bluuebunny/crossref_metadata_2025 huggingface dataset:
Health Services Use by Children of Migratory Agricultural Workers: Exploring the Role of Need for Care
Authors: Weathers Andrea , Minkovitz Cynthia , O’Campo Patricia , Diener-West Marie
Published: August 2004

Objective. For migrant children: 1) to assess the determinants of health services use among users and nonusers of health services; 2) to evaluate the association between health status and health services use, while controlling for potential confounders.

Design. A cross-sectional household survey using multistage, partially random sampling to identify migrant families in eastern North Carolina.

Participants. Adult caretakers of 1 randomly selected child under 13 years old.

Results. Forty-four percent of children (N = 300) visited a doctor in the preceding 3 months. Those visiting a doctor disproportionately reported having less than very good health (29% vs 10%), insurance (46% vs 11%), interpreters (45% vs 27%), a family member receiving Special Supplemental Nutrition Program for Women, Infants, and Children (50% vs 16%), and a legal caretaker (30% vs 18%). Compared with those without a doctor visit, a larger proportion of children visiting a doctor were 6 years or younger in age (71% vs 35%), born in the United States (51% vs 15%), female (64% vs 45%), and had not moved in 6 or more months (19% vs 10%). Controlling for enabling resource and sociodemographic confounders, children with less than very good health were 2.4 times more likely than those in very good health to have visited a doctor (95% confidence interval [1.1–5.2]).

Conclusions. Migrant children using health services are distinct from nonusers with regards to sociodemographic factors, enabling resources, and need for care. Health services use is associated with less than very good perceived health, despite resource barriers and sociodemographic disadvantages. More efforts are needed to improve access to health care for migrant children.
Serious Bacterial Infections in Febrile Infants Younger Than 90 Days of Age: The Importance of Ampicillin-Resistant Pathogens
Authors: Byington Carrie L. , Rittichier Kristine K. , Bassett Kathlene E. , Castillo Heidi , Glasgow Tiffany S. , Daly Judy , Pavia Andrew T.
Published: August 2004

Background. Intrapartum antibiotic prophylaxis against group B Streptococcus (GBS) has reduced the occurrence of serious bacterial infections (SBI) in young infants caused by GBS. Recommendations for initial antibiotic therapy for the febrile infant 1 to 90 days old were developed when infections with GBS were common and antibiotic resistance was rare.

Objective. To document the pathogens responsible for SBI in recent years in febrile infants 1 to 90 days old and the antibiotic susceptibility of these organisms.

Methods. The results of bacterial cultures from infants 1 to 90 days old evaluated for fever at Primary Children’s Medical Center in Salt Lake City, Utah, between July 1999 and April 2002 were analyzed. Antibiotic susceptibility profiles were collected and patient records were reviewed to determine if initial antibiotic therapy was changed following the identification of the organism.

Results. Of 1298 febrile infants enrolled from the Primary Children’s Medical Center emergency department, 105 (8%) had SBI. The mean age of the infants with SBI was 39 days (range 2–82 days) and 2 (2%) were <7 days. SBI included urinary tract infection (UTI; 67%), bacteremia (16%), bacteremia and UTI (6%), bacteremia and meningitis (5%), meningitis (2%), abscess (2%), meningitis and UTI (1%), and meningitis and gastroenteritis (1%). Eighty-three (79%) of 105 episodes of SBI were caused by Gram-negative bacteria, including 92% of UTI, 54% of bacteremia, and 44% of meningitis cases. The most common pathogen was Escherichia coli (61%). Other Gram-negative pathogens were responsible for 19% of SBI. Staphylococcus aureus was the most common Gram-positive pathogen, causing 8% of SBI. GBS accounted for 6% of SBI.

Of the 105 pathogens, 56 (53%) were resistant to ampicillin. Of the pathogens causing meningitis, UTI, and bacteremia, 78%, 53%, and 50%, respectively, were resistant to ampicillin. Antibiotic therapy was changed in 54% of cases of SBI following identification of the organism.

Conclusions. In Utah, ampicillin-resistant Gram-negative bacteria are the most common cause of SBI in febrile infants <90 days old. This finding impacts antibiotic selection, especially in cases of meningitis. Local surveillance of pathogens and antibiotic susceptibility patterns is critical to determine appropriate antibiotic therapy.
Extrauterine Growth Restriction Remains a Serious Problem in Prematurely Born Neonates
Authors: Clark Reese H. , Thomas Pam , Peabody Joyce
Published: August 2004

Background. Poor growth is a common problem in premature neonates and may be associated with neurodevelopmental delay.

Objective. To evaluate the incidence of extrauterine growth restriction (growth values ≤10th percentile of intrauterine growth expectation based on estimated postmenstrual age in premature (23–34 weeks’ estimated gestational age) neonates at the time they are discharged from the hospital.

