bluuebunny/crossref_metadata_2025 huggingface dataset:
The Management of Minor Closed Head Injury in Children
Authors:   Committee on Quality Improvement, American Academy of Pediatrics Commission on Clinical Policies and Research, American Academy of Family Physicians
Published: August 2004

This Clinical Practice Guideline was retired January 2012.

The American Academy of Pediatrics (AAP) and its Committee on Quality Improvement in collaboration with the American Academy of Family Physicians (AAFP) and its Commission on Clinical Policies and Research, and in conjunction with experts in neurology, emergency medicine and critical care, research methodologists, and practicing physicians have developed this practice parameter. This parameter provides recommendations for the management of a previously neurologically healthy child with a minor closed head injury who, at the time of injury, may have experienced temporary loss of consciousness, experienced an impact seizure, vomited, or experienced other signs and symptoms. These recommendations derive from a thorough review of the literature and expert consensus. The methods and results of the literature review and data analyses including evidence tables can be found in the technical report. This practice parameter is not intended as a sole source of guidance for the management of children with minor closed head injuries. Rather, it is designed to assist physicians by providing an analytic framework for the evaluation and management of this condition. It is not intended to replace clinical judgment or establish a protocol for all patients with a minor head injury, and rarely will provide the only appropriate approach to the problem.

The practice parameter, “The Management of Minor Closed Head Injury in Children,” was reviewed by the AAFP Commission on Clinical Policies and Research and individuals appointed by the AAFP and appropriate committees and sections of the AAP including the Chapter Review Group, a focus group of office-based pediatricians representing each AAP District: Gene R. Adams, MD; Robert M. Corwin, MD; Diane Fuquay, MD; Barbara M. Harley, MD; Thomas J. Herr, MD, Chair; Kenneth E. Matthews, MD; Robert D. Mines, MD; Lawrence C. Pakula, MD; Howard B. Weinblatt, MD; and Delosa A. Young, MD.

The supporting data are contained in a technical report available athttp://www.pediatrics.org/cgi/content/full/104/6/e78.
Acellular Vaccines Containing Reduced Quantities of Pertussis Antigens as a Booster in Adolescents
Authors: Minh Nhu Nguyen Tran , He Qiushui , Ramalho Anya , Kaufhold Achim , Viljanen Matti K. , Arvilommi Heikki , Mertsola Jussi
Published: August 2004

Objective.

To evaluate the immunogenicity and reactogenicity of an acellular pertussis vaccine (pa) either formulated with diphtheria and tetanus toxoids (dTpa) or administered consecutively with a licensed tetanus and diphtheria vaccine (Td) as a 5th dose in adolescents.

Methods.

A total of 510 healthy children 10 to 13 years of age were assigned randomly, using a single-blind design, to receive either the dTpa vaccine or the Td vaccine with the pa vaccine 1 month later. The quantities of 3 pertussis antigens (pertussis toxin, filamentous hemagglutinin, and pertactin) in the dTpa and the pa vaccines were one third of those of the Infanrix vaccine (SmithKline Beecham Biologicals, Rixensart, Beligium) licensed for use in infants. For enzyme-linked immunosorbent assay measurement of serum immunoglobulin G antibodies and proliferation assay of peripheral blood mononuclear cells, blood samples were obtained before and 1 month after immunization. Local and systemic reactions were recorded on diary cards for 15 days after immunization.

Results.

After immunization with dTpa or pa, significant and comparable rises in geometric mean values of antibodies (12- to 46-fold) and proliferations (8- to 18-fold) to each of the pertussis antigens were noted. After immunization with dTpa or Td, significant rises in geometric mean values of antidiphtheria and antitetanus antibodies (35- to 76-fold) were noted, and all subjects had values of these antibodies ≥.1 international units/mL. The dTpa and pa vaccines were at least as well tolerated as the licensed Td vaccine.

Conclusions.

Booster immunization of adolescents with an acellular vaccine containing reduced quantities of pertussis antigens in addition to diphtheria and tetanus toxoids induces good responses in both arms of the immune system without an increase in adverse reactions.
The Impact of Low Birth Weight, Perinatal Conditions, and Sociodemographic Factors on Educational Outcome in Kindergarten
Authors: Resnick Michael B. , Gueorguieva Ralitza V. , Carter Randy L. , Ariet Mario , Sun Yuanshan , Roth Jeffrey , Bucciarelli Richard L. , Curran John S. , Mahan Charles S.
Published: August 2004

Objective.

To assess the relative effects and the impact of perinatal and sociodemographic risk factors on long-term morbidity within a total birth population in Florida.

Methods.

School records for 339 171 children entering kindergarten in Florida public schools in the 1992–1993, 1993–1994, or 1994–1995 academic years were matched with Florida birth records from 1985 to 1990. Effects on long-term morbidity were assessed through a multivariate analysis of an educational outcome variable, defined as placement into 9 mutually exclusive categories in kindergarten. Of those categories, 7 were special education (SE) classifications determined by statewide standardized eligibility criteria, 1 was academic problems, and the reference category was regular classroom. Generalized logistic regression was used to simultaneously estimate the odds of placement in SE and academic problems. The impact of all risk factors was assessed via estimated attributable excess/deficit numbers, based on the multivariate analysis.

Results.

