bluuebunny/crossref_metadata_2025 huggingface dataset:
Hydrolyzed Protein Accelerates Feeding Advancement inVery Low Birth Weight Infants
Authors: Mihatsch Walter A. , Franz Axel R. , Högel Josef , Pohlandt Frank
Published: August 2004

Background. Feeding intolerance is common in very low birth weight (VLBW; <1500 g) infants. Hydrolyzed protein preterm infant formula (HPF) has been shown to accelerate the gastrointestinal transit of formula. The aim of this study was to investigate whether HPF improves early feeding tolerance compared with standard preterm infant formula (SPF). We hypothesized that HPF would accelerate early enteral feeding advancement.

Methods. Primary outcome was the time from initiation of milk feeds until full feeds (150 mL/kg birth weight/d) were achieved in infants who received <10% human milk (HM) to exclude HM as a confounder. Because the availability of HM was not predictable at the time of enrollment, all eligible VLBW infants (n = 129) were randomly assigned in a randomized, controlled trial to receive HPF or SPF if HM was not available. Infants who received >10% HM (n = 42) were excluded. Milk bolus feeding every 2 to 3 hours was started at the discretion of the attending physician and advanced by 16 mL/kg/d. Preprandial gastric residuals were tolerated up to 5 mL/kg; otherwise, feedings were reduced or withheld. Data are shown as median (5th and 95th percentile).

Results. Forty-six and 41 (HPF vs SPF) infants received <10% HM. There was no significant difference with regard to birth weight, gestational age, and onset of milk feeds (day 3 [1–8] vs 4 [2–6]). The time from initiation of milk feeds to full feeds was significantly shorter with HPF feeding (10 [9–27] vs 12 [9–28] days).

Conclusion. HPF improved the feeding tolerance and enabled a more rapid establishment of full enteral feeding in VLBW infants compared with SPF.
Incidence and Short-Term Outcome of Children With Symptomatic Presentation of Organic Acid and Fatty Acid Oxidation Disorders in Germany
Authors: Klose Daniela A. , Kölker Stefan , Heinrich Beate , Prietsch Viola , Mayatepek Ertan , von Kries Rüdiger , Hoffmann Georg F.
Published: August 2004

Objective. To determine the incidence of symptomatic children with inherited organic acid disorders (OADs) and fatty acid oxidation disorders (FAODs) in Germany.

Methods. An active surveillance of symptomatic children with inherited OADs and FAODs was conducted during a time period of 24 months (1999–2000) in Germany. Monthly inquiries were sent to all Departments of Pediatrics by the German Pediatric Surveillance Unit (ESPED) and quarterly to all specialized metabolic laboratories. Newly diagnosed patients were added to the database, recording clinical and biochemical information via a standardized questionnaire.

Results. Prospective surveillance enrolling 844 575 children identified a total of 57 symptomatic children with newly diagnosed OADs or FAODs in states with conventional neonatal screening, resulting in an estimated cumulative incidence of 1:14 800. The most frequent diagnosis among these children was medium-chain acyl-CoA dehydrogenase deficiency (n = 20). The majority of symptomatic children revealed clinical symptoms during the first year of life (n = 36), frequently presenting with acute metabolic crises (n = 31). Eight children died during these crises. Notably, 47 of the symptomatic children suffered from diseases potentially detectable by expanded neonatal screening programs. This subgroup included 29 children presenting with metabolic crises and 7 of the 8 deaths.

Conclusions. Despite increased clinical awareness of OADs and FAODs, the mortality and morbidity for these children remains high, if they are diagnosed after manifestation of clinical disease. An introduction of nationwide neonatal screening programs would change the focus for organic acid analysis from patients presenting with acute metabolic crises to more chronic clinical presentations, especially the cerebral organic acid disorders.
Chiari I Malformation in the Very Young Child: The Spectrum of Presentations and Experience in 31 Children Under Age 6 Years
Authors: Greenlee Jeremy D. W. , Donovan Kathleen A. , Hasan David M. , Menezes Arnold H.
Published: August 2004

Introduction. The entity of hindbrain herniation without myelodysplasia in the very young child has been poorly described. A retrospective analysis of children diagnosed with Chiari I malformation (CM I) before their sixth birthday is presented.

Methods. Since 1985, 31 children with CM I (0.3–5.8) years of age have been diagnosed at University of Iowa Hospitals and Clinics. Their records were reviewed for presenting symptoms, signs, radiographic findings, treatment, complications, and outcome.

Results. The average age at diagnosis was 3.3 years. Sixteen patients were under age 3. Chief presenting complaints included impaired oropharyngeal function (35%), scoliosis (23%), headache or neck pain (23%), sensory disturbance (6%), weakness (3%), and other (10%). Sixty-nine percent of children under age 3 had abnormal oropharyngeal function. Three patients under age 3 (19%) had undergone fundoplication and/or gastrostomy before diagnosis of CM I.

Common physical findings included abnormal tendon reflexes (68%), scoliosis (26%), abnormal gag reflex (13%), and normal examination (13%). Vocal cord dysfunction (26%, all under age 3) and syringohydromyelia (52%) were also seen.