Design/Methods. Using a database formed from a computer-assisted tool that generates clinical progress notes and discharge summaries on neonatal intensive care unit admissions, we reviewed data on neonates discharged from 124 neonatal intensive care units between January 1, 1997, and December 31, 2000. We evaluated neonates who were born between 23 and 34 weeks’ estimated gestational age without congenital anomalies and who were cared for at and discharged from the same hospital. For each patient, we compared the discharge growth values to the expected values based on our intrauterine growth data and postmenstrual age on the day of discharge. We defined extrauterine growth restriction as having a measured growth value (weight, length or head circumference) that was ≤10th percentile of the predicted value. In each specific birth weight and estimated gestational age group, we counted the number of neonates ≤10th percentile for each growth parameter and calculated the percentage of patients who had values ≤10th percentile at discharge. Using logistic regression, we evaluated the factors associated with extrauterine growth restriction for weight, length, and head circumference.

Results. Our sample included 24 371 premature neonates. Data on discharge weight, length, and head circumference was available on 23 970, 17 203, and 20 885 neonates, respectively. The incidence of extrauterine growth restriction was common (28%, 34%, and 16% for weight, length, and head circumference, respectively). For each growth parameter, the incidence of extrauterine growth restriction increased with decreasing estimated gestational age and birth weight. Factors independently associated with extrauterine growth restriction were male gender, need for assisted ventilation on day 1 of life, a history of necrotizing enterocolitis, need for respiratory support at 28 days of age, and exposure to steroids during the hospital course.

Conclusions. Extrauterine growth restriction remains a serious problem in premature neonates especially for neonates who are small, immature, and critically ill.
Medication Use in the Treatment of Pediatric Insomnia: Results of a Survey of Community-Based Pediatricians
Authors: Owens Judith A. , Rosen Carol L. , Mindell Jodi A.
Published: August 2004

Objectives. To examine clinical practice patterns, beliefs, and attitudes regarding the use of both nonprescription and prescription medications by community-based pediatricians for children with significant difficulties in initiating and/or maintaining sleep.

Methods. A survey was mailed to 3424 American Academy of Pediatrics members in 6 US cities.

Results. The final sample (n = 671) consisted of practitioners who identified themselves as primary care pediatricians. Three percent ± 7% of visits in the respondents’ practices were for pediatric insomnia, although there was a wide range in the numbers of children identified during a typical 6-month practice period. More than 75% of practitioners had recommended nonprescription medications, and >50% had prescribed a sleep medication. Specific clinical circumstances in which medications were most commonly used were acute pain and travel, followed by children with special needs (mental retardation, autism, and attention-deficit/hyperactivity disorder). Antihistamines were the most commonly reported nonprescription medications for sleep. Melatonin or herbal remedies had been recommended by approximately 15% of the respondents. α-agonists were the most frequently prescribed sleep medications (31%). The likelihood of prescribing medication for sleep was 2- to 4-fold greater in respondents who treated children with attention-deficit/hyperactivity disorder for daytime behavioral problems or nocturnal sleep problems, respectively. Practitioners expressed a range of concerns about sleep medication appropriateness, safety, tolerance, and side effects in children.

Conclusions. The practice of prescribing or recommending sedatives and hypnotics for pediatric insomnia is common among community-based pediatricians, especially among special needs patients. An empirically based approach to the use of these medications is needed.
Economic Analysis of Promotion of Hepatitis B Vaccinations Among Vietnamese-American Children and Adolescents in Houston and Dallas
Authors: Zhou Fangjun , Euler Gary L. , McPhee Stephen J. , Nguyen Thoa , Lam Tram , Wong Ching , Mock Jeremiah
Published: August 2004

Objective. To ascertain the cost-effectiveness and benefit-cost ratios of 2 public health campaigns conducted in Dallas and Houston in 1998–2000 for “catch-up” hepatitis B vaccination of Vietnamese-Americans born 1984–1993.

Design. Program evaluation.

Setting. Houston and Dallas, Texas.

Participants. A total of 14 349 Vietnamese-American children and adolescents.

Interventions. Media-led information and education campaign in Houston, and community mobilization strategy in Dallas. Outcomes were compared with a control site: Washington, DC.

Main outcome measures. Receipt of 1, 2, or 3 doses of hepatitis B vaccine before and after the interventions, costs of interventions, cost-effectiveness ratios for intermediate outcomes, intervention cost per discounted year of life saved, and benefit-cost ratio of the interventions.

Results. The number of children who completed the series of 3 hepatitis B vaccine doses increased by 1176 at a total cost of $313 904 for media intervention, and by 390 and at $169 561 for community mobilization. Costs per child receiving any dose, per dose, and per completed series were $363, $101, and $267 for media intervention and $387, $136, and $434 for community mobilization, respectively. For media intervention, the intervention cost per discounted year of life saved was $9954 and 131 years of life were saved; for community mobilization, estimates were $11 759 and 60 years of life. The benefit-cost ratio was 5.26:1 for media intervention and 4.47:1 for community mobilization.