Educational outcome was significantly influenced by both perinatal and sociodemographic factors. Perinatal factors had greater adverse effects on the most severe SE types, with birth weight <1000 g having the greatest effect. Sociodemographic predictors had greater effects on the mild educational disabilities. Because of their greater prevalence, the impact attributable to each of the factors (poverty, male gender, low maternal education, or non-white race) was between 5 and 10 times greater than that of low birth weight and >10 times greater than that of very low birth weight, presence of a congenital anomaly, or prenatal care.

Conclusions.

Results are consistent with the hypothesis that adverse perinatal conditions result in severe educational disabilities, whereas less severe outcomes are influenced by sociodemographic factors. Overall, sociodemographic factors have a greater total impact on adverse educational outcomes than perinatal factors.
Prednisolone Treatment of Respiratory Syncytial Virus Infection: A Randomized Controlled Trial of 147 Infants
Authors: Bülow Susanne M. , Nir Marta , Levin E. , Friis Birgitte , Thomsen Lise L. , Nielsen Jens Erik , Holm Jens-Christian , Møller Tina , Bonde-Hansen Mie E. , Nielsen Hans Erik
Published: August 2004

Objective.

To evaluate the effect of systemic prednisolone as an adjunct to conventional treatment with β2-agonist, respiratory support, and fluid replacement in hospitalized infants <24 months of age with respiratory syncytial virus (RSV) infection.

Methods.

The study was randomized, double-blind, and placebo-controlled. During the winter of 1995–1996, 147 infants <2 years of age, hospitalized with RSV infection, were allocated to treatment with either systemic prednisolone mixture 2 mg/kg daily or placebo for 5 days.

Main Outcome Measures.

The acute effect variables were duration of stay in hospital, use of medicine, and supportive measures while in hospital. At follow-up 1 month after discharge, the acute effect variables were duration of illness, start in day care center, morbidity, and use of medicine. At follow-up 1 year after discharge, the acute effect variables were morbidity, use of medicine, and skin prick tests with allergens.

Results.

Prednisolone treatment had no effect on any of the outcome measures.

Conclusions.

Our randomized prospective study in infants hospitalized with acute RSV infection showed no effect of systemic prednisolone treatment either in the acute state of RSV infection, nor in the follow-up 1 month and 1 year after admission to hospital. We find our results in agreement with the largest studies reported earlier; therefore, corticosteroid, whether by the systemic route or by inhalation, should not be prescribed to infants with RSV infection.
Prevention of Lyme Disease
Authors:   Committee on Infectious Diseases
Published: August 2004

This Policy Statement was retired October 2003.

Lyme disease is currently the most frequently reported vector-borne illness in the United States, accounting for more than 95% of such cases. The purpose of this report is to provide recommendations for preventing Lyme disease, including the use of Lyme disease vaccine. Individuals can reduce their risk of Lyme disease by avoiding tick-infested habitats when in endemic areas. If exposure to tick-infested habitats cannot be avoided, individuals may reduce their risk of infection by using repellents, wearing protective clothing, and regularly checking for and removing attached ticks. Morbidity from Lyme disease can be reduced significantly by detecting and treating the infection in its early stages; early and appropriate treatment almost always results in a prompt and uncomplicated cure. A Lyme disease vaccine (LYMErix, SmithKline Beecham, Collegeville, PA) was licensed by the US Food and Drug Administration on December 21, 1998, for persons 15 to 70 years of age. This vaccine seems to be safe and effective, but whether its use is cost-effective has yet to be clearly established. Use of this vaccine causes false-positive enzyme immunoassay results for Lyme disease. Lyme disease can be diagnosed in vaccinated persons by immunoblot testing. Decisions about the use of this vaccine should be based on an assessment of a person's risk as determined by activities and behaviors relating to tick exposure in endemic areas. This vaccine should be considered an adjunct to, not a replacement for, the practice of personal protective measures against tick exposure and the early diagnosis and treatment of Lyme disease.
Risk Factors and Opportunities for Prevention of Early-onset Neonatal Sepsis: A Multicenter Case-Control Study
Authors: Schuchat Anne , Zywicki Sara S. , Dinsmoor Mara J. , Mercer Brian , Romaguera Josefina , O'Sullivan Mary Jo , Patel Daksha , Peters Mark T. , Stoll Barbara , Levine Orin S. ,   the Prevention of Early-onset Neonatal Sepsis (PENS) Study Group
Published: August 2004

Background.

Early-onset group B streptococcal (GBS) prevention efforts are based on targeted use of intrapartum antibiotic prophylaxis (IAP); applicability of these prevention efforts to infections caused by other organisms is not clear.

Methods.

Multicenter surveillance during 1995 to 1996 for culture-confirmed, early-onset sepsis in an aggregate of 52 406 births; matched case-control study of risk factors for GBS and other sepsis.

Results.

Early-onset disease occurred in 188 infants (3.5 cases per 1000 live births). GBS (1.4 cases per 1000 births) andEscherichia coli (0.6 cases per 1000 births) caused most infections. GBS sepsis less often occurred in preterm deliveries compared with other sepsis. Compared with gestation-matched controls without documented sepsis, GBS disease was associated with intrapartum fever (matched OR, 4.1; CI, 1.2–13.4) and frequent vaginal exams (matched OR, 2.9; CI, 1.1–8.0). An obstetric risk factor—preterm delivery, intrapartum fever, or membrane rupture ≥18 hours—was found in 49% of GBS cases and 79% of other sepsis. IAP had an adjusted efficacy of 68.2% against any early-onset sepsis. Ampicillin resistance was evident in 69% of E coliinfections. No deaths occurred among susceptible E coliinfections, whereas 41% of ampicillin-resistant E coliinfections were fatal. Ninety-one percent of infants who developed ampicillin-resistant E coli infections were preterm, and 59% of these infants were born to mothers who had received IAP.

