bluuebunny/crossref_metadata_2025 huggingface dataset:
Out-of-School Suspension and Expulsion
Authors:   Committee on School Health
Published: August 2004

Suspension and expulsion from school are used to punish students, alert parents, and protect other students and school staff. Unintended consequences of these practices require more attention from health care professionals. Suspension and expulsion may exacerbate academic deterioration, and when students are provided with no immediate educational alternative, student alienation, delinquency, crime, and substance abuse may ensue. Social, emotional, and mental health support for students at all times in all schools can decrease the need for expulsion and suspension and should be strongly advocated by the health care community. This policy statement, however, highlights aspects of expulsion and suspension that jeopardize children’s health and safety. Recommendations are targeted at pediatricians, who can help schools address the root causes of behaviors that lead to suspension and expulsion and can advocate for alternative disciplinary policies. Pediatricians can also share responsibility with schools to provide students with health and social resources.
Closure of Patent Ductus Arteriosus With Oral Ibuprofen Suspension in Premature Newborns: A Pilot Study
Authors: Heyman Eli , Morag Iris , Batash David , Keidar Rimona , Baram Shaul , Berkovitch Matitiahu
Published: August 2004

Objective. Patent ductus arteriosus (PDA), a common finding among premature infants, is conventionally treated by intravenous indomethacin. Intravenous ibuprofen was recently shown to be as effective and to have fewer adverse reactions in preterm infants. If equally effective, then oral ibuprofen for PDA closure would have several important advantages over the intravenous route. This study was designed to determine whether oral ibuprofen treatment is efficacious and safe in closure of a PDA in premature infants with respiratory distress syndrome.

Methods. Twenty-two preterm newborns (gestational age: 27.5 ± 1.75 [range: 23.9–31 weeks]; weight: 979 ± 266 [range: 380-1500 g]) with PDA and respiratory distress syndrome were studied prospectively. They received oral ibuprofen suspension 10 mg/kg/body weight for the first dose, followed at 24-hour intervals by 2 additional doses of 5 mg/kg each, if needed, starting on the second day of life. Echocardiography was performed before treatment and 24 hours after each dose. Every child underwent cranial ultrasonography before and after each ibuprofen dose. The rate of ductal closure, the need for additional treatment, side effects, complications, and the infants’ clinical courses were recorded.

Results. Ductal closure was achieved in all newborns except for 1 (95.5%), in whom clinically nonsignificant ductal shunting persisted. No infant required surgical ligation of the ductus. There was no reopening of the ductus after closure had been achieved. Fourteen newborns were treated with 1 dose of ibuprofen, 6 were treated with 2 doses, and the remaining 2 were treated with 3 doses. The survival rate at 1 month was 86.4% (19 of 22). Three (13.6%) infants died from the following causes: 1 who was born at 24 weeks’ gestation with a birth weight of 380 g died as a result of extreme prematurity complications, necrotizing enterocolitis, and low birth weight; 1 died as a result of Candida sepsis; and the third died as a result of Klebsiella sepsis. Intraventricular hemorrhage was observed in 7 infants. The classification was changed from grade 2 to grade 3 in 1 and from grade 0 to grade 1 or higher in 3 others. The rate of survival to discharge was 86.4% (19 of 22). No bronchopulmonary dysplasia was observed in the study group, and there was no case of tendency to bleed. There were no significant differences in the levels of serum creatinine before and after treatment with oral ibuprofen.

Conclusions. Oral ibuprofen suspension may be an effective and safe alternative for PDA closure in premature infants with PDA. However, larger comparative studies are warranted.
Disparity Between Pediatricians’ Knowledge and Practices Regarding Perinatal Human Immunodeficiency Virus Counseling and Testing
Authors: Kline Mark W. , O’Connor Karen G.
Published: August 2004

Objectives. This survey of members of the American Academy of Pediatrics (AAP) was initiated by the AAP Committee on Pediatric AIDS to assess the knowledge, attitudes, and behaviors of pediatricians regarding prenatal and neonatal screening as a means to reduce mother-to-child transmission of human immunodeficiency virus (HIV).

Methods.  The survey consisted of a 4-page, self-administered questionnaire, which was mailed to a random sample of 1647 active US members of the AAP. The original and 5 subsequent mailings to nonresponders were conducted from July to November 2001.

Results. Completed questionnaires were received from 982 pediatricians, for a response rate of 59.6%. Nearly all pediatricians (96.6%) agree on the importance of knowing the HIV status of pregnant women, and more than three-fourths (78.5%) do not think that HIV screening during pregnancy or postpartum should be limited to women with perceived risk for infection. Approximately 6 (58.5%) of 10 pediatricians indicate that they counsel or provide education on HIV screening to pregnant women or mothers of newborns whose HIV status is unknown; 41.5% do not. Pediatricians reported evaluating an average of 56 newborns each during the 3 months before the survey. The HIV infection status of the mother was unknown for 40.6% of these cases. During the same time period, pediatricians said that they discussed a newborn or maternal HIV screening test with only 10.4% of the mothers whose HIV infection status was unknown. Reasons given for not counseling mothers with unknown HIV infection status about maternal and/or newborn screening for HIV included low prevalence of HIV in the pediatrician’s practice area (65.4%), assessment by the pediatrician that the parents did not fit the profile of those “at risk” for HIV infection (56.1%), fear of offending the parents (50.2%), parental lack of understanding regarding the importance of screening (50.1%), and lack of sufficient time for counseling (44.4%).