Conclusion. Although the increases in the number of children who completed series of 3 doses were modest for both the Houston and Dallas areas, both media education and, to a lesser degree, community mobilization interventions proved cost-effective and cost-beneficial.
Occult Head Injury in High-Risk Abused Children
Authors: Rubin David M. , Christian Cindy W. , Bilaniuk Larissa T. , Zazyczny Kelly Ann , Durbin Dennis R.
Published: August 2004

Objective. Head injury is the leading cause of death in abused children under 2 years of age. Evidence for establishing guidelines regarding screening for occult head injury in a neurologically asymptomatic child with other evidence of abuse is lacking. This is particularly important given that many children with acute inflicted head injury have evidence of old injury when they are diagnosed. The primary aim of this study was to estimate the prevalence of occult head injury in a high-risk sample of abused children with normal neurologic examinations. The secondary aim was to describe characteristics of this population.

Methods. Children under 2 years of age admitted to an urban children’s hospital between January 1998 and December 2001 with injuries suspicious for child abuse were eligible for this study if they had a normal neurologic examination on admission. Subjects were selected if they met 1 of the following “high-risk” criteria: rib fractures, multiple fractures, facial injury, or age <6 months. Subjects were excluded if they had a history of neurologic dysfunction, seizures, respiratory arrest, or if their initial physical examination revealed scalp injury.

Results. Of the 65 patients who met these criteria, 51 (78.5%) had a head computed tomography or magnetic resonance imaging in addition to skeletal survey. Of these 51 patients, 19 (37.3%, 95% confidence interval 24.2–50.4%) had an occult head injury. Injuries included scalp swelling (74%), skull fracture (74%), and intracranial injury (53%). All except 3 of the head-injured patients had at least a skull fracture or intracranial injury. Skeletal survey alone missed 26% (5/19) of the cases. Head-injured children were younger than non-head-injured children (median age 2.5 vs 5.1 months); all but 1 head-injured child was <1 year of age. Among the head-injured children, 72% came from single parent households, 37% had mothers whose age was <21 years, and 26% had a history of prior child welfare involvement in their families. Ophthalmologic examination was performed in 14 of the 19 cases; no retinal hemorrhages were noted.

Conclusions. Our results support a recommendation for universal screening in neurologically asymptomatic abused children with any of the high-risk criteria used in this study, particularly if that child is under 1 year of age. Ophthalmologic examination is a poor screening method for occult head injury, and one should proceed directly to computed tomography or magnetic resonance imaging. Given the high prevalence of occult head injury detected in this study, further study is warranted to estimate the prevalence of occult head injury in lower risk populations of abused children.
Differential Influence of Family History of Hypertension and Premature Myocardial Infarction on Systolic Blood Pressure and Left Ventricular Mass Trajectories in Youth
Authors: Dekkers J. Caroline , Treiber Frank A. , Kapuku Gaston , Snieder Harold
Published: August 2004

Objective. To examine the influence of genetic susceptibility to essential hypertension (EH) and the genetic susceptibility to premature myocardial infarction (MI) on longitudinal development of systolic blood pressure (SBP) and left ventricular mass (LVM) in youth.

Methods. Individual SBP and LVM growth curves across age were created for a sample of 745 subjects (age range: 4.9–27.5 years) and a sample of 687 subjects (age range: 8.2–27.5 years), respectively. Each sample had an approximately equal proportion of African American and European American males and females, with annual assessments over a 10-year period. Family history (FH) of EH and FH of premature MI were used as measures of genetic susceptibility to EH and to premature MI, respectively. Positive FH (FH+) of EH and of premature MI were defined, respectively, as verified EH in 1 or both biological parents, and verified MI in any biological parent or grandparent before 55 years of age.

Results. Subjects with an FH+ of EH had higher SBP levels and stronger increases in SBP over time than subjects with a negative FH (FH−) of EH. Subjects with an FH+ of EH also showed higher LVM levels than subjects with an FH− of EH. In addition, the effect of an FH+ of EH on LVM was stronger in females than males. The effects of FH of EH on SBP and LVM could not be explained by differences in socioeconomic status, but the effect on LVM was no longer significant after adjustment for BMI. FH of MI had no significant effects on SBP or LVM.

Conclusions. Effects of genetic susceptibility to EH on SBP and LVM trajectories were observed in childhood, whereas no such effects were found for FH of MI. Genetic markers of EH may improve the understanding of individual differences in susceptibility to develop hypertension and LV hypertrophy.
National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Chronic Kidney Disease in Children and Adolescents: Evaluation, Classification, and Stratification
Authors: Hogg Ronald J. , Furth Susan , Lemley Kevin V. , Portman Ronald , Schwartz George J. , Coresh Josef , Balk Ethan , Lau Joseph , Levin Adeera , Kausz Annamaria T. , Eknoyan Garabed , Levey Andrew S.
Published: August 2004

Objectives. A series of new guidelines has been developed by the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative to improve the detection and management of chronic kidney disease (CKD). In most instances of CKD, the earliest manifestations of the disorder may be identified by relatively simple tests. Unfortunately, CKD is often “underdiagnosed,” in part because of the absence of a common definition of CKD and a classification of the stages in its progression. The Kidney Disease Outcomes Quality Initiative clinical practice guidelines for CKD evaluation, classification, and stratification provide a basis to remedy these deficits. The specific goals of the guidelines described in this review are to provide: 1) an overview of the clinical practice guidelines as they pertain to children and adolescents, 2) a simple classification of the stages of CKD, and 3) a practical approach to the laboratory assessment of kidney disease in children and adolescents.