Conclusions.

Either prenatal GBS screening or a risk-based strategy could potentially prevent a substantial portion of GBS cases. Sepsis caused by other organisms is more often a disease of prematurity. IAP seemed efficacious against early-onset sepsis. However, the severity of ampicillin-resistant E colisepsis and its occurrence after maternal antibiotics suggest caution regarding use of ampicillin instead of penicillin for GBS prophylaxis.
Transient but Not Permanent Neonatal Diabetes Mellitus is Associated With Paternal Uniparental Isodisomy of Chromosome 6
Authors: Hermann Robert , Laine Antti-Pekka , Johansson Calle , Niederland Tamas , Tokarska Lidia , Dziatkowiak Hanna , Ilonen Jorma , Soltész Gyula
Published: August 2004

Objectives.

The factors determining the pathogenesis of transient and permanent neonatal diabetes mellitus are poorly characterized. The purpose of this study was to examine the role of chromosome 6 in the pathogenesis of neonatal diabetes mellitus and to detect differences between these 2 phenotypes.

Methods.

Microsatellite markers (D6S334, D6S286, D6S310, D6S308, D6S292, D6S311, and D6S403) and human leukocyte antigen DQ alleles were examined using polymerase chain reaction and DNA fragment electrophoresis in 3 patients with transient and 3 patients with permanent neonatal diabetes mellitus. Humoral markers of islet cell autoimmunity and clinical characteristics were analyzed in the 2 groups.

Results.

A patient with transient neonatal diabetes mellitus (TND) and macroglossia carrying paternal uniparental isodisomy (UPD) of chromosome 6 has been identified. The isodisomy affected the whole chromosome; no maternal chromosome 6 sequences were detected. The permanent neonatal diabetes mellitus cases and the other 2 cases with TND did not have UPD. None of the patients had high-risk type 1 diabetes human leukocyte antigen DQ alleles and most infants were negative for islet cell-specific autoantibodies indicating that none of the 2 forms of neonatal diabetes mellitus is likely to be of autoimmune origin. An association of TND and persistent granulocytopenia is described for the first time.

Conclusions.

We propose that transient and permanent forms of neonatal diabetes mellitus have different genetic background and represent different disease entities. TND is associated with UPD of chromosome 6 suggesting that an imprinted gene on chromosome 6 is responsible for this phenotype. It seems that 2 copies of the paternal allele are necessary for the development of TND; therefore, it is likely that overexpression of a putative gene located on chromosome 6 alters pancreatic β-cell maturation and insulin secretion.
Clinical and Histologic Features of Chronic Hepatitis C Virus Infection After Blood Transfusion in Japanese Children
Authors: Hoshiyama Atsuo , Kimura Akihiko , Fujisawa Takuji , Kage Masayoshi , Kato Hirohisa
Published: August 2004

Objective.

To characterize the clinical and histologic features of chronic hepatitis C virus (HCV) infection after blood transfusion in Japanese children.

Study Design.

We studied 231 children with a history of blood product transfusion. Patients were divided into two groups: 116 patients with a history of malignant disease (group 1), 115 patients who had undergone open heart surgery (group 2). We examined changes in serum alanine aminotransferase (ALT) activity and HCV markers, and patients' clinical course. Moreover, in 38 patients in whom the time of HCV infection could be defined, we examined liver histology.

Results.

The proportions of patients in each group who were anti-HCV-positive were 35 out of 116 (30%) and 20 out of 115 (17%), respectively. Of the anti-HCV-positive patients, the proportions of HCV RNA-positive patients in each group were 30 out of 35 (86%) and 12 out of 20 (60%), respectively. Levels of ALT activity in patients with HCV infection varied widely for several years after blood transfusion; thereafter ALT activity fell to <100 IU/L in 2 groups. Serum ALT activity in patients who were HCV RNA-negative became normal. With regard to liver histology, there were no differences in the grade of necroinflammation or stage of fibrosis in patients with different durations of infection or when patients were analyzed according to the presence or absence of malignant disease. Patients mostly had grade 2–4 inflammation and stage 1–2 fibrosis. Thus, chronic hepatitis C was a morphologically mild disease in most children in this study.

Conclusions.

Sixty percent to 80% of children with HCV infection in this study developed chronic hepatitis C. However, examination of liver histology findings in children with chronic hepatitis C showed only mild changes.
Midazolam Nasal Spray Reduces Procedural Anxiety in Children
Authors: Ljungman Gustaf , Kreuger Anders , Andréasson Svenerik , Gordh Torsten , Sörensen Stefan
Published: August 2004

Objective.

Anxiety and pain even in minor procedures are still great problems in pediatrics, not least in pediatric oncology. Conscious sedation is indicated when other means to overcome a child's fear fail. The aim of this study was to investigate whether intranasal administration of midazolam given before insertion of a needle in a subcutaneously implanted central venous port could reduce anxiety, discomfort, pain, and procedure problems.

Method.

