bluuebunny/crossref_metadata_2025 huggingface dataset:
Sequelae of Severe Respiratory Syncytial Virus Infection in Infancy and Early Childhood Among Alaska Native Children
Authors: Singleton Rosalyn J. , Redding Greg J. , Lewis Toby C. , Martinez Patricia , Bulkow Lisa , Morray Barbara , Peters Helen , Gove James , Jones Carol , Stamey David , Talkington Deborah F. , DeMain Jeffrey , Bernert John T. , Butler Jay C.
Published: August 2004

Objective. In 1993–1996, we conducted a nested case-control study to determine risk factors for hospitalization with respiratory syncytial virus (RSV) infection among Alaska Native infants and young children. In the current study, we returned to former RSV case-patients and their control subjects during 1999–2001 to determine whether children who are hospitalized with RSV at <2 years of age are more likely to develop chronic respiratory conditions.

Methods. For each former RSV case-patient and control subject from remote villages in southwest Alaska, we reviewed medical records, interviewed parents, performed physical examinations and spirometry, collected sera, and analyzed chest radiographs. Case-patients were identified through surveillance for RSV hospitalization, and matched control subjects without lower respiratory infection (LRI)-related hospitalization were identified.

Results. Hospitalization for RSV infection was associated with a significant increase in wheezing, LRIs, and asthma diagnosis during the first 4 years of life. The association decreased with age and was no longer significant by 5 years of age. However, hospitalization for RSV infection was associated with increased respiratory symptoms and increased chronic productive cough at 5 to 8 years of age. Children who were hospitalized with RSV were not more likely at follow-up to have allergies, eczema, or a positive family history of asthma.

Conclusions. Severe RSV infection in infancy may produce airway injury, which is manifested in chronic productive cough with or without wheezing and recurrent LRIs. Although the association of RSV infection with wheezing seems to be transient, children remain at higher risk for chronic productive cough at 5 to 8 years of age. RSV prevention modalities may prevent sequelae that occur early and later in childhood.
Resuscitation of Newborn Infants With 21% or 100% Oxygen: Follow-Up at 18 to 24 Months
Authors: Saugstad Ola D. , Ramji Siddarth , Irani Simin F. , El-Meneza Safaa , Hernandez Emil A. , Vento Maximo , Talvik Tiina , Solberg Rønnaug , Rootwelt Terje , Aalen Odd O.
Published: August 2004

Objective. To follow-up children who had been resuscitated at birth with either 21% or 100% oxygen (O2).

Methods. A multicenter study with 10 participating centers recruited 609 infants to the Resair 2 study where resuscitation was performed with either 21% or 100% O2. A follow-up between ages 18 and 24 months was performed. However, during follow-up registration, it was found that 18 infants had been enrolled twice in the original Resair 2 study with different registration numbers, leaving 591 enrolled in the Resair 2 study and 410 enrolled in the 7 centers participating in the follow-up. Of these 410 infants, 79 died (76 in the neonatal and 3 in the postneonatal period). Furthermore, for 8 infants informed consent was not obtained, leaving 323 eligible for follow-up. Of these, 213 infants (66%) were followed-up: 91 (62%) had been resuscitated with 21% O2, and 122 (69%) with 100% O2. At a median age of 22 and 20 months (not significant) in the 21% and 100% groups, respectively, a simple questionnaire was filled out and neurologic assessment was performed in addition to measuring anthropometric data.

Results. There were no significant differences in weight, height, or head circumference between the 2 groups. Cerebral palsy developed in 10% and 7%, respectively, in the 2 groups (not significant). In total, 11 cases (12%) in the 21% versus 11 cases (9%) in the 100% O2 group (odds ratio: 1.39, 95% confidence interval: 0.57–3.36) developed cerebral palsy and/or mental or other delay. Furthermore, it was concluded that 14 (15%) in the 21% group and 12 (10%) in the 100% group were not normal (odds ratio: 1.67, 95% confidence interval: 0.73–3.80).

Conclusions. There were no significant differences in somatic growth or neurologic handicap at an age of 18 to 24 months in infants resuscitated with either 21% or 100% O2 at birth. Based on these data, resuscitation with ambient air seems to be safe, at least in most cases. More studies are needed to settle this issue.
Learning, Cognitive, and Attentional Problems in Adolescents Born Small for Gestational Age
Authors: O’Keeffe Michael J. , O’Callaghan Michael , Williams Gail M. , Najman Jake M. , Bor William
Published: August 2004

Objective. To determine whether the presence, severity, or symmetry of growth restriction in term infants is an independent risk factor for learning, cognitive, and attentional problems in adolescence.

Methods. A total of 7388 term infants have been followed prospectively since birth. At 14 years, 5059 mothers completed a Child Behavior Checklist and provided information on their child’s school progress. A total of 5051 adolescents completed a Youth Self Report, with 3703 also undergoing psychometric testing with Ravens Progressive Matrices and Wide Range Achievement Test (WRAT) reading subtest. Outcomes were compared on the basis of birth weight groups and measures of body symmetry and were adjusted for the level of social risk at birth.