Conclusions. Pediatricians exhibit a high degree of understanding of the importance of HIV screening as a means to reduce mother-to-child transmission of HIV, but this does not always translate into their clinical practices.
Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit
Authors: Garros Daniel , Rosychuk Rhonda J. , Cox Peter N.
Published: August 2004

Objective. Approximately 60% of deaths in pediatric intensive care units follow limitation or withdrawal of life-sustaining treatment (LST). We aimed to describe the circumstances surrounding decision making and end-of-life care in this setting.

Methods. We conducted a prospective, descriptive study based on a survey with the intensivist after every consecutive death during an 8-month period in a single multidisciplinary pediatric intensive care unit. Summary statistics are presented as percentage, mean ± standard deviation, or median and range; data are compared using the Mantel-Haenszel test and shown as survival curves.

Results. Of the 99 observed deaths, 27 involved failed cardiopulmonary resuscitation; of the remaining 72, 39 followed withdrawal/limitation (W/LT) of LST, 20 were do not resuscitate (DNR), and 13 were brain deaths (BDs). Families initiated discussions about forgoing LST in 24% (17 of 72) of cases. Consensus between caregivers and staff about forgoing LST as the best approach was reached after the first meeting with 51% (35 of 68) of families; 46% (31 of 68) required ≥2 meetings (4 not reported). In the DNR group, the median time to death after consensus was 24 hours and for W/LT was 3 hours. LST was later withdrawn in 11 of 20 DNR cases. The family was present in 76% (45 of 59) of cases when LST was forgone. The dying patient was held by the family in 78% (35 of 45) of these occasions.

Conclusions. More than 1 formal meeting was required to reach consensus with families about forgoing LST in almost half of the patients. Families often held their child at the time of death. The majority of children died quickly after the end-of-life decision was made.
Increased Diagnosis of Lemierre Syndrome and Other Fusobacterium necrophorum Infections at a Children’s Hospital
Authors: Ramirez Susan , Hild Tannaz G. , Rudolph Colin N. , Sty John R. , Kehl Susan C. , Havens Peter , Henrickson Kelly , Chusid Michael J.
Published: August 2004

Objective. To assess the apparent increase in the diagnosis of Lemierre syndrome (LS) and other Fusobacterium necrophorum infections at a large children’s hospital. Infections with F necrophorum ranged from peritonsillar abscess to potentially fatal LS. LS is an oropharyngeal infection characterized by septic thrombophlebitis of head and neck veins, complicated by dissemination of septic emboli to pulmonary and systemic sites.

Methods. Review of the medical and laboratory records was conducted of all patients who were seen at or admitted to the Children’s Hospital of Wisconsin with the diagnosis of LS and/or isolation of F necrophorum from a clinical specimen between January 1995 and January 2002.

Results. During the 7-year period of the study, there was an increase in the isolation of F necrophorum from patients who were seen at Children’s Hospital of Wisconsin, as well as the number of cases of LS. There was 1 isolation of F necrophorum from clinical specimens per year from 1996 to 1999, which increased to 10 isolates of the organism from January 2000 to January 2002. During the most recent period, January 2001–January 2002, 5 cases of LS were diagnosed, a distinctive entity not recognized previously at the institution.

Conclusions. The cause for the recent increase in the number of serious infections caused by F necrophorum infection diagnosed at our institution is unclear but does not seem to be related to changes in microbiologic techniques or patient demography. We speculate that it could be attributable, in part, to alterations in antibiotic usage patterns in our region. Clinicians need to be aware of the increasing clinical importance of F necrophorum infections and the life-threatening nature of LS.
Warfarin Therapy in Children Who Require Long-Term Total Parenteral Nutrition
Authors: Newall Fiona , Barnes Chris , Savoia Helen , Campbell Janine , Monagle Paul
Published: August 2004

Objective. To determine whether warfarin can be safely administered to children who require long-term total parenteral nutrition (TPN), for the purpose of preventing central venous access device (CVAD)-related thrombosis.

Methods. A prospective cohort study was conducted of 8 children with short-gut syndrome or small intestinal anomalies. All patients received oral anticoagulant therapy (warfarin) managed by the hematology department at a tertiary pediatric center. Data collected included demographic details, nutritional intake, age, weight, history of deep vein thrombosis, number and functional duration of CVADs, warfarin requirements, and adverse event rates.

Results. A total of 15.2 warfarin years were studied prospectively. The target therapeutic range was achieved 51.1% of time. The mean dose of warfarin required to achieve the target therapeutic range (international normalized ratio) of 2.0 to 3.0 was 0.33 mg/kg/d. The mean duration between warfarin monitoring tests was 6.6 days. The median vitamin K intake per patient was 0.367 mg/kg/d (range: 0.018–2.85 mg/kg/d). Before commencing anticoagulant therapy, the mean CVAD duration was 160.9 days. Concomitant warfarin therapy was associated with a mean CVAD duration of 351.7 days. There were no major bleeding events, and no clinical extension of thrombosis was observed.