Forty-three children with cancer participated in this randomized, double-blind, placebo-controlled, crossover study in which nasal administration of midazolam spray, .2 mg/kg body weight, was compared with placebo. Children, parents, and nurses completed a visual analog scale questionnaire to evaluate efficacy.

Results.

Parents and nurses reported reduced anxiety, discomfort, and procedure problems for children in the midazolam group and would prefer the same medication at next procedure. They also reported pain reduction. Children reported reduced anxiety and procedure problems but reduction of pain and discomfort was not significant. No serious or unexpected side effects occurred. Nasal discomfort was the most common side effect (17/38≈45%) and the primary reason for dropouts (8/43≈19%).

Anxiety varied with age but not with gender. When anxiety increased, the differences between midazolam and placebo increased.

Conclusion.

Nasal midazolam spray offers relief to children anxious about procedures, such as insertion of a needle in a subcutaneously implanted intravenous port, venous blood sampling, venous cannulation, etc. Its use, however, may be limited by nasal discomfort in some patients for whom rectal and oral routes might be alternatives.
Extensive Swelling After Booster Doses of Acellular Pertussis–Tetanus–Diphtheria Vaccines
Authors: Rennels Margaret B. , Deloria Maria A. , Pichichero Michael E. , Losonsky Genevieve A. , Englund Janet A. , Meade Bruce D. , Anderson Edwin L. , Steinhoff Mark C. , Edwards Kathryn M.
Published: August 2004

Background.

Diphtheria and tetanus toxoid combined with acellular pertussis (DTaP) vaccines are less reactogenic than diphtheria and tetanus toxoid combined with whole cell pertussis (DTwP) vaccines. However, local reactions increase in rate and severity with each successive DTaP dose, and swelling of the entire injected limb has been reported after booster doses.

Methods.

We reviewed reports of swelling of the entire thigh or upper arm after the fourth and fifth dose, respectively, of DTaP vaccines administered in the National Institutes of Health multicenter comparative DTaP studies. Relationships were explored among reports of severe swelling, rates of other reactions, quantity of vaccine contents, and prevaccination and postvaccination antibody levels to pertussis toxin, tetanus toxin, and diphtheria toxin.

Results.

Entire thigh swelling was an unsolicited reaction reported in 20 (2%) of the 1015 children who received 4 consecutive doses of the same DTaP vaccine. The reaction was associated with 9 of the 12 DTaP vaccines evaluated. Although there were no reports of swelling of the entire upper arm in 121 children given a fifth dose of the same DTaP, 4 (2.7%) of 146 recipients of 5 doses of a mixed schedule of DTaP vaccines experienced such swelling. Rates of other reactions were higher in children with entire thigh swelling than in those without. Of the children with entire thigh swelling, 60% had local pain, and 60% had erythema. All swelling subsided spontaneously without sequelae. There was a significant linear association between the rates of entire thigh swelling after dose 4 and diphtheria toxoid content in the DTaP products. Lesser degrees of swelling (>50 mm but less than entire limb) correlated with pertussis toxoid content after dose 4 and aluminum content after dose 5. No relationship was established between levels of serum antibody to diphtheria, tetanus, or pertussis toxin and rates of swelling of the whole thigh.

Conclusions.

Booster doses of DTaP vaccines can cause entire limb swelling, which is usually associated with redness and pain. Our data suggest that this extensive swelling reaction may be more common with vaccines containing high diphtheria toxoid content.
Skin-to-Skin Contact Is Analgesic in Healthy Newborns
Authors: Gray Larry , Watt Lisa , Blass Elliott M.
Published: August 2004

Objectives.

To determine whether skin-to-skin contact between mothers and their newborns will reduce the pain experienced by the infant during heel lance.

Design.

A prospective, randomized, controlled trial.

Setting.

Boston Medical Center, Boston, Massachusetts.

Participants.

A total of 30 newborn infants were studied.

Interventions.

Infants were assigned randomly to either being held by their mothers in whole body, skin-to-skin contact or to no intervention (swaddled in crib) during a standard heel lance procedure.

Outcome Measures.

The effectiveness of the intervention was determined by comparing crying, grimacing, and heart rate differences between contact and control infants during and after blood collection.

Results.

Crying and grimacing were reduced by 82% and 65%, respectively, from control infant levels during the heel lance procedure. Heart rate also was reduced substantially by contact.

Conclusion.

Skin-to-skin contact is a remarkably potent intervention against the pain experienced during heel stick in newborns.
Childhood Obesity and Self-Esteem
Authors: Strauss Richard S.
Published: August 2004

Background.

Although childhood obesity may have detrimental consequences for childhood self-esteem, the prevalence and magnitude of this problem is controversial. In addition, the social and emotional effects of decreased self-esteem in obese children are unknown.

Methods.

A total of 1520 children, 9 to 10 years of age, born to mothers in the National Longitudinal Survey of Youth were studied. Comprehensive demographic data including race and family income were available in 97% of the cohort. Self-esteem was measured using Self-Perception Profile for Children. The 4-year follow-up Self-Perception Profile for Children scores were available in 79% of the children. Obesity was defined as a body mass index greater than the 95th percentile for age and gender. Additional data include a self-administered questionnaire at 13 to 14 years of age concerning emotional well being, smoking, and alcohol consumption. Data were stratified by race and gender. The data were weighted to reflect a nationally representative sample of children born to mothers 17 to 28 years of age.

Results.