Results. Adolescents who were born small for gestational age (SGA), when compared with their appropriately grown counterparts (>10th percentile), were more likely to experience learning difficulties, with a higher prevalence in those of birth weight ≤3rd percentile. Girls of birth weight ≤3rd percentile were more likely to have attentional problems and low WRAT reading scores. There was no significant difference in Ravens IQ or mean WRAT reading scores between SGA and non-SGA groups. There was no association between body symmetry and any of the outcomes studied.

Conclusions. SGA status seems to have only modest independent effects on learning, cognition, and attention in adolescence. Severity but not symmetry of growth restriction predicted learning difficulties.
Children’s Health Insurance Status and Emergency Department Utilization in the United States
Authors: Luo Xuemei , Liu Gordon , Frush Karen , Hey Lloyd A.
Published: August 2004

Objectives. Emergency department (ED) overcrowding has become a national problem. Children account for nearly 25% of overall ED visits. It has been reported that uninsured and publicly insured children are likely to visit the ED for urgent and nonurgent problems, yet it remains unclear to what extent health insurance status would influence children’s overall ED utilization or ED utilization for nonurgent problems at the national level after controlling for other confounding factors. The objective of this study was to examine the effect of health insurance status on children’s overall ED utilization and children’s ED utilization for nonurgent problems among the general pediatric population in the United States.

Methods. Secondary analysis of the household component of the 1997 Medical Expenditure Panel Survey on 10 193 children younger than 18 years. The main outcome measures were annual overall ED utilization and ED utilization for nonurgent problems.

Results. During 1997, 10.8% of children were uninsured for the entire year. A total of 17.5% of children were publicly insured the entire year, whereas 55.3% of children held private insurance the entire year. There were also 16.5% of children who were insured only part of the year. Without adjusting for covariates, publicly insured children were more likely to have an ED visit during the year than both privately insured children (unadjusted odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.03–1.55) and uninsured children (unadjusted OR: 1.46; 95% CI: 1.1–1.95). The difference between publicly insured and privately insured children (adjusted OR: 0.90; 95% CI: 0.70–1.16) and between publicly insured and uninsured children (adjusted OR: 1.12; 95% CI: 0.84–1.49) became insignificant after controlling for covariates. With or without adjustments for covariates, there was no significant difference in the likelihood of having an ED visit between privately insured and uninsured children. Similar to the utilization pattern of overall ED visits, publicly insured children were more likely to have a nonurgent ED visit than both privately insured (unadjusted OR: 1.86; 95% CI: 1.36–2.53) and uninsured children (unadjusted OR: 1.81; 95% CI: 1.15–2.84). Both differences disappeared after controlling for covariates. There was no significant difference in the likelihood of nonurgent ED visits between privately insured and uninsured children with or without adjustments for covariates.

Conclusions. Health insurance status was not associated with children’s overall ED use or children’s ED use for nonurgent problems at the national level. Our findings suggest that policy efforts in an attempt to relieve ED overcrowding conditions should look for measures beyond solely making changes in health insurance coverage for children.
The Natural Course of Infantile Pompe’s Disease: 20 Original Cases Compared With 133 Cases From the Literature
Authors: van den Hout Hannerieke M. P. , Hop Wim , van Diggelen Otto P. , Smeitink Jan A. M. , Smit G. Peter A. , Poll-The Bwee-Tien T. , Bakker Henk D. , Loonen M. Christa B. , de Klerk Johannis B. C. , Reuser Arnold J. J. , van der Ploeg Ans T.
Published: August 2004

Objective. Infantile Pompe’s disease is a lethal cardiac and muscular disorder. Current developments toward enzyme replacement therapy are promising. The aim of our study is to delineate the natural course of the disease to verify endpoints of clinical studies.

Methods. A total of 20 infantile patients diagnosed by the collaborative Dutch centers and 133 cases reported in literature were included in the study. Information on clinical history, physical examination, and diagnostic parameters was collected.

Results. The course of Pompe’s disease is essentially the same in the Dutch and the general patient population. Symptoms start at a median age of 1.6 months in both groups. The median age of death is 7.7 and 6 months, respectively. Five percent of the Dutch patients and 8% of all reported patients survive beyond 1 year of age. Only 2 patients from literature became older than 18 months. A progressive cardiac hypertrophy is characteristic for infantile Pompe’s disease. The diastolic thickness of the left ventricular posterior wall and cardiac weight at autopsy increase significantly with age. Motor development is severely delayed and major developmental milestones are generally not achieved. For the Dutch patient group, growth deviates significantly from normal despite start of nasogastric tube feeding. Levels of aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine kinase, or creatine kinase-myocardial band isoenzyme are typically elevated, although aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase increase significantly with age. The patients have fully deleterious mutations. Acid α-glucosidase activity is severely deficient.

