of <35 weeks' gestation to use the MP or the EP and measured total milk volume expressed while using the randomized pump during the infant's hospital stay, pattern of milk output and creamatocrit of milk expressed during a test period in the second week, and pump characteristics by maternal questionnaire.

Results.

Mothers who used the EP, who frequently double pumped, showed shorter expression times but produced no more milk than mothers who used the MP. When both pumped sequentially, however, mothers who used the MP showed significantly greater milk flow and total volume over 20 minutes. Creamatocrit was unaffected by pump type. The MP was rated significantly higher than the EP on 5 major characteristics.

Conclusions.

When compared on equal terms (sequential pumping), mothers who used the MP showed greater milk flow, perhaps reflecting more physiologic pump design. Even with double pumping, mothers who used the EP did not advantage their infants with greater milk production. We believe that this novel, effective MP, preferred by mothers and costing a fraction of the EP price, reflects a significant advance in milk expression for high-risk infants.breast pumps, randomized trial, preterm infants.
A Validity Test of Movie, Television, and Video-Game Ratings
Authors: Walsh David A. , Gentile Douglas A.
Published: August 2004

Context.

Numerous studies have documented the potential effects on young audiences of violent content in media products, including movies, television programs, and computer and video games. Similar studies have evaluated the effects associated with sexual content and messages. Cumulatively, these effects represent a significant public health risk for increased aggressive and violent behavior, spread of sexually transmitted diseases, and pediatric pregnancy. In partial response to these risks and to public and legislative pressure, the movie, television, and gaming industries have implemented ratings systems intended to provide information about the content and appropriate audiences for different films, shows, and games.

Objective.

To test the validity of the current movie-, television-, and video game-rating systems.

Design.

Panel study.

Measure.

Participants used the KidScore media evaluation tool, which evaluates films, television shows, and video games on 10 aspects, including the appropriateness of the media product for children based on age.

Results.

When an entertainment industry rates a product as inappropriate for children, parent raters agree that it is inappropriate for children. However, parent raters disagree with industry usage of many of the ratings designating material suitable for children of different ages. Products rated as appropriate for adolescents are of the greatest concern. The level of disagreement varies from industry to industry and even from rating to rating. Analysis indicates that the amount of violent content and portrayals of violence are the primary markers for disagreement between parent raters and industry ratings.

Conclusions.

As 1 part of a solution to the complex public health problems posed by violent and sexually explicit media products, ratings can have value if used with caution. Parents and caregivers relying on the ratings systems to guide their children's use of media products should continue to monitor content independently. Industry ratings systems should be revised with input from the medical and scientific communities to improve their reliability and validity. A single ratings system, applied universally across industries, would greatly simplify the efforts of parents and caregivers to use the system as well as the efforts of outside parties to monitor the use and validity of the system.
Effects of Medicaid Managed Care on Quality: Childhood Immunizations
Authors: Alessandrini Evaline A. , Shaw Kathy N. , Bilker Warren B. , Schwarz Donald F. , Bell Louis M.
Published: August 2004

Background.

Underimmunization is distributed unevenly across populations, concentrated among the impoverished. Managed care has stimulated the development of quality indicators such as immunization rates to assess health status of populations.

Objective.

To determine if enrollment in Medicaid managed care (MMC) improves quality of health care as reflected by immunization rates when compared with fee-for-service Medicaid (FFSM).

Design.

Prospective cohort study of infants born between May 1994 and April 1995 with a 24-month follow-up period.

Setting.

Urban teaching hospital and surrounding ambulatory settings.

Participants.

Consecutive sample of infants (n = 644) enrolled in MMC or FFSM. Ninety-two percent of eligible patients were enrolled, and 87% completed follow-up.

Main Outcome Measure.

Up-to-date immunization status.

Results.