Methods. The guidelines were developed as part of an evidence-based evaluation of CKD and its consequences in patients of all ages. The data that were used to generate the guidelines in this article were extracted from a structured analysis of articles that reported on children with CKD.

Results and Conclusions. This review presents the definition and 5-stage classification system of CKD developed by the work group assigned to develop the guidelines, and summarizes the major recommendations regarding the early detection of CKD. Major emphasis is placed on the identification of children and adolescents with CKD by measuring the protein-to-creatinine ratio in spot urine specimens and by estimating the glomerular filtration rate from serum creatinine using prediction equations.
Fatal Malignant Hyperthermia-Like Syndrome With Rhabdomyolysis Complicating the Presentation of Diabetes Mellitus in Adolescent Males
Authors: Hollander Abby S. , Olney Robert C. , Blackett Piers R. , Marshall Bess A.
Published: August 2004

Objective. This report describes a new fatal syndrome observed in adolescent males at the initial presentation of diabetes mellitus. The features include hyperglycemic hyperosmolar coma complicated by a malignant hyperthermia-like picture with fever, rhabdomyolysis, and severe cardiovascular instability.

Design. Case series.

Setting. Pediatric intensive care units of 3 tertiary care facilities in the United States.

Patients. Six adolescent males, 5/6 obese with acanthosis nigricans, 4/6 black.

Results. Four of 6 patients died. Four of 6 patients did not have significant ketosis. Six of 6 patients had increased temperature after the administration of insulin.

Conclusions. The underlying etiology of this syndrome remains unclear. Possibilities include an underlying metabolic disorder such as a fatty acid oxidation defect, an unrecognized infection, exposure to an unknown toxin, or a genetic predisposition to malignant hyperthermia. Evaluation for all these possibilities and empiric treatment with dantrolene should be considered for this type of patient until this syndrome is better characterized.
Postexposure Prophylaxis in Children and Adolescents for Nonoccupational Exposure to Human Immunodeficiency Virus
Authors: Havens Peter L. ,   Committee on Pediatric AIDS
Published: August 2004

This Clinical Report was retired July 2017.

Exposure to human immunodeficiency virus (HIV) can occur in a number of situations unique to, or more common among, children and adolescents. Guidelines for postexposure prophylaxis (PEP) for occupational and nonoccupational (eg, sexual, needle-sharing) exposures to HIV have been published by the US Public Health Service, but they do not directly address nonoccupational HIV exposures unique to children (such as accidental exposure to human milk from a woman infected with HIV or a puncture wound from a discarded needle on a playground), and they do not provide antiretroviral drug information relevant to PEP in children.

This clinical report reviews issues of potential exposure of children and adolescents to HIV and gives recommendations for PEP in those situations. The risk of HIV transmission from nonoccupational, nonperinatal exposure is generally low. Transmission risk is modified by factors related to the source and extent of exposure. Determination of the HIV infection status of the exposure source may not be possible, and data on transmission risk by exposure type may not exist. Except in the setting of perinatal transmission, no studies have demonstrated the safety and efficacy of postexposure use of antiretroviral drugs for the prevention of HIV transmission in nonoccupational settings. Antiretroviral therapy used for PEP is associated with significant toxicity. The decision to initiate prophylaxis needs to be made in consultation with the patient, the family, and a clinician with experience in treatment of persons with HIV infection. If instituted, therapy should be started as soon as possible after an exposure—no later than 72 hours—and continued for 28 days. Many clinicians would use 3 drugs for PEP regimens, although 2 drugs may be considered in certain circumstances. Instruction for avoiding secondary transmission should be given. Careful follow-up is needed for psychologic support, encouragement of medication adherence, toxicity monitoring, and serial HIV antibody testing.
Impact of the Thimerosal Controversy on Hepatitis B Vaccine Coverage of Infants Born to Women of Unknown Hepatitis B Surface Antigen Status in Michigan
Authors: Biroscak Brian J. , Fiore Anthony E. , Fasano Nancy , Fineis Patrick , Collins Michael P. , Stoltman Gillian
Published: August 2004

Objective. Hepatitis B vaccine is recommended for all infants, and the series may be started during the delivery admission. For infants who are born either to women who are positive for hepatitis B surface antigen (HBsAg) or to women whose HBsAg status is unknown, vaccination should be started within 12 hours of birth to prevent perinatal and early childhood hepatitis B virus infection. Because of concerns about mercury exposures from vaccines that contain thimerosal, the United States Public Health Service (USPHS) and the American Academy of Pediatrics (AAP) recommended in July 1999 that the first dose of hepatitis B vaccine be deferred until 2–6 months of age but only for infants who are born to HBsAg-negative women. To assess the impact on birth-dose vaccine coverage for infants who are born to women with unknown HBsAg status, we measured coverage before and after July 1999.

Methods. A sample of Michigan infants who were born to women whose HBsAg status was either unknown or missing were identified by reviewing newborn screening cards for infants who were born during 1) March–April 1999 (before recommendation changes [T1]); 2) July 15–September 15, 1999 (immediately after recommendation changes [T2]); and 3) March–April 2000 (6 months after resumption of pre-1999 practices were recommended [T3]). We verified maternal HBsAg screening and newborn hepatitis B vaccination by reviewing infant and maternal hospital records.