Twenty-five patients were treated surgically at our institution with posterior fossa decompression, duraplasty, and cerebellar tonsillar shrinkage. Three patients were lost to follow-up. Ninety-one percent of patients reported improved symptomatology at last follow-up (mean: 3.9 years). Three patients required reoperation for recurrence of symptoms. Syringomyelia improved in all patients. Scoliosis resolved in 2 of 8 patients, improved in 5, and stabilized in 1. There was no permanent morbidity from surgery.

Discussion. We show that children with Chiari I abnormality are very likely to present with oropharyngeal dysfunction if under age 3, and either scoliosis or headache or neck pain worsened by valsalva if age 3 to 5. These symptoms are very likely to improve after Chiari decompression, which can be done with low morbidity.

Conclusions. Very young children presenting with oropharyngeal dysfunction, pain worsened by valsalva, or scoliosis should prompt the clinician to consider CM I as a possible cause.
Trends in the Prevalence of Cerebral Palsy in a Population-Based Study
Authors: Winter Sarah , Autry Andrew , Boyle Coleen , Yeargin-Allsopp Marshalyn
Published: August 2004

Objective. To determine trends in the prevalence of congenital cerebral palsy (CP) over a 16-year period for 1-year survivors using a large, population-based surveillance program.

Methods. We determined birth weight-specific trends in the prevalence of CP in live birth and 1-year survivor cohorts of children in a 5-county metropolitan Atlanta area for the periods from 1975–1977, 1981–1985, and 1986–1991. We ascertained children with CP in metropolitan Atlanta by record review as part of an ongoing developmental disability surveillance program conducted by the Centers for Disease Control and Prevention and the Georgia Department of Human Resources. A total of 110, 262, and 443 cases of congenital CP were identified for the birth years 1975–1977, 1981–1985, and 1986–1991, respectively. Data were analyzed by birth weight, race, subtypes of CP, and whether the CP existed as an isolated disability or was accompanied by another disability.

Results. There was a modest increase in the overall prevalence of congenital CP from 1.7 to 2.0 per 1000 1-year survivors during the period from 1975–1991. This trend was primarily attributable to a slight increase in CP in infants of normal birth weight—CP rates in moderately low and very low birth weight infants did not show consistent trends. There was an increase in the proportion of children who had CP and no other disabilities that was most apparent in infants of normal birth weight from 17% in 1975–1977 to 39% in 1986–1991. For children weighing <1500 g, the proportion of children with spastic diplegic CP increased over time (7% of cases in 1975–1977, 36% in 1985–1988, and 32% in 1986–1991).

Conclusions. In the only ongoing population-based study of CP in the United States, there has been a modest increase in the prevalence of CP in 1-year survivors born from 1975–1991. This increase however was seen only in infant survivors of normal birth weight. No change was seen in the trends in CP prevalence in low birth weight and very low birth weight infant based on infant survivors.
Working to Improve Mental Health Services: The North Carolina Advocacy Effort
Authors: Foy Jane Meschan , Earls Marian F. , Horowitz David A.
Published: August 2004

Poor reimbursement of pediatricians for behavioral and developmental services and the disarray of children’s mental health services in the state led leaders of the North Carolina chapter of the American Academy of Pediatrics to organize an advocacy effort with the following objectives: 1) to articulate pediatricians’ perspective on the current crisis in delivering and coordinating children’s behavioral health services; 2) to represent the collective voice of both academic and community pediatricians in dialogue with mental health providers, Medicaid leaders, and the health and mental health segments of state government; 3) to build consensus about an achievable plan of action to address pediatricians’ reimbursement and systems issues; 4) to develop a full and appropriate role for pediatricians as providers and, potentially, coordinators of behavioral health care; and 5) to facilitate implementation of Medicaid changes, as a first step in carrying out this plan. This article describes the 24-month process that achieved these objectives.
Reduction of the Influenza Burden in Children
Authors:   Committee on Infectious Diseases
Published: August 2004

This Policy Statement was retired January 2009.

Epidemiologic studies indicate that children with certain chronic conditions, such as asthma, and otherwise healthy children younger than 24 months are hospitalized for influenza and its complications at high rates similar to those experienced by the elderly. Currently, annual influenza immunization is recommended for all children 6 months and older with high-risk conditions. To protect these children more fully against the complications of influenza, increased efforts are needed to identify and recall high-risk children for annual influenza immunization. In addition, immunization of children 6 through 23 months of age and their household contacts and out-of-home caregivers is now encouraged to the extent feasible. The ultimate goal is a universal recommendation for influenza immunization. Issues that need to be addressed before institution of routine immunization of healthy young children include education of physicians and parents about the morbidity caused by influenza, adequate vaccine supply, and appropriate reimbursement of practitioners for influenza immunization.
Effect of Sepsis Syndrome on Neonatal Oxygen Consumption and Energy Expenditure
Authors: Bauer Jacqueline , Hentschel Roland , Linderkamp Otwin
Published: August 2004

Objective. To evaluate oxygen consumption (Vo2), carbon dioxide production, and energy expenditure (EE) in full-term neonates with early-onset neonatal septicemia daily for 7 days beginning at the day of clinical diagnosis of sepsis.