Conclusions. This is the first published study to report uniform warfarin prophylaxis for CVADs in children. Warfarin therapy can be administered safely in children who require long-term TPN. Warfarin prophylaxis seems to prolong CVAD survival
A Dose-Response Study of OROS Methylphenidate in Children With Attention-Deficit/Hyperactivity Disorder
Authors: Stein Mark A. , Sarampote Christopher S. , Waldman Irwin D. , Robb Adelaide S. , Conlon Charles , Pearl Phillip L. , Black David O. , Seymour Karen E. , Newcorn Jeffrey H.
Published: August 2004

Objective. OROS methylphenidate HCL (MPH) is a recently developed long-acting stimulant medication used to treat attention-deficit/hyperactivity disorder (ADHD). This study was conducted to examine dosage effects on ADHD symptoms and stimulant side effects and to explore potential moderating effects of ADHD subtype.

Methods. Children with ADHD combined type (ADHD-CT) or predominantly inattentive type (ADHD-PI; n = 47), ages 5 to 16 years, underwent a placebo-controlled, crossover trial using forced titration with weekly switches at 3 dosage levels. Parent and teacher ratings of ADHD symptoms were used to evaluate efficacy. In addition, vital signs and standardized measures of stimulant side effects were obtained weekly.

Results. Parent ratings were more sensitive to treatment effects than teacher ratings. ADHD symptoms and Clinical Global Impressions Severity Index ratings at each dose condition differed significantly from placebo and baseline ratings, which did not differ from one another. For those with ADHD-CT, there was a clear linear dose-response relationship, with clinically significant reductions in ADHD Rating Scale-IV scores occurring in two thirds to three fourths of the subjects during either 36- or 54-mg dose conditions. Children with ADHD-PI, conversely, were more likely to respond optimally to lower doses and derived less benefit from higher doses, with 60% displaying significant improvement on the ADHD Rating Scale-IV at 36 mg or lower. Mild stimulant side effects were reported during placebo and at all dosage levels. With the exception of insomnia and decreased appetite, which were more common at higher doses, parent report of side effects was not related to dose. In addition, younger and smaller children were more likely to display sleep difficulties and decreased appetite at the higher dose levels Although pulse rate increased slightly with increasing dose, there were no dose effects on blood pressure.

Conclusions. In children with ADHD-CT, the most common subtype of ADHD, increasing doses of stimulant medication were associated with increased improvement of inattention and hyperactivity symptoms. In children with ADHD-PI, symptom improvement occurred at lower doses and less benefit was derived from higher doses. In both ADHD subtypes, higher doses were associated with parent ratings of increased insomnia and decreased appetite.
Increased Prevalence of Familial Autoimmunity in Probands With Pervasive Developmental Disorders
Authors: Sweeten Thayne L. , Bowyer Suzanne L. , Posey David J. , Halberstadt Gary M. , McDougle Christopher J.
Published: August 2004

Objectives. Increased prevalence of familial autoimmune disease is a common finding among probands with various autoimmune disorders. Autistic disorder (autism) is a highly genetic disorder with known immune and immunogenetic abnormalities. Previous research has found an increased frequency of autoimmune disorders in families with autistic probands. We further investigated this association by determining the frequency of autoimmune disorders in families that have probands with pervasive developmental disorders (PDDs), including autism, compared with 2 control groups.

Methods. Three well-defined study groups, including 1) families that have a child with a PDD, 2) families that have a child with an autoimmune disorder, and 3) families with a healthy control child, constituted the sample. A questionnaire inquiring about which first- and second-degree family members had received a diagnosis of having specific autoimmune disorders was completed by 101 families in each group.

Results. The frequency of autoimmune disorders was significantly higher in families of the PDD probands compared with families of both the autoimmune and healthy control probands. Autoimmunity was highest among the parents of PDD probands compared with parents of the healthy control subjects. Hypothyroidism/Hashimoto’s thyroiditis and rheumatic fever were significantly more common in families with PDD probands than in the healthy control families.

Conclusions. Autoimmunity was increased significantly in families with PDD compared with those of healthy and autoimmune control subjects. These preliminary findings warrant additional investigation into immune and autoimmune mechanisms in autism.
Improvement of Aggressive and Antisocial Behavior After Resection of Temporal Lobe Tumors
Authors: Nakaji Peter , Meltzer Hal S. , Singel Søren A. , Alksne John F.
Published: August 2004

Seizures associated with temporal lobe tumors may rarely manifest as episodic aggressive behavior. We describe 2 cases involving pediatric patients who presented with histories of unusually aggressive and antisocial behavior. Magnetic resonance imaging identified right mesial temporal lobe masses in both patients. After craniotomy for tumor removal, both patients were seizure-free and had marked reductions in their aggressive behavior. Tumors in the temporal lobe may be associated with behavioral problems, including aggression and rage attacks, which can be alleviated with surgical intervention. It is important to distinguish this subgroup of pediatric patients from those with alternative diagnoses such as attention-deficit/hyperactivity disorder or oppositional defiant disorder.
Bullying Among Young Adolescents: The Strong, the Weak, and the Troubled
Authors: Juvonen Jaana , Graham Sandra , Schuster Mark A.
Published: August 2004

Objectives. Bullying and being bullied have been recognized as health problems for children because of their association with adjustment problems, including poor mental health and more extreme violent behavior. It is therefore important to understand how bullying and being bullied affect the well-being and adaptive functioning of youth. We sought to use multiple data sources to better understand the psychological and social problems exhibited by bullies, victims, and bully-victims.

Design, Setting, and Participants. Analysis of data from a community sample of 1985 mostly Latino and black 6th graders from 11 schools in predominantly low socioeconomic status urban communities (with a 79% response rate).

