bluuebunny/crossref_metadata_2025 huggingface dataset:
Annual Summary of Vital Statistics—1998
Authors: Guyer Bernard , Hoyert Donna L. , Martin Joyce A. , Ventura Stephanie J. , MacDorman Marian F. , Strobino Donna M.
Published: August 2004

Most vital statistics indicators of the health of Americans were stable or showed modest improvements between 1997 and 1998. The preliminary birth rate in 1998 was 14.6 births per 1000 population, up slightly from the record low reported for 1997 (14.5). The fertility rate, births per 1000 women aged 15 to 44 years, increased 1% to 65.6 in 1998, compared with 65.0 in 1997. The 1998 increases, although modest, were the first since 1990, halting the steady decline in the number of births and birth and fertility rates in the 1990s.

Fertility rates for total white, non-Hispanic white, and Native American women each increased from 1% to 2% in 1998. The fertility rate for black women declined 19% from 1990 to 1996, but has changed little since 1996. The rate for Hispanic women, which dropped 2%, was lower than in any year for which national data have been available. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women remained about the same at one third.

The birth rate for teen mothers declined again for the seventh consecutive year, and the use of timely prenatal care (82.8%) improved for the ninth consecutive year, especially for black (73.3%) and Hispanic (74.3%) mothers.

The number and rate of multiple births continued their dramatic rise; the number of triplet and higher-order multiple births jumped 16% between 1996 and 1997, accounting, in part, for the slight increase in the percentage of low birth weight (LBW) births. LBW continued to increase from 1997 to 1998 to 7.6%.

The infant mortality rate (IMR) was unchanged from 1997 to 1998 (7.2 per 1000 live births). The ratio of the IMR among black infants to that for white infants (2.4) remained the same in 1998 as in 1997. Racial differences in infant mortality remain a major public health concern. In 1997, 65% of all infant deaths occurred to the 7.5% of infants born LBW. Among all of the states, Maine, Massachusetts, and New Hampshire had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage LBW, and birth weight-specific neonatal mortality rate for each state. The United States continues to rank poorly in international comparisons of infant mortality.

Expectation of life at birth increased slightly to 76.7 years for all gender and race groups combined. Death rates in the United States continue to decline, including a drop in mortality from human immunodeficiency virus. The age-adjusted death rate for suicide declined 6% in 1998; homicide declined 14%. Death rates for children from all major causes declined again in 1998. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.
The Effect of Passenger Airbags on Child Seating Behavior in Motor Vehicles
Authors: Wittenberg Eve , Nelson Toben F. , Graham John D.
Published: August 2004

Objective.

The purpose of this study was to determine the effect of the presence of passenger airbags on places where children sit when traveling in motor vehicles.

Methodology.

An observational and driver interview survey of 503 passenger vehicles was conducted in five New England states at randomly selected long- and short-distance travel sites during the summer of 1998. Each vehicle was occupied by at least 1 child <13 years of age. Seating position, vehicle information, and driver and passenger characteristics were collected. Logistic regression analysis was used to identify the association between the presence of passenger airbags in vehicles and the seating positions of children.

Results.

Controlling for the effects of the driver and vehicle characteristics, children <13 years of age were less likely to be observed riding in the front right seat when a passenger airbag was present in the vehicle (odds ratio: .34; 95% confidence interval: .19–.61). Of the vehicles carrying children, 23% had at least 1 child riding in the front seat. Children rode in the front seat in 17% of vehicles with a passenger airbag, and in 30% of those without a passenger airbag. Half of all vehicles without a teenage or adult passenger carried a child in the front seat. In 91% of vehicles with a child riding in the front seat, there was at least one available seat in the rear. Driver safety belt use, younger child age, and the presence of an adult passenger in the vehicle were all associated with children being seated in the rear.

Conclusions.

Some New England drivers are protecting children from the risks of passenger airbags by seating them in the rear. There remains, however, a substantial number of children who are being exposed to the risk of passenger airbag deployment.
Prophylaxis Against Early Adrenal Insufficiency to Prevent Chronic Lung Disease in Premature Infants
Authors: Watterberg Kristi L. , Gerdes Jeffrey S. , Gifford Kathleen L. , Lin Hung-Mo
Published: August 2004

Background.

Many extremely low birth weight infants (<1000 g) show biochemical evidence of adrenal insufficiency in the first week of life, correlating with subsequent development of chronic lung disease (CLD).

Methods.

We conducted a randomized, double-masked, placebo-controlled pilot study to test whether early treatment with low-dose hydrocortisone for 12 days (1 mg/kg/day for 9 days followed by .5 mg/kg/day for 3 days), begun before 48 hours of life, would increase the likelihood of survival without CLD.

Results.

Forty patients were enrolled at two centers. Birth weight and gestation were similar for treatment and placebo groups: 732 ± 135 g versus 770 ± 135 g and 25.2 ± 1.3 weeks versus 25.4 ± 1.5 weeks. More infants treated with hydrocortisone achieved study success, defined as survival without supplemental oxygen at 36 weeks' postconception (12/20 [60%] vs 7/20 [35%]). Lower birth weight, histologic chorioamnionitis, and preeclampsia were significant risk factors, whereas study center, prenatal steroids, sex, and ethnicity were not significant. Hydrocortisone treatment decreased days on >40% oxygen, days on >25% oxygen, days on ventilator, and oxygen at discharge. Among infants exposed to chorioamnionitis, hydrocortisone treatment also was associated with increased enteral intake during the first month of life and with increased weight at 36 weeks' postconception. Five treated infants and 6 placebo infants developed sepsis; 3 in each group died.