Methods. A total of 17 spontaneously breathing full-term neonates, 10 with clinical signs of sepsis and 7 healthy neonates (control group), were enrolled in the study. Age at first study day was 3 ± 0.9 days in both groups. Sepsis syndrome was defined as a systemic response to a bacterial infection with clinical signs of infection, elevated values of interleukins 6 and 8 and C-reactive protein, and abnormal white blood cell count and positive blood cultures (9 group B streptococci, 1 Escherichia coli). Measurements of Vo2 and carbon dioxide production were performed daily for 7 days by means of indirect calorimetry.

Results. In the septic infants, Vo2 and EE were increased by about 20% at days 1 to 3 and by 15% at day 4 when compared with the controls. From days 1 to 3, EE averaged 57 ± 3 kcal/kg/d in the septic neonates and 47 ± 2 kcal/kg/d in the controls. At day 4, EE was 55 ± 2 and 47 ± 2 kcal/kg/d, respectively. Energy intake was about the same in both groups, whereas weight gain during the 7 study days was significantly lower in the sick patients than in the control group (19 ± 2 g/d vs 33 ± 9 g/d and 5.4 ± 0.5 g/kg/d vs 9.4 ± 2.6 g/kg/d, respectively). Increased EE was associated with increased heart rate (126 ± 4 vs 112 ± 4 min−1 at day 1) and respiratory rate (56 ± 6 vs 40 ± 4 min−1 at day 1). There were no differences in rectal temperature (37.3 ± 0.4 °C vs 37.4 ± 0.2 °C), skin temperature (36.5 ± 0.4 °C vs 36.6 ± 0.3 °C), and oxygen saturation (96 ± 3% vs 96 ± 3%) between the 2 groups.

Conclusions. Neonates with sepsis syndrome have elevated Vo2 and EE values that could explain impaired growth during the illness period and may make the infants vulnerable to insufficient calorie supply during the acute phase of septic disease.
Spontaneous Arousals in Supine Infants While Swaddled and Unswaddled During Rapid Eye Movement and Quiet Sleep
Authors: Gerard Claudia M. , Harris Kathleen A. , Thach Bradley T.
Published: August 2004

Objective. Supine sleep is recommended for infants to decrease the risk of sudden infant death syndrome, but many parents report that their infants seem uncomfortable supine. Many cultures swaddle infants for sleep in the supine position. Swaddled infants are said to “sleep better”; presumably they sleep longer or with fewer arousals. However, there have been no studies of the effect of swaddling on spontaneous arousals during sleep. Arousal is initiated in brainstem centers and manifests as a sequence of reflexes: from sighs to startles and then to thrashing movements. Such “brainstem arousals” may progress to full arousal, but most do not.

Methods. Twenty-six healthy infants, aged 80 ± 7 days, were studied during normal nap times. Swaddled (cotton spandex swaddle) and unswaddled trials were alternated for each infant. Sleep state (rapid eye movement [REM] or quiet sleep [QS]) was determined by behavioral criteria (breathing pattern, eye movements) and electroencephalogram/electrooculogram (10 infants). Respitrace, submental and biceps electromyogram, and video recording were used to detect startles and sighs (augmented breaths). Full arousals were classified by eye opening and/or crying. Frequencies of sighs, startles, and full arousals per hour were calculated. Progression of events was calculated as percentages in each sleep state, as was duration of sleep state.

Results. Swaddling decreased startles in QS and REM, full arousal in QS, and progression of startle to arousal in QS. It resulted in shorter arousal duration during REM sleep and more REM sleep.

Conclusions. Swaddling has a significant inhibitory effect on progression of arousals from brainstem to full arousals involving the cortex in QS. Swaddling decreases spontaneous arousals in QS and increases the duration of REM sleep, perhaps by helping infants return to sleep spontaneously, which may limit parental intervention. For these reasons, a safe form of swaddling that allows hip flexion/abduction and chest wall excursion may help parents keep their infants in the supine sleep position and thereby prevent the sudden infant death syndrome risks associated with the prone sleep position.
Factors That Influence Receipt of Recommended Preventive Pediatric Health and Dental Care
Authors: Yu Stella M. , Bellamy Hilary A. , Kogan Michael D. , Dunbar Jennifer L. , Schwalberg Renee H. , Schuster Mark A.
Published: August 2004

Objective. This study examined the factors that affect children’s receipt of recommended well-child and dental visits using nationally representative data.

Methods. We analyzed the Child Public Use File of the 1999 National Survey of America’s Families, including 35 938 children who were younger than 18 years. Bivariate and multivariate analyses were conducted to examine the relationship between dependent variables, including receipt of well-child visits as recommended by the American Academy of Pediatrics’ periodicity schedule and dental visits as recommended by the American Academy of Pediatric Dentistry and Bright Futures, and independent variables, including health status and sociodemographic and economic indicators.

Results. Overall, 23.4% of children did not receive the recommended well-child visits, whereas 46.8% did not receive the recommended number of dental visits. The factors that predict nonreceipt of care differed for well-child and dental care and with child’s age. Logistic regression reveals that children who were young (<10 years old), uninsured, non-Hispanic white, had a parent who was less than college educated, or in poor health were least likely to meet the recommendations for well-child care. Children who did not meet the dental recommendation were more likely to be black, uninsured, from families with low incomes, have a parent who was less than college educated, and have postponed dental care in the last year. These risk factors increased with children’s age.