Main Outcome Measures. Peer reports of who bullies and who is victimized, self-reports of psychological distress, and peer and teacher reports of a range of adjustment problems.

Results. Twenty-two percent of the sample was classified as involved in bullying as perpetrators (7%), victims (9%), or both (6%). Compared with other students, these groups displayed school problems and difficulties getting along with classmates. Despite increased conduct problems, bullies were psychologically strongest and enjoyed high social standing among their classmates. In contrast, victims were emotionally distressed and socially marginalized among their classmates. Bully-victims were the most troubled group, displaying the highest level of conduct, school, and peer relationship problems.

Conclusions. To be able to intervene with bullying, it is important to recognize the unique problems of bullies, victims, and bully-victims. In addition to addressing these issues directly with their patients, pediatricians can recommend school-wide antibullying approaches that aim to change peer dynamics that support and maintain bullying.
Does Presentation Format at the Pediatric Academic Societies’ Annual Meeting Predict Subsequent Publication?
Authors: Carroll Aaron E. , Sox Colin M. , Tarini Beth A. , Ringold Sarah , Christakis Dimitri A.
Published: August 2004

Objective. The validity of research presented at scientific meetings continues to be a concern. Presentations are chosen on the basis of submitted abstracts, which may not contain sufficient information to assess the validity of the research. The objective of this study was to determine 1) the proportion of abstracts presented at the annual Pediatric Academic Society (PAS) meeting that were ultimately published in peer reviewed journals; 2) whether the presentation format of abstracts at the meeting predicts subsequent full publication; and whether the presentation format was related to 3) the time to full publication or 4) the impact factor of the journal in which research is subsequently published.

Methods. We assembled a list of all abstracts submitted to the PAS meetings in general pediatrics categories in 1998 and 1999, using both CD-ROM and journal publications. In each year, we chose up to 80 abstracts from each presentation format (“publish only,” “poster,” “poster symposium,” “platform presentation”). We chose either 1) all abstracts in each format or 2) when there were >80 abstracts, a random selection of 80 of them. We assessed each selected abstract for subsequent full publication by searching Medline in March 2003; if published, then we recorded the journal, month, and year of publication. We used logistic and linear regression to determine whether publication, time to publication, and the journal’s impact factor were associated with the abstract’s presentation format.

Results. Overall, 44.6% of abstracts presented at the PAS meeting achieved subsequent full publication within 4 to 5 years. There were significant differences between the rates of subsequent full publication of abstracts submitted but not chosen for presentation at the meeting (22.2%) and those that were chosen for presentation in poster sessions (40.0%), poster symposia (44.1%), and platform presentations (53.8%). There were no meaningful differences between the presentation formats in their mean time to publication and their mean journal impact factor.

Conclusions. PAS meeting attendees and the press should be cautious when interpreting the presentation format of an abstract as a predictor of either its subsequent publication in a peer-reviewed journal or the impact factor of the journal in which it will appear.
Screening for Retinoblastoma: Presenting Signs as Prognosticators of Patient and Ocular Survival
Authors: Abramson David H. , Beaverson Katherine , Sangani Poorab , Vora Robin A. , Lee Thomas C. , Hochberg Hilary M. , Kirszrot James , Ranjithan Murali
Published: August 2004

Objective. To correlate 3 common presenting signs of retinoblastoma with patient and ocular survival and to assess the efficacy of current pediatric screening practices for retinoblastoma.

Methods. A retrospective study was conducted of 1831 retinoblastoma patients from our center (1914–June 2000). Patient survival (excluding deaths from other primary neoplasms) and ocular survival (presenting eyes) rates were calculated and analyzed using the Kaplan-Meier method.

Results. Leukocoria correlated with excellent patient survival (>86%, 5 years) but poor ocular survival in unilateral (4%, 5 years) and bilateral patients (29%, 5 years). A total of 308 (19%) of 1654 patients presented with strabismus: patient survival was excellent (90%, 5 years), and ocular survival was poor (17%, 5 years) yet better than leukocoria. Patients who had a family history of retinoblastoma and were clinically screened for retinal tumors from birth were diagnosed younger (8 months of age) and earlier (Reese Ellsworth group 1 = 26 [58%] of 45) and had better ocular survival than nonscreened patients with a family history. More patients were initially detected by family/friends (1315 [80%] of 1632) than pediatricians (123 [8%] of 1632) or ophthalmologists (156 [10%] of 1632).

Conclusion. Most US children whose retinoblastoma is diagnosed initially present with leukocoria detected by a parent, despite routine pediatric screening for leukocoria via the red reflex test. Initial disease detection at the point of leukocoria or strabismus correlated with high patient survival rates and poor ocular survival rates for the presenting eye. Saving eyes and vision requires disease recognition before leukocoria, as demonstrated by the better ocular salvage rate among patients who had a positive family history and received clinical surveillance via early, routine dilated funduscopic examinations by an ophthalmologist.
Changes in Globus Pallidus With (Pre)Term Kernicterus
Authors: Govaert Paul , Lequin Maarten , Swarte Renate , Robben Simon , De Coo René , Weisglas-Kuperus Nynke , De Rijke Yolanda , Sinaasappel Maarten , Barkovich James
Published: August 2004

Objective. We report serial magnetic resonance (MR) and sonographic behavior of globus pallidus in 5 preterm and 3 term infants with kernicterus and describe the clinical context in very low birth weight preterm infants. On the basis of this information, we suggest means of diagnosis and prevention.