Conclusions.

First, early treatment with low-dose hydrocortisone in this population of extremely low birth weight infants increased the likelihood of survival without CLD. Second, the benefit was particularly apparent in infants with chorioamnionitis. Third, a larger multicenter trial is needed to verify the primary outcome and to better evaluate risks and benefits.
The Prevention of Unintentional Injury Among American Indian and Alaska Native Children: A Subject Review
Authors:   Committee on Native American Child Health and Committee on Injury and Poison Prevention
Published: August 2004

Among ethnic groups in the United States, American Indian and Alaska Native (AI/AN) children experience the highest rates of injury mortality and morbidity. Injury mortality rates for AI/AN children have decreased during the past quarter century, but remain almost double the rate for all children in the United States. The Indian Health Service (IHS), the federal agency with the primary responsibility for the health care of AI/AN people, has sponsored an internationally recognized injury prevention program designed to reduce the risk of injury death by addressing community-specific risk factors. Model programs developed by the IHS and tribal governments have led to successful outcomes in motor vehicle occupant safety, drowning prevention, and fire safety. Injury prevention programs in tribal communities require special attention to the sovereignty of tribal governments and the unique cultural aspects of health care and communication. Pediatricians working with AI/AN children on reservations or in urban environments are strongly urged to collaborate with tribes and the IHS to create community-based coalitions and develop programs to address highly preventable injury-related mortality and morbidity. Strong advocacy also is needed to promote childhood injury prevention as an important priority for federal agencies and tribes.
Human Immunodeficiency Virus and Other Blood–borne Viral Pathogens in the Athletic Setting
Authors:   Committee on Sports Medicine and Fitness
Published: August 2004

This Policy Statement was retired September 2019.

Because athletes and the staff of athletic programs can be exposed to blood during athletic activity, they have a very small risk of becoming infected with human immunodeficiency virus, hepatitis B virus, or hepatitis C virus. This statement, which updates a previous position statement of the American Academy of Pediatrics,1 discusses sports participation for athletes infected with these pathogens and the precautions needed to reduce the risk of infection to others in the athletic setting. Each of the recommendations in this statement is dependent upon and intended to be considered with reference to the other recommendations in this statement and not in isolation.
Neisseria gonorrhea Infections in Girls Younger Than 12 Years of Age Evaluated for Vaginitis
Authors: Shapiro Robert A. , Schubert Charles J. , Siegel Robert M.
Published: August 2004

Objective.

This study examined the prevalence of gonorrhea in girls <12 years of age who presented with vaginitis and in whom sexual abuse was not suspected.

Design.

A prospective, consecutive patient series was performed in a pediatric emergency department with 90 000 visits per year and in 2 affiliated pediatric continuity clinics. All girls (Tanner I or II) between the ages of 12 months and 12 years, presenting with a chief complaint of vaginal discharge, burning, pain, or itching, were enrolled (n = 93). Patients were excluded (n = 6) if there was a history of sexual abuse. The presence or absence of vaginal discharge, vaginal erythema, or trauma was recorded. Physicians were instructed to collect cultures forNeisseria gonorrhea (GC), Chlamydia trachomatis, and bacteria/yeast. Wet prep, urinalysis, urine culture, serum rapid plasma reagin, and fungal culture were obtained at the physician's discretion.

Results.

Of the girls, 43 had a vaginal discharge on examination. Of these girls, 4 (9%) had GC, 9 (26%) had group A, B, or F streptococcus and 1 had Staphylococcus aureus. Of the girls, 44 had no discharge on examination. In this group, 3 had streptococcus infection and 2 had Candida albicans. Both children with C albicans had been treated recently with systemic antibiotics. Those girls with a vaginal discharge on examination had a microbial etiology significantly more often than did those without discharge. All of the girls with infection were Tanner I on genital examination.

Conclusions.

The prevalence of unsuspected GC infection was high and emphasizes the importance of culturing Tanner I girls for GC when they have a vaginal discharge along with routine bacterial cultures. Testing and/or treating for C albicans should be considered when there has been recent antibiotic use. Girls with vaginal complaints but without vaginal discharge may have a bacterial infection, but such diagnoses occur less frequently than with girls who have a discharge.
Evaluation of the Effects of Oxandrolone on Malnourished HIV-Positive Pediatric Patients
Authors: Fox-Wheeler Sarah , Heller Linda , Salata Cathleen M. , Kaufman Francine , Loro M. Louisa , Gilsanz Vincente , Haight Michael , Umman Gwenn C. , Barton Norman , Church Joseph A.
Published: August 2004

Objective.

To determine the safety and efficacy of anabolic therapy to prevent or reverse wasting and malnutrition in human immunodeficiency virus (HIV)-infected pediatric patients. The anabolic steroid, oxandrolone, was evaluated because of its safe and effective use in other pediatric conditions.

Methods.

