bluuebunny/crossref_metadata_2025 huggingface dataset:
Hair and Skin Disorders as Signs of Mitochondrial Disease
Authors: Bodemer Christine , Rötig Agnès , Rustin Pierre , Cormier Valerie , Niaudet Patrick , Saudubray Jean-Marie , Rabier Denis , Munnich Arnold , de Prost Yves
Published: August 2004

Objective.

To compare and explore the skin manifestations of mitochondrial disorders in 14 children with puzzling and unexpected cutaneous presentations.

Study Design.

One hundred forty children with mitochondrial disorders who had been under observation in our hospital for the last 10 years, were carefully examined by the same physicians. Skin and hair characteristics were investigated by the same dermatologist. All the children developed an early unexplained association of symptoms. Metabolic screening for abnormal oxidative-reduction in plasma and mitochondrial enzyme investigations confirmed the diagnosis of oxidative phosphorylation disorders.

Results.

Fourteen children with mitochondrial disorders (10% of the original cohort) developed specific hair and skin abnormalities. Their cutaneous manifestations were similar, and could be classified into four categories: hair abnormalities, rashes and pigmentation disorders, hypertrichosis, and acrocyanosis. In 3 cases, skin disorders constituted the puzzling and unexpected manifestations of mitochondrial disease. Respiratory chain deficiencies in the cultured skin fibroblasts of 3 patients and heteroplasmic mitochondrial DNA rearrangement in the skin fibroblasts of 1 patient indicated that mitochondrial disorders may be expressed in the skin.

Conclusion.

Hair abnormalities and pigmented skin eruptions might belong to the broad spectrum of presenting symptoms of mitochondrial disease. The association of these dermatologic lesions with unrelated disorders should lead physicians to consider a diagnosis of mitochondriopathy as early as possible.
Regulation of Arginine Vasopressin in Enuretic Children Under Fluid Restriction
Authors: Eggert Paul , Müller-Schlüter Karen , Müller Dominik
Published: August 2004

Background.

Treatment of primary nocturnal enuresis using 1-deamino-8-d-arginine-vasopressin is based on the hypothesis that antidiuretic hormone (arginine vasopressin [AVP]) secretion is insufficient during the night. Persisting doubts about the theoretical background of this treatment and first results pointing to a different AVP regulation in children with nocturnal enuresis were the motives for the present study.

Objective.

To determine if children with primary nocturnal enuresis have different AVP levels during fluid restriction when compared with normal controls.

Methods.

Twenty-three children with nocturnal enuresis (median age, 11 years) were compared with a corresponding control group of 18 healthy children. Plasma osmolality, urine osmolality, and plasma AVP concentrations were determined before and after a defined fluid restriction.

Results.

Regarding plasma and urine osmolality, no differences were found between the two groups. AVP levels after fluid restriction, however, showed significant differences. To maintain osmolality, the plasma AVP concentrations of the controls rose to a median value of 5.7 pg/mL (range: 0.9–29.0 pg/mL) in comparison to a median of 14.0 pg/mL (range: 3.5–64.0 pg/mL, P = .015) for the enuretic children.

Conclusion.

The results are consistent with the established fact that AVP secretion is a function of plasma osmolality. They contradict the hypothesis that enuretic children have a AVP deficiency that has to be supplemented. Rather, the results point to a defect at the AVP receptor level or of the signal transduction pathway.
Mitochondrial Dysfunction in Skeletal Muscle of Children With Cardiomyopathy
Authors: Marin-Garcia Jose , Ananthakrishnan Radha , Goldenthal Michael J. , Filiano James J. , Perez-Atayde Antonio
Published: August 2004

Objectives.

This study sought to examine skeletal muscle of children with cardiomyopathy (CM) for changes in mitochondrial enzyme activities and in mitochondrial DNA (mtDNA).

Background.

Heart mitochondrial enzymatic activity defects have been often found in dilated and hypertrophic CM. The defects primarily involve the activities of the electron transport system and oxidative phosphorylation pathway including respiratory complexes I, III, IV, and V.

Methods.

Skeletal muscle biopsies of 8 children with CM were examined for specific mitochondrial enzyme activities, mtDNA copy number and the presence of pathogenic mutations and deletions in mtDNA.

Results.

A marked deficiency in specific mitochondrial enzyme activities was found in 6 of 8 patients in skeletal muscle as well as in 2 of 3 hearts of those in whom cardiac tissue was available. Specific activity defects were found in complex I (2 cases), complex III (5 cases), complex IV (3 cases), and complex V (4 cases). Complex II and citrate synthase activities were unaffected. None of the previously reported pathogenic mutations associated with CM were detected, nor was there any evidence of mtDNA depletion. The incidence of defective respiratory complex activities in skeletal muscle was similar to the incidence of defective complex activities previously reported in cardiac tissue.

Conclusions.

Mitochondrial analysis of skeletal muscle is warranted in the overall clinical evaluation of children with CM, and particularly before consideration for cardiac transplantation.
How Pediatricians Can Respond to the Psychosocial Implications of Disasters
Authors:   Committee on Psychosocial Aspects of Child and Family Health
Published: August 2004

This Policy Statement was retired October 2005.