Results. Of 1201 infants who were born to women whose HBsAg status was indicated as unknown or missing on the newborn screening card during the 3 time periods, 216 (18%) were born to women whose status was truly unknown at the time of delivery, as determined by medical record review. During T1, 53% of these 216 infants received hepatitis B vaccine before hospital discharge, compared with 7% of infants who were born during T2 and 57% of infants who were born during T3. During T1, 19% of these infants received hepatitis B vaccine within 12 hours of birth compared with 1% of infants who were born during T2 and 14% of infants who were born during T3.

Conclusions. Hepatitis B vaccine birth-dose coverage for infants who were born to women whose HBsAg status was unknown at the time of delivery was already low in Michigan before the July 1999 USPHS/AAP Joint Statement but decreased significantly during the 2 months after the USPHS/AAP Joint Statement. Abrupt changes in established vaccination recommendations for lower risk children may lead to decreased coverage among higher risk children. Increases in hepatitis B vaccine coverage at birth are necessary to reduce the risk of perinatal infection for infants who are born to women with unknown HBsAg status.
Symptoms of Posttraumatic Stress Disorder in Parents of Transplant Recipients: Incidence, Severity, and Related Factors
Authors: Young Gregory S. , Mintzer Lisa Libman , Seacord Debra , Castañeda Marleen , Mesrkhani Violet , Stuber Margaret L.
Published: August 2004

Objective. To examine the incidence, severity, and factors related to posttraumatic stress disorder (PTSD) symptoms in parents of pediatric solid organ transplant recipients.

Method. A total of 170 caregivers of pediatric transplant recipients completed self-report measures of psychological functioning between 10 and 38 months after their child’s most recent transplant. Demographic data, child health variables, and ratings of medical attitudes and social functioning were also collected to help explain individual differences in psychological functioning.

Results. Although caregivers of pediatric transplant recipients did not report elevated levels of depression or anxiety, they did report elevated levels of PTSD symptoms. Multiple regression analyses revealed that PTSD symptoms were most strongly associated with parent reports of child health, family impact of the transplant, and attitudes toward medical caregivers.

Conclusions. PTSD seems to be relatively common in parents of pediatric transplant recipients and may be largely the result of how parents perceive and interpret the transplant experience.
Clinician Support and Psychosocial Risk Factors Associated With Breastfeeding Discontinuation
Authors: Taveras Elsie M. , Capra Angela M. , Braveman Paula A. , Jensvold Nancy G. , Escobar Gabriel J. , Lieu Tracy A.
Published: August 2004

Objective. Breastfeeding rates fall short of goals set in Healthy People 2010 and other national recommendations. The current, national breastfeeding continuation rate of 29% at 6 months lags behind the Healthy People 2010 goal of 50%. The objective of this study was to evaluate associations between breastfeeding discontinuation at 2 and 12 weeks postpartum and clinician support, maternal physical and mental health status, workplace issues, and other factors amenable to intervention.

Methods. A prospective cohort study was conducted of low-risk mothers and infants who were in a health maintenance organization and enrolled in a randomized, controlled trial of home visits. Mothers were interviewed in person at 1 to 2 days postpartum and by telephone at 2 and 12 weeks. Logistic regression modeling was performed to assess the independent effects of the predictors of interest, adjusting for sociodemographic and other confounding variables.

Results. Of the 1163 mother-newborn pairs in the cohort, 1007 (87%) initiated breastfeeding, 872 (75%) were breastfeeding at the 2-week interview, and 646 (55%) were breastfeeding at the 12-week interview. In the final multivariate models, breastfeeding discontinuation at 2 weeks was associated with lack of confidence in ability to breastfeed at the 1- to 2-day interview (odds ratio [OR]: 2.8; 95% confidence interval [CI]: 1.02–7.6), early breastfeeding problems (OR: 1.5; 95% CI: 1.1–1.97), Asian race/ethnicity (OR: 2.6; 95% CI: 1.1–5.7), and lower maternal education (OR: 1.5; 95% CI: 1.2–1.9). Mothers were much less likely to discontinue breastfeeding at 12 weeks postpartum if they reported (during the 12-week interview) having received encouragement from their clinician to breastfeed (OR: 0.6; 95% CI: 0.4–0.8). Breastfeeding discontinuation at 12 weeks was also associated with demographic factors and maternal depressive symptoms (OR: 1.18; 95% CI: 1.01–1.37) and returning to work or school by 12 weeks postpartum (OR: 2.4; 95% CI: 1.8–3.3).

Conclusions. Our results indicate that support from clinicians and maternal depressive symptoms are associated with breastfeeding duration. Attention to these issues may help to promote breastfeeding continuation among mothers who initiate. Policies to enhance scheduling flexibility and privacy for breastfeeding mothers at work or school may also be important, given the elevated risk of discontinuation associated with return to work or school.
Brief Psychosocial Screening at Health Supervision and Acute Care Visits
Authors: Borowsky Iris Wagman , Mozayeny Sara , Ireland Marjorie
Published: August 2004

Objective. To identify factors associated with positive scores on a brief psychosocial screening tool with subscales for internalizing, externalizing, and attention problems.