Seventy-three percent of the MMC and 72.4% of the FFSM patients were up-to-date on their immunizations: relative risk 1.01, (95% confidence interval [CI] 0.87, 1.17). No differences were found in age at immunization between the MMC and FFSM groups. After adjusting for other factors in multivariate analysis, insurance status remained unassociated with immunization status: adjusted odds ratio (OR) 1.04, (95% CI: 0.90, 1.10). Factors associated with up-to-date immunization included firstborn child, OR 2.28 (95% CI: 1.45, 3.60) and adequate maternal prenatal care, OR 2.24 (95% CI: 1.44, 3.48). Variables characterizing children less likely to be adequately immunized included father living in home with child, OR 0.53 (95% CI: 0.33, 0.85) and using private office-based primary care, OR 0.39 (95% CI: 0.23, 0.63).

Conclusions.

Enrollment in MMC did not improve rates of immunizations when compared with FFSM.
Renal Function After Pediatric Cardiac Transplantation: The Effect of Early Cyclosporin Dosage
Authors: Hornung Tim S. , de Goede Christian G.E.L. , O'Brien Chris , Moghal Nadeem E. , Dark John H. , O'Sullivan John J.
Published: August 2004

Background.

There is little data on renal function in pediatric heart transplant recipients. Early rejection is a major concern and most units run high cyclosporin A (CyA) levels during the 2 to 3 months after transplantation. We sought to document long-term renal function after transplantation and to assess influence of early CyA levels.

Methods.

We reviewed all of our pediatric transplants between June 1985 and August 1998 who survived longer than 6 months (n = 54). Glomerular filtration rate (GFR) was estimated at 1, 2, 4, and 8 years posttransplantation using the Schwartz formula:

GFR (mL/min/1.73m2) = [Ht(cm)/creatinine(μmol/L)] × X

We also analyzed whether change in renal function correlated with trough CyA levels.

Results.

Median age at transplant was 4 years and median follow-up was 5 years. Survival rates were 87% at 1 year and 80% at 5 years. Mean GFR pretransplant was 79 ± 19 mL/min/1.73 m2, reflecting prerenal impairment. One year later, mean GFR was 72 mL/min/1.73 m2; after 2 years it was 65 mL/min/1.73 m2, after 4 years (n = 35) it was 60 mL/min/1.73 m2, and after 8 years (n = 14) it was 57 mL/min/1.73 m2. CyA levels during the first 2 months correlated with the change in GFR during the first year (r2 = 0.21).

Conclusions.

This study demonstrates for the first time that decline in renal function after heart transplantation correlates with early CyA exposure; this dysfunction persists even when CyA doses are subsequently reduced.
Child Health Status, Neurodevelopmental Outcome, and Parental Satisfaction in a Randomized, Controlled Trial of Nitric Oxide for Persistent Pulmonary Hypertension of the Newborn
Authors: Ellington Marty , O'Reilly Deirdre , Allred Elizabeth N. , McCormick Marie C. , Wessel David L. , Kourembanas Stella
Published: August 2004

Objective.

To describe health and neurodevelopmental outcomes and parental satisfaction with hospital care among surviving intervention and control enrollees in a randomized, controlled trial of nitric oxide for persistent pulmonary hypertension of the newborn (PPHN).

Methods.

All surviving enrollees 1 to 4 years of age were eligible for follow-up. Outcomes were assessed by telephone using a trained interviewer and standardized instruments. Domains assessed included parental report of specific conditions and hospital use, rating of general health, cognitive and motor development, behavior problems, temperament, and satisfaction with the hospital stay. Fisher's exact test and the Wilcoxon rank sum test assessed differences between intervention and control infants.

Results.

Interviews were completed on 60 of 83 survivors (72%). Eighteen families (22%) could not be located, 2 (2%) were non-English-speaking, and 3 (4%) declined participation. No postdischarge deaths were ascertained. Among those interviewed, race, income, and education of parents of intervention and controls were comparable, as were entry oxygenation index, extracorporeal oxygenation utilization, and days of hospitalization. No differences were found in pulmonary, neurologic, cognitive, behavioral, or neurosensory outcomes; hospital readmission rates; or parental ratings of child's health. The overall neurologic handicap rate was 15%. The rate of hearing deficit was 7%. The rate of significant behavioral problems was 26%. Levels of satisfaction expressed were high for each group. No differences in parental ratings were found between the 2 groups.