Natural and human-caused disasters, violence with weapons, and terrorist acts have touched directly the lives of thousands of families with children in the United States.1 Media coverage of disasters has brought images of floods, hurricanes, and airplane crashes into the living rooms of most American families, with limited censorship for vulnerable young children. Therefore, children may be exposed to disastrous events in ways that previous generations never or rarely experienced. Pediatricians should serve as important resources to the community in preparing for disasters, as well as acting in its behalf during and after such events.
Clinical and Hematologic Features Do Not Reliably Identify Children With Unsuspected Meningococcal Disease
Authors: Kuppermann Nathan , Malley Richard , Inkelis Stanley H. , Fleisher Gary R.
Published: August 2004

Objective. 

To determine the frequency of unsuspected meningococcal disease (UMD) in young febrile children with meningococcal infections and evaluate whether clinical and laboratory parameters commonly used in the evaluation of fever can help identify children with UMD.

Methods. 

We reviewed the records of children with meningococcal disease from 1985 to 1996 at four referral centers. Children who were evaluated as outpatients and then discharged to home, from whom Neisseria meningitidis was isolated from blood or cerebrospinal fluid cultures obtained during these outpatient visits, were considered to have UMD. We compared clinical and laboratory parameters between these children and 6414 febrile outpatients 3 to 36 months old with negative blood cultures enrolled in a separate study of occult bacteremia.

Results. 

We identified 381 children with meningococcal disease, of whom 45 (12%) had UMD. Of the 45 with UMD, 37 (82%) were 3 to 36 months old. Compared with the 6414 culture-negative patients, these 37 patients with UMD were significantly younger (8.9 ± 5.4 vs 14.2 ± 8.1 months) and had significantly higher band counts (14.3 ± 11.1 vs 7.3 ± 7.5%). There were no significant differences, however, in temperature, white blood cell counts, and absolute neutrophil counts. Multivariate analysis identified young age and the band count as independent predictors of UMD.

Conclusions. 

Children ultimately diagnosed with meningococcal disease have commonly been evaluated as outpatients and discharged to home before diagnosis. Of the hematologic parameters frequently used in the evaluation of fever, only the band count differs significantly between young febrile children with UMD and those with negative cultures. Because UMD is uncommon in young febrile pediatric outpatients, however, the predictive value of the band count is low. Thus, the complete blood count is not routinely helpful for the diagnosis of UMD.
A Study of 10 296 Pediatric and Adolescent Papanicolaou Smear Diagnoses in Northern New England
Authors: Mount Sharon L. , Papillo Jacalyn L.
Published: August 2004

Objective.

This study analyzes pediatric and adolescent Papanicolaou (Pap) smear diagnoses to determine the prevalence rates of squamous intraepithelial lesion (SIL) as well as infectious and reactive processes in this age group.

Design.

A total of 10 296 Pap smear diagnoses from patients 10 to 19 years of age collected over a 1-year period and classified according to the Bethesda system were reviewed. This population was almost exclusively white, the majority residing in rural or suburban areas of Maine, New Hampshire, and Vermont. The percentage of abnormal smear results was then compared with data generated for older age subsets.

Results.

The following diagnoses were made on 10 296 Pap smears from patients 10 to 19 years of age: 7208 (70.01%) normal; 1689 (16.4%) benign cellular change; 1004 (9.75%) atypical squamous cells of undetermined significance; 388 (3.77%) squamous intraepithelial lesion (SIL); and 7 (0.06%) atypical glandular cells of undetermined significance. A total of 1503 (14.6%) of smears showed infectious processes. Compared with the results of adult Pap smears collected over the same time period, the age 20 to 29 subset with 27 067 Pap smears and the age 30+ subset with 42 617 Pap smears showed 11.79% and 8.43% infectious processes and 3.49% and 1.27% SIL, respectively. Therefore, the highest rate of infectious processes and SIL was found in the subset of patients age 10 to 19 years.

Conclusions.

Because the development of SIL and hence cervical cancer is causally related to sexually transmitted human papilloma virus (HPV) infection, this high rate of abnormal Pap smear results of both an infectious and precancerous nature in this population may reflect a high level of sexual activity among adolescent girls. These data reinforce the importance of implementing early cervical Pap smear screening in the sexually active pediatric and adolescent population.
Clinical Studies of Families With Hearing Loss Attributable to Mutations in the Connexin 26 Gene (GJB2/DFNB1)
Authors: Cohn Edward S. , Kelley Philip M. , Fowler Thomas W. , Gorga Michael P. , Lefkowitz David M. , Kuehn Harold J. , Schaefer G. Bradley , Gobar Lisa S. , Hahn Francis J. , Harris Djuana J. , Kimberling William J.
Published: August 2004

Objective.

This retrospective study describes the phenotype associated with the single most common cause of genetic hearing loss. The frequency of childhood deafness is estimated at 1/500. Half of this hearing loss is genetic and ∼80% of genetic hearing loss is nonsyndromic and inherited in an autosomal recessive manner. Approximately 50% of childhood nonsyndromic recessive hearing loss is caused by mutations in the connexin 26 (Cx26) gene (GJB2/DFNB1), making it the most common form of autosomal recessive nonsyndromic hearing loss with a carrier rate estimated to be as high as 2.8%. One mutation, 35delG, accounts for ∼75% to 80% of mutations at this gene.

Methods.

Hearing loss was examined in 46 individuals from 24 families who were either homozygous or compound heterozygous for Cx26 mutations. A subset of these individuals were examined for vestibular function, otoacoustic emissions, auditory brainstem response, temporal bone computed tomography, electrocardiography, urinalyses, dysmorphology, and thyroid function.

