bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Viral Lower Respiratory Tract Infection on Lung Function in Infants With Cystic Fibrosis
Authors: Hiatt Peter W. , Grace Susan C. , Kozinetz Claudia A. , Raboudi Soufia Helioui , Treece Denise G. , Taber Larry H. , Piedra Pedro A.
Published: August 2004

Objective.

To determine the effect of respiratory viral infections on pulmonary function in infants with cystic fibrosis (CF) after the respiratory virus season (October through March).

Methods.

Recruitment was for one respiratory virus season during a 3-year span, 1988 to 1991, with reenrollment allowed; 22 infants <2 years of age with CF (30 patient-seasons) and 27 age-matched controls (28 patient-seasons) participated. Primary outcome variables were preseason and postseason pulmonary function tests and serology for viral antibodies. Twice-weekly telephone calls screened for respiratory symptoms. The presence of respiratory symptoms triggered a home visit and an evaluation for upper or lower (LRTI) respiratory tract infection. A nasopharyngeal sample for viral culture was performed with each visit.

Results.

Controls and CF infants each had a mean of 5.3 acute respiratory illnesses; CF infants were four times more likely to develop an LRTI compared with controls (odds ratio, 4.6; 95% confidence interval, 1.3 and 16.5). Three of 7 (43%) CF infants with respiratory syncytial virus infection (documented by culture) required hospitalization. Controls had no association between respiratory illness and postseason pulmonary function. For CF infants, reduced postseason maximal flow at functional residual capacity (V′maxFRC) was associated with two interactions, ie, respiratory syncytial virus infection and LRTI, and male sex and LRTI; increased gas trapping (FRC) was associated with an interaction between respiratory syncytial virus and LRTI and day care . Postseason pulmonary function tests were obtained a mean of 3.2 months after final LRTI.

Conclusions.

Infants with CF incurring respiratory virus infection are at significant risk for LRTI, for hospitalization, and for deterioration in lung function that persists months after the acute illness.
The Efficacy of Routine Outpatient Management Without Antibiotics of Fever in Selected Infants
Authors: Baker M. Douglas , Bell Louis M. , Avner Jeffrey R.
Published: August 2004

Background.

A previous study produced a protocol for outpatient management of febrile infants (FIs) judged to be at low risk for serious bacterial illness (SBI). This Philadelphia protocol demonstrated that 40% of FIs seen in the emergency department could be safely managed without antibiotics at home; and it was established by the emergency department staff as the standard of care at our institution.

Objective.

To determine 1) the actual practices of management of FIs 18 months after establishment of the Philadelphia protocol as the standard of care, and 2) the continued efficacy of noninvasive outpatient management of fever in FIs who, using the Philadelphia protocol, were identified as low risk for SBI.

Design.

Thirty-six-month consecutive cohort study.

Setting.

Urban pediatric emergency department.

Participants.

Four hundred twenty-two infants, 29 to 60 days of age, with rectal temperatures ≥38.0°C.

Interventions.

After a complete history taking, physical examination, and workup for SBI, infants were managed at the discretion of the attending physician in the emergency department. Subsequently, those management practices were reviewed and compliance with the Philadelphia protocol was evaluated. In addition, the overall efficacy and safety of that standard during 8 years of use was assessed.

Results.

Of the 422 FIs enrolled, 101 (24%) were prospectively identified as low risk for SBI, and safe for management without antibiotics. Twenty-eight (6%) FIs were managed out of accordance with the Philadelphia protocol. Seven were admitted out of accordance, 10 (2 with UTI) were discharged out of accordance, and 11 inpatients (1 with bacterial gastroenteritis) initially received no antibiotics out of accordance with the protocol. Physician failure to consider the results of the complete blood count or urinalysis accounted for errors involving FIs with SBI. None of the 43 FIs with SBI were identified by the Philadelphia protocol to be at low risk for SBI.

Conclusions.

The Philadelphia protocol for outpatient management without antibiotics of FIs at low risk for SBI remains practical, reliable, and safe. Because breaches do occur, physicians must carefully scrutinize protocol compliance, especially with regard to the complete blood count and urinalysis.fever, febrile infant.
Clinical Utility of Direct Mutation Testing for Congenital Nephrogenic Diabetes Insipidus in Families
Authors: Wildin Robert S. , Cogdell David E.
Published: August 2004

Objective.

To ascertain the clinical scenarios in which genetic testing for congenital nephrogenic diabetes insipidus (NDI) by direct detection of mutations might prove valuable, and to assess the use of automated sequencing for testing.

Methods.

We reviewed NDI cases referred to our research laboratory for enrollment in our study of mutations in the AVPR2 gene that is disrupted in the X-linked form of the disease. We selected 5 cases that illustrate the value of genetic testing in different clinical situations. Clinical information was obtained from the patient's personal physicians and the patients' families. Direct automated fluorescent DNA sequencing of AVPR2 gene amplification product was used to identify disease-associated mutations in patients. The presence or absence of mutations in family members was then established by using automated sequencing, restriction enzyme analysis, or both.

Results.

In 2 of the 5 selected cases, the diagnosis of a genetic form of NDI was confirmed by mutation analysis in a sporadic case of an affected boy. In 2 cases, a suspected diagnosis of X-linked NDI was confirmed in an affected girl. In 4 of the cases, 1 or more unaffected female relatives were determined to carry or not to carry the disease-associated gene. In 2 cases, testing of the newborn child of a known or suspected carrier confirmed the clinical suspicion of affected status and justified proactive therapy. In 4 of the 5 cases, the mode of inheritance was not clear from the family history and was established as X-linked by the testing. Assay for restriction sites changed by disease-associated mutations agreed with the automated sequencing results.