Conclusions. A substantial proportion of US children do not receive preventive care according to professionally recommended standards, particularly dental care. Publicly insured children experience higher rates of recommended well-child visits; however, much improvement is needed among public programs in providing recommended dental care, especially among adolescents and children in poor general health.
Plasma Concentrations of N-Terminal Pro-Brain Natriuretic Peptide in Control Children From the Neonatal to Adolescent Period and in Children With Congestive Heart Failure
Authors: Mir Thomas S. , Marohn Sönke , Läer Stephanie , Eiselt Michele , Grollmus Oswin , Weil Jochen
Published: August 2004

Objective. To determine plasma levels of N-terminal pro-brain natriuretic peptide (N-BNP) in control children to establish a normal age-dependent range from the neonatal period to adulthood. In addition, plasma concentrations of N-BNP were measured in children with congestive heart failure (CHF) and correlated with ejection fraction and clinical symptoms of heart failure.

Methods. For establishing a normal age-dependent range of plasma N-BNP, venous blood samples were taken in 133 control patients from the neonatal period to adulthood (10 days–32 years) and in 31 children with CHF. Plasma N-BNP levels were determined by an enzyme immunoassay. In children (1 month–14 years) with CHF, plasma N-BNP levels were correlated to ejection fraction measured by echocardiography and clinical symptoms of heart failure using the Ross Score.

Results. N-BNP levels in control children, adolescents, and adults did not show a significant age-related difference. In control children, the normal range was established between 150 (10th percentile) and 430 fmol/mL (90th percentile). Mean plasma N-BNP in control children was 311 fmol/mL (range: 74–654 fmol/mL). In 31 children with CHF, the plasma N-BNP levels were significantly higher (mean: 846; range: 219-2718) than in control children. N-BNP levels showed a negative correlation with the ejection fraction (r = −0.53) and a positive correlation with the clinical heart failure score (r = 0.74).

Conclusions. Plasma N-BNP levels reflect the severity of symptoms of heart failure and the impairment of cardiac function in children with CHF. In the future, determination of plasma N-BNP levels may be used as a helpful adjunct to monitor the effect of various treatments for CHF in children.
Bottle Feeding in the Bed or Crib Before Sleep Time and Wheezing in Early Childhood
Authors: Celedón Juan C. , Litonjua Augusto A. , Ryan Louise , Weiss Scott T. , Gold Diane R.
Published: August 2004

Objective. Bottle feeding in the bed or crib before sleep time has been associated with an increased risk of wheezing in the first year of life. We examined whether bottle feeding in the bed or crib before sleep time in the first year of life is associated with wheezing in the first 5 years of life.

Methods. In a prospective cohort study of 448 children with parental history of atopy followed from birth, we examined the relation between the number of bimonthly parental reports of bottle feeding in the bed or crib before sleep time in the first year of life (range: 0–6 reports) and parental report of wheezing in the first 5 years of life. Additional outcome measures included recurrent wheezing (≥2 episodes of wheezing in the previous year) and asthma (physician-diagnosed asthma and ≥1 episode of wheezing in the previous year) at the age of 5 years.

Results. The risk of recurrent wheezing and asthma at 5 years of age increased significantly with each additional report of bottle feeding in the bed or crib before sleep time in the first year of life. The risk of wheezing between the ages of 1 and 5 years increased with each additional report of bottle feeding in the bed or crib before sleep time in the first year of life. As an example, a child whose parents reported bottle feeding in the bed or crib before sleep time on 3 occasions in the first year of life had 1.5 times higher risk of wheezing between the ages of 1 and 5 years than a child whose parents did not report bottle feeding in the bed or crib before sleep time in the first year of life (95% confidence interval for relative risk: 1.12–2.12).

Conclusions. Among children with parental history of atopy, bottle feeding in the bed or crib before sleep time in the first year of life is a risk factor for recurrent wheezing and asthma at 5 years of age and a risk factor for wheezing between the ages of 1 and 5 years.
Risks of Ancient Practices in Modern Times
Authors: van Gestel Josephus Petrus Johannes , L’Hoir Monique Pauline , ten Berge Maartje , Jansen Nicolaas Johannes Georgius , Plötz Frans Berend
Published: August 2004

Swaddling, ie, wrapping the child to restrict movement, is an ancient practice. In the Netherlands, it is becoming increasingly popular as an intervention for excessive crying in infants. However, one must be well aware of the potential risks. We present the case reports of a twin boy and girl who had been swaddled and kept in a heated room for several days. On admission to the hospital, both infants suffered from severe hypovolemic shock, hyperthermia, and secondary respiratory insufficiency. The girl developed multiple organ dysfunction syndrome and died, whereas the boy had an uneventful recovery. When swaddling is being considered as an intervention for excessive crying in infants, parents have to be well-informed about the possible side effects and about additional measures that they may have to take to make it a safe intervention.
A Rare and Often Unrecognized Cause of Hematochezia and Tenesmus in Childhood: Solitary Rectal Ulcer Syndrome
Authors: Ertem Deniz , Acar Yesim , Karaa Esin Kotiloglu , Pehlivanoglu Ender
Published: August 2004

Solitary rectal ulcer syndrome (SRUS) is an unusual disorder of childhood, which usually presents with rectal bleeding, mucous discharge, prolonged straining, tenesmus, and localized pain in the perineal area. After the first description by Cruveilhier, Madigan and Morson further detailed the clinical and pathologic features of SRUS in 1969. The pathogenesis of the syndrome is not well-understood. The postulated mechanism responsible for rectal prolapse in most cases seems to be excessive straining efforts during which high intra-abdominal pressure forces the anterior rectal mucosa firmly into the contracting puborectalis muscle. The anterior rectal mucosa is frequently forced into the anal canal and as a consequence becomes strangulated, causing congestion, edema, and ulceration.