Results.

Although all persons had hearing impairment, no consistent audiologic phenotype was observed. Hearing loss varied from mild-moderate to profound, even within the group of families homozygous for the common mutation 35delG, suggesting that other factors modify the phenotypic effects of mutations in Cx26. Furthermore, the hearing loss was observed to be progressive in a number of cases. No associations with inner ear abnormality, thyroid dysfunction, heart conduction defect, urinalyses, dysmorphic features, or retinal abnormality were noted.

Conclusion.

Newborns with confirmed hearing loss should have Cx26 testing. Cx26 testing will help define a group in which ∼60% will have profound or severe-profound hearing loss and require aggressive language intervention (many of these patients will be candidates for cochlear implants).
Parental Knowledge and Attitudes of Minnesota Laws Concerning Adolescent Medical Care
Authors: Cutler Ellen M. , Bateman Michael D. , Wollan Peter C. , Simmons Patricia S.
Published: August 2004

Objective.

To determine parents' knowledge and attitudes of medicolegal issues affecting adolescent medical care.

Design.

An anonymous, mailed survey with 16 questions concerning Minnesota consent and confidentiality laws that affect adolescents' medical care.

Setting.

A community of >70 000 in rural, southeastern Minnesota.

Participants.

Parents of 600 randomly selected 7th- through 12th-grade public school students.

Results.

Two hundred eighty-eight (48%) parents returned the surveys. Parents achieved a median score of 18.8% (range, 0%–93.8%) correct on a test of knowledge. Opinion was a median of +0.3 on a scale where −1 signified “a bad law,” 0 signified “neither a good nor bad law,” and +1 signified “a good law.” Four questions, however, generated a more intense response. Seventy-seven percent of parents reported that, as a whole, the laws in the survey had no effect on them and/or their children.

Conclusions.

These results suggest that parents are not knowledgeable of Minnesota laws that affect adolescent medical care. Overall opinion of these laws was mildly positive, with notable exceptions. Parents also lack a sense of impact of laws affecting adolescent medical care. Lack of knowledge and the presence of certain attitudes allow for identification of issues that clinicians should address by incorporating medicolegal education into the care of adolescents and their families. These results are especially timely in light of the Parental Rights and Responsibilities Act under consideration in Congress, which would provide parents greater authority over their children's medical care.
The Effects of Valproate, Carbamazepine, and Oxcarbazepine on Growth and Sexual Maturation in Girls With Epilepsy
Authors: Rättyä Johanna , Vainionpää Leena , Knip Mikael , Lanning Peter , Isojärvi Jouko I. T.
Published: August 2004

Objective.

Antiepileptic drugs (AEDs) have endocrine effects that may interfere with growth and sexual maturation in children. The aim of this study was to evaluate the effects of AEDs on growth and pubertal development in girls with epilepsy.

Study Design.

Forty girls taking valproate (VPA), 19 girls taking carbamazepine (CBZ), and 18 girls taking oxcarbazepine (OXC) for epilepsy and 49 healthy control girls participated in the study, which included a cross-sectional clinical examination when the girls were 8 to 18 years old and a longitudinal growth analysis from the age of 1 year.

Results.

VPA, CBZ, or OXC did not affect linear growth or pubertal development in girls with epilepsy. However, the patients taking VPA gained weight, and an increase in relative weight was seen in girls who started their medication before as well as during puberty. The body mass index of the VPA-treated girls (19.8 ± 4.8 kg/m2) was higher than that of the control girls (18.0 ± 2.5 kg/m2) at clinical examination. The weight of the girls taking CBZ or OXC for epilepsy was similar to that of the control girls. Plasma insulin-like growth factor-I (IGF-I) levels were higher in girls treated with CBZ and OXC than in the control girls, but AEDs did not affect fasting serum insulin, IGF-binding protein-1, or IGF-binding protein-3 concentrations in girls on VPA, CBZ, or OXC medication during the period of exposure (average 2.8, 4.1, and 1.9 years, respectively) in this study.

Conclusions.

AEDs do not seem to have any adverse effects on linear growth or sexual maturation in girls with epilepsy. VPA-related weight gain can be seen already in prepuberty and it is not associated with hyperinsulinemia in these young patients. The clinical significance of high circulating concentrations of IGF-I in patients taking CBZ or OXC remains to be defined.
Are All Growth-restricted Newborns Created Equal(ly)?
Authors: Kramer Michael S. , Platt Robert , MSc Hong Yang , McNamara Helen , Usher Robert H.
Published: August 2004

Background.

Previous etiologic studies have defined intrauterine growth restriction (IUGR) based on a single cutoff.

Objective.

To assess the relative importance of known etiologic determinants for different degrees (mild versus severe) and timing (preterm versus term) of fetal growth restriction.

Design.

Hospital-based cohort study.

Setting.

Tertiary-care university hospital.

Participants.

Sixty-five thousand two hundred eighty inborn singleton infants without major congenital anomalies delivered between January 1, 1978 and March 31, 1996.

Measurements.

Comparison of adjusted odds ratios (ORs) and 95% confidence intervals for mild IUGR (defined as birth weight 75% to <85% of the mean for gestational age, the latter cutoff equivalent to the 9.9th percentile for this cohort) and severe IUGR (<75% of mean, or 2.3rd percentile), after controlling for maternal age, education, marital status, and other potential determinants by means of multiple logistic regression.