Methods. Parents of 2028 children between the ages of 7 and 15 years seen in a sample of 8 primary care practices in the Minneapolis-St Paul metropolitan area completed a brief questionnaire that included the 17-item Pediatric Symptom Checklist (PSC), demographic information, and the reason for the child’s visit to the clinic.

Results. Overall, 22% of the youth had at least 1 positive PSC-17 subscale or a positive PSC-17 total score. Twelve percent scored positive on the internalizing subscale, 10% on the externalizing subscale, 7% on the attention subscale, and 11% had a positive PSC-17 total score. Although boys were more likely than girls to score positive on the attention and aggression subscales, boys and girls were equally likely to have a positive score on the depression subscale. Children not living with both biological parents and those with a household member receiving public assistance were significantly more likely to show psychosocial dysfunction. Controlling for demographic characteristics, patients presenting for an illness-related or injury visit were more likely to score positive on the screen than those presenting for a routine well-child visit (odds ratio: 1.46; 95% confidence interval: 1.07–1.98).

Conclusions. Clinicians will miss opportunities to identify emotional and behavioral disorders among children and adolescents who may be at a higher risk if they limit psychosocial screening to health supervision visits. Further research is needed to identify effective strategies for using primary care for recognizing, diagnosing, and treating mental health disorders in children and adolescents.
Pemphigus Vulgaris: The Eyes Have It
Authors: Merchant Saba , Weinstein Michael
Published: August 2004

Pemphigus vulgaris is a potentially fatal autoimmune blistering disease that is rare in childhood. We report 2 recent cases seen contemporaneously in adolescents who presented with chronic oral mucosal lesions and conjunctivitis. The previously unemphasized ocular manifestations are described and the importance of a biopsy in establishing the diagnosis in instances of unexplained chronic mucositis is stressed.
Immunization of Preterm and Low Birth Weight Infants
Authors: Saari Thomas N. ,   and Committee on Infectious Diseases
Published: August 2004

This Clinical Report was retired May 2009.

Preterm (PT) infants are at increased risk of experiencing complications of vaccine-preventable diseases but are less likely to receive immunizations on time. Medically stable PT and low birth weight (LBW) infants should receive full doses of diphtheria, tetanus, acellular pertussis, Haemophilus influenzae type b, hepatitis B, poliovirus, and pneumococcal conjugate vaccines at a chronologic age consistent with the schedule recommended for full-term infants. Infants with birth weight less than 2000 g may require modification of the timing of hepatitis B immunoprophylaxis depending on maternal hepatitis B surface antigen status. All PT and LBW infants benefit from receiving influenza vaccine beginning at 6 months of age before the beginning of and during the influenza season. All vaccines routinely recommended during infancy are safe for use in PT and LBW infants. The occurrence of mild vaccine-attributable adverse events are similar in both full-term and PT vaccine recipients. Although the immunogenicity of some childhood vaccines may be decreased in the smallest PT infants, antibody concentrations achieved usually are protective.
Morbidity Patterns Among Low-Income Wheezing Infants
Authors: Klinnert Mary D. , Price Marcella R. , Liu Andrew H. , Robinson JoAnn L.
Published: August 2004

Objective. This study describes morbidity attributable to wheezing illness in a multi-ethnic sample of low-income infants younger than age 2, and examines biological, environmental, and psychosocial correlates of morbidity indexes.

Method. Infants 9 to 24 months old, considered at risk for developing asthma on the basis of having had 3 or more health care contacts with documented wheezing, received comprehensive evaluations as part of an environmental intervention study. Baseline evaluations with the infants, their families, and their home environments focused on biological, environmental, and psychosocial factors that would potentially increase asthma risk for the children. At study entry, prior morbidity attributable to wheezing illness was assessed with caregiver reports of symptom frequency and severity and medication use, caregiver quality of life, and medical record documentation of hospitalizations and emergency department (ED) visits.

Results. Forty-six percent of the infants had 1 or more hospitalizations and 59% had 2 or more ED visits since birth for wheezing illness. Foreign-born Hispanic families had significantly more ED visits for their children’s wheezing illness than US-born Hispanic families, whites, or blacks, although they used fewer controller medications and they reported less illness severity. Multivariate analyses showed 3 biological factors, respiratory syncytial virus, elevated child IgE, and cockroach allergen in the home, were independently associated with hospitalizations within this sample. Similar analyses showed that ED visits were not associated with biological variables, but rather with caregivers with single parent status and smokers. Caregiver reports of wheezing illness severity were correlated with ED visits, but not with hospitalizations. Severity ratings were higher for children of mothers with asthma and for those whose caregivers had higher anxiety and stress. The only correlate of caregiver ratings of poor quality of life was high caregiver anxiety.