Conclusions.

We conclude that direct mutation analysis in patients suspected of NDI and in selected family members is indicated. The results of testing can confirm a clinical diagnosis of disease, which may otherwise be difficult to make in girls. It can further establish the mode of inheritance, unambiguously distinguish carriers from noncarriers, and justify special observation or treatment of newborns at risk, thereby averting dehydration and the attendant complications. We also conclude that, with proper controls, automated sequencing is the preferred method of testing, because it is sufficiently robust, sensitive, and adaptable for this short gene with a large variety of causative mutations.
Foreign Aid, International Organizations, and the World's Children
Authors: Wegman Myron E.
Published: August 2004

Recent improvement in child mortality has taken place in all regions of the world. In developing countries, major remaining causes are neonatal problems, diarrheal diseases, vaccine-preventable diseases, and respiratory diseases. Foreign aid has come in many forms, among them individual persons, nongovernmental organizations, national governments, and international agencies. Governmental involvement in health activities abroad can advance foreign policy interests as well as help protect a country's citizens against existing and potential disease foci. Intergovernmental health agencies, regional and worldwide, have been in existence only in this century; the World Health Organization is barely 50 years old and suffers from US delinquency in paying its dues. Child labor has health aspects in industrialized as well as in developing countries. The United Nations Convention on the Rights of the Child has significant implications for health. Despite broad support, including that of the American Academy of Pediatrics, the United States has not ratified the convention, the only nation in the world beside Somalia not to do so.
Tyrosinemia Type 1 Should Be Suspected in Infants With Severe Coagulopathy Even in the Absence of Other Signs of Liver Failure
Authors: Croffie Joseph M. , Gupta Sandeep K. , Chong Sonny K. F. , Fitzgerald Joseph F.
Published: August 2004

Tyrosinemia type l is an inherited metabolic disorder attributable to deficiency of fumarylacetoacetate hydrolase, a terminal enzyme in the degradation pathway of tyrosine. Affected individuals may present with any of a number of signs and symptoms, including failure to thrive, fever, vomiting, diarrhea, hepatomegaly, ascites, jaundice, renal Fanconi syndrome, or conditions such as rickets and hepatocellular carcinoma.1If untreated, the patient may die of acute liver failure before the second year of life, or from chronic liver failure or hepatocellular carcinoma before the end of the second decade of life.2

Although overt liver failure with coagulopathy may be part of the presentation of tyrosinemia, a significant coagulopathy in the absence of overt signs of liver disease has not been emphasized as a clue to the diagnosis of this condition. We report two tyrosinemic infants who presented with severe coagulopathies and no other signs of liver failure to stress this diagnostic point.
Prenatal and Postnatal Management of Hyperprostaglandin E Syndrome After Genetic Diagnosis From Amniocytes
Authors: Konrad Martin , Leonhardt Andreas , Hensen Peter , Seyberth Hannsjörg W. , Köckerling Arnold
Published: August 2004

Objective.

To describe prenatal genetic diagnosis in hyperprostaglandin E syndrome (HPS) and the effect of indomethacin therapy on the course of the disease before birth and in the neonatal period.

Methods.

Mutational analysis of the ROMK channel gene (KCNJ1) from amniocytes by single-strand conformational analysis and direct sequencing. Review of the clinical and laboratory findings during pregnancy and the neonatal period in two siblings affected with HPS.

Results.

Compound heterozygosity of the fetus inKCNJ1 (D74Y/P110L) confirmed the clinical diagnosis of HPS at 26 weeks of gestation. Indomethacin therapy from 26 to 31 weeks prevented further progression of polyhydramnios without major side effects. In contrast to the elder brother, who had been diagnosed at the age of 2 months, the neonatal course was uncomplicated. Hypovolemic renal failure after excessive renal loss of salt and water could be prevented and severe nephrocalcinosis did not occur.

Conclusions.

Genetic diagnosis of HPS and subsequent prenatal indomethacin therapy seems to have a beneficial effect on the natural course of HPS, especially progression of polyhydramnios; therefore, extreme prematurity could be prevented. Also, postnatally the early diagnosis allows the effective water and electrolyte substitution before severe volume depletion.hyperprostaglandin E syndrome, Bartter syndrome, ROMK, indomethacin.
Circumcision Policy Statement
Authors:   Task Force on Circumcision
Published: August 2004

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.
Risk Factors for Invasive Pneumococcal Disease in Children: A Population-based Case–Control Study in North America
Authors: Levine Orin S. , Farley Monica , Harrison Lee H. , Lefkowitz Lewis , McGeer Allison , Schwartz Benjamin ,   for the Active Bacterial Core Surveillance Team
Published: August 2004

Objective.

To identify risk factors for invasive pneumococcal disease, including penicillin-resistant infections, among children 2 to 59 months of age.

Design.

Case–control study.

Participants.

Patients with invasive pneumococcal infections identified by population-based surveillance (n = 187) and controls identified through random-digit telephone dialing (n = 280).

Outcome measures.