Results.

Maternal prepregnancy overweight (body mass index [BMI] >26.0–29.0 kg/m2) and obesity (BMI >29.0 kg/m2) had stronger protective effects against mild IUGR than against severe IUGR, but most of the determinants showed the opposite pattern. This was especially true for pathologic determinants; ORs (and 95% confidence intervals) for severe versus mild IUGR were 18.5 (14.5–23.8) vs 4.6 (3.6–5.8) for severe pregnancy-induced hypertension (PIH), 3.5 (2.2–5.5) vs 2.3 (1.5–3.4) for prepregnancy hypertension, and 3.4 (2.9–3.9) vs 2.2 (2.0–2.4) for smoking ≥11 cigarettes/day. Primiparity, short stature, prepregnancy BMI, maternal weight gain, and cigarette smoking had significantly larger effects on term IUGR, whereas the effect of severe PIH was more than twice as large for preterm IUGR (OR = 9.7 [7.3–13.0]) as for term IUGR (OR = 4.0 [3.0–5.3]).

Conclusion.

Pathologic determinants of IUGR such as prepregnancy and PIH and cigarette smoking predispose to more severe fetal growth retardation, and PIH in particular seems to do so before 37 weeks. Growth-restricted newborns are not, therefore, all created equal(ly).
More Awakenings and Heart Rate Variability During Supine Sleep in Preterm Infants
Authors: Goto Kazuya , Mirmiran Majid , Adams Marian M. , Longford Robyn V. , Baldwin Roger B. , Boeddiker Margaret A. , Ariagno Ronald L.
Published: August 2004

Objective.

The Task Force of The American Academy of Pediatrics (1996) recommends the nonprone sleeping position for asymptomatic preterm infants to prevent sudden infant death syndrome. The mechanism by which the nonprone sleeping position reduces the rate of sudden infant death syndrome is unclear for full-term infants and the precise effect of sleeping position on sleep and cardiorespiratory characteristics has never been addressed in preterm infants. The purpose of the present study was to clarify the effect of sleeping position on sleep and cardiorespiratory characteristics in preterm infants at an age when they are ready for discharge.

Study Design.

Sixteen asymptomatic preterm infants were studied in both supine and prone sleeping positions at 36.5 ± 0.6 weeks' postconceptional age using videosomnography. Sleep, respiratory, and heart rate characteristics were compared between the two positions using each infant as his/her own control.

Results.

More awakenings (ie, arousals ≥60 seconds) were seen during all sleep states in the supine sleeping position but overall the total sleep and percent sleep state were not affected by sleeping position. After each feeding, the first quiet sleep was significantly shorter, with more heart rate variability and awakenings in the supine position. There were no significant differences in the occurrence of arousals (<60 seconds) or the incidence or severity of apnea and periodic breathing. No clinically significant apnea (≥15 seconds), bradycardia, or oxygen desaturations were seen.

Conclusion.

In 36-week-postconceptional age preterm infants, the supine sleeping position had less quiet sleep and was associated with greater heart rate variability during the first sleep cycle after the feeding. More awakenings were seen during all sleep states in the supine position. These data support the American Academy of Pediatrics recommendation for “Back to Sleep” for asymptomatic preterm infants because more awakenings and lower threshold for arousal may provide some benefit for the infant responding to a life-threatening event. However, further studies are needed to address positional effect on the physiologic measures in preterm infants at older ages (later stages of development). Precisely what constitutes the most healthy or advantageous sleep for newborn infants remains an important question.
Surfactant Replacement Therapy for Respiratory Distress Syndrome
Authors:   Committee on Fetus and Newborn
Published: August 2004

Respiratory failure secondary to surfactant deficiency is a major cause of morbidity and mortality in low birth weight immature infants. Surfactant therapy substantially reduces mortality and respiratory morbidity for this population. The statement summarizes the indications for surfactant replacement therapy. Because respiratory insufficiency may be a component of multiorgan dysfunction in sick infants, surfactant should be administered only at institutions with qualified personnel and facilities for the comprehensive care of sick infants.
High Glycemic Index Foods, Overeating, and Obesity
Authors: Ludwig David S. , Majzoub Joseph A. , Al-Zahrani Ahmad , Dallal Gerard E. , Blanco Isaac , Roberts Susan B.
Published: August 2004

Objective.

The prevalence of obesity has increased dramatically in recent years. However, the role of dietary composition in body weight regulation remains unclear. The purpose of this work was to investigate the acute effects of dietary glycemic index (GI) on energy metabolism and voluntary food intake in obese subjects.

Methods.

Twelve obese teenage boys were evaluated on three separate occasions using a crossover study protocol. During each evaluation, subjects consumed identical test meals at breakfast and lunch that had a low, medium, or high GI. The high- and medium-GI meals were designed to have similar macronutrient composition, fiber content, and palatability, and all meals for each subject had equal energy content. After breakfast, plasma and serum concentrations of metabolic fuels and hormones were measured. Ad libitum food intake was determined in the 5-hour period after lunch.

Results.