Scholastic and global self-esteem scores were not significantly different among 9- to 10-year-old obese and nonobese children. However, over the 4-year period, obese Hispanic females and obese white females showed significantly decreased levels of global self-esteem compared with nonobese Hispanic females and nonobese white females, respectively. Mild decreases in self-esteem also were observed in obese boys compared with nonobese boys. As a result, by 13 to 14 years of age, significantly lower levels of self-esteem were observed in obese boys, obese Hispanic girls, and obese white girls compared with their nonobese counterparts. Decreasing levels of self-esteem in obese children were associated with significantly increased rates of sadness, loneliness, and nervousness compared with obese children whose self-esteem increased or remained unchanged. In addition, obese children with decreasing levels of self-esteem over the 4-year period were more likely to smoke and drink alcohol compared with obese children whose self-esteem increased or remained unchanged.

Conclusion.

Obese Hispanic and white females demonstrate significantly lower levels of self-esteem by early adolescence. In addition, obese children with decreasing levels of self-esteem demonstrate significantly higher rates of sadness, loneliness, and nervousness and are more likely to engage in high-risk behaviors such as smoking or consuming alcohol.
Injury Prevention Education Using Pictorial Information
Authors: Powell Elizabeth C. , Tanz Robert R. , Uyeda Andrew , Gaffney Mary Beth , Sheehan Karen M.
Published: August 2004

Background.

Written materials used in pediatric public health settings often exceed the reading skills of caretakers.

Objective.

To compare a pictorial anticipatory guidance (PAG) sheet requiring limited reading skills to a TIPP (The Injury Prevention Program) sheet for providing injury prevention information to low-income urban families.

Design and Setting.

A convenience sample of families with children treated at an urban pediatric clinic affiliated with a teaching hospital.

Methods.

Parents of children ≤6 years old received either a PAG sheet or a TIPP sheet during a well-child care clinic visit; parents of children seen in the morning clinic received a PAG sheet and those seen during the afternoon clinic a TIPP sheet. All also received injury prevention counseling by a clinic nurse. The recall of injury prevention information was assessed by telephone questionnaire 14 to 28 days after the clinic encounter.

Results.

We interviewed 66 parents (57% of families enrolled): 46 were in the PAG group and 20 in the TIPP group. There were no differences between groups in mean parent age, percent minority race, or percent public aid. Eighty-seven percent of PAG and 100% of TIPP parents recalled receiving an information sheet; 17% of PAG and 20% of TIPP parents could recall no specific injury topics. The mean number of topics recalled was 2.1 ± 1.5 from parents in the PAG group and 1.6 ± 1.1 from those in the TIPP group. No specific injury topic was recalled by more than half the parents in either group.

Conclusions.

Recall of injury information several weeks after a clinic visit is limited. The use of PAG sheets did not improve recall; lack of literacy is not the sole cause of poor recall. Successful injury prevention counseling in this population may require comprehensive and repetitive efforts.
The Use of School-Based Vaccination Clinics to Control Varicella Outbreaks in Two Schools
Authors: Hall Susan , Galil Karin , Watson Barbara , Seward Jane
Published: August 2004

School-based vaccination clinics were offered in 2 schools experiencing varicella outbreaks. The clinics raised coverage of susceptible children from 52.9% to 92.2% and from 68.8% to 85.3% in the 2 schools, respectively. Although routine immunization and school-entry requirements are the best strategies for preventing outbreaks, school-based vaccination clinics may greatly increase coverage and shorten outbreaks.
The Relationship Between Social Stratification and All-Cause Mortality Among Children in the United States: 1968–1992
Authors: DiLiberti John H.
Published: August 2004

Background.

US childhood poverty rates have increased for most of the past 2 decades. Although overall mortality among children has apparently fallen during this interval, these aggregate mortality rates may hide a disproportionate burden imposed on the least advantaged. This study assessed the impact of social stratification on long-term US childhood mortality rates and examined the temporal relationship between mortality attributable to social stratification and childhood poverty rates.

Methods.

Using US childhood mortality data obtained from the Compressed Mortality File (National Center for Health Statistics) and a county-level measure of social stratification (residential telephone availability), I evaluated the impact of social stratification on long-term trends (1968–1992) in age-adjusted mortality and compared the resulting attributable proportions to trends in childhood poverty rates.

Results.

Between 1968 and 1987 the proportion of US childhood deaths attributable to social stratification decreased from .22 to .17. Subsequently, it increased to .24 in 1992, despite continuous declines in overall childhood mortality rates. These proportions correlated strongly with earlier childhood poverty rates, taking into account an apparent 9-year lag. Among black children comparable trends were not observed, although throughout this time period their mortality rates were far higher than among the rest of the population and declined more slowly.

Conclusions.

Despite declining childhood mortality rates between 1968 and 1992, children living in the least advantaged counties continued to die at higher rates than those living in the most advantaged counties. This differential worsened considerably after 1987, and by 1992 had a substantive impact on US life expectancy at birth, resulting in perhaps the most significant (in terms of years of life lost) reversal in the health of the US public in the 20th century.
Does Sensitization to Contact Allergens Begin in Infancy?
Authors: Bruckner Anna L. , Weston William L. , Morelli Joseph G.
Published: August 2004

Objective.

Because previous studies have found allergic contact sensitization common in children by 5 years of age, our aim was to determine the prevalence of positive epicutaneous test results in children <5 years of age and to determine whether sensitization to contact allergens was as common in infancy.