Invasive pneumococcal disease was defined as isolation of Streptococcus pneumoniae from a normally sterile site. Patients 2 to 59 months of age who were residents of one of four active surveillance areas were included.S pneumoniae isolates were tested by broth microdilution. Isolates with a minimum inhibitory concentration to penicillin ≥2 μg/mL were considered resistant.

Results.

Invasive pneumococcal disease was strongly associated with underlying disease and with day care attendance in the previous 3 months. Among 2- to 11-month-olds, current breastfeeding was associated with a decreased likelihood of invasive pneumococcal disease (odds ratio, 0.27; 95% confidence interval: 0.08, 0.90). Penicillin-resistant infections were independently associated with day care attendance, at least one course of antibiotics, and at least one ear infection in the previous 3 months.

Conclusions.

This study shows the association of underlying illnesses, day care attendance, and lack of breastfeeding with risk of invasive pneumococcal disease in children. The association of recent antibiotic use and infection with penicillin-resistantS pneumoniae highlights the need to avoid unnecessary antibiotic use in children.
Pediatricians' Practices and Attitudes Regarding Breastfeeding Promotion
Authors: Schanler Richard J. , O'Connor Karen G. , Lawrence Ruth A.
Published: August 2004

Objective.

Public awareness of the benefits of breastfeeding is expected to increase during and after the national, federally funded Best Start Breastfeeding Promotion Campaign. It is anticipated that this will result in more breastfeeding-based interactions between families and pediatricians. The American Academy of Pediatrics conducted a survey of its members to identify their educational needs regarding breastfeeding to assist in the design of appropriate information programs.

Method.

An eight-page, self-administered questionnaire was sent to 1602 active Fellows of the American Academy of Pediatrics.

Results.

The response rate was 71%. Breastfeeding, as the exclusive feeding practice for the first month after birth, was recommended by only 65% of responding pediatricians; only 37% recommended breastfeeding for 1 year. A majority of pediatricians agreed with or had a neutral opinion about the statement that breastfeeding and formula-feeding are equally acceptable methods for feeding infants. Reasons given for not recommending breastfeeding included medical conditions with known treatments that did not preclude breastfeeding. The majority of pediatricians (72%) were unfamiliar with the contents of the Baby-Friendly Hospital Initiative. The majority of pediatricians had not attended a presentation on breastfeeding management in the previous 3 years; most said they wanted more education on breastfeeding management.

Conclusion.

Pediatricians have significant educational needs in the area of breastfeeding management. breastfeeding, education, pediatricians, survey.
Preventing Neonatal Group B Streptococcal Disease: Cost-Effectiveness in a Health Maintenance Organization and the Impact of Delayed Hospital Discharge for Newborns Who Received Intrapartum Antibiotics
Authors: Mohle-Boetani Janet C. , Lieu Tracy A. , Ray G. Thomas , Escobar Gabriel ,   for the Neonatal GBS Prevention Working Group
Published: August 2004

Objectives.

To estimate the cost and health benefits of implementing a risk factor-based prevention strategy for early-onset neonatal group B streptococcal (GBS) disease, using baseline assumptions and costs from a health maintenance organization. With the risk factor-based strategy, intrapartum antibiotics (IPAs) would be provided to women with fever, prolonged rupture of membranes, or preterm labor. A second objective was to determine the impact of an increased length of stay for well term infants with mothers who received IPAs.

Methods.

We used decision analysis to compare the costs and benefits of the prevention strategy with usual obstetric practice for a cohort of 100 000 women and their newborn infants. We derived baseline values from a previous study based on chart review and automated cost data from a health maintenance organization in Northern California. In sensitivity analyses, we varied baseline assumptions, including additional costs for observing well term infants who received IPAs.

Results.

If adherence to guidelines were 100%, 17% of mothers would receive IPAs at a cost of $490 000; $1.6 million would be saved by preventing 66 GBS cases (64% reduction). The net savings would be $1.1 million and 61 life-years. The net cost is sensitive to the cost of caring for well infants who received IPAs. If each term infant of a mother who received IPAs had 1 more day of observation than other term infants, there would be a net cost of $8.1 million; the cost per GBS case prevented would be $120 000 and the cost per life-year saved would be $130 000.

Conclusions.

Implementation in a health maintenance organization of a risk factor-based strategy to prevent neonatal GBS disease can prevent substantial disease and be cost saving. However, if the length of hospital stay were extended among well term infants whose mothers received IPAs, the strategy would be relatively costly compared with other medical interventions.
Factors That Predict Preexisting Colonization With Antibiotic-Resistant Gram-Negative Bacilli in Patients Admitted to a Pediatric Intensive Care Unit
Authors: Toltzis Philip , Hoyen Claudia , Spinner-Block Sara , Salvator Ann E. , Rice Louis B.
Published: August 2004

Objective.

To predict which patients hospitalized in a pediatric intensive care unit (ICU) are colonized with antibiotic-resistant Gram-negative rods on admission.

Methods.

Consecutive children admitted to a pediatric ICU over a 6-month period were entered into the study. A questionnaire soliciting information regarding the child's medical history and home environment was completed by the parent or guardian. Nasopharyngeal and rectal cultures were obtained on each of the first 3 days of ICU admission, and organisms resistant to ceftazidime or tobramycin were identified. Only clonally distinct organisms, as confirmed by pulsed field gel electrophoresis, were analyzed. The association between identification of colonization with an antibiotic-resistant Gram-negative rod within 3 days of ICU admission and factors included in the questionnaire was tested by χ2 or ttest.