Voluntary energy intake after the high-GI meal (5.8 megajoule [mJ]) was 53% greater than after the medium-GI meal (3.8 mJ), and 81% greater than after the low-GI meal (3.2 mJ). In addition, compared with the low-GI meal, the high-GI meal resulted in higher serum insulin levels, lower plasma glucagon levels, lower postabsorptive plasma glucose and serum fatty acids levels, and elevation in plasma epinephrine. The area under the glycemic response curve for each test meal accounted for 53% of the variance in food intake within subjects.

Conclusions.

The rapid absorption of glucose after consumption of high-GI meals induces a sequence of hormonal and metabolic changes that promote excessive food intake in obese subjects. Additional studies are needed to examine the relationship between dietary GI and long-term body weight regulation. glycemic index, obesity, dietary carbohydrate, diets, insulin.
The Effects of Early Pacifier Use on Breastfeeding Duration
Authors: Howard Cynthia R. , Howard Fred M. , Lanphear Bruce , deBlieck Elisabeth A. , Eberly Shirley , Lawrence Ruth A.
Published: August 2004

Objective.

To evaluate the effects of pacifier use and the timing of pacifier introduction on breastfeeding duration, problems, and frequency.

Methods.

A cohort of 265 breastfeeding mother–infant dyads was followed prospectively. Maternal interviews were conducted at delivery, 2, 6, 12, and 24 weeks, and thereafter every 90 days until breastfeeding ended. Information was obtained regarding pacifier use, infant feeding, use of supplemental foods and breastfeeding frequency, duration, and problems. The effect of pacifier introduction by 6 weeks of age on breastfeeding duration was evaluated with Kaplan-Meier and Cox proportional hazards models. The effect of the timing of pacifier introduction (≤2 weeks and ≤6 weeks) on breastfeeding duration at 2 and 3 months was evaluated using logistic regression modeling.

Results.

A total of 181 mothers (68%) introduced a pacifier before 6 weeks. In adjusted analyses, pacifier introduction by 6 weeks was associated with a significantly increased risk for shortened duration of full (hazard ratio, 1.53; 95% confidence interval: 1.15, 2.05) and overall (hazard ratio, 1.61; 95% confidence interval: 1.19,2.19) breastfeeding. Women who introduced pacifiers tended to breastfeed their infants fewer times per day, with significant differences noted at 2 (8.1 ± 2.6 vs 9.0 ± 2.3) and 12 weeks' (6.3 ± 2.0 vs 7.4 ± 1.6) postpartum. At 12 weeks postpartum, women who introduced pacifiers also were more likely to report that breastfeeding was inconvenient and that they had insufficient milk supplies. Pacifier use begun either before 2 weeks or before 6 weeks' postpartum was not significantly associated with breastfeeding duration at 2 and 3 months.

Conclusions.

Pacifier use was independently associated with significant declines in the duration of full and overall breastfeeding. Breastfeeding duration in the first 3 months' postpartum, however, was unaffected by pacifier use. Women who introduced pacifiers tended to breastfeed their infants less frequently and experienced breastfeeding problems consistent with infrequent feeding. Findings from this study suggest that the decreases in breastfeeding duration associated with pacifier use may be a consequence of less frequent breastfeeding among women who introduce pacifiers to their infants.
Identification of Attentional and Hyperactivity Problems in Primary Care: A Report From Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network
Authors: Wasserman Richard C. , Kelleher Kelly J. , Bocian Alison , Baker Alison , Childs George E. , Indacochea Fernando , Stulp Clydette , Gardner William P.
Published: August 2004

Objectives.

To 1) determine the frequency of identification of attentional and hyperactivity problems (AHPs) by clinicians, and 2) examine whether minority children or children from less well-educated, lower-income, or lower-functioning families would be more likely to be identified as having AHPs.

Design.

Prospective cohort study of 22 059 consecutive children 4 to 15 years of age being seen for acute, chronic, and health supervision visits.

Setting.

Practices of 401 pediatric and family practice clinicians in 44 states, Puerto Rico, and 4 Canadian provinces.

Methods.

Parent questionnaires included demographic information and the Pediatric Symptom Checklist. Clinician questionnaires categorized psychosocial problems and addressed how assessment of problems was made. Analyses compared children with newly identified AHPs with those with other newly identified psychosocial problems.

Results.

Clinicians identified behavior problems in 18.7% of children, with 9.2% of the entire sample identified as having AHPs. Among those with newly assessed AHPs, clinicians identified minority children and those from low-income or poorly functioning families as having AHPs at the same rate as other children. However, even after controlling for symptoms, males were more likely than females (odds ratio, 2.81) to be identified as having AHPs. Older clinicians were significantly more likely to identify children as having AHPs (odds ratio, 2.09). In assessing AHPs, clinicians used standardized tools such as behavioral questionnaires for only 36.9% of children, and Diagnostic and Statistical Manual criteria for 38.3% of children.

Conclusions.

AHPs are highly prevalent in primary care practice. Clinicians do not appear predisposed to label children from disadvantaged backgrounds as having AHPs. Primary care assessment of AHPs lacks standardization.
The Relationship Between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior
Authors: Mangione-Smith Rita , McGlynn Elizabeth A. , Elliott Marc N. , Krogstad Paul , Brook Robert H.
Published: August 2004

Context.

Despite growing concern over the escalating antimicrobial resistance problem, physicians continue to inappropriately prescribe. It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided.

Objectives.

To explore the extent to which parental previsit expectations and physician perceptions of those expectations are associated with inappropriate antimicrobial prescribing; and to explore the relationship between fulfillment of expectations and parental visit-specific satisfaction.