Nine HIV-positive children who were malnourished or at risk for malnutrition (4 females, 5 males; 4–14 years of age) took oxandrolone for 3 months (.1 mg/kg/day orally). Quantitative HIV ribonucleic acid polymerase chain reaction and CD4+ T-cell levels, complete blood cell count (CBC) and chemistry profile, endocrinologic studies, resting energy expenditure, respiratory quotient, nutritional measures, body composition assessment with quantitative computed tomography, and skinfold body composition measurements were determined before treatment, during treatment (3 months), and for 3 months after treatment. Statistical analyses were completed using the Friedman two-way analysis of variance and Spearman correlation tests.

Results.

No adverse clinical or laboratory events or changes in Tanner staging or virilization occurred. Quantitative HIV ribonucleic acid polymerase chain reaction and CD4+ T-cell levels did not change significantly. Insulin-like growth factor 1 increased, suggesting an anabolic effect of treatment. The rate of weight gain increased during treatment and was maintained after treatment. Linear growth continued and was maintained throughout treatment, whereas bone age did not increase significantly. Anthropometric assessments indicated an increase in muscle mass and a decrease in fat while patients were on treatment, and a mild decrease of muscle and increased fat posttreatment. Likewise, computed tomography scan results demonstrated similar changes in muscle mass. Resting energy expenditure and respiratory quotient remained stable throughout treatment and follow-up. No significant changes were seen in the quality of life questionnaire.

Conclusions.

Treatment with oxandrolone for 3 months in HIV-infected children was well-tolerated, safe, and associated with markers of anabolism. The latter effect was maintained partially for 3 months after discontinuation of a 3-month course of therapy. Additional studies are needed to assess the potential benefits and risks of a longer course of therapy or a higher dose of oxandrolone in HIV-infected children.
Plasma Creatinine Rises Dramatically in the First 48 Hours of Life in Preterm Infants
Authors: Miall Lawrence S. , Henderson Michael J. , Turner Alison J. , Brownlee Keith G. , Brocklebank J. Trevor , Newell Simon J. , Allgar Vicki L.
Published: August 2004

Objective.

Published data show that plasma creatinine falls steadily during the first 28 days of life and that creatinine levels in the neonatal period are higher in more premature infants. However, the best reference data commence on day 2 of life. The objective of this study was to document how plasma creatinine changes in the first 48 hours of life and to examine the reason for the apparently high levels of creatinine in preterm infants, compared with maternal levels.

Design.

A prospective observational study on a regional neonatal intensive care unit.

Patients.

A total of 42 preterm infants, mean gestational age of 29.4 weeks (range: 23–35), mean birth weight of 1.42 kg (.55–2.77), divided into 4 gestation groups: 23 to 26 weeks (n = 9), 27 to 29 weeks (n = 13), 30 to 32 weeks (n = 12), and 33 to 35 weeks (n = 8).

Interventions.

Measurement of plasma creatinine and urea concentration in cord blood and in serial samples taken for routine arterial blood gas analysis.

Outcome Measurements.

Changes in creatinine concentration with time and relationship to gestational age, birth weight, and illness severity.

Results.

Mean creatinine at birth was 73 μmol/L (95% confidence interval [CI]: 68–79 μmol/L). Plasma creatinine rose significantly over the first 48 hours. Mean peak creatinine in the most preterm infants (23–26 weeks) was 221 μmol/L (CI: 195–247 μmol/L). Peak plasma creatinine was inversely related to gestation (Spearman's coefficient: −.73) and birth weight (Spearman's coefficient: −.76). Significant differences in creatinine concentration were seen among different gestational groups at 24 and 48 hours of life. Peak creatinine correlated with a high Clinical Risk Index for Babies score (Spearman's coefficient: .64). The fall in creatinine began later in more premature infants. All 38 surviving infants had normal renal function; their mean plasma creatinine at discharge was 52 μmol/L (CI: 46–58 μmol/L).

Conclusions.

Rather than falling steadily from birth, creatinine rises dramatically in the first 48 hours of life, especially in infants of <30 weeks' gestation. Even large rises in creatinine in the first 48 hours may be expected and should not be used in isolation to diagnose renal failure.
Steroid Therapy of a Proliferating Hemangioma: Histochemical and Molecular Changes
Authors: Hasan Qurratulain , Tan Swee T. , Gush Jason , Peters Sue G. , Davis Paul F.
Published: August 2004

Objectives.

Hemangioma is a primary tumor of the microvasculature in which angiogenesis is initially excessive, followed by regression of the newly formed vessels. Intervention is necessary in up to 20% of cases, high-dose systemic or intralesional steroids being the first-line treatment. As the mechanism of action of steroids is unknown, we undertook an investigation of the cellular and molecular effects of their action.

Study Design.

A unique opportunity to study the effect of steroid treatment was presented when biopsy material was obtained from an infant with an ulcerated proliferating hemangioma before and after intralesional triamcinolone injection, which resulted in an accelerated regression of the lesion. Histochemical quantitation of mast cells, molecular analysis by reverse transcriptase-polymerase chain reaction (RT-PCR) for 7 growth factor transcripts and differential display RT-PCR (DD RT-PCR) were conducted.

Results.

After steroid therapy, the mast cell number increased (untreated x̄ = 2.22 ± .27 [standard error of the mean {SEM}]; treated x̄ = 8.7± .71 [SEM] mast cells per field, respectively;P < .0001; n = 40 fields for each group), and the transcriptional expression of cytokines: platelet-derived growth factor-A and -B; interleukin-6; transforming growth factor-β1 and -β3 decreased, while that of basic fibroblast growth factor (bFGF) and vascular endothelial cell growth factor remained unaltered. Elevated urinary bFGF levels noted in cases of proliferating hemangioma, persisted even after steroid treatment. Using DD RT-PCR an amplicon that shared 100% sequence homology with the human mitochondrial cytochromeb gene was detected in the hemangioma biopsy after steroid treatment.