Methods.

We recruited 95 asymptomatic children 6 months to 5 years of age from well-child visits at Denver area pediatric practices for epicutaneous patch testing using the T.R.U.E. Test system. Allergens were placed on the skin for 48 hours, and at a later follow-up visit, positive reactions were evaluated.

Results.

A total of 85 patients completed the study. Of these, 20 (24.5%) had 1 or more positive reactions to the tested allergens. Positive reactors ranged from 6 to 65.5 months of age, with an average of 30.4 months of age. Of the children, 16 reacted to 1 allergen, and 4 reacted to 2. Eleven positive reactions were observed to nickel, followed by 8 to thimerosal. Other positive reactions were to neomycin, cobalt, and kathon CG.

Conclusions.

Children as young as 6 months of age may be sensitized to contact allergens. Within this pediatric population, the prevalence of sensitization is 24.5%. Sensitization to contact allergens may occur in infants.
Granulocyte Colony-Stimulating Factor Is Present in Human Milk and Its Receptor Is Present in Human Fetal Intestine
Authors: Calhoun Darlene A. , Lunøe Mathilde , Du Yan , Christensen Robert D.
Published: August 2004

Objective.

Human milk provides neonates with a meaningful degree of protection from infection, but the responsible mechanisms are not well understood. Discovering these mechanisms is important, because of the possibility of supplementing infant formulas with factors that simulate human milk's protective capacity. We postulated that granulocyte colony-stimulating factor (G-CSF), a cytokine known to augment antibacterial defenses through its salutory effect on neutrophil production, might be one such factor. To test this hypothesis, we quantified G-CSF in milk of healthy women and those with intraamniotic infection, and sought the presence of functional G-CSF receptors (G-CSF-R) in fetal/neonatal intestinal villi.

Study Design.

G-CSF was measured by enzyme-linked immunoassay in 126 milk samples obtained from breast-feeding women, and the concentrations were analyzed according to gestational age, postpartum day of collection (first 2 days vs greater 2 days), and the presence versus absence of intraamniotic infection. G-CSF-R messenger ribonucleic acid transcripts were sought from fetal/neonatal intestine using reverse transcriptase polymerase chain reaction, and localized using in situ RT-PCR. G-CSF-R protein, and specific intracellular signaling proteins (Janus tyrosine kinase-1, Janus tyrosine kinase-2, and tyrosine kinase-2), were sought by immunohistochemistry.

Results.

All milk samples contained G-CSF, and significantly more G-CSF was contained in milk collected during the first 2 postpartum days than during subsequent days. Milk from women who delivered prematurely had less G-CSF during the first 2 postpartum days than milk from women who delivered at term. When intraamniotic infection was present, the concentration of G-CSF in milk was elevated significantly compared with concentrations in milk of noninfected women. G-CSF concentrations were also higher in milk collected during the first 2 postpartum days from women who had received intrapartum recombinant G-CSF treatment, compared with milk obtained from women with intraamniotic infection, regardless if they delivered prematurely or at term. G-CSF-R messenger ribonucleic acid and protein were expressed on fetal villus enterocytes, and Janus tyrosine kinase-1, Janus tyrosine kinase-2, and tyrosine kinase-2 were present within the cytoplasm of these cells.

Conclusions.

Human milk contains substantial quantities of G-CSF. G-CSF-R are abundant on villus enterocytes, and specific proteins associated with G-CSF-R signaling are present in these cells.
Influence of Congenital Heart Disease on Mortality After Noncardiac Surgery in Hospitalized Children
Authors: Baum Victor C. , Barton David M. , Gutgesell Howard P.
Published: August 2004

Objective.

To evaluate the incremental risk of congenital heart disease on mortality after noncardiac surgery in children.

Design.

We reviewed the clinical information network database of the University Hospital Consortium for the period January 1, 1993, through December 31, 1996, and identified 191 261 patients <18 years old having 1 or more noncardiovascular surgical procedures. Of these patients, 6.5% had a diagnosis of congenital heart disease. Patients having ambulatory surgery are excluded from this database. Short-term (1-, 2-, and 3-day) and 30-day mortality were compared, as well as mortality for neonates, infants (31 days to 1 year), and older children (1–17 years); mortality for the 100 most common surgical procedures, mortality for 10 relatively minor surgical procedures, and mortality in subgroups of patients with minor versus severe cardiac diagnoses.

Results.

Short-term and 30-day mortality was increased in the patients with congenital heart disease patients (30-day mortality odds ratio 3.5; 95% confidence limit, 3.2–3.9). Mortality was also increased in patients with congenital heart disease in the 2 youngest age groups, for the 100 most common operations, and for 10 relatively minor operations. Children with more severe heart disease diagnoses had higher mortality than did children carrying less serious cardiac diagnoses.

Conclusion.

A diagnosis of congenital heart disease adds significant incremental risk of mortality in children requiring inpatient noncardiovascular surgery. This outcome difference is present for both minor and major surgical procedures, and regardless of whether mortality is measured at 1, 3, or 30 days. The incremental risk is greatest in neonates and infants where the presence of congenital heart disease is associated with a 2-fold increase in mortality from noncardiac surgery.
Changes in Mesenteric Blood Flow Response to Feeding: Conventional Versus Fiber-optic Phototherapy
Authors: Pezzati Marco , Biagiotti Roberto , Vangi Venturella , Lombardi Enrico , Wiechmann Lisa , Rubaltelli Firmino F.
Published: August 2004

Objective.