Design.

Previsit and postvisit survey of parents and postvisit survey of physicians.

Setting.

Two private pediatric practices, one community based and one university based.

Participants.

Ten physicians (response rate = 77%), and a consecutive sample of 306 eligible parents (response rate = 86%) who were attending sick visits for their children between October 1996 and March 1997. Parents were screened for eligibility in the waiting rooms of the two practices and were invited to participate if they spoke and read English and their child was 2 to 10 years old, had a presenting complaint of ear pain, throat pain, cough, or congestion, was off antimicrobial therapy for the past 2 weeks, and was seeing one of the participating physicians.

Main Outcome Measures.

Antimicrobial prescribing decision, probability of assigning a bacterial diagnosis, and parental visit-specific satisfaction.

Results.

Based on multivariate analysis, physicians' perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology; when physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. However, physician antimicrobial prescribing behavior was not associated with actual parental expectations for receiving antimicrobials. In addition, when physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Failure to meet parental expectations regarding communication events during the visit was the only significant predictor of parental satisfaction. Failure to provide expected antimicrobials did not affect satisfaction.

Conclusions.

The antibiotic resistance epidemic should lead to immediate replication of this study in a larger more generalizable population. If inaccurate physician perceptions of parent desires for antimicrobials for viral infections are confirmed, then an intervention to change the way physicians acquire this set of perceptions should be undertaken.
Is Greater Continuity of Care Associated With Less Emergency Department Utilization?
Authors: Christakis Dimitri A. , Wright Jeffrey A. , Koepsell Thomas D. , Emerson Scott , Connell Frederick A.
Published: August 2004

Background.

The benefits of continuity of care (COC) have not been firmly established for pediatric patients.

Objective.

To assess whether greater COC is associated with lower emergency department (ED) utilization.

Setting.

Outpatient teaching clinic at Children's Hospital and Regional Medical Center, Seattle, WA.

Patients.

All 785 Medicaid managed care children ages 0 to 19 years followed at Children's Hospital and Regional Medical Center between 1993 to 1997 who had at least four outpatient visits.

Methods.

Retrospective claims-based analysis. COC was quantified based on the number of different care providers in relation to the number of clinic visits.

Results.

Attending COC was significantly greater than resident COC. In a multiple event survival analysis, compared with those patients in the lowest tertile of attending COC, those in the middle tertile had 30% lower ED utilization (hazard ratio 0.70 [0.53–0.93]) and those in the highest tertile had 35% lower ED use (hazard ratio 0.65 [0.50–0.80]). Resident COC was not significantly associated with ED use.

Conclusion.

Greater COC with attending physicians in outpatient teaching clinics is associated with lower ED utilization.
Ipratropium Bromide Added to Asthma Treatment in the Pediatric Emergency Department
Authors: Zorc Joseph J. , Pusic Martin V. , Ogborn C. Jean , Lebet Ruth , Duggan Anne K.
Published: August 2004

Objective.

To determine if the addition of ipratropium bromide to the emergency department (ED) treatment of childhood asthma reduces time to discharge, number of nebulizer treatments before discharge, and the rate of hospitalization.

Methods.

Patients >12 months of age were eligible if they were to be treated according to a standardized ED protocol for acute asthma with nebulized albuterol (2.5 mg/dose if weight <30 kg, otherwise 5 mg/dose) and oral prednisone or prednisolone (2 mg/kg up to 80 mg). Subjects were randomized to receive either ipratropium (250 μg/dose) or normal saline (1 mL/dose) with each of the first three nebulized albuterol doses. Further treatment after the first hour was determined by physicians blinded to subject group assignment. Records were reviewed to determine the length of time to discharge home from the ED, number of doses of albuterol given before discharge, and the number of patients admitted to the hospital.

Results.

Four hundred twenty-seven patients were randomized to ipratropium or control groups; these groups were similar in all baseline measures. Among patients discharged from the ED, ipratropium group subjects had 13% shorter treatment time (mean, 185 minutes, vs control, 213 minutes) and fewer total albuterol doses (median, three, vs control, four). Admission rates did not differ significantly (18%, vs control, 22%).

Conclusions.

The addition of three doses of ipratropium to an ED treatment protocol for acute asthma was associated with reductions in duration and amount of treatment before discharge.
Atypical Chronic Lung Disease Patterns in Neonates
Authors: Charafeddine Lama , D'Angio Carl T. , Phelps Dale L.
Published: August 2004

Objective.

To determine, in the postsurfactant era, the incidence and clinical characteristics of infants with atypical versus traditionally defined bronchopulmonary dysplasia (BPD) among premature infants with birth weights <1251 g.

Design.

Retrospective cohort study.

Setting.

A single regional neonatal intensive care unit (level III/IV).

Patients.

Two hundred thirty-two premature infants <1251 g at birth consecutively admitted during a 2-year period.

Main Outcome Measure.

Incidence of classic BPD and atypical chronic lung disease (CLD) (occurring without preceding respiratory distress or after recovery from respiratory distress).

Results.