Methods. Charts and MR and ultrasound images of 5 preterm infants and 3 term infants with suspected bilirubin-associated brain damage were reviewed. Included were preterm infants with severe hearing loss, quadriplegic hypertonia, and abnormal hypersignal of globus pallidus on T2-weighted MR imaging (MRI). In 1 infant who died on day 150, the diagnosis was confirmed during the neonatal period. The others were picked up as outpatients and scanned at 12 or 22 months’ corrected age. Three instances of term kernicterus were included for comparison of serial MRI in the neonatal period and early infancy: they were caused by glucose-6-phosphate dehydrogenase deficiency, urosepsis, and dehydration plus fructose 1–6 biphosphatase deficiency.

Results. Five preterm infants of 25 to 29 weeks’ gestational age presented with total serum bilirubin (TSB) levels below exchange transfusion thresholds commonly advised. Mixed acidosis was present in 3 infants around the TSB peak. The bilirubin/albumin molar ratio was >0.5 in all, in the absence of displacing drugs. All failed to pass bedside hearing screen tests and had severe hearing loss on auditory brain response testing. Symmetrical homogeneous hyperechogenicity of globus pallidus was the alerting feature in 1 infant. Globus pallidus was hyperintense on T1-weighted MR images in this child. The other infants presented with severe developmental delay as a result of dyskinetic quadriplegia and hearing loss. Globus pallidus was normal on T1- but hyperintense on T2-weighted MR images at 12 or 22 months’ corrected age. Subthalamic involvement was documented in coronal fluid attenuated inversion recovery MRI in 2 infants. The term infants with classical clinical presentation in the neonatal period had MR behavior similar to the preterms, but pallidal injury was not recognized with targeted sonographic examination. Their neonatal MR images demonstrated pallidal T1 hyperintensity and mild T2 hyperintensity.

Conclusion. Acidotic very low birth weight preterm infants with low serum albumin levels develop MR-confirmed pallidal injury and hearing loss facing “accepted” TSB levels. Serial MRI documents a shift from acute mainly T1 hypersignal to permanent T2 hypersignal in globus pallidus within the late neonatal period. Subthalamic and not thalamic involvement helps to differentiate from ischemic or metabolic disorder. As newborns, these infants are rigid and have severe apnea, before developing hypertonic quadriplegia in infancy.
Management of Hyperbilirubinemia in Newborns: Measuring Performance by Using a Benchmarking Model
Authors: Chou Shu-Chiung , Palmer R. Heather , Ezhuthachan Sudhakar , Newman Christine , Pradell-Boyd Brenna , Maisels M. Jeffrey , Testa Marcia A.
Published: August 2004

Background. Accreditors hold hospitals accountable for harm from serious newborn hyperbilirubinemia, yet standards for evaluating performance in prevention are lacking.

Objective. We confirmed prognostic variables for newborn hyperbilirubinemia and developed a benchmarking model for self-evaluation of hyperbilirubinemia management.

Methods. We conducted a 3-year prospective cohort study in the Henry Ford Health System (HFHS) on 5507 healthy newborns of ≥35 weeks’ gestational age. HFHS follows a rigorous protocol for hyperbilirubinemia management. Defining hyperbilirubinemia as age-specific levels of total serum bilirubin exceeding American Academy of Pediatrics criteria for considering phototherapy and severe hyperbilirubinemia as total serum bilirubin ≥20 mg/dL, we used logistic and Poisson regressions to determine predictors and estimate parameters for a benchmarking model. We compared incidence rates for severe hyperbilirubinemia from HFHS to aggregate data from 11 hospitals reported to have less rigorous management.

Results. Newborns were 52.9% black, 14.4% white, 24.3% Latino, and 2.4% Asian; 30% were exclusively and 28% partially breastfed. Regression analyses revealed associations for hyperbilirubinemia and severe hyperbilirubinemia with black mothers (negative) and exclusive or partial breastfeeding and younger gestational age (positive). Male newborns and older mothers were also associated with severe hyperbilirubinemia. For all 5 variables, we found a lower risk for severe hyperbilirubinemia at HFHS than in the comparison hospital group. To compare hospitals, we developed a benchmarking model for incidence of hyperbilirubinemia adjusting for race, feeding method, and gestational age.

Conclusions. Hospitals with access to newborns’ inpatient and postdischarge data can use our benchmarking model to compare their management of hyperbilirubinemia with a reference population that received rigorous care.
Fatal Pulmonary Hypertension Associated With Pertussis in Infants: Does Extracorporeal Membrane Oxygenation Have a Role?
Authors: Halasa Natasha B. , Barr Frederick E. , Johnson Joyce E. , Edwards Kathryn M.
Published: August 2004

Objective. The deaths of 4 infants who had confirmed pertussis infection at our hospital during the past year motivated us to review their cases as well as the use of extracorporeal membrane oxygenation (ECMO) in respiratory failure caused by pertussis.

Methods. Retrospective chart reviews of the 4 infants who had pertussis and died at Vanderbilt University Medical Center (VUMC) from May 2001 to May 2002 were conducted. The Extracorporeal Life Support Organization (ELSO) database is an international voluntary registry established in 1986 to compile passive reports of adult and pediatric patients placed on ECMO. We searched this database for pertussis cases and analyzed the clinical outcomes by age, ventilatory management, and measurements of cardiopulmonary status.