Conclusions.

No adverse health or neurodevelopmental outcomes have been observed among infants treated with nitric oxide for PPHN. The parents of the critically ill infants enrolled in our clinical trial welcomed their child's inclusion and all expressed satisfaction with the care that their child received while at a tertiary care hospital. Enrollment in either arm of this randomized, controlled trial did not seem to affect parental satisfaction with the hospital care that their child received.
Short-Term Outcomes After Acute Treatment of Pediatric Asthma
Authors: Stevens Martha W. , Gorelick Marc H.
Published: August 2004

Context.

The short-term course of pediatric patients after emergency department (ED) treatment for acute asthma has not been comprehensively documented; most previous studies have limited outcomes to ED length-of-stay, hospital admission, and relapse.

Objective.

To describe symptom persistence, medication use, functional disability, follow-up, and relapse in these children in the 2 weeks after acute treatment and ED discharge.

Design.

Randomly selected, prospective cohort from September 1996 to August 1997; follow-up telephone interviews at 1 and 2 weeks.

Setting.

A large, inner-city children's hospital emergency department.

Patients.

Random sample of pediatric asthma visits requiring ED treatment but not admission; 457 were eligible, 388 with complete follow-up (85%); final sample included 367 patients after multiple visits deleted.

Main Outcome Measures.

Details of symptom persistence, functional disability, medication use, relapse, and routine follow-up.

Results.

Results included significant morbidity: 23% (95% confidence interval [CI]: 19, 27) with cough and 12% (95% CI: 9, 15) with wheeze persistent at 2 weeks; 20% (95% CI: 16, 24) with decreased activity at 1 week; 45% (95% CI: 39, 51) missed >2 and 24% (95% CI: 19, 29) ≥5 days of school or day care; 17% (95% CI: 13, 21) spent ≥3 days in bed; 54% (95% CI: 47, 60) of caretakers missed at least 1 and 18% (95% CI: 13, 24) missed >2 days of school or work; and 32% (95% CI: 28, 38) of patients were still using greater than baseline medication at 2 weeks. Reported relapse rates were averaged at 13% (95% CI: 10, 17) with 3% (95% CI: 1, 5) admitted. Routine office follow-up was poor: 29% (95% CI: 25, 34) had had a visit; 48% (95% CI: 43, 54) reported no visit/none planned.

Conclusions.

A considerable proportion of inner-city pediatric patients discharged from the hospital from the ED after standard treatment for acute asthma had poor short-term outcomes. Conventional markers of successful ED treatment, such as avoiding hospital admission or relapse, do not adequately describe outcomes of acute care. The patient-oriented measures described here may provide more useful indicators of outcome in the evaluation of acute asthma care.
Iron Deficiency and Cognitive Achievement Among School-Aged Children and Adolescents in the United States
Authors: Halterman Jill S. , Kaczorowski Jeffrey M. , Aligne C. Andrew , Auinger Peggy , Szilagyi Peter G.
Published: August 2004

Context.

Iron deficiency anemia in infants can cause developmental problems. However, the relationship between iron status and cognitive achievement in older children is less clear.

Objective.

To investigate the relationship between iron deficiency and cognitive test scores among a nationally representative sample of school-aged children and adolescents.

Design.

The National Health and Nutrition Examination Survey III 1988–1994 provides cross-sectional data for children 6 to 16 years old and contains measures of iron status including transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Children were considered iron-deficient if any 2 of these values were abnormal for age and gender, and standard hemoglobin values were used to detect anemia. Scores from standardized tests were compared for children with normal iron status, iron deficiency without anemia, and iron deficiency with anemia. Logistic regression was used to estimate the association of iron status and below average test scores, controlling for confounding factors.

Results.