Among 177 infants <1251 g who survived to 28 days, 27 (15%) had atypical CLD and 61 (34.5%) had classic BPD. Atypical CLD infants were significantly heavier and more mature than classic BPD infants (mean birth weights, 922 ± 152 g vs 854 ± 173 g; and mean gestational age, 26.8 ± 1.3 weeks vs 26.1 ± 1.6 weeks). Median duration of ventilator support (31 days; range, 2 to 127 vs 42 days; range, 4–145 days) and oxygen therapy (30 days; range, 11 to 163 vs 48 days; range, 19–180 days) were shorter in atypical CLD infants than in classic BPD infants.

Conclusion.

Atypical CLD comprised 31% of total cases of CLD. Atypical CLD appears to be less severe than classic BPD. These data suggest that initial, acute lung injuries are not the sole antecedents of neonatal CLD.
Vagal Nerve Stimulation in Epileptic Encephalopathies
Authors: Parker Alasdair P. J. , Polkey Charles E. , Binnie Colin D. , Madigan Catherine , Ferrie Colin D. , Robinson Richard O.
Published: August 2004

Objective.

To study the effect of vagal nerve stimulation (VNS) in children with epileptic encephalopathies.

Methods and Materials.

All children receiving VNS during a 2-year period at our center were studied prospectively for changes in seizure frequency, electroencephalogram (EEG), adaptive behavior, quality of life, and where appropriate, verbal/nonverbal performance. Assessments were made before and for at least 1 year after implant.

Results.

Sixteen children were studied. One device was removed because of infection. Of the remaining 15 children, 4 had a >50% reduction and 2 had a >50% increase in seizure frequency at 1 year after implant. Median reduction in seizure frequency was 17%. There was no trend toward improvement of the EEG or adaptive behavior. Quality of life was unchanged in most areas, except in perceived treatment side effects and general behavior that were improved. In 6 children undergoing further assessment, there was a significant improvement in verbal performance; this did not correlate with reduction in seizure frequency.

Conclusion.

VNS did not significantly improve seizure frequency, severity, adaptive behavior, or the EEG during the first year of treatment for the group as a whole, although 4 children (27%) had a worthwhile reduction in seizure frequency. There were significant improvements in perceived treatment side effects and general behavior.
Neurocognitive Sequelae of Scaphocephaly
Authors: Virtanen Riitta , Korhonen Tapio , Fagerholm Janita , Viljanto Jouko
Published: August 2004

Objective.

Early cranioplasty for scaphocephaly has become routine in most countries. In addition to normalizing the shape of the skull, it has been found to decrease intracranial hypertension. Whether corrective surgery benefits the child's cognitive outcome has been poorly documented.

Design.

Eighteen children whose sagittal suture showed premature fusion at birth or soon thereafter were operated on at age 1 week to 7 months. All patients healed without complications and were followed-up at regular intervals. At the age of 7.8 to 16.3 years they were examined to clarify their neurocognitive development and to compare the results with their age- and gender-matched healthy controls.

Results.

Originally scaphocephalic children, although operated on, had mild deficiencies in auditory short-term memory and language development when examined with the general comprehension, similarities, and digit span subscales of the Wechsler Intelligence Scale for Children–Revised. In all other respects their developmental outcome was equal to that of the controls.

Conclusions.

Despite relative early correction of the skull shape, originally scaphocephalic children's neurocognitive performances do not reach the same level in all of the neurocognitive domains as their matched controls at school age. Early operation (≤1 month) may decrease this developmental delay. This implies that impairment of brain function has already taken place in utero. For the same reason an early operation seems to be justified not only for correction of the skull shape, but also to allow unrestricted development for the brain. Postponement of the operation would not serve either of these aims.
Nosocomial Infections in Pediatric Intensive Care Units in the United States
Authors: Richards Michael J. , Edwards Jonathan R. , Culver David H. , Gaynes Robert P. ,   the National Nosocomial Infections Surveillance System
Published: August 2004

Objectives.

To describe the epidemiology of nosocomial infections in pediatric intensive care units (ICUs) in the United States.

Background.

Patient and ICU characteristics in pediatric ICUs suggest the pattern of nosocomial infections experienced may differ from that seen in adult ICUs.

Methods.

Data were collected between January 1992 and December 1997 from 61 pediatric ICUs in the United States using the standard surveillance protocols and nosocomial infection site definitions of the National Nosocomial Infections Surveillance System's ICU surveillance component.

Results.

Data on 110 709 patients with 6290 nosocomial infections were analyzed. Primary bloodstream infections (28%), pneumonia (21%), and urinary tract infections (15%) were most frequent and were almost always associated with use of an invasive device. Primary bloodstream infections and surgical site infections were reported more frequently in infants aged 2 months or less as compared with older children. Urinary tract infections were reported more frequently in children >5 years old compared with younger children. Coagulase-negative staphylococci (38%) were the most common bloodstream isolates, and aerobic Gram-negative bacilli were reported in 25% of primary bloodstream infections. Pseudomonas aeruginosa (22%) was the most common species reported from pneumonia and Escherichia coli (19%), from urinary tract infections. Enterobacter spp. were isolated with increasing frequency from pneumonia and were the most common Gram-negative isolates from bloodstream infections. Device-associated infection rates for bloodstream infections, pneumonia, and urinary tract infections did not correlate with length of stay, the number of hospital beds, or season.

Conclusions.