Results. All 4 infants who died from pertussis infection at VUMC were younger than 3 months and had severe pulmonary hypertension, and ECMO therapy was considered for respiratory failure. Review of the international ELSO database, focusing only on children from 1986 to July 2002, revealed a total of 23 970 patients placed on ECMO. Since the first pertussis case treated with ECMO in 1990, a total of 61 children with pertussis have been treated with ECMO, representing an increase from 0.09% to 1% of the total cases. Mean age of the pertussis patients placed on ECMO was 88 days (1 day–2.7 years). The overall mortality was 70.5% (43 of 61) but was significantly higher for infants who were younger than 6 weeks (84%) compared with infants who were older than 6 weeks (61%). When evaluating pre-ECMO management, survivors had received significantly higher mean positive end expiratory pressures than nonsurvivors (11.1 ± 4.5 vs 7.3 ± 3.1 cmH2O) and had significantly higher serum pH than nonsurvivors (7.31 ± 0.14 vs 7.14 ± 0.19). There was no effect of duration of ECMO, positive inspiratory pressure, mean arterial pressure, ECMO mode (venoarterial vs venovenous mode), or sex on mortality.

Conclusions. Although the ECMO registry is not an active surveillance system, it suggests that the numbers of children who require ECMO for pertussis have significantly increased. The high fatality rates of pertussis patients who have placed on ECMO are alarming and should stimulate reevaluation of whether this high-risk intervention is beneficial to patients with pertussis. This review, coupled with the 4 infants who died of pertussis at VUMC, suggests that improved measures are needed to prevent pertussis in infants.
Ventilator-Associated Pneumonia in Extremely Preterm Neonates in a Neonatal Intensive Care Unit: Characteristics, Risk Factors, and Outcomes
Authors: Apisarnthanarak Anucha , Holzmann-Pazgal Galit , Hamvas Aaron , Olsen Margaret A. , Fraser Victoria J.
Published: August 2004

Objective. To determine the rates, characteristics, risk factors, and outcomes of ventilator-associated pneumonia (VAP) in extremely preterm neonates in a neonatal intensive care unit (NICU).

Methods. A prospective cohort study was conducted at the St Louis Children’s Hospital on all patients who had birth weight ≤2000 g and were admitted to the NICU for ≥48 hours from October 2000 to July 2001. Extremely preterm neonates were defined as neonates with estimated gestational age (EGA) <28 weeks. The primary outcome was the development of VAP. Secondary outcomes were death and NICU length of stay (LOS). Multiple logistic regression was performed to determine independent predictors for VAP and mortality.

Results. A total of 229 patients were enrolled. Sixty-seven (29%) had EGA <28 weeks. Nineteen episodes of VAP occurred in 19 (28.3%) of 67 mechanically ventilated patients. VAP rates were 6.5 per 1000 ventilator days for patients with EGA <28 weeks and 4 per 1000 ventilator days for EGA ≥28 weeks. By multivariate analysis, bloodstream infection before VAP (adjusted odds ratio: 3.5; 95% confidence interval [CI]: 1.2–10.8) was an independent risk factor for VAP after adjustment for the duration of endotracheal intubation. Ventilator-associated pneumonia (adjusted odds ratio: 3.4; 95% CI: 1.2–12.3) was an independent predictor of mortality. A strong association between VAP and mortality was observed in neonates who stayed in the NICU >30 days (relative risk: 8.0; 95% CI: 1.9–35.0). Patients with VAP also had prolonged NICU LOS (median: 138 vs 82 days).

Conclusions. VAP occurred at high rates in extremely preterm neonates and was associated with increased mortality. Additional studies are needed to develop interventions to prevent VAP in NICU patients.
The Impact of Preterm Birth on Hospital Inpatient Admissions and Costs During the First 5 Years of Life
Authors: Petrou Stavros , Mehta Ziyah , Hockley Christine , Cook-Mozaffari Paula , Henderson Jane , Goldacre Michael
Published: August 2004

Objectives. To compare the cumulative use and cost of hospital inpatient services to 5 years of age by individuals divided into 4 subgroups by gestational age at birth.

Design. Costs applied to the hospital service utilization profile of each infant born in 2 areas covered by the Oxford Record Linkage Study during 1970–1993.

Setting. Oxfordshire and West Berkshire, southern United Kingdom.

Subjects. 239 694 individuals divided into 4 subgroups by gestational age at birth: <28 weeks, 28 to 31 weeks, 32 to 36 weeks, ≥37 weeks.

Main Outcome Measures. Number and duration of hospital admissions during the first 5 years of life and costs, expressed in £ sterling and valued at 1998–1999 prices, of hospital inpatient services.

Results. The total duration of hospital admissions for infants born at <28 and at 28 to 31 gestational weeks was 85 and 16 times that for term infants, respectively, once duration of life had been taken into account. Hospital inpatient service costs were significantly higher for preterm infants than for term infants, with the cost differences persisting throughout infancy and early and mid-childhood. Over the first 5 years of life, the adjusted mean cost difference was estimated at £14 614 (US $22 798) when infants born at <28 weeks gestational age were compared with term infants and £11 958 (US $18 654) when infants born at 28 to 31 weeks gestational age were compared with term infants. Independent contributions to total cost came from being born: small for gestational age, a multiple, during the 1970s and early 1980s, to a woman of extreme maternal age or who was hospitalized antenatally, and from experiencing extended survival or childhood disease. However, preterm birth remained the strongest predictor of high cost.