Results.

In 64 (8.8%) of 727 admissions, an antibiotic-resistant Gram-negative bacillus was isolated within the first 3 ICU days. More than half were identified on the day of admission. Colonization was associated with two factors related to the patient's medical history, namely, number of past ICU admissions (1.98 vs .87) and administration of intravenous antibiotics within the past 12 months (67.9% vs 28.2%). No association was found between colonization and exposure to oral antibiotics. In addition, factors related to the child's environment were also associated with presumed importation of an antibiotic-resistant Gram-negative rod into the ICU. Specifically, residence in a chronic care facility was strongly associated with colonization (28.3% vs 2.6%); exposure to a household contact who had been hospitalized in the past 12 months also predicted colonization (41.7% vs 18.5%).

Conclusions.

These data suggest that a profile can be established characterizing children colonized with resistant Gram-negative bacilli before admission to a pediatric ICU. Infection control measures may help to contain these potentially dangerous bacteria once they have been introduced into the unit.antibiotic resistance, nosocomial infections, Gram-negative aerobic bacteria, disease transmission, pediatric intensive care unit, pulsed field gel electrophoresis.
Cerebral Magnetic Resonance Imaging and Ultrasonography Findings After Neonatal Hypoglycemia
Authors: Kinnala Anne , Rikalainen Hellevi , Lapinleimu Helena , Parkkola Riitta , Kormano Martti , Kero Pentti
Published: August 2004

Objective.

The aim of this study was to investigate sequential neuroradiologic changes in the brains of infants after transient neonatal hypoglycemia. We used magnetic resonance imaging (MRI) and ultrasonography (US) head scans.

Methods.

Eighteen symptomatic full-term infants whose serum glucose concentrations were ≤45 mg/dL (2.5 mmol/L) without any other diseases were included in the hypoglycemic group. MRI and US head scans were performed at full-term age and at the age of 2 months. The imaging results were compared with the findings of MRI and US scans in 19 healthy normoglycemic term newborn infants at the respective ages. The neurologic outcome was followed in the both groups.

Results.

MRI or US showed evidence of abnormality in 39% the hypoglycemic infants. MRI detected more abnormalities in the brains than US. Four infants showed patchy hyperintensity lesions either in the occipital periventicular white matter or the thalamus on T1-weighted images. These lesions had a good tendency to recover and only 1 of these infants appeared to be neurologically affected. Of the 19 controls, 10% (2 of 19) had caudothalamic cysts, which were detected both with MRI and US. The relative risk of the hypoglycemic child compared with nonhypoglycemic child, to have any abnormality detected in the brain, was 3.7, with a 90% confidence interval from 1.11 to 12.28.

Conclusions.

Postnatal full-term MRI and US scans showed abnormalities four times more often after transient neonatal hypoglycemia than in the healthy control group. However, most often lesions were absent 2 months later. The clinical relevance of these abnormal findings remains to be clarified with detailed neurologic examinations and follow-up.
Circulating Pro- and Counterinflammatory Cytokine Levels and Severity in Necrotizing Enterocolitis
Authors: Edelson Mary B. , Bagwell Charles E. , Rozycki Henry J.
Published: August 2004

Objectives.

To evaluate the relationship between the severity of necrotizing enterocolitis (NEC) and circulating concentrations of proinflammatory cytokines interleukin (IL)-1β and IL-8 and counterinflammatory cytokines IL-1 receptor antagonist (IL-1ra) and IL-10. These cytokines have been associated with bowel injury or inflammation and may be released more slowly or later than previously examined cytokines. Also, to determine if any one of these cytokines will predict the eventual severity of NEC when measured at symptom onset.

Method.

Serial blood samples at onset, 8, 24, 48, and 72 hours were obtained from newborn infants with predefined signs and symptoms of NEC. Normal levels were defined from weight-, gestation-, and age-matched controls. Concentrations of the four cytokines were determined by enzyme-linked immunosorbent assay and compared throughout the time period by stage of NEC, using sepsis as a co-factor. Mean concentrations of each cytokine at onset were compared with the controls. Threshold values were obtained with the best combination of high sensitivity and high specificity for defining stage 1 NEC or for diagnosing stage 3 NEC at onset.

Results.

There were 12 cases of stage 1, 18 cases of stage 2, and 6 cases of stage 3 NEC included in the study, as well as 20 control infants. Concentrations of IL-8 and IL-10 were significantly higher in infants with stage 3 NEC from onset through 24 hours compared with infants with less severe NEC. At onset, concentrations of all four cytokines were significantly higher in stage 3 NEC. To identify, at onset, the infants with a final diagnosis of stage 3 NEC, an IL-1ra concentration of >130 000 pg/mL had a sensitivity of 100% and a specificity of 92%. At 8 hours, an IL-10 concentration of >250 pg/mL had a sensitivity of 100% and a specificity of 90% in identifying stage 3 NEC in infants with symptoms suggestive of NEC at onset.

Conclusions.

The severity of NEC and its systemic signs and symptoms are not due to a deficiency of counterregulatory cytokines. In fact, mean concentrations of IL-1ra in NEC are higher than what has been reported in other populations. The cytokines IL-8, IL-1ra, and IL-10 are released later or more slowly after a stimulus and may be more useful in identifying, within hours of symptom onset, which infant will develop significant NEC.
Primary Prevention of Childhood Lead Exposure: A Randomized Trial of Dust Control
Authors: Lanphear Bruce P. , Howard Cynthia , Eberly Shirley , Auinger Peggy , Kolassa John , Weitzman Michael , Schaffer Stanley J. , Alexander Keith
Published: August 2004

Background.