Histologically, the presence of fibromuscular obliteration of the lamina propria with disorientation of muscle fibers is characteristic, which could be secondary to chronic mechanical and ischemic trauma and inflammation by hard stools, and intussusception of the rectal mucosa. Although the syndrome is well-recognized in adults, the pediatric experience with this condition is limited and often remains unrecognized or misdiagnosed. A misdiagnosis has been reported in one fourth of adult cases, and the correct diagnosis usually delayed approximately 5 to 7 years. There are few pediatric case reports in English literature. Here, we describe 2 children with SRUS, aged 11 and 14 years, whose SRUS was diagnosed 2 and 6 years, respectively, after the onset of the first signs and symptoms.
The Role of Emergent Neuroimaging in Children With New-Onset Afebrile Seizures
Authors: Sharma Sujit , Riviello James J. , Harper Marvin B. , Baskin Marc N.
Published: August 2004

Objectives. The objectives of this study were 1) to determine the frequency of clinically significant abnormal neuroimaging in children coming to the emergency department (ED) with new-onset afebrile seizures (ASZ), and 2) to identify children at high or low risk for clinically significant abnormal neuroimaging.

Design/Methods. Five hundred consecutive cases of new-onset ASZ seen in the ED of a tertiary care children’s hospital were reviewed. Neuroimaging reports were categorized as normal, clinically insignificant abnormal, or clinically significant abnormal. Recursive partition analysis was used to identify clinical variables that separated children into high- and low-risk groups for clinically significant abnormal neuroimaging.

Results. Ninety-five percent of patients (475/500) with new-onset ASZ had neuroimaging. Clinically significant abnormal neuroimaging was noted in 8% (95% confidence interval [CI]: 6, 11; 38/475) of patients. Recursive partition analysis identified 2 criteria associated with high risk for clinically significant abnormal neuroimaging: 1) the presence of a predisposing condition, and 2) focal seizure if <33 months old. Of the high-risk patients, 26% (95% CI: 17, 35; 32/121) had clinically significant abnormal neuroimaging compared with 2% (95% CI: 0.6, 3.7; 6/354) in the low-risk group.

Conclusions. In this large, retrospective review of children with new-onset ASZ, clinically significant abnormal neuroimaging occurred with relatively low frequency. Emergent neuroimaging should be considered, however, for children who meet high-risk criteria. Well-appearing children who meet low-risk criteria can be safely discharged from the ED (if follow-up can be assured) without emergent neuroimaging, because their risk for clinically significant abnormal neuroimaging is appreciably lower.
Effects of Sufentanil on Electroencephalogram in Very and Extremely Preterm Neonates
Authors: Nguyen The Tich Sylvie , Vecchierini Marie-Françoise , Debillon Thierry , Péréon Yann
Published: August 2004

Objective. The electroencephalogram (EEG) is used in neonatal intensive care units to assess brain maturation and neurologic prognosis in preterm newborns. Most of these newborns are sedated by opioids because of long-term assisted ventilation. The aim of this study was to describe the effects of sufentanil on the EEG in preterm newborns and to evaluate the consequences of such a treatment on neurologic assessment.

Methods. Fifteen preterm newborns <28 days of extrauterine life were studied. All of them were sedated by sufentanil (initial bolus injection of 0.5 μg/kg, followed by continuous infusion of 0.2 μg/kg/h). Three EEGs were performed: the first before and during the bolus injection, the second in the 48 hours after the start of the continuous infusion, and the third at least 24 hours after the treatment was stopped. Qualitative and quantitative methods were used to analyze each EEG.

Results. EEG patterns were not affected by sufentanil treatment. Bolus injection and continuous infusion induced a significant increase of EEG discontinuity in preterm newborns affecting mean burst percentage and mean and maximum interburst duration.

Conclusions. The present data demonstrate that EEG is affected by bolus injection and continuous infusion of sufentanil. Sedation must therefore be considered to avoid misinterpretation of EEGs.
Major Surgery Within the First 3 Months of Life and Subsequent Biobehavioral Pain Responses to Immunization at Later Age: A Case Comparison Study
Authors: Peters Jeroen W. B. , Koot Hans M. , de Boer Josien B. , Passchier Jan , Bueno-de-Mesquita Jolien M. , de Jong Frank H. , Duivenvoorden Hugo J. , Tibboel Dick
Published: August 2004

Objectives. Pain exposure during early infancy affects the pain perception beyond infancy into childhood. The objective of this study was to examine whether major surgery within the first 3 months of life in combination with preemptive analgesia alters pain responses to immunization at 14 or 45 months and to assess whether these alterations are greater in toddlers with a larger number of negative hospital experiences.