To evaluate whether fiberoptic phototherapy influences the postprandial increase in mesenteric blood flow velocity similarly to conventional phototherapy in preterm infants.

Patients and Methods.

With the use of Doppler color ultrasonography, blood flow velocity in the superior mesenteric artery was measured both preprandially and postprandially in 19 preterm infants during and after conventional phototherapy, and in 20 preterm infants during and after fiber-optic phototherapy. The mean arterial blood pressure/mean flow velocity ratio was calculated as an estimate of relative vascular resistance of the superior mesenteric artery.

Results.

The study shows that conventional phototherapy blunts the postprandial mesenteric blood flow response to feeding in preterm infants. Furthermore, it shows that the postprandial increase in intestinal blood flow is not attenuated when fiber-optic phototherapy is administered, and that such postprandial increase of blood flow is significantly greater than in infants receiving conventional phototherapy. During and after fiber-optic phototherapy, a significant reduction in postprandial relative vascular resistance was found; such reduction was significantly greater than during conventional phototherapy.

Conclusions.

Fiber-optic phototherapy is preferable to conventional phototherapy for the treatment of hyperbilirubinemia in preterm infants because it does not affect the physiologic postprandial redistribution of blood flow from the periphery to the gastrointestinal system as does conventional phototherapy.
Can Peak Expiratory Flow Predict Airflow Obstruction in Children With Asthma?
Authors: Eid Nemr , Yandell Ben , Howell Laura , Eddy Martha , Sheikh Shahid
Published: August 2004

Study Objectives.

A recent trend in the treatment of asthma has been the widespread, independent use of peak expiratory flow (PEF). We examined whether PEF monitoring creates inaccuracies in assessment of children with moderate to severe asthma.

Methods.

We compared the negative predictive value of PEF in relation to the forced expiratory volume in 1 second (FEV1), and to the forced expiratory flow between 25% and 75% of the vital capacity (FEF25–75%) at different levels of air trapping as determined by the residual volume over total lung capacity ratio (RV/TLC).

Results.

The study included 244 patients, ages 4 to 18 years with all classes of asthma severity, with FEV1ranging from 28% to 134% of predicted value. We analyzed 367 sets of pulmonary function tests performed throughout a 3-year period. Thirty percent of patients with a normal PEF value had an abnormal FEV1 or FEF25–75%. As air trapping increased, the ability of a normal PEF to predict normal FEV1 and FEF25–75% readings fell from 83% to 53%. The negative predictive value was significantly lower for patients with RV/TLC ratio >30 compared with patients with RV/TLC <30.

Conclusions.

The results of this study suggest that it might be possible to identify children for whom the PEF is likely to give false-negative results. As air trapping increases, it causes the PEF to give misleading reassurance of normal pulmonary function. Furthermore, poor predictiveness of PEF is obtained when values 80% of predicted for age are considered normal.
The Incidence of Necrotizing Enterocolitis After Introducing Standardized Feeding Schedules for Infants Between 1250 and 2500 Grams and Less Than 35 Weeks of Gestation
Authors: Kamitsuka Michael D. , Horton Mary K. , Williams Michelle A.
Published: August 2004

Objective.

To evaluate the incidence of necrotizing enterocolitis (NEC) after implementing standardized feeding schedules.

Method.

This was a cohort study, which retrospectively reviewed the incidence of NEC for a 3-year period before implementing feeding schedules and prospectively evaluated the incidence of NEC for a 3-year period after implementing feeding schedules in infants with birth weights between 1250 and 2500 g and <35 weeks' gestation. The feeding schedules were comprised of 3 parts. First, no group was fed within the first 24 hours of life. Feeds were started between 24 to 72 hours of life based on birth weight. Second, the initial feed was full-strength breast milk or half-strength formula. Half-strength formula was changed to full-strength formula on the fourth day for all groups. Third, the daily feeding volume increase was no greater than 20 mL/kg for all groups.

Results.

In the 477 infants before the feeding schedules, there were 23 (4.8%) cases of definite NEC defined as pneumatosis on abdominal film or NEC confirmed at the time of surgery, and in the 466 infants after the feeding schedules, there were 5 (1.1%) cases of NEC. Before the feeding schedules, those who developed NEC started feeds sooner 1.5 ± 1.5 (± standard deviation [SD]) days versus 3.0 ± .7 (±SD) days, reached full feeds sooner 4.0 ± 1.8 (± SD) days versus 9.8 ± .5 (±SD) days and were more likely to have been started on formula than those who developed NEC after implementing the feeding schedules. The mean time for NEC to occur after the feeding schedules increased from 5.9 ± 4.1 (±SD) days to 19.4 ± 16.3 (± SD) days, although not statistically significant. The number of mothers who received prenatal steroids increased after the feeding schedules. The number of infants with NEC, however, significantly decreased whether their mothers were pretreated with steroids. The risk of NEC was reduced 84% after the introduction of feeding schedules as determined by multiple logistic regression analysis and adjusting for confounding by birth weight, white race, prenatal steroid exposure, day of life of first feed, day of life to reach full feeds, and breast milk.

Conclusion.