Conclusions.

The regression of this hemangioma subsequent to steroid therapy was accompanied by a significant increase in mast cell density, reduced transcription of several cytokines, and an enhanced expression of the mitochondrial cytochrome bgene.
Gastric Perforation Attributable to Liquid Nitrogen Ingestion
Authors: Koplewitz Benjamin Z. , Daneman Alan , FRACR Sc, , Ein Sigmund H. , McGuigan Michael A. , Mian Marcellina
Published: August 2004

Despite the widespread use of liquid nitrogen in medicine and industry, there are only a few reports of injuries associated with its use. We report a case of a 13-year-old boy who developed gastric perforation after liquid nitrogen ingestion. This is a previously unreported complication.
Forehead Lipoblastoma Mimicking a Hemangioma
Authors: Perlis Clifford S. , Collins Margaret H. , Honig Paul J. , Low David W.
Published: August 2004

A case of forehead lipoblastoma simulating a hemangioma in a male infant is reported, to alert pediatricians to this rare tumor and to increase the index of suspicion in atypical hemangiomas.

A 2-month-old male infant developed a protruding forehead mass with increased vascularity. It demonstrated progressive and accelerated growth over the subsequent 6 months, unresponsive to steroid therapy. A magnetic resonance imaging scan supported the diagnosis of hemangioma because of the hypervascular nature of the lesion. Surgical excision was performed because of visual obstruction. Pathologic examination of the specimen was consistent with a very primitive lipoblastoma.

This tumor is a rare, benign lesion of immature fat cells that is found almost exclusively in the pediatric population. Lipoblastomas are more common in males than females and frequently present as asymptomatic, rapidly enlarging, soft lobular masses on the extremities. Complete surgical excision is the definitive treatment. In the vast majority of reported cases, however, the preoperative diagnosis was incorrect, underscoring the diagnostic dilemma presented by these rare tumors.
Guiding Principles for Managed Care Arrangements for the Health Care of Newborns, Infants, Children, Adolescents, and Young Adults
Authors:   Committee on Child Health Financing
Published: August 2004

By including the precepts of primary care in the delivery of services, managed care can be a tool to increase access to a full range of health care clinicians and services. On the other hand, managed care can result in underutilization of appropriate services and reduced quality of care. Therefore, the American Academy of Pediatrics urges the use of the principles outlined in this statement in designing and implementing managed care for newborns, infants, children, adolescents, and young adults for several reasons. This policy statement replaces the 1995 policy statement, “Guiding Principles for Managed Care Arrangements for the Health Care of Infants, Children, Adolescents and Young Adults,” and outlines the key principles of managed care for newborns, infants, children, adolescents, and young adults.
Consensus Report for Regionalization of Services for Critically Ill or Injured Children
Authors:   American Academy of Pediatrics, Committee on Pediatric Emergency Medicine Pediatric Section American College of Critical Care Medicine and Society of Critical Care Medicine, Pediatric Section, Task Force on Regionalization of Pediatric Critical Care
Published: August 2004

The care of critically ill children has become more complex and demanding. This document establishes recommendations for developing regionalized integration of the care of these children into the emergency medical services system. These recommendations were developed by pediatricians with expertise in pediatric critical care, transport, and emergency medicine from the Committee on Pediatric Emergency Medicine, and the Pediatric Section of the Society of Critical Care Medicine Task Force on Regionalization of Pediatric Critical Care. The document was developed from existing guidelines from a number of professional organizations including the American Academy of Pediatrics and the Society of Critical Care Medicine, a thorough review of the literature, and expert consensus.
Eosinophilia at the Time of Respiratory Syncytial Virus Bronchiolitis Predicts Childhood Reactive Airway Disease
Authors: Ehlenfield Daryl R. , Cameron Kathleen , Welliver Robert C.
Published: August 2004

Objective.

Bronchiolitis in infancy is viewed as a risk factor for childhood asthma, but factors predicting which infants will have persistent wheezing have not been identified. In addition, the nature of the association between the 2 conditions is uncertain. We wished to determine whether eosinophil counts at the time of acute bronchiolitis predicted the presence of wheezing in later childhood.

Methods.

We retrospectively identified infants hospitalized with bronchiolitis, determined peripheral blood eosinophil counts at the time of bronchiolitis, and then contacted their families when they had reached 7 years of age.

Results.

Eosinophil counts at the time of bronchiolitis were greater in subjects who would have wheezing at 7 years of age (median: 98 cells/mm3) than in infants who would have no recurrent wheezing (median: 0 cells/mm3) or transient wheezing only up to 3 years of age (median: 0 cells/mm3). When the effects of family history of asthma, gender, and passive exposure to cigarette smoke were examined, only eosinophilia at the time of bronchiolitis demonstrated a statistically significant relationship to the presence of wheezing at 7 years of age.

Conclusions.