Methods. Two groups of 50 toddlers each were compared: index group and control group. All index toddlers had participated within the first 3 months of their life in a randomized, clinical trial that evaluated the efficacy of preemptive morphine administration for postoperative analgesia. The controls were matched by type of immunization and community health care pediatrician. Pain reactions were recorded at routine immunization at either 14 (measles-mumps-rubella immunization) or 45 months (diphtheria-tetanus-trivalent polio immunization) of age. Outcome measures were facial reaction, coded by the Maximum Discriminative Facial Movement Coding System; heart rate (HR); and cortisol saliva concentration. Negative hospital experiences included number of operations requiring postoperative morphine administration, cumulative Therapeutic Intervention Scoring System scores, and length of stay in the intensive care unit or total hospitalization days.

Results. No differences were found between the index and control groups in the facial display of pain, anger, or sadness or in physiologic parameters such as HR and cortisol concentrations. Intragroup analyses of the index group showed that after measles-mumps-rubella vaccination, the number of negative hospital experiences correlated positively with the facial responsiveness and negatively with HR responses. No effect was seen after diphtheria-tetanus-trivalent polio immunization.

Conclusions. Major surgery in combination with preemptive analgesia within the first months of life does not alter pain response to subsequent pain exposure in childhood. Greater exposure to early hospitalization influences the pain responses after prolonged time. These responses, however, diminish after a prolonged period of nonexposure.
Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in Girls
Authors: Mattsson Sven , Gladh Gunilla
Published: August 2004

Objective. The objective of this study was to estimate the frequency of urethrovaginal reflux as the cause of daytime incontinence in school-age girls, and to study the characteristic symptoms and the effect of simple instructions intended to amend the problem.

Material and Methods. Girls with urethrovaginal reflux were identified in a group of 169 girls, aged 7 to 15 years, referred to a specialist clinic because of daytime incontinence. They were evaluated by a noninvasive screening protocol, including a careful history and neurourologic examination, bladder diaries, urine analysis, uroflows, and residual urine determined by ultrasound. Girls with urethrovaginal reflux were instructed by a urotherapist on how to achieve better toilet habits.

Results. Urethrovaginal reflux was found in 21 (12.4%) of 169 girls as the sole (19) or contributing (2) cause of their daytime urinary incontinence. They all had a typical history of small leakage 5 to 10 minutes after voidings during the day, confirmed by a specific bladder diary. All were neurologically healthy, and all but 2 had a normal bladder function. The latter 2 girls had residual urine and asymptomatic bacteriuria. At follow-up after median 2 years, all girls were free from postmicturition leakage, but the 2 with residual urine remained daytime incontinent with cystometrically proven phasic detrusor overactivity.

Conclusions. Urethrovaginal reflux is a common cause of urinary incontinence in girls. The diagnosis is easily obtained by an adequate history, completed with a specific bladder diary. The problem is easily resolved by proper voiding instructions.
Cost-Effectiveness Analysis of Predischarge Monitoring for Apnea of Prematurity
Authors: Zupancic John A. F. , Richardson Douglas K. , O’Brien Bernie J. , Eichenwald Eric C. , Weinstein Milton C.
Published: August 2004

Objective. It is standard practice to defer discharge of premature infants until they have achieved a set number of days without experiencing apnea. The duration of this period, however, is highly variable across institutions, and there is scant literature on its effectiveness or value-for-money. Our objective was to establish the economic impact of varying durations of predischarge observation for apnea of prematurity.

Methods. Using computer simulation, we compared the alternatives of hospital monitoring for 1 to 10 days, after apparent cessation of apnea, with no monitoring and with the next longest period of monitoring. The daily probability of apnea requiring stimulation after a given number of apnea-free days was obtained from chart review of 216 infants, beginning on the day they attained both full feeds and temperature stability in an open crib. Baseline rates of survival or impairment, utilities for calculation of quality-adjusted life years (QALYs), outcomes for respiratory arrest at home, and long-run costs for neurodevelopmental impairment were derived from the literature. Hospital expenditures were obtained from itemized billing records for infants on each of the final 10 days of hospitalization and converted to costs using Medicare cost-to-charge ratios. Costs are reported in 2000 US dollars.

Results. For infants born at 24 to 26 weeks’ gestation, each additional day of monitoring cost from $41000 per QALY saved for the first day to >$130000 per additional QALY gained for the tenth day. Cost-effectiveness was poorer for infants who were born at gestational ages >30 weeks. Results were sensitive to the proportion of charted apneas requiring stimulation that would actually progress, without intervention, to respiratory arrest.

Conclusions. In this model, the cost-effectiveness of predischarge monitoring for apnea of prematurity declined significantly as the duration of monitoring was increased. Consideration should be given to alternative uses for resources in formulating neonatal discharge guidelines.
To Dye or Not to Dye: A Randomized, Clinical Trial of a Triple Dye/Alcohol Regime Versus Dry Cord Care
Authors: Janssen Patricia A. , Selwood Barbara L. , Dobson Simon R. , Peacock Donlim , Thiessen Paul N.
Published: August 2004

Objective. The use of antibacterial agents to clean and dry the stump of the newborn’s umbilical cord after birth has recently been abandoned by many neonatal units in favor of dry cord care. The objective of this study was to compare cord bacterial colonization and morbidity among newborns whose cords were treated with triple dye and alcohol versus dry cord care.