Conclusions. Ethnic and immigrant status was an important factor in morbidity attributable to infant wheezing illness. In addition to respiratory infection, both allergic processes and social variables were associated with morbidity as measured by health care utilization. Caregiver reports of illness severity were significantly correlated with psychosocial factors.
Prospective Diagnosis of 2-Methylbutyryl-CoA Dehydrogenase Deficiency in the Hmong Population by Newborn Screening Using Tandem Mass Spectrometry
Authors: Matern Dietrich , He Miao , Berry Susan A. , Rinaldo Piero , Whitley Chester B. , Madsen Pia P. , van Calcar Sandra C. , Lussky Richard C. , Andresen Brage S. , Wolff Jon A. , Vockley Jerry
Published: August 2004

Objective. 2-Methylbutyryl-CoA dehydrogenase deficiency, also known as short/branched-chain acyl-CoA dehydrogenase (SBCAD) deficiency, is a recently described autosomal recessive disorder of l-isoleucine metabolism. Only 4 affected individuals in 2 families have been described. One patient developed athetoid cerebral palsy, and another had severe motor developmental delay with muscle atrophy. A sibling of the first patient is asymptomatic after prenatal diagnosis and early treatment. Family investigations in the second family revealed that the patient’s mother was also affected but asymptomatic.

Methods. We report 8 additional patients identified by prospective newborn screening using tandem mass spectrometry.

Results. Molecular genetic analysis performed for 3 of these patients revealed that all are homozygous for an 1165A>G mutation that causes skipping of exon 10 of the SBCAD gene. Although there was no obvious consanguinity, all patients belong to the Hmong, an ancient ethnic group that originated in China and constitutes only 0.8% and 0.6% of the Minnesota and Wisconsin population, respectively. Dietary treatment was initiated in the neonatal period. Except for 1 patient who developed mild muscle hypotonia, all patients remain asymptomatic at ages ranging from 3 to 14 months of age.

Conclusions. These cases suggest that SBCAD deficiency is another inborn error of metabolism detectable by newborn screening using tandem mass spectrometry. The continued efficacy of long-term dietary therapy instituted presymptomatically remains to be established.
Serum Cardiac Troponin and Subclinical Cardiac Status in Pediatric Chronic Renal Failure
Authors: Lipshultz Steven E. , Somers Michael J. G. , Lipsitz Stuart R. , Colan Steven D. , Jabs Kathy , Rifai Nader
Published: August 2004

Background. Patients with uremia often have elevated serum cardiac troponin T (cTnT) even without clinical heart damage. Pediatric patients are ideal for studies of the relationship between uremia and heart disease because they are unlikely to have cardiac risk factors other than uremia.

Objective. To determine the relationship between uremia and cTnT levels.

Design. Echocardiograms and blood chemistry results were obtained from 50 pediatric patients with chronic renal failure and without clinical heart disease. Levels of cTnT were tested for correlation with cardiac dysfunction. In multivariate analysis, biochemical aspects of renal disease and its treatment were tested for correlation with cardiac dysfunction.

Results. Forty-nine patients had cardiovascular abnormalities, including increased left ventricular function and mass, elevated heart rate and blood pressure, and reduced LV afterload. LV contractility was inversely correlated with cTnT level (r = −0.36). Higher cTnT also correlated with higher serum creatine kinase-MB mass, lower serum parathyroid hormone, higher blood urea nitrogen and bicarbonate levels, and the use of diuretics, but not with higher cardiac troponin I. Left ventricular contractility was inversely related to serum creatinine, phosphorus, and the use of β-blockers.

Conclusions. Elevated cTnT levels are not artifactual, but are genuine indicators of cardiomyocyte damage. Cardiac damage, indicated by either elevated cTnT or low LV contractility, is related to uremia, deranged calcium and phosphorus metabolism, and bicarbonate levels. Serum cTnT and LV contractility identify subclinical cardiac damage that could be treated to hopefully reduce cardiovascular morbidity and mortality in this high-risk population.
Aminophylline for the Prevention of Apnea During Prostaglandin E1 Infusion
Authors: Lim D.S. , Kulik Thomas J. , Kim Dennis W. , Charpie John R. , Crowley Dennis C. , Maher Kevin O.
Published: August 2004

Background. Apnea is associated with prostaglandin E1 infusion (PGE1) used in the palliation of ductal-dependent congenital heart lesions.

Hypothesis. Aminophylline is a central respiratory stimulant and will decrease the incidence of PGE1-associated apnea and the need for intubation for apnea in infants with ductal-dependent congenital heart disease.

Methods. Informed consent was obtained for all patients. In a prospective, double-blinded, placebo-controlled study, newborn infants with ductal-dependent congenital heart disease were randomized to receive either aminophylline or placebo during initiation and maintenance of PGE1, which was started at 0.01 μg/kg/min and increased to 0.03 μg/kg/min. Aminophylline was given as a bolus dose of 6 mg/kg before or during initiation of PGE1, and continued at 2 mg/kg dose every 8 hours for 72 hours. Serum aminophylline levels were checked at 18 and 36 hours. The primary study endpoint was intubation for apnea, with a secondary endpoint of apnea, as defined as acute cessation of breathing with associated hypoxia and bradycardia.