Dust control is recommended as one of the primary strategies to prevent or control children's exposure to residential lead hazards, but the effect of dust control on children's blood lead levels is poorly understood.

Objective.

To determine the effectiveness of dust control in preventing children's exposure to lead, as measured by blood lead levels, during their peak age of susceptibility.

Design.

A randomized, controlled trial.

Setting.

Rochester, NY.

Participants.

A total of 275 urban children were randomized at 6 months of age, of whom 246 (90%) were available for the 24-month-old follow-up visit.

Interventions.

Children and their families were randomly assigned to an intervention group (n = 140), which received cleaning equipment and up to eight visits by a dust control advisor, or a control group (n = 135).

Outcome Measures.

Geometric mean blood lead levels and prevalence of elevated blood lead levels (ie, >10 μg/dL, 15 μg/dL, and 20 μg/dL).

Results.

At baseline, children's geometric mean blood lead levels were 2.9 μg/dL (95% confidence interval [CI] = 2.7, 3.1); there were no significant differences in characteristics or lead exposure by group assignment, with the exception of water lead levels. For children in the intervention group, the mean number of visits by a dust control advisor during the 18-month study period was 6.2; 51 (36%) had 4 to 7 visits, and 69 (49%) had 8 visits. At 24 months of age, the geometric mean blood lead was 7.3 μg/dL (95% CI = 6.6, 8.2) for the intervention group and 7.8 μg/dL (95% CI = 6.9, 8.7) for the control group. The percentage of children with a 24-month blood lead ≥10 μg/dL, ≥15 μg/dL, and ≥20 μg/dL was 31% versus 36%, 12% versus 14%, and 5% versus 7% in the intervention and control groups, respectively.

Conclusions.

We conclude that dust control, as performed by families and in the absence of lead hazard controls to reduce ongoing contamination from lead-based paint, is not effective in the primary prevention of childhood lead exposure. blood lead, lead-contaminated house dust, randomized trial, children, environmental exposure, lead poisoning, primary prevention, prevention.
A Case-Control Study of Necrotizing Fasciitis During Primary Varicella
Authors: Zerr Danielle M. , Alexander E. Russell , Duchin Jeffrey S. , Koutsky Laura A. , Rubens Craig E.
Published: August 2004

Objective.

An increase in the incidence of necrotizing fasciitis (NF) occurring in previously healthy children with primary varicella was noted in the Washington State area between December 1993 and June 1995. Our objective was to investigate ibuprofen use and other risk factors for NF in the setting of primary varicella.

Methods.

Case-control study. Demographic information, clinical parameters, and potential risk factors for NF were compared for cases and controls. Cases of NF were analyzed to identify potential determinants of NF complicated by renal insufficiency and/or streptococcal toxic shock syndrome. Multivariate logistic regression was used to evaluate the association between ibuprofen use and NF. A case was defined as a child with NF hospitalized within 3 weeks of primary varicella (n = 19). Controls were children hospitalized with a soft tissue infection other than NF within 3 weeks of primary varicella (n = 29). Odds ratios (ORs) of ibuprofen, as well as other potential risk factors were evaluated. In addition, demographic and clinical data as well as other potential risk factors were compared between cases and controls.

Results.

After controlling for gender, age, and group A streptococcus isolation, cases were more likely than controls to have used ibuprofen before hospitalization (OR, 11.5; 95% confidence interval, 1.4 to 96.9). In most children, ibuprofen was initiated after the onset of symptoms of secondary infection. Children with NF complicated by renal insufficiency and/or streptococcal toxic shock syndrome were more likely than children with uncomplicated NF to have used ibuprofen (OR, 16.0; 95% confidence interval, 1.0 to 825.0). Children with complicated NF also had a higher mean maximum temperature (40.9°C vs 39.3°C), and a longer mean duration of secondary symptoms (1.7 days vs 0.6 days) before admission than children with uncomplicated NF.

Conclusion.

Ibuprofen use was associated with NF in the setting of primary varicella. Additional studies are needed to establish whether ibuprofen use has a causal role in the development of NF and its complications during varicella.
A Randomized, Controlled Trial of Prophylactic Granulocyte-Macrophage Colony-Stimulating Factor in Human Newborns Less Than 32 Weeks Gestation
Authors: Carr Robert , Modi Neena , Doré Caroline J. , El-Rifai Rim , Lindo Dwight
Published: August 2004

Objective.

Preterm neonates undergoing intensive care have high morbidity from sepsis. These infants also frequently develop neutropenia, and when this is associated with sepsis, mortality is high. This study investigates the potential for granulocyte-macrophage colony-stimulating factor (GM-CSF) to effect a clinically relevant increase in neutrophil number when used prophylactically in high-risk preterm neonates, and assesses its safety in this population.

Design.

In an open, randomized, controlled study, 75 neonates (25 small for gestational age) <32 weeks gestation were randomized to receive GM-CSF (10 μg/kg/d) by subcutaneous injection for 5 days from <72 hours after birth, or to a control group. The primary outcome measure was the neutrophil count during 14 days from study entry. The infants were monitored for potential toxicity. Clinical outcomes, sepsis, and mortality, were recorded, but this initial study was not designed to address clinical benefit.