Methodology. We randomly allocated 766 newborns to either 2 applications of triple dye to the umbilical cord stump on the day of birth with alcohol swabbing twice daily until the cord fell off (n = 384) or dry care (n = 382). Dry care consisted of spot cleaning soiled skin in the periumbilical area with soap and water, wiping it with a dry cotton swab or cloth, and allowing the area to air dry. Umbilical stumps on all subjects were swabbed and cultured. Community health nurses visiting at 2 or 3 days after hospital discharge observed the stump for signs of infection. Follow-up phone calls were made to mothers within 3 weeks of discharge.

Results. One infant in the dry care group was diagnosed with omphalitis. The umbilical stump was colonized with α-hemolytic streptococcus and coagulase-negative staphylococcus. Infants in the dry care group were significantly more likely to be colonized with Escherichia coli (34.2% vs 22.1%), coagulase-negative staphylococci (69.5% vs 50.5%), Staphylococcus aureus (31.3% vs 2.8%), and group B streptococci (11.7% vs 6.0%). Community health nurses were significantly more likely to observe exudate (7.4% vs 0.3%) and foul odor (2.9% vs 0.7%) among infants allocated to the dry care group during the home visit.

Conclusions. Omphalitis remains a clinical issue. Cessation of bacteriocidal care of the umbilical stump must be accompanied by vigilant attention to the signs and symptoms of omphalitis.
Rumination Syndrome in Children and Adolescents: Diagnosis, Treatment, and Prognosis
Authors: Chial Heather J. , Camilleri Michael , Williams Donald E. , Litzinger Kristi , Perrault Jean
Published: August 2004

Objectives. To characterize the clinical features, results of diagnostic testing, and treatment outcomes for children and adolescents with rumination syndrome.

Methods. Review of the medical records for all 147 patients ages 5 to 20 diagnosed with rumination syndrome at our institution between 1975 and 2000. Data are presented as mean ± the standard error of the mean.

Results. Sixty-eight percent were female. Age at diagnosis was 15.0 ± 0.3 years. Symptom duration before diagnosis was 2.2 ± 0.3 years, 73% missed school/work, and 46% had been hospitalized because of symptoms. Before diagnosis, 16 (11%) underwent surgery for evaluation or management of symptoms. Twenty-four (16%) had psychiatric disorders; 3.4% had anorexia or bulimia nervosa. All patients described postprandial regurgitation after almost every meal (2.7 ± 0.1 meals per day). Weight loss was described by 42.2% (median: 7 kg). Additional symptoms included: abdominal pain, 38%; constipation, 21%; nausea, 17%; and diarrhea, 8%. Structural studies were normal. Gastric emptying of solids at 4 hours was delayed in 26 of 56 patients. Esophageal pH testing in 24 patients showed reflux/regurgitation in 54%. Gastroduodenal manometry in 65 patients showed characteristic rumination-waves in 40%. Outcome data (at median follow-up 10 months) were available for 54 patients. Symptoms resolved in 16 (30%) and improved in 30 (56%).

Conclusions. Recognition of the clinical features of rumination syndrome in children and adolescents is essential; the diagnosis is often delayed and associated with morbidity. Extensive diagnostic testing is unnecessary. Early behavioral therapy is advocated, and patient outcomes are generally favorable.
Acute Backpack Injuries in Children
Authors: Wiersema Brent M. , Wall Eric J. , Foad Susan L.
Published: August 2004

Objective. To identify the most common mechanisms and sites of injury associated with book backpacks in school-aged children, who present to the emergency department. This should help with the development of backpack injury prevention strategies.

Design. A descriptive analysis of The National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission (CPSC) National Injury Information Clearinghouse data on backpacks.

Setting. One hundred emergency department departments throughout the United States that participate in NEISS data collection served as the setting.

Participants. All children between 6 and 18 years old who were recorded in the NEISS database with a backpack-related injury were studied.

Methods. Patients were identified by review of the NEISS data from 1999–2000. We separated patient data by age, sex, location of injury, and mechanism of injury.

Results. There were 247 children with backpack injuries. The mean age was 11.8 years, and 50% were male. The most common injury location was the head/face (22%) followed by the hand (14%), wrist/elbow (13%), shoulder (12%), and foot/ankle (12%). The back ranked sixth (11%). Of these back injuries, 59% were associated with carrying a backpack. The most common mechanism for injury was tripping over the backpack (28%), followed by wearing (13%), and getting hit by the backpack (13%).

Conclusions. Although the CPSC data on backpack injuries is frequently quoted in articles relating backpacks with back injury, 89% of backpack injuries in our study do not involve the back. Our study does not support the hypothesis that back injury is the major problem with book backpacks in the emergency department setting.
Outcomes Research in Pediatric Settings: Recent Trends and Future Directions
Authors: Forrest Christopher B. , Shipman Scott A. , Dougherty Denise , Miller Marlene R.
Published: August 2004

Objective. Pediatric outcomes research examines the effects of health care delivered in everyday medical settings on the health of children and adolescents. It is an area of inquiry in its nascent stages of development.