In pediatric ICUs, bloodstream infections were the most common nosocomial infection. The distribution of infection sites and pathogens differed with age and from that reported from adult ICUs. Device-associated infection rates were the best rates currently available for comparisons between units, because they were not associated with length of stay, the number of beds in the hospital, or season.
Zinc Supplementation in Malnourished Children With Persistent Diarrhea in Pakistan
Authors: Bhutta Zulfiqar Ahmed , Nizami Shaikh Qamaruddin , Isani Zeenat
Published: August 2004

Objective.

To evaluate the potential benefit of dietary supplementation of a rice-lentil (Khitchri) and yogurt diet with 3 mg/kg/d of elemental zinc (as zinc sulfate) in hospitalized malnourished children (age 6–36 months) with persistent diarrhea for 14 days.

Methodology.

Randomized, double-blind placebo-controlled trial.

Setting.

Nutrition Research Ward at the National Institute of Child Health, Karachi, Pakistan, where children were admitted for 14 days of inpatient supervised rehabilitation.

Main Outcome Measures.

Primary outcome: overall weight gain by day 14. Secondary outcomes: overall energy intake, stool output, time to diarrheal recovery and weight gain (≥3 days), plasma zinc, copper, prealbumin, and insulin-like growth factor-1.

Results.

Of 87 children randomized for supplementation with either zinc or placebo, the two groups were comparable at admission in terms of severity and duration of diarrhea, as well as nutritional and anthropometric parameters. The overall weight gain, stool volume, stool frequency, as well as the time taken for diarrheal recovery or steady weight gain, were comparable for both supplemented children and controls. Supplemented children had a significant improvement in plasma zinc levels and serum alkaline phosphatase by day 14 of therapy in comparison with controls. Plasma copper levels were low in both groups at admission and although an increase was seen in control children, levels decreased further after zinc supplementation. There was no significant difference between the two groups for hemoglobin, serum albumin, prealbumin, and plasma insulin-like growth factor-1 increments during the course of therapy. Evaluation of primary and secondary outcome criteria among the subset of children with plasma zinc levels <60 μg/d at admission did not reveal any significant differences.

Conclusions.

Although there was satisfactory recovery in malnourished children with persistent diarrhea receiving the Khitchri-yogurt diet, there was no evidence of improved weight gain or acceleration of recovery from diarrhea with zinc supplementation. In contrast, the reduction in plasma copper levels in zinc-supplemented malnourished children suggests that caution should be exercised in supplementing severely malnourished children with zinc alone.
Anaphylactic Reaction to Oral Cefaclor in a Child
Authors: Grouhi Masoud , Hummel David , Roifman Chaim M.
Published: August 2004

Adverse drug reactions are a common clinical problem. It has been estimated1 that 6% to 15% of hospitalized patients experience some sort of adverse drug reaction. Clinical manifestations of adverse drug reactions include skin rash; a serum sickness-like reaction; drug fever; pulmonary, hepatic, and renal involvement; and systemic anaphylaxis. Many of these adverse events are not immunologically mediated. Actual allergic or immunologic drug reactions probably account for <25% of adverse drug reactions overall.1

Antibiotics are one of the major contributors to drug hypersensitivity. Cefaclor, an oral second-generation cephalosporin with a β-lactam ring, is used against various infectious diseases of the respiratory tract, especially in children. Several cases of cefaclor hypersensitivity have been reported.2,3 The most common presentations are either erythematous or papular eruptions, although serum sickness-like reactions have also been described. Anaphylactic reactions, although rare, have been observed in adults. Here we report a case of anaphylactic reaction to cefaclor in a 2½-year-old patient.
Intravenous Catheter Blood Cultures: Utility and Contamination
Authors: McQuillen Kemedy K. , Santucci Karen A. , Conrad Margaret A. , Nelson David G. , Lewander William , Duffy Susan J. , Anderson Angela C.
Published: August 2004

Objective.

In pediatrics, blood cultures (BCs) are often drawn as intravenous (IV) catheters are placed. This routine minimizes the number of painful and often difficult punctures a child must undergo but results in the discarding of multiple BC bottles when these cultures are later determined to be unnecessary. If the contamination rate of BCs drawn through an indwelling IV did not exceed the contamination rate of BCs drawn at the time of IV placement, BCs could be drawn from the IV without subjecting the patient to another venipuncture. This study was done to compare the contamination rates of BCs drawn by these two methods. Additionally, we sought to determine if the collection of two BCs enhances pathogen recovery.

Methods.

Prospective comparison of contamination and bacteremia rates of BCs drawn by two different methods: the first BC was drawn at the time of IV line placement and the second BC was drawn from the previously placed IV at a later time.

Setting.

Urban pediatric emergency department with an annual census of 40 000.

Participants.

One thousand five hundred sixty-four patients between the ages of 3 days and 22.1 years. The median age was 2.2 years. Sixty-four patients were excluded because we were unable to draw the second BC. Forty-six percent of eligible patients (n = 690) were girls.

Results.

Fifty-seven (1.9%) of 3000 grew contaminants: 27 in the first and 30 in the second BC for contamination rates of 1.8% and 2.0%. Thirty-eight (1.3%) of 3000 BCs grew pathogens: 24 represent 12 patients with growth in two out of two cultures and 14 represent 14 patients with growth in one out of two cultures. Pathogen rates were 1.1% (16/1500) with one BC per patient and 1.7% (22/1500) with two BCs per patient.

Conclusions.

There is no difference in the contamination rates of two BCs drawn from the same site at two different times. The collection of two BCs per patient may enhance pathogen recovery.