Eosinophilia at the time of bronchiolitis generally predicts the development of wheezing persisting into later childhood. Therefore, the association of bronchiolitis and childhood asthma seems more likely to be attributable to an immunologic anomaly that precedes the development of, or is induced by, bronchiolitis rather than to structural damage to the airway as a result of bronchiolitis.
Post-Varicella Epiglottitis and Necrotizing Fasciitis
Authors: Slack Christopher L. , Allen Gregory C. , Morrison John E. , Garren Kurt C. , Roback Mark G.
Published: August 2004

Varicella is a nearly ubiquitous acquired childhood disease. Infectious complications of varicella can be life- or limb-threatening. These complications appear 3 to 4 days after the appearance of varicella exanthem and are heralded by fever, pain, and erythema of the overlying skin. Airway complications of varicella are rare, rapidly evolving, and, unfortunately, difficult to visualize. We report a child who presented with a unique combination of varicella-induced airway complications—acute epiglottitis and subsequent necrotizing fasciitis of the head and neck. varicella, epiglottitis, necrotizing fasciitis, group A β-hemolytic streptococcus, nasopharyngoscopy.
Cerebrospinal Fluid Findings in Aseptic Versus Bacterial Meningitis
Authors: Negrini Barbara , Kelleher Kelly J. , Wald Ellen R.
Published: August 2004

Background.

Aseptic meningitis is often reported to be characterized by a mononuclear cell predominance in the cerebrospinal fluid (CSF), whereas bacterial meningitis is characterized by a polymorphonuclear (PMN) cell predominance. In contrast, other studies suggest that PMNs can be the most prevalent cell in early aseptic meningitis followed by a shift to mononuclear cells within 24 hours. These contradictory reports may lead to uncertainty in the diagnosis and treatment of meningitis.

Objectives.

To assess 1) the characteristics of the CSF differential in aseptic versus bacterial meningitis, 2) the influence of duration of illness on the CSF differential, and 3) the role of the CSF differential in discriminating between aseptic versus bacterial meningitis.

Methods.

A retrospective chart review was conducted of all cases of meningitis in children >30 days of age hospitalized during the peak months for enteroviral meningitis (April to October) between 1992 to 1997. Cases of aseptic meningitis were defined as having at least 20 white blood cells/mm3 and the absence of bacterial growth on culture. Patients were excluded if they received antibiotic therapy within the previous 5 days. Cases of bacterial meningitis were defined as having a positive culture of the CSF or the presence of a CSF pleocytosis with positive cultures of the blood. CSF variables including white blood cell differential and time from the onset of symptoms to the performance of a lumbar puncture were analyzed. PMNs were considered to be predominant when the percentage of neutrophils added to juvenile forms was >50% of cells.

Results.

One hundred fifty-eight cases of meningitis were reviewed: 138 were aseptic and 20 were bacterial. The patients ranged in age from 30 days to 18 years; 61% were male. Fifty-seven percent of cases of aseptic meningitis had a PMN predominance. The percentage of PMNs in the CSF in patients with aseptic meningitis was not statistically different for patients who had a lumbar puncture performed either within or beyond 24 hours of the onset of symptoms. Fifty-one percent of the 53 patients with aseptic meningitis and duration of illness >24 hours had a PMN predominance. The ability of a PMN predominance to differentiate between aseptic and bacterial meningitis was assessed. The sensitivity of a PMN predominance for aseptic meningitis is 57% whereas the specificity is 10%. The positive predictive value of a PMN predominance for aseptic disease is 81% but the negative predictive value is 3%. Alternative definitions of PMN predominance from 60% to 90% were not useful as a clinical indicator of bacterial disease.

Conclusions.

The majority of children with aseptic meningitis have a PMN predominance in the CSF. The PMN predominance is not limited to the first 24 hours of illness. Because the majority of children with a PMN predominance during enteroviral season will have aseptic disease, a PMN predominance as a sole criterion does not discriminate between aseptic and bacterial meningitis.
Child and Adolescent Illness Falsification
Authors: Libow Judith A.
Published: August 2004

Objective.

To review the current state of knowledge on factitious illness in children and adolescents to help clarify the relationship of this phenomenon to a range of somatizing disorders in children and factitious disorder by proxy.

Design.

The literature of the past 30 years was reviewed for cases describing children <18 years old who have intentionally falsified symptoms of illness, without known parental involvement. Cases in which a parent was involved, the child acknowledged a credible motive, the deception was identified after age 18, or which appeared in foreign languages were excluded. Data on age, gender, factitious symptoms, method, duration of deception, and outcome of confrontation, where available, were gathered from case studies.

Results.

Forty-two cases of illness falsification by children were identified, with a mean age of 13.9, and a range from 8 to 18 years. The majority of patients were female (71%), and the gender imbalance was greater for the older children. The most commonly reported falsified or induced conditions were fevers, ketoacidosis, purpura, and infections, and the fabrications ranged from false symptom-reporting to active injections, bruising, and ingestions. The mean duration of the falsifications was almost 16 months before detection. Many of the children admitted to their deceptions when confronted, and some had positive outcomes at follow-up. The descriptions of some of these children as bland, depressed, and fascinated with health care were remarkably similar to adults with factitious disorders.

Conclusions.