Methods. We conducted a systematic literature review that covered articles published during the 6-year interval 1994–1999 and in 39 peer-reviewed journals chosen for their likelihood of containing child health services research. This article summarizes the article abstraction, reviews the literature, describes recent trends, and makes recommendations for future work.

Results. In the sample of journals that we examined, the number of pediatric outcomes research articles doubled between 1994 and 1999. Hospitals and primary care practices were the most common service sectors, accounting for more than half of the articles. Common clinical categories included neonatal conditions, asthma, psychosocial problems, and injuries. Approximately 1 in 5 studies included multistate or national samples; 1 in 10 used a randomized controlled trial study design. Remarkably few studies examined the health effects of preventive, diagnostic, long-term management, or curative services delivered to children and adolescents.

Conclusions. Outcomes research in pediatric settings is a rapidly growing area of inquiry that is acquiring breadth but has achieved little depth in any single content area. Much work needs to be done to inform decision making regarding the optimal ways to finance, organize, and deliver child health care services. To improve the evidence base of pediatric health care, more effectiveness research is needed to evaluate the overall and relative effects of services delivered to children and adolescents in everyday settings.
Does Stimulant Therapy of Attention-Deficit/Hyperactivity Disorder Beget Later Substance Abuse? A Meta-analytic Review of the Literature
Authors: Wilens Timothy E. , Faraone Stephen V. , Biederman Joseph , Gunawardene Samantha
Published: August 2004

Objective.Concerns exist that stimulant therapy of youths with attention-deficit/hyperactivity disorder (ADHD) may result in an increased risk for subsequent substance use disorders (SUD). We investigated all long-term studies in which pharmacologically treated and untreated youths with ADHD were examined for later SUD outcomes.

Methods.A search of all available prospective and retrospective studies of children, adolescents, and adults with ADHD that had information relating childhood exposure to stimulant therapy and later SUD outcome in adolescence or adulthood was conducted through PubMed supplemented with data from scientific presentations. Meta-analysis was used to evaluate the relationship between stimulant therapy and subsequent SUD in youths with ADHD in general while addressing specifically differential effects on alcohol use disorders or drug use disorders and the potential effects of covariates.

Results.Six studies—2 with follow-up in adolescence and 4 in young adulthood—were included and comprised 674 medicated subjects and 360 unmedicated subjects who were followed at least 4 years. The pooled estimate of the odds ratio indicated a 1.9-fold reduction in risk for SUD in youths who were treated with stimulants compared with youths who did not receive pharmacotherapy for ADHD (z = 2.1; 95% confidence interval for odds ratio [OR]: 1.1–3.6). We found similar reductions in risk for later drug and alcohol use disorders (z = 1.1). Studies that reported follow-up into adolescence showed a greater protective effect on the development of SUD (OR: 5.8) than studies that followed subjects into adulthood (OR: 1.4). Additional analyses showed that the results could not be accounted for by any single study or by publication bias.

Conclusion.Our results suggest that stimulant therapy in childhood is associated with a reduction in the risk for subsequent drug and alcohol use disorders.
Child Abuse by Intentional Iron Poisoning Presenting as Shock and Persistent Acidosis
Authors: Black Judy , Zenel Joseph A.
Published: August 2004

A case of intentional iron poisoning presented to our hospital. The patient’s persistent acidosis and the team’s observation of maternal indifference indicated the diagnosis. This case should alert physicians to a potential source for intentional poisoning that is present in most homes with young infants.
Cervical Spine Involvement in Larsen’s Syndrome: A Case Illustration
Authors: Banks Jason T. , Wellons John C. , Shane Tubbs R. , Blount Jeffrey P. , Jerry Oakes W. , Grabb Paul A.
Published: August 2004

We present the progressive clinical course of a child with myelopathy attributable to cervical spine abnormalities associated with Larsen’s syndrome. After anterior and posterior cervical fusion, his preoperative symptoms of weakness, gait dysfunction, and hyperreflexia have improved at 9-month follow-up. The progressive course and importance of early referral and intervention should be of interest to the general pediatric community.
Identifying and Treating Eating Disorders
Authors:   Committee on Adolescence
Published: August 2004

Pediatricians are called on to become involved in the identification and management of eating disorders in several settings and at several critical points in the illness. In the primary care pediatrician’s practice, early detection, initial evaluation, and ongoing management can play a significant role in preventing the illness from progressing to a more severe or chronic state. In the subspecialty setting, management of medical complications, provision of nutritional rehabilitation, and coordination with the psychosocial and psychiatric aspects of care are often handled by pediatricians, especially those who have experience or expertise in the care of adolescents with eating disorders. In hospital and day program settings, pediatricians are involved in program development, determining appropriate admission and discharge criteria, and provision and coordination of care. Lastly, primary care pediatricians need to be involved at local, state, and national levels in preventive efforts and in providing advocacy for patients and families. The roles of pediatricians in the management of eating disorders in the pediatric practice, subspecialty, hospital, day program, and community settings are reviewed in this statement.