Results.

Prophylactic GM-CSF therapy completely abolished neutropenia in treated infants, when both well and septic, throughout the period of study. Neutropenia (≤1.7 × 109/L) developed in 16 of 39 control infants. Five control infants experienced an acute decrease in neutrophil count coincident with the onset of sepsis. There was no evidence of hematologic, respiratory, or gastrointestinal toxicity in treated infants. Treated infants had a trend to fewer symptomatic, blood culture positive septic episodes than controls during 2 weeks from study entry (11/36 vs 18/39).

Conclusion.

Five-day prophylactic GM-CSF completely abolishes postnatal neutropenia and sepsis-induced neutropenia in preterm neonates at high risk of sepsis, and so removes an important risk factor for sepsis and sepsis-related mortality.GM-CSF, preterm neonates, neutropenia, sepsis.
Pitfall in the Use of Genotype Analysis as the Sole Diagnostic Criterion for Cystic Fibrosis
Authors: Chmiel James F. , Drumm Mitchell L. , Konstan Michael W. , Ferkol Thomas W. , Kercsmar Carolyn M.
Published: August 2004

In this report, we present an asymptomatic infant, seen for a second opinion, who was given the diagnosis of cystic fibrosis (CF) as a neonate based on the presence of two mutant alleles, ΔF508 and R117H. The diagnosis of CF adversely affected the family's emotional, employment, and financial statuses. Our evaluation included sweat chloride, nasal transepithelial potential difference, and bronchoscopy with bronchoalveolar lavage measurements, all which were consistent with findings expected from an individual without CF. Genotype analysis for the sequence polymorphism in intron 8 of the cystic fibrosis transmembrane conductance regulator (CFTR) gene revealed the 7 thymidines and 9 thymidines alleles. We conclude that this patient probably expresses enough epithelial cell surface CFTR function such that she has a normal phenotype. Based on our evaluation, she does not meet the current diagnostic criteria for CF. Although genotype analysis can be an useful adjunct, it should not be the sole diagnostic criterion for CF.
Advance Directives in a Pediatric Emergency Department
Authors: Walsh-Kelly Christine M. , Lang Kellie R. , Chevako Jane , Blank Ellen L. , Korom Nancy , Kirk Kristi , Gray Amanda
Published: August 2004

Parents of children with terminal illnesses are not always present when a life-threatening event occurs. For many of these children, an advance directive specifying alternate code orders has been written by the parent or legal guardian (hereafter the use of parent is to be interpreted as parent/legal guardian) and the patient's attending physician. Implementing a pediatric advanced directive presents significant problems for emergency personnel if the parent is not present to identify the existence of the directive and interpret the contents in the context of the current medical crisis.
Natural History of Wolf-Hirschhorn Syndrome: Experience With 15 Cases
Authors: Battaglia Agatino , Carey John C. , Cederholm Peeches , Viskochil David H. , Brothman Arthur R. , Galasso Cinzia
Published: August 2004

Wolf-Hirschhorn syndrome (WHS) is a well-known chromosomal disorder attributable to partial deletion of the short arm of chromosome 4 (4p-). Although about 120 cases have been reported so far, there is still very little data on its natural history. Information given to parents at the time of diagnosis tends to be skewed to the extreme negative. To help delineate more thoroughly the natural history of WHS, and to obtain better information to answer parents' questions in a clinical setting, we evaluated 15 patients (12 females, 3 males) in three centers with the 4p- syndrome. Four of the cases had a follow-up spanning 16 years. Thirteen cases were detected by standard cytogenetics (regular G-banding 10, high-resolution banding 3), while the remaining 2 required fluorescence in situ hybridization. A total of 5/15 (33.3%) had heart lesions; 7/15 (46.6%) had oral facial clefts; 13/15 (86.6%) had a seizure disorder, that tended to disappear with age; and 100% had severe/profound developmental retardation. One Italian patient had sensorineural deafness and 1 Utah patient had a right split hand defect. Of note, 2 Utah patients were able to walk with support (at 4 and 12 years of age, respectively), whereas 3 Italian patients and 1 Utah patient were able to walk unassisted (at 4, 5, 5 years 9 months, and 7 years of age, respectively). Two of the 3 Italian patients also achieved sphincter control (by day). The 8 patients receiving serial electroencephalogram studies showed fairly distinctive abnormalities, usually outlasting seizures. A slow, but constant progress in development was observed in all cases, during the follow-up period. In conclusion, the combined cases of the three centers represent considerable experience, providing new information on several aspects of this important deletion syndrome.Wolf-Hirschhorn syndrome; del(4p) syndrome; natural history.
Guidelines for Developing Admission and Discharge Policies for the Pediatric Intensive Care Unit
Authors:   American Academy of Pediatrics, Committee on Hospital Care and Section on Critical Care,   Society of Critical Care Medicine, Pediatric Section Admission Criteria Task Force
Published: August 2004

These guidelines were developed to provide a reference for preparing policies on admission to and discharge from pediatric intensive care units. They represent a consensus opinion of physicians, nurses, and allied health care professionals. By using this document as a framework for developing multidisciplinary admission and discharge policies, use of pediatric intensive care units can be optimized and patients can receive the level of care appropriate for their condition.
Primary Care Physicians' Use of Screening Echocardiography
Authors: Bensky Andrew S. , Covitz Wesley , DuRant Robert H.
Published: August 2004

Objective.