Medical conditions fabricated by children may go undetected for a variety of reasons, or diagnosed as somatization. Further study of children who falsify symptoms may in some cases help identify earlier experiences of Munchausen by proxy abuse or covert parental coaching of illness falsification, and provide more effective interventions. Better understanding and identification of these children is likely to help prevent the development of more chronic adult factitious disorders.
Evaluation of a State Health Insurance Program for Low-Income Children: Implications for State Child Health Insurance Programs
Authors: Szilagyi Peter G. , Zwanziger Jack , Rodewald Lance E. , Holl Jane L. , Mukamel Dana B. , Trafton Sarah , Shone Laura Pollard , Dick Andrew W. , Jarrell Lynne , Raubertas Richard F.
Published: August 2004

Background.

The State Child Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991, New York State implemented Child Health Plus (CHPlus), a health insurance program that became a model for SCHIP.

Objective.

To examine changes in access to care, utilization of services, and quality of care among children enrolled in CHPlus.

Design.

A pre–post design was used to evaluate the health care experiences of children in the year before enrollment in CHPlus and during the year after CHPlus enrollment.

Setting.

New York State, stratified into 4 regions: New York City, urban counties around New York City, upstate urban counties, and upstate rural counties.

Participants.

A total of 2126 children (0–12.99 years of age) who enrolled in CHPlus in 1992–1993.

Data Collection.

Parents were interviewed by telephone, and primary care medical charts were reviewed for 694 children (0–3.99 years of age).

Analysis.

Access, utilization, and quality of care measures for each child were compared for the year before and the year after CHPlus enrollment, controlling for age, geographic region, previous insurance coverage, and CHPlus plan type (indemnity or managed care).

Results.

Enrollment in CHPlus was associated with fewer children lacking a medical home (5% before CHPlus vs 1% during CHPlus), with the greatest change occurring in New York City (11% vs 1%), where access before CHPlus was lowest. CHPlus was also associated with increased primary care visits: by 25% for preventive visits, by 52% for acute visits, and by 42% for total visits. The number of specialists seen during CHPlus was more than twice as high than before CHPlus. CHPlus was not associated with changes in emergency department utilization, although hospitalizations, which were not covered by CHPlus, were 36% lower during CHPlus coverage. Use of public health departments for immunizations declined by 64%, with more immunizations delivered in the medical home during CHPlus coverage. One third of parents reported improved quality of health care for their child as a result of CHPlus, and virtually none noted worse quality of care.

Conclusions.

This statewide health insurance program for low-income children was associated with improved access, utilization, and quality of care, suggesting that SCHIP has the potential to improve health care for low-income American children.
Late Abnormal Findings on High-Resolution Computed Tomography AfterMycoplasmaPneumonia
Authors: Kim Chang Keun , Chung Churl Young , Kim Joung Sook , Kim Woo Sun , Park Yang , Koh Young Yull
Published: August 2004

Background.

The clinical course ofMycoplasma pneumonia is typically mild and self-limited. There are, however, several case reports of severe complication following this illness with considerable morbidity and mortality.

Objectives.

This study was conducted to investigate, using high-resolution computed tomography (HRCT), the long-term pulmonary structural abnormalities after Mycoplasma pneumonia and to identify risk factors (chest radiograph findings, antibody titers, and host factors) that might increase the likelihood of developing the sequelae.

Methods.

Thirty-eight children requiring hospitalization attributable to Mycoplasma pneumonia were recruited by the retrospective examination of hospital records. They underwent HRCT after an interval of 1.0 to 2.2 years. A control group of 17 children with the history of Mycoplasma upper respiratory infection was also studied after a similar interval.

Results.

Abnormal HRCT findings were present in 37% (14/38) of the pneumonia group, compared with 12% (2/17) of the control group. The abnormalities in the pneumonia group, which appeared alone or in combination, included mosaic perfusion (n =12), bronchiectasis (n = 8), bronchial wall thickening (n = 4), decreased vascularity (n = 1), and air trapping on expiratory scan (9 of 29 tested). The area affected by these abnormalities, usually involving 2 or more lobes, corresponded in all cases to the location of the infiltrate on chest radiograph at the time of pneumonia. Between subjects with abnormal HRCT (n = 14) and normal HRCT (n = 24) in the pneumonia group, significant differences were observed in age at the time of pneumonia (mean ± standard deviation: 5.3 ± 2.0 years vs 7.7 ± 3.4 years) and peak antimycoplasma antibody titer (geometric mean [range of 1 standard deviation]; 1:7943 [3126–19 953] vs 1:3093 [832–11 482]).

Conclusions.

We conclude that a considerable proportion of children with history of Mycoplasma pneumonia have abnormal findings on HRCT, suggestive of small airway obstruction and that younger age and higher antibody titer at the time of pneumonia may be risk factors for these sequelae.
The Discrepancy Between Maturation of Visual-Evoked Potentials and Cognitive Outcome at Five Years in Very Preterm Infants With and Without Hemodynamic Signs of Fetal Brain-Sparing
Authors: Scherjon Sicco , Briët Judy , Oosting Hans , Kok Joke
Published: August 2004

Objective.

After intrauterine growth restriction we found at the age of 6 months an acceleration of neurophysiologic maturation. However, at later ages impaired cognitive outcome has been reported. Therefore, we investigated in children with and without fetal hemodynamic adaptation to intrauterine growth restriction whether the accelerated neurophysiologic maturation in infancy might be associated with impaired cognitive outcome at preschool age.

Design.