Conclusions. Preterm birth is a major predictor of how much an individual will cost hospital service providers during the first 5 years of life.
A Comparison of On-Site and Off-Site Patent Ductus Arteriosus Ligation in Premature Infants
Authors: Gould Douglas S. , Montenegro Lisa M. , Gaynor J. William , Lacy Suzanne P. , Ittenbach Richard , Stephens Paul , Steven James M. , Spray Thomas L. , Nicolson Susan C.
Published: August 2004

Introduction. Persistent patent ductus arteriosus (PDA) often produces hemodynamic and respiratory derangement necessitating use of inotropic drugs and escalating ventilatory support in premature infants. When medical therapy fails, surgical ligation is indicated. Because of the risks of transferring unstable neonates to the operating room, ductal ligation is routinely performed at the neonatal intensive care unit (NICU) bedside. Some patients, however, require transfer from hospitals without pediatric cardiac surgical teams. In an attempt to eliminate the risks associated with transfer, a surgical team from our institution offered to perform duct ligation in the NICUs of referring institutions. This experienced team consisted of a pediatric cardiac attending anesthesiologist and certified registered nurse anesthetist, cardiac operating room nurses, an attending cardiothoracic surgeon, and a cardiothoracic surgery fellow. We retrospectively reviewed our experience.

Methods. After approval from the Committee for the Protection of Human Subjects, the charts of premature neonates who underwent PDA ligation in the NICU at the Children’s Hospital of Philadelphia NICU or in a network NICU between January 1996 and April 2002 were reviewed. Data abstracted included institution, gender, gestational age, birth weight, weight at surgery, and number of courses of indomethacin. Mean arterial blood pressure and use of inotropic drugs and ventilatory parameters (fraction of inspired oxygen, peak inspiratory pressure) were recorded at the time of surgery and 96 hours postoperatively. Perioperative complications were recorded.

Results. Seventy-two patients met the criteria for inclusion. PDA ligation was performed in the Children’s Hospital of Philadelphia NICU in 38 of 72 patients, 53% (group 1). The remainder, 34 of 72 (47%) underwent PDA ligation in the NICU at 1 of 6 referring institutions (group 2). There were no significant differences between groups with respect to demographics, number of courses of indomethacin, or use of inotropic drugs or ventilatory support. The incidence of perioperative complications did not differ between groups: 3 in group 1 (bleeding, chylothorax, and pleural effusion) and 3 in group 2 (pneumothorax [3]). There were no anesthetic-related complications. Seven patients died (4 in group 1 and 3 in group 2), none within 96 hours of surgery and none secondary to the procedure.

Discussion. The data demonstrate that an experienced team can perform PDA ligation safely in NICUs of hospitals without on-site pediatric cardiac surgical capabilities in critically ill neonates without incurring the risks inherent in patient transport. Most importantly, patient care is continued by the neonatology team most familiar with the infant’s medical and social history, and the patient’s family is minimally inconvenienced.
Postreduction Management of Intussusception in a Children’s Hospital Emergency Department
Authors: Bajaj Lalit , Roback Mark G.
Published: August 2004

Objective. To evaluate the current management of patients with intussusception who have undergone successful reduction by contrast enema in a tertiary care children’s hospital. To compare differences in the incidence of recurrence and adverse events between those patients who were hospitalized after enema reduction and those who were observed in the emergency department (ED).

Methods. This was a retrospective cohort study of children 0 to 18 years of age who underwent uncomplicated enema reduction for intussusception. Hospitalization versus ED observation management were compared for length of stay, incidence of recurrence, and adverse events.

Results. One hundred twenty-three children were identified with an International Classification of Diseases, Ninth Revision code for intussusception. Of those, 106 patients (86%) had an enema reduction attempted. Three had a normal enema and were given the diagnosis of “resolved intussusception.” Eighty-three (80%) of the patients had a successful reduction. Seventy-eight (94%) of those patients had no preexisting condition and had complete medical records. Of those 78 patients, 27 (35%) were hospitalized and 51 (65%) were observed in the ED. The mean length of hospitalization was 22.7 hours (range: 10–50 hours), and the mean length of ED observation was 7.2 hours (range: 0–21 hours). Eleven recurrences were observed in 8 of these 78 patients (10% recurrence rate). Four patients in the hospitalized group and 4 patients in the ED observation group had recurrences (5 hours-10.9 months). Four of the 8 patients had a recurrence within the first 48 hours. All first recurrences occurred after the patient had been discharged from the hospital or ED observation unit. No adverse events occurred in any of the patients who had a successful initial reduction (95% confidence interval [0%–4.6%]).

Conclusions. The postreduction management of intussusception is variable at our institution. Previously healthy patients who have undergone successful enema reductions are unlikely to have adverse outcomes. Postreduction observation in the ED or the hospital does not seem to affect outcomes in this clinical setting.
Prevalence of Blood Lead Levels ≥5 μg/dL Among US Children 1 to 5 Years of Age and Socioeconomic and Demographic Factors Associated With Blood of Lead Levels 5 to 10 μg/dL, Third National Health and Nutrition Examination Survey, 1988–1994
Authors: Bernard Susan M. , McGeehin Michael A.
Published: August 2004

Objectives. As part of an investigation into the impact of a potential revision in federal childhood lead poisoning prevention policy that would result in screening children for blood lead levels (BLLs) ≥5 μg/dL rather than the current 10 μg/dL, we analyzed the most recent available, nationally representative data to identify prevalence of BLLs ≥5 μg/dL and socioeconomic and demographic characteristics of 1- to 5-year-old children with BLLs ≥5 but <10 μg/dL.