To survey primary care physicians to understand their reasons for using echocardiography to screen for congenital heart disease in children and to assess their understanding of the costs associated with cardiology services.

Design.

A questionnaire.

Participants.

Eight hundred sixty-seven pediatricians and family physicians in our region were surveyed, 494 (57%) responded and 466 were used for the analysis.

Results.

The majority of pediatricians and family physicians in our area do not know the relative costs associated with cardiology consultation and echocardiography. They also believe it likely that a cardiologist will routinely obtain an echocardiogram as part of their evaluation of a child with a murmur, although this is not the case. The availability and convenience of specialist appointments was found to significantly influence the decision to order an echocardiogram. Family physicians were significantly more likely than pediatricians to order an echocardiogram for a variety of clinical indications.

Conclusions.

Improving primary care physicians' knowl- edge of the costs associated with cardiology services and current cardiology practice patterns, in addition to improving the availability of cardiology referrals, may reduce the number of expensive and unnecessary echocardiograms. echocardiography, heart murmur, congenital heart disease, cost-effectiveness.
Pediatricians' Response to the Demand for School Health Programming
Authors: Barnett Stephen , Duncan Paula , O'Connor Karen G.
Published: August 2004

Objective.

Because of the broad and increasing interest in school health, the American Academy of Pediatrics (AAP) surveyed its members to determine their awareness of school health education/programs, their level of participation, their desire to participate, and their resource needs to participate more effectively.

Methods.

Self-administered questionnaires were mailed to a randomized representative sample of AAP members (N= 1602). Overall response rate was 64.5%. Some responses were stratified for analysis by gender; age (>45 years or ≤45 years); practice area (urban, suburban, or rural); practice setting (solo, group, or hospital); and type of practice (general versus specialty). χ2 Tests were used to compare responses.

Results.

Greater than half of the pediatricians who responded to the questionnaire were aware of school health education curriculum on risky adolescent behaviors in their community, counseling services (58%), school nursing services (63%), and screening services (71%); however, more than half were not aware of curriculum on injury/violence prevention, fitness, or whether a school health advisory council was available. Most pediatricians supported comprehensive school health education (pregnancy prevention, 82%; violence prevention, 77%; mental health, 56%). Also, respondents supported services (counseling, 76%; nutrition, 65%; screening/referral, 58%; school-based primary care, 58%). Although 22% of AAP pediatricians are currently working with local school programs, >70% wanted to become involved or more involved and needed information on how they may be able to participate. Only 25% believed they were adequately prepared. Two thirds believed school-based clinics were one of the best ways to reach underserved children and adolescents and should include preteens.

Conclusion.

AAP pediatricians want to become more involved with comprehensive school health programs. The ways in which they want to participate vary substantially. Most pediatricians thought they needed additional education. The AAP has developed recommendations for graduate medical education and continuing medical education for pediatricians to participate in integrated school health services.
A Phase I Study of Abacavir (1592U89) Alone and in Combination With Other Antiretroviral Agents in Infants and Children With Human Immunodeficiency Virus Infection
Authors: Kline Mark W. , Blanchard Suzette , Fletcher Courtney V. , Shenep Jerry L. , McKinney Ross E. , Brundage Richard C. , Culnane Mary , Van Dyke Russell B. , Dankner Wayne M. , Kovacs Andrea , McDowell James A. , Hetherington Seth ,   for the AIDS Clinical Trials Group 330 Team
Published: August 2004

Objectives.

To evaluate the pharmacokinetic features, safety, and tolerance of abacavir, given alone and in combination with other nucleoside antiretroviral agents, in symptomatic human immunodeficiency virus (HIV)-infected children.

Methods.

HIV-infected children discontinued prior antiretroviral therapy and were given abacavir orally, 4 mg/kg every 12 hours for 6 weeks, followed by 8 mg/kg every 12 hours for 6 weeks (n = 39); or 8 mg/kg every 12 hours for 12 weeks (n = 8). Children then were randomized to receive a second nucleoside antiretroviral agent (zidovudine, stavudine, didanosine, or lamivudine), plus abacavir. Pharmacokinetics, safety, tolerance, CD4+ lymphocyte counts, and plasma HIV RNA concentrations were evaluated.

Results.

At a dose of 8 mg/kg every 12 hours, area under the plasma concentration-versus-time curves and plasma half-life values were comparable with those reported for adults receiving abacavir at a dose of 300 mg twice daily. One case each of hypersensitivity reaction and peripheral neuropathy occurred during abacavir monotherapy. Three children experienced neutropenia while receiving abacavir in combination with another antiretroviral agent. Mean CD4+lymphocyte count and plasma HIV RNA concentration did not change when prior antiretroviral therapy was changed to abacavir monotherapy.

Conclusions.

Abacavir therapy is associated with good short-term tolerance and safety in HIV-infected children. Phase III studies are in progress to assess the antiviral activity of abacavir in children and adults.
Lack of Vancomycin-associated Nephrotoxicity in Newborn Infants: A Case–Control Study
Authors: Bhatt-Mehta Varsha , Schumacher Robert E. , Faix Roger G. , Leady Michelle , Brenner Timothy
Published: August 2004

Objective.