At 5 years of age cognitive function was assessed using the Revision of the Amsterdam Children's Intelligence Test in 73 preterm infants (26–33 weeks) who were prospectively followed from the antenatal period up to the age of 5 years. Maternal educational level was used as a background variable to estimate the confounding effects of socioeconomic status on cognitive function. Fetal Doppler studies were performed and the umbilical artery pulsatility index (PI) divided by the middle cerebral artery PI ratio (U/C ratio) was calculated. A U/C ratio >0.725 was considered as an indication of fetal cerebral hemodynamic adaptation to a compromised placental perfusion, ie, fetal brain-sparing. Visual-evoked potentials (VEPs) were recorded at 6 months and 1 year of age. In addition, data on neurologic status at 3 years were available.

Results.

Mean IQ score was significantly lower for children born with a raised U/C ratio (87 ± 16) compared with children with a normal U/C ratio (96 ± 17). VEP latencies decreased significantly in infants with a normal U/C ratio, whereas no decrease was found in infants with a raised U/C ratio. Variables contributing significantly to the variance of cognitive function were: U/C group, VEP latency maturation, level of maternal education, and neurodevelopmental outcome at 3 years. The linear regression model explained 33% of the variance in cognitive function.

Conclusions.

Both being born with a raised U/C ratio and an acceleration of VEP latencies are negatively associated with cognitive outcome at 5 years of age. Fetal brain-sparing, although a seemingly beneficial adaptive mechanism for intact neurologic survival, is, however, later associated with a poorer cognitive outcome.
Nocturnal Pulse Oximetry as an Abbreviated Testing Modality for Pediatric Obstructive Sleep Apnea
Authors: Brouillette Robert T. , Morielli Angela , Leimanis Andra , Waters Karen A. , Luciano Rina , Ducharme Francine M.
Published: August 2004

Objective.

To determine the utility of pulse oximetry for diagnosis of obstructive sleep apnea (OSA) in children.

Methods.

We performed a cross-sectional study of 349 patients referred to a pediatric sleep laboratory for possible OSA. A mixed/obstructive apnea/hypopnea index (MOAHI) greater than or equal to 1 on nocturnal polysomnography (PSG) defined OSA. A sleep laboratory physician read nocturnal oximetry trend and event graphs, blinded to clinical and polysomnographic results. Likelihood ratios were used to determine the change in probability of having OSA before and after oximetry results were known.

Results.

Of 349 patients, 210 (60%) had OSA as defined polysomnographically. Oximetry trend graphs were classified as positive for OSA in 93 and negative or inconclusive in 256 patients. Of the 93 oximetry results read as positive, PSG confirmed OSA in 90 patients. A positive oximetry trend graph had a likelihood ratio of 19.4, increasing the probability of having OSA from 60% to 97%. The median MOAHI of children with a positive oximetry result was 16.4 (7.5, 30.2). The 3 false-positive oximetry results were all in the subgroup of 92 children who had diagnoses other than adenotonsillar hypertrophy that might have affected breathing during sleep. A negative or inconclusive oximetry result had a likelihood ratio of .58, decreasing the probability of having OSA from 60% to 47%. Interobserver reliability for oximetry readings was very good to excellent (κ = .80).

Conclusions.

In the setting of a child suspected of having OSA, a positive nocturnal oximetry trend graph has at least a 97% positive predictive value. Oximetry could: 1) be the definitive diagnostic test for straightforward OSA attributable to adenotonsillar hypertrophy in children older than 12 months of age, or 2) quickly and inexpensively identify children with a history suggesting sleep-disordered breathing who would require PSG to elucidate the type and severity. A negative oximetry result cannot be used to rule out OSA.
In Situ Hybridization Detection of Human Herpesvirus 6 in Brain Tissue From Fatal Encephalitis
Authors: Ahtiluoto Satu , Mannonen Laura , Paetau Anders , Vaheri Antti , Koskiniemi Marjaleena , Rautiainen Paula , Muttilainen Marketta
Published: August 2004

A 23-month-old girl died after 2 days' illness with rash, fever, and convulsions. Neuropathologic findings were consistent with viral hemorrhagic encephalitis in pontine tegmentum and medial thalamic areas. Human herpesvirus 6 (HHV-6) DNA was detected in pontine nuclei by in situ hybridization. In addition, polymerase chain reaction for HHV-6 of serum and paraffin-embedded pontine tissue was positive, and serology indicated an acute primary infection. This is the first case showing HHV-6 DNA in the brain cells of an immunocompetent patient with acute encephalitis.
Provision of Educationally-Related Services for Children and Adolescents With Chronic Diseases and Disabling Conditions
Authors:   Committee on Children With Disabilities
Published: August 2004

This Policy Statement was retired January 2018.

Children and adolescents with chronic diseases and disabling conditions often need related services. As medical home professionals, pediatricians can assist children, adolescents, and their families with the complex federal, state, and local laws, regulations, and systems associated with these services. Expanded roles for pediatricians in Individual Family Service Plan, Individualized Education Plan, and 504 Plan development and implementation are recommended.

The complex range of federal, state, and local laws, regulations, and systems for special education and related services for children and adolescents in public schools is beyond the scope of this statement. Readers are referred to the policy statement “The Pediatrician's Role in Development and Implementation of an Individual Education Plan (IEP) and/or an Individual Family Services Plan”1 by the American Academy of Pediatrics for additional background materials.
Urinary Tract Infection in Febrile Infants Younger Than Eight Weeks of Age
Authors: Lin Dar-Shong , Huang Shing-Huey , Lin Chun-Chun , Tung Yi-Chen , Huang Tsu-Tzu , Chiu Nan-Chang , Koa Hsin-An , Hung Han-Yang , Hsu Chyong-Hsin , Hsieh Wen-Shyang , Yang Dien-Ie , Huang Fu-Yuan
Published: August 2004

Objective.