Methods. We performed statistical analyses on data from the Third National Health and Nutrition Examination Survey (NHANES III) (1988–1994) to describe trends in BLLs ≥5 μg/dL overall and among subpopulations of children <6 years old and to compare risk factors for falling within 1 of 3 groups of children (those with BLLs ≥5 but <10 μg/dL; ≥10 but <20 μg/dL; and ≥20 μg/dL) using the group reported as 0.7 to <5 μg/dL as the referent.

Results. Overall prevalence of BLLs ≥5 μg/dL among 1- to 5-year-old children was 25.6%, although most (76%) of these children had BLLs <10 μg/dL. Children with BLLs ≥5 μg/dL included 46.8% of non-Hispanic black children, 27.9% of Mexican American children, and 18.7% of non-Hispanic white children; 42.5% of children in housing built before 1946, 38.9% of children in housing built between 1946 and 1973, and 14.1% of children in housing built after 1973 had BLLs ≥5 μg/dL. Compared with non-Hispanic white children, non-Hispanic black children were 3 times more likely to have a BLL ≥5 but <10 μg/dL, 7 times more likely to have a BLL of 10–20 μg/dL, and 13.5 times more likely to have a BLL ≥20 μg/dL. Similar increases in the association between risk factor and BLL were seen with respect to other known risk factors including age of housing, region of the country, and poverty.

Conclusions. The high prevalence of BLLs ≥5 μg/dL overall and within US subpopulations will be an important variable in any change in screening and intervention criteria. However, most children with BLLs ≥5 μg/dL are below the current intervention level of 10 μg/dL. Exposure to lead from multiple sources is suggested by the prevalence of BLLs ≥5 μg/dL but <10 μg/dL among children with uncertain risk factors. The probable presence of one or more known risk factors for childhood lead poisoning increases as BLL increases.
Generalist-Subspecialist Communication for Children With Chronic Conditions: A Regional Physician Survey
Authors: Stille Christopher J. , Primack William A. , Savageau Judith A.
Published: August 2004

Objective. To identify target areas for interventions to improve communication between pediatric generalists (PCPs) and pediatric subspecialists (SPs) in the outpatient care of children with chronic conditions.

Methods. We constructed a 4-page mailed questionnaire probing communication practices, opinions about the role of communication in care, and perceived barriers and facilitators to PCP-SP communication in the care of children with chronic conditions. In the spring of 2001, we surveyed all 495 New England SPs who were members of the American Academy of Pediatrics (AAP) and/or SP societies and a random sample of 495 generalist AAP members in New England. Eligible were those actively providing outpatient care. Most items were rated on a 5-point scale.

Results. Of those eligible, 48% (412/860) completed the questionnaire. Although 98% of respondents agreed that communication was important for good care, reported practices reflected large gaps in this area. Frequent receipt (>60% of the time) of communication about an initial referral was reported by only 28% of SPs. Barriers reported as most important involved inefficiencies in telephone contact, transcription delay, and failure to keep all providers informed when >1 specialist is involved. Important facilitators included letters or phone calls at or before the time of consultation, and clear and specific referral questions from PCPs. PCPs saw communication as more of a problem than did SPs (40% vs 28%), and reported several barriers as more important. Although 86% of respondents had access to e-mail in their practices, <20% used it often.

Conclusions. PCPs and SPs sharing care for children with chronic conditions are troubled by their frequent failure or inability to contact their colleagues by phone and letter. PCPs communicate less frequently than SPs yet perceive more problems with communication. Interventions to promote efficient contact between providers at or before the time of subspecialty visits can lead to improved coordination of care, which in turn may better meet the needs of families.
Impact of Television Viewing Patterns on Fruit and Vegetable Consumption Among Adolescents
Authors: Boynton-Jarrett Reneé , Thomas Tracy N. , Peterson Karen E. , Wiecha Jean , Sobol Arthur M. , Gortmaker Steven L.
Published: August 2004

Background. National data indicate that children and youth do not meet Healthy People 2010 objectives for fruit and vegetable intake. Television viewing is hypothesized as a contributing factor because of its documented role in encouraging consumption of highly advertised foods that may lead to the replacement of fruits and vegetables.

Methods. A sample of 548 ethnically diverse students (average age: 11.7 ± 0.8 years) from public schools in 4 Massachusetts communities were studied prospectively over a 19-month period from October 1995 to May 1997. We examined the associations between baseline and change in hours of television and video viewing per day (the predictor variables) and change in energy-adjusted intake of fruits and vegetables by using linear regression analyses to control for potentially confounding variables and the clustering of observations within schools.

Findings. For each additional hour of television viewed per day, fruit and vegetable servings per day decreased (−0.14) after adjustment for anthropometric, demographic, dietary variables (including baseline percent energy from fat, sit-down dinner frequency, and baseline energy-adjusted fruit and vegetable intake), and physical activity. Baseline hours of television viewed per day was also independently associated with change in fruit and vegetable servings (−0.16).

Conclusions. Television viewing is inversely associated with intake of fruit and vegetables among adolescents. These associations may be a result of the replacement of fruits and vegetables in youths’ diets by foods highly advertised on television.