Among the 5398 children in the sample, 3% were iron-deficient. The prevalence of iron deficiency was highest among adolescent girls (8.7%). Average math scores were lower for children with iron deficiency with and without anemia, compared with children with normal iron status (86.4 and 87.4 vs 93.7). By logistic regression, children with iron deficiency had greater than twice the risk of scoring below average in math than did children with normal iron status (odds ratio: 2.3; 95% confidence interval: 1.1–4.4). This elevated risk was present even for iron-deficient children without anemia (odds ratio: 2.4; 95% confidence interval: 1.1–5.2).

Conclusions.

We demonstrated lower standardized math scores among iron-deficient school-aged children and adolescents, including those with iron deficiency without anemia. Screening for iron deficiency without anemia may be warranted for children at risk.
Prothrombotic Disorders and Abnormal Neurodevelopmental Outcome in Infants With Neonatal Cerebral Infarction
Authors: Mercuri Eugenio , Cowan Frances , Gupte Girish , Manning Richard , Laffan Mike , Rutherford Mary , Edwards A.  David , Dubowitz Lilly , Roberts Irene
Published: August 2004

Background and Purpose.

The aim of this study was to evaluate the occurrence of prothrombotic disorders in a well-characterized cohort of infants with neonatal stroke and to document any association of prothrombotic disorders with the type of infarct seen on magnetic resonance imaging (MRI) and clinical outcome.

Methods.

Twenty-four infants with perinatal cerebral infarction confirmed by neonatal MRI were enrolled in the study. All the infants and, when possible, both parents were tested to identify inherited and acquired prothrombotic disorders.

Results.

None of the infants had a significant bleeding diathesis, but 10 (42%) had at least 1 prothrombotic risk factor. Five children showed heterozygosity for factor V Leiden, and 6 had high factor VIIIc concentrations. There was a striking association between the occurrence of these abnormalities and both the presence of cerebral hemorrhage on MRI and poor neurologic outcome. Eight of the 11 patients (73%) with hemiplegia or global developmental delay had factor V Leiden and/or raised factor VIIIc, whereas only 1 of the 13 patients (8%) with normal outcome had any prothrombotic risk factors. In particular, all 5 infants with factor V Leiden had hemiplegia, compared with only 4 of the 19 infants without factor V Leiden (21%).

Conclusions.

These data suggest that the presence of prothrombotic risk factors and, in particular, of the factor V Leiden mutation, is significantly associated with poor outcome after perinatal cerebral infarction.
Promoting Education, Mentorship, and Support for Pediatric Research
Authors:   Committee on Pediatric Research
Published: August 2004

Pediatricians have an important role to play in the advancement of child health research and should be encouraged and supported to pursue research activities. Education and training in child health research should be part of every level of pediatric training. Continuing education and access to research advisors should be available to practitioners and academic faculty. Recommendations to promote additional research education and support at all levels of pediatric training, from premedical to continuing medical education, as well as suggestions for means to increase support and mentorship for research activities, are outlined in this statement.
Ethical Issues With Genetic Testing in Pediatrics
Authors:   Committee on Bioethics
Published: August 2004

Advances in genetic research promise great strides in the diagnosis and treatment of many childhood diseases. However, emerging genetic technology often enables testing and screening before the development of definitive treatment or preventive measures. In these circumstances, careful consideration must be given to testing and screening of children to ensure that use of this technology promotes the best interest of the child. This statement reviews considerations for the use of genetic technology for newborn screening, carrier testing, and testing for susceptibility to late-onset conditions. Recommendations are made promoting informed participation by parents for newborn screening and limited use of carrier testing and testing for late-onset conditions in the pediatric population. Additional research and education in this developing area of medicine are encouraged.
The Prenatal Visit
Authors:   Committee on Psychosocial Aspects of Child and Family Health
Published: August 2004

In their role as advocates for children and families, pediatricians are in an excellent position to support and guide parents during the prenatal period. Prenatal visits allow the pediatrician to gather basic information from parents, provide information and advice to them, and identify high-risk situations in which parents may need to be referred to appropriate resources for help. In addition, prenatal visits are the first step in establishing a relationship between the pediatrician and parents and help parents develop parenting skills. The prenatal visit may take several possible forms depending on the experience and preferences of the parents, competence and availability of the pediatrician, and provisions of the health care plan.