Results. The study evaluated 42 infants. The 2 groups were similar for gestational age, weight, hematocrit, and use of sedation. In the aminophylline group, serum levels were 7.6 ± 1.2 μg/mL. No significant side effects of aminophylline were seen. Infants receiving aminophylline (n = 21) were less likely to have apnea (2 vs 11) or be intubated for apnea (0 vs 6). Length of postoperative stay and survival to discharge were similar between the 2 groups.

Conclusions. Aminophylline was effective for the prevention of apnea and intubation for apnea associated with PGE1 in infants with ductal-dependent congenital heart disease.
Anogenital Injuries in Child Pedestrians Run Over by Low-Speed Motor Vehicles: Four Cases With Findings That Mimic Child Sexual Abuse
Authors: Boos Stephen C. , Rosas Angela J. , Boyle Cathy , McCann John
Published: August 2004

Objective. Differentiating between child sexual abuse and nonintentional causes of anogenital injury can be challenging, and a misdiagnosis can have a profound impact on the child and family. This case series documents an important nonintentional mechanism of anogenital injury that mimics the physical findings of child sexual abuse.

Methods. Four children were examined after being run over by a slow-moving motor vehicle. In each case, the wheel of the vehicle passed longitudinally over the child’s torso.

Results. Two children had perianal lacerations, and 2 had hymenal lacerations. One child with hymen injuries was followed for 4 weeks and developed findings identical to those seen in healed sexual abuse.

Conclusions. Children run over by motor vehicles should be evaluated for anogenital injury. If such injury is suspected, it should be fully delineated and documented with colposcopy and follow-up examination. Although the possibility of sexual abuse must be considered, awareness of the occurrence of anogenital injuries in children run over by motor vehicles may prevent the misdiagnosis of acute sexual abuse in children. Conversely, children presenting for evaluation of acute or past sexual abuse should be questioned as to whether they were ever run over by a motor vehicle.
Office Preparedness for Pediatric Emergencies: A Randomized, Controlled Trial of an Office-Based Training Program
Authors: Bordley W. Clayton , Travers Debbie , Scanlon Patricia , Frush Karen , Hohenhaus Sue
Published: August 2004

Objective. Many children enter the emergency medical system through primary care offices, yet these offices may not be adequately prepared to stabilize severely ill children. We conducted this study to evaluate the effectiveness of an office-based educational program designed to improve the preparation of primary care practices for pediatric emergencies.

Methods. A prospective, randomized, controlled trial was conducted of primary care practices (pediatric, family practice, and health departments) that were recruited from an existing database of North Carolina practices. Practices that agreed to participate were randomly assigned to either the intervention or the control group. Unannounced mock codes were conducted in the intervention practices by 2 emergency medicine clinicians (medical doctor and/or registered nurse). Practices were expected to respond to the mock code using their own staff, equipment, and local emergency medical system. After the exercise, the emergency medicine clinicians and the local emergency medical system team led a structured debriefing session providing constructive feedback to the staff on their performance, a review of the office’s equipment, and a resource manual designed for the project. The primary outcome measures were obtained by survey 3 to 6 months postintervention and included 1) purchase of new pediatric emergency equipment and medications, 2) receipt or updating of basic life support/pediatric advanced life support/advanced life support training by staff members, and 3) development of written emergency pediatric protocols. The control practices received no interventions during the trial and completed a similar outcome survey.

Results. Thirty-nine practices (20 intervention, 19 control) completed the trial. There were no significant differences in practice characteristics between the 2 groups. Intervention practices were more likely to develop written office protocols (60% vs 21%); more staff in the intervention practices received additional basic life support/pediatric advanced life support/advanced life support training 3 to 6 months after the intervention (118 vs 54). There were no significant differences in the purchase of new equipment or medications. Ninety percent of the intervention practices rated the intervention as useful for their practice, and 95% believed that the program should be continued.

Conclusions. The findings suggest that the intervention was well received and motivated practices to take concrete actions to prepare for pediatric emergencies.
Parental Evaluation of Informing Interviews for Cleft Lip and/or Palate
Authors: Byrnes Abigail L. , Berk Nancy W. , Cooper Margaret E. , Marazita Mary L.
Published: August 2004

Objective. This study was conducted to record subjective information concerning parental experiences and preferences with regard to informing interviews for cleft lip and/or palate. The analysis of these data was intended to help informants improve the way in which such conversations are conducted.

Methods. The study used a self-administered questionnaire. Study participants were the biological parents of children who had cleft lip and/or palate and were seen in the University of Pittsburgh Cleft Palate-Craniofacial Center.

Results. Results revealed that parents wanted informing health professionals to be in greater control of the informing conversation, to show more caring and confidence, to show more of their own feelings, to give parents more of an opportunity to talk and show feelings, to make a greater effort to comfort parents, to provide more information, to initiate more of a discussion about the association between clefts and mental retardation/learning disabilities, and to provide more referrals to other parents during the informing interview. A positive association between the degree to which parents reported knowing the health professionals and reported satisfaction was identified for 10 dimensions of health professional behavior.

Conclusions. Parents are dissatisfied with several aspects of informing interviews for cleft lip and/or palate. The results of this study suggest ways to improve informing interviews for oral-facial clefts and other congenital anomalies.