The incidence of NEC was significantly decreased after the implementation of standardized feeding schedules, which was independent of birth weight, prenatal steroid exposure, breast milk, day of life of first feed, and the number of days to reach full feeds.
Granulocyte Colony-Stimulating Factor Serum and Urine Concentrations in Neutropenic Neonates Before and After Intravenous Administration of Recombinant Granulocyte Colony-Stimulating Factor
Authors: Calhoun Darlene A. , Lunøe Mathilde , Du Yan , Hutson Alan D. , Veerman Mark , Christensen Robert D.
Published: August 2004

Background.

Recombinant granulocyte colony-stimulating factor (rG-CSF) has been suggested as a treatment for certain varieties of neonatal neutropenia, but little is known about the pharmacologic disposition of rG-CSF in that population.

Methods.

Ten neutropenic neonates were treated with rG-CSF, 10 μg/kg intravenously once daily for 3 to 5 days. Serum and urine samples were obtained before rG-CSF dosing and at intervals thereafter for G-CSF quantification by enzyme-linked immunosorbent assay.

Results.

Five of the neutropenic neonates (termed group 1) were not infected but likely had hyporegenerative neutropenia (4 were born after pregnancy-induced hypertension/intrauterine growth restriction, and 1 had Rh hemolytic disease). Five other infants (group 2) had neutropenia accompanying bacterial sepsis and shock. Before receiving the first dose of rG-CSF, endogenous G-CSF serum and urine concentrations were relatively low in group 1, averaging 130 pg/mL (range: 48–209) in serum and 53 pg/mL (range: 15–141) in urine. Serum concentrations immediately before the final dose were much higher (range: 81–24 835 pg/mL), whereas urine concentrations were unchanged (range: <7 pg/mL–126 pg/mL). In group 2 patients, before receiving the first-dose of rG-CSF, endogenous concentrations were very high, averaging 59 575 pg/mL (range: 20 028–98 280) in serum and 3189 pg/mL (range: 23–4770) in urine. Predose serum concentrations before the final dose (range: 427–14 460 pg/mL) were lower than before the first dose. The area under the concentration curve after the first dose of rG-CSF administration in group 1 was significantly lower than after the first dose in group 2, but no difference in area under the concentration curve was observed between groups 1 and 2 after the last dose of rG-CSF.

Speculation.

The principal means of clearing G-CSF from the serum is by saturable binding to specific G-CSF receptors (G-CSF-Rs). Therefore, the very high G-CSF serum and urine concentrations of group 2 patients before the first rG-CSF dose implies that their G-CSF-Rs were saturated before the dose was given. We speculate that if G-CSF-Rs are saturated with endogenous G-CSF, treatment with rG-CSF will add little or nothing to the granulocytopoietic effort. On this basis, we judge that neonates with septic shock and neutropenia are unlikely to derive benefit from rG-CSF administration.
Unintentional Pediatric Superwarfarin Exposures: Do We Really Need a Prothrombin Time?
Authors: Mullins Michael E. , Brands Christina L. , Daya Mohamud R.
Published: August 2004

Objective.

To determine whether routine follow-up coagulation studies are useful in children with accidental exposures to rodenticides containing superwarfarin compounds.

Design.

Retrospective review of poison center charts involving pediatric superwarfarin exposures occurring in two 2-year periods.

Setting.

An American Association of Poison Control Centers-certified regional poison control center with an annual call volume of 55 000 calls per year from a 2-state area with a combined population of 4 million people.

Outcome Measures.

Prothrombin times and/or international normalized ratios and reported clinical signs of excessive anticoagulation after exposure.

Results.

Of 542 children in 4 years of data collection, follow-up prothrombin times and/or international normalized ratios measurements did not detect any significant coagulation abnormalities. No child developed bleeding complications. No child required or received antidotal treatment with vitamin K.

Conclusion.

Normal preschool-aged children with unintentional acute exposures to superwarfarin rodenticides do not require any routine follow-up laboratory studies and do not require any medical intervention.
Liver Failure Attributable to Hepatitis A Virus Infection in a Developing Country
Authors: Shah Uzma , Habib Zehra
Published: August 2004

In young children hepatitis A virus (HAV) infections are usually subclinical events. However, HAV is also associated with progressive hepatic failure and even death in some patients. This study was undertaken to characterize the course of hepatitis A-related acute liver failure in children from a developing country where hepatitis A is endemic and produces significant morbidity.

Patients <15 years of age with confirmed hepatitis A, seen at the Aga Khan University Hospital between January 1991 and August 1998 were identified using the patient registry. Of the 2735 patients seen with hepatitis A, 232 were admitted to the hospital. Of these 30 patients developed progressive hepatic dysfunction and liver failure. During this period, 45 children were admitted with liver failure attributable to other causes. Of the patients admitted with hepatitis A-related liver failure, 25 (83.3%) were encephalopathic at presentation and 36.7% of the patients died. The prothrombin time was the most significant predictor of survival. There was a significant difference between those who survived and those who died on discriminant analysis with respect to age, grade of hepatic encephalopathy, duration of hospitalization, prothrombin time, and duration of jaundice when taken as a group.

There is a striking prevalence of liver dysfunction progressing to hepatic failure among children seen at a hospital in Karachi, Pakistan. This study demonstrates the significant morbidity and mortality that can attend HAV infections in children in a developing country despite tertiary medical facilities. The risk of HAV and its sequelae could probably be effectively reduced in these settings with improved sanitation and universal immunization.