The purpose of this study was to compare the incidence of nephrotoxicity, defined as doubling of baseline serum creatinine concentration, in newborn infants with peak vancomycin serum concentrations ≤40 μg/mL at steady state to infants with peak vancomycin serum concentrations >40 μg/mL. A secondary objective was to correlate concomitant disease states and potentially nephrotoxic drug therapy with rises in serum creatinine in vancomycin recipients.

Methods.

Newborn infants with culture-provenStaphylococcus aureus or coagulase-negative staphylococcal septicemia who received vancomycin therapy for >3 days between 1985 and 1995 were identified from an existing database and a review of medical record. All 69 patients included in the study had serial serum creatinine determinations, including a baseline value within 48 hours of starting treatment with vancomycin, and serum vancomycin concentrations determined after at least three doses, with peak and trough concentrations determined 1 hour after a 60-minute infusion and 15 to 30 minutes before a dose, respectively. Infants with congenital renal or cardiac anomalies were excluded. Demographic characteristics, vancomycin dosing regimen, serum vancomycin concentrations and sample times, concomitant drug therapy, and disease states were recorded. Patients were divided into group A (peak vancomycin concentration ≤40 μg/mL) and group B (peak vancomycin concentration >40 μg/mL). The change in serum creatinine concentration between the start and end of vancomycin therapy was determined. Nephrotoxicity was identified if serum creatinine doubled at any time from the start to the end of vancomycin therapy. Alternative definitions of nephrotoxicity (any rise in serum creatinine to >0.6 mg/dL or new abnormalities of urine sediment) were used in additional analyses.

Results.

A total of 69 evaluable patients (gestational age, 28.9 ± 3.0 weeks; birth weight, 1219 ± 516 g) were identified, 61 in group A and 8 in group B. Six patients in group A underwent doubling of serum creatinine concentration during vancomycin therapy, whereas none in group B did so. Serum creatinine doubled to >0.6 mg/dL in only 3 infants (all in group A). Any increase in serum creatinine to >0.6 mg/dL was seen in 10 infants, 9 of whom were in group A. No confounding variable, including previous or concomitant underlying disease states associated with renal dysfunction or treatment with other potentially nephrotoxic agents, were associated with a significant rise in serum creatinine.

Conclusion.

Vancomycin-associated nephrotoxicity is rare in neonates, even with serum peak concentrations >40 μg/mL.
Diagnostic Testing Unwarranted for Children With Blood Lead 10 to 14 μg/dL
Authors: Sargent James D. , Dalton Madeline , Klein Robert Z.
Published: August 2004

Background.

Recent statements from the American Academy of Pediatrics and Centers for Disease Control and Prevention recommend diagnostic venous blood lead testing within 90 days of a marginally elevated screening test (10–14 μg/dL).

Objective.

To evaluate the ability of a marginally elevated capillary (CScr) or venous (VScr) blood lead screening test to predict venous diagnostic (VPb) blood lead (taken within 90 days of the screening test) that would prompt environmental evaluation (≥20 μg/dL).

Design.

Population-based follow-up study comparing CScr and VScr with VPb drawn within 90 days of the screening sample. This study population was drawn from all children aged 0 to 4 years who were screened in Worcester County, Massachusetts, and Providence County, Rhode Island, with CScr and VScr during calendar year 1994.

Outcome Measures.

To evaluate predictive validity, CScr and VScr were correlated with VPb. CScr, VScr, and VPb results were then separated into the following categories: <10, 10 to 14, 15 to 19, and ≥20 μg/dL. CScr and VScr categories were cross-tabulated against VPb categories, and logistic regression analysis was used to evaluate categorical elevations of CScr and VScr as predictors of VPb ≥20 μg/dL.

Results.

Of 31 904 children screened with CScr, 5450 (17.1%) were elevated and 1278 were followed up with VPb within 90 days. Of 14 623 children screened with VScr, 2979 (20.4%) were elevated and 614 were followed up with VPb within 90 days. CScr was only weakly correlated with VPb (r = 0.39), whereas VScr was more strongly correlated with VPb (r = 0.73). Compared with CScr <10 μg/dL, CScr in the 10 to 14 μg/dL range did not identify a higher percentage of children with VPb elevation in any category, and falsely misclassified as lead poisoned some 77% of children. Compared with VScr <10 μg/dL, VScr in the 10 to 14 μg/dL range identified higher percentages of children with VPb in the 10 to 19 μg/dL range but not with VPb ≥20 μg/dL, and falsely misclassified as lead poisoned 42% of children. Compared with screening tests <10 μg/dL, the odds of identifying a child with VPb ≥20 were no different from 1 for CScr of 10 to 14 μg/dL (adjusted odds ratio 1.4 [95% confidence interval 0.3, 6.6]), CScr of 15 to 19 μg/dL (3.2 [0.7, 15.7]), or VScr of 10 to 14 μg/dL (0.9 [0.3, 3.0]). CScr and VScr in the 15 to 19 μg/dL range were associated with significantly higher odds of having VPb ≥20 μg/dL when compared with screening tests <10 μg/dL.

Conclusions.

These data indicate that special diagnostic testing within 90 days for children with CScr and VScr in the 10 to 14 μg/dL range does not result in greater identification of VPb ≥20. Raising the set point for diagnostic testing to 15 μg/dL in this sample would eliminate the unnecessary follow-up of 5162 children, of whom 3360 were falsely misclassified as having undue lead exposure.