To assess the usefulness of laboratory parameters, including peripheral white blood cell (WBC) count, C-reactive protein (CRP) concentration, erythrocyte sedimentation rate (ESR), and microscopic urinalysis (UA), for identifying febrile infants younger than 8 weeks of age at risk for urinary tract infection (UTI), and comparison of standard UA and hemocytometer WBC counts for predicting the presence of UTI.

Methods.

A total of 162 febrile children <8 weeks of age were enrolled in this prospective study. All underwent clinical evaluation and laboratory investigation, including WBC count and differential; ESR; CRP; blood culture; a lumbar puncture for cell count and differential, glucose level, protein level, Gram stain, and culture; and a UA and urine culture. All urine specimens were obtained by suprapubic aspiration and microscopically analyzed with standard UA as well as with hemocytometer WBC counts. Quantitative urine cultures were performed. Sensitivity, specificity, accuracy, likelihood ratios, and receiver operating characteristic (ROC) curves were determined for each of the screening tests.

Results.

There were 22 positive urine culture results of at least 100 colony-forming unit/mL. Eighteen of these 22 patients were males, and all were uncircumcised. There were significant differences for pyuria ≧5 WBCs/hpf, pyuria ≧10 WBC/μL, CRP >20 mg/L, and ESR >30 mm/hour between culture-positive and culture-negative groups (P < .05). The ROC area for hemocytometer WBC count, standard UA, peripheral WBC count, ESR, and CRP concentration were .909 ± .045, .791 ± .065, .544 ± .074, .787 ± .060, and .822 ± .036, respectively. The ROC curve analysis indicates that the CRP, ESR, and standard UA were powerful but imperfect tools with which to discriminate for UTI in potentially infected neonates. Hemocytometer WBC counts had the highest sensitivity, specificity, accuracy, and likelihood ratios for identifying very young infants with positive urine culture results. For all assessments, hemocytometer WBC counts were significantly different, compared with the standard urinalysis. ESR, CRP, and peripheral WBC counts were not helpful in identifying UTI in febrile infants.

Conclusion.

UTI had a prevalence of 13.6% in febrile infants <8 weeks of age. The CRP, ESR, and standard UA were imperfect tools in discriminating for UTI, and the sensitivity of these laboratory parameters was relatively low. Hemocytometer WBC count was a significantly better predictor of UTI in febrile infants.
Effect of Cisapride on the QT Interval in Infants With Gastroesophageal Reflux
Authors: Khoshoo Vikram , Edell Dean , Clarke Robert
Published: August 2004

Objective.

We prospectively studied the effect of cisapride per se on QT interval in young infants (3–6 months) with gastroesophageal reflux (GER) in a controlled setting.

Study Design.

The infants diagnosed with GER and deemed to require therapy with cisapride were divided into 2 groups. Group A comprised infants with GER who underwent an electrocardiogram (ECG) before initiation of therapy with cisapride in the dose of 1 mg per kg per 24 hours, divided into 3 doses. They were reweighed after 7 to 10 days, and the dose was adjusted for their new weight. A repeat ECG was performed after ∼2 weeks (12–18 days) of therapy. The QT interval was measured in each ECG and then the corrected QT interval was calculated by Bazett's formula. Group B comprised infants with GER who had already been on therapy with cisapride for over 1 month. All infants in group B received cisapride in an approximate dose of 1 mg per kg per 24 hours (.8–1.1 mg/kg/24 hours) given in 3 divided doses. They underwent only 1 ECG, ie, at 1 to 4 months after initiation of therapy. The measurement of the actual dose of cisapride was demonstrated to every parent and a marked measuring syringe was provided. The following categories of infants were not included: those with any underlying cardiopulmonary, renal, or hepatic problem; those with a history of apnea; those using a macrolide antibiotic or azole antifungal at any stage during the study; and infants hospitalized for any reason during the course of the study.

Results.

Cisapride therapy in the dose of 1 mg/kg/day frequently resulted in a slight increase in the QT interval (pretreatment: 390 ± 18 milliseconds; posttreatment: 400 ± 20 milliseconds) but the increase was still below the accepted upper limit of 440 milliseconds and not statistically significant. Even with prolonged therapy, the pattern of change in QT interval was similar to that with therapy for 2 weeks. Overall, 2 of 100 (2%) infants developed a prolongation of corrected QT interval beyond the normal range (456 and 486 milliseconds). Neither infant had evidence of any arrhythmia or conduction defect on ECG. No additional factor could be identified in either infant to explain prolongation of the QT interval.

Conclusion.

Our experience suggests that cautious cisapride therapy in young infants in a modest dose does not result in arrhythmias or conduction defects. We recommend that: 1) the dose of cisapride in infants be <1.2 mg/kg/day and preferably between .8 and 1 mg/kg/day; 2) the right measure of the dose be actually demonstrated to the parents; and 3) parents be provided a list of drug interactions with cisapride. One should think twice before denying the use of an effective drug simply because of the need for closer monitoring and extra time spent for parent education.