Conclusions. Survival, decrease of the diastolic thickness of the left ventricular posterior wall, and achievement of major motor milestones are valid endpoints for therapeutic studies of infantile Pompe’s disease. Mutation analysis and measurement of the α-glucosidase activity should be part of the enrollment program.
Cadaver-Donor Renal Transplantation of Children in Israel (1990–2001): Racial Disparities in Health Care Delivery?
Authors: Drukker Alfred , Feinstein Sofia , Rinat Choni , Rotem-Braun Anat , Frishberg Yaacov
Published: August 2004

Objective. To evaluate the allocation and outcome of cadaver-donor renal transplantation (CDRTx) among Jewish and Arab children in Israel.

Methods. Data on CDRTxs in patients who had end-stage renal failure (ESRF), were younger than 18 years, and were on dialysis treatment were obtained for the 11-year period of January 1990 to December 2000 from the Israeli Dialysis and Transplant Registry, supplemented by 10 years of follow-up (January 1991–December 2000) from our own center.

Results. The Israeli Dialysis and Transplant Registry data show that 64 of 130 available cadaver-donor kidneys (CDKs) were allocated to Jewish patients (49.2%) and 66 of 130 were allocated to Arab children (50.8%): Moslem, Druze, or Christian. The Jew/Arab patient ratio for a waiting time of <1 year was 0.97 and for 1 to 2 years was 1.45, whereas that ratio was 0.6 for 2 to 4 years and 2.0 for >4 years. The mean renal transplant score (RTx score), reflecting the urgency of the need for RTx of an ESRF patient, was identical for Jew and Arab: 4.93 and 4.96. Our own center data refer to 69 dialysis (47 Arabs and 22 Jews) and 4 predialysis patients younger than 18 years who underwent 78 RTxs. Eighteen Arab and 14 Jewish children from our center received 20 and 15 CDRTxs in Israel, with a mean waiting time of 29.6 and 25.4 months for Jew and Arab, respectively (ratio: 1.16). In our center, the outcome (after 7 years) of graft survival and function was not different between Jewish and Arab RTx recipients.

Conclusions. Allocation of CDRTxs between young Jewish and Arab ESRF patients on dialysis did not differ and was associated with comparable waiting times, identical RTx scores, and similar long-term outcome. This is a remarkable finding, certainly in the face of the unequal race allocation of RTxs in the United States as well as the long unstable local (Middle East) political situation.
Randomized Trial of Prolonged Low-Dose Versus Conventional-Dose Indomethacin for Treating Patent Ductus Arteriosus in Very Low Birth Weight Infants
Authors: Lee Jiun , Rajadurai Victor Samuel , Tan Keng Wee , Wong Keng Yean , Wong Ee Hwee , Leong Joy Yoke Ngan
Published: August 2004

Objective. Indomethacin is used for closing the patent ductus arteriosus in premature infants. Prolonged low-dose indomethacin given over 6 days could potentially improve closure rates because ductal constriction is maintained long enough for more effective anatomic closure. We compared the efficacy of this regimen to conventional dosing in a cohort of very low birth weight infants.

Methods. In a 2-arm clinical trial, 140 infants were randomized to either conventional dose (0.2 mg/kg/dose every 12 hours for 3 doses) or prolonged low-dose indomethacin (0.1 mg/kg/dose daily for 6 doses). The primary outcome measure was ductal closure rate, and the secondary outcomes were the need for a second course of treatment, surgical ligation rates, and side effects.

Results. Ductal closure after 1 course of indomethacin was similar between the 2 groups: 68% for the conventional dose group and 72% for the prolonged low dose (mean difference −4%; 95% confidence interval: −19% to 11%). The incidence of transient oliguria was higher in the conventional dose group, 31% versus 9%. There was a trend toward more necrotizing enterocolitis in the prolonged low-dose group, 7.0% versus 1.4%.

Conclusions. There was no difference in efficacy between the 2 dosing regimens. In view of this and with its higher incidence of necrotizing enterocolitis, we do not recommend using prolonged low-dose indomethacin for closing the patent ductus arteriosus in very low birth weight infants.
Impact of the Rapid Diagnosis of Influenza on Physician Decision-Making and Patient Management in the Pediatric Emergency Department: Results of a Randomized, Prospective, Controlled Trial
Authors: Bonner Aleta B. , Monroe Kathy W. , Talley Lynya I. , Klasner Ann E. , Kimberlin David W.
Published: August 2004

Objective. To determine the impact of the rapid diagnosis of influenza on physician decision-making and patient management, including laboratory tests and radiographs ordered, patient charges associated with these tests, antibiotics/antivirals prescribed, and length of time to patient discharge from the emergency department.

Methods. Patients aged 2 months to 21 years presenting to an urban children’s teaching hospital emergency department were screened for fever and cough, coryza, myalgias, headache, and/or malaise. After obtaining informed consent, patients were randomized to 1 of 2 groups: 1) physician receives (physician aware of) the rapid influenza test result; or 2) physician does not receive (physician unaware of) the result. For patients in the physician aware group, nasopharyngeal swabs were obtained, immediately tested with the FluOIA test for influenza A and B, and the result was placed on the chart before patient evaluation by the attending physician. For the physician unaware group, nasopharyngeal swabs were obtained, stored according to manufacturer’s directions, and tested within 24 hours. Results for the physician unaware group were not disclosed to the treating physicians at any time. The 2 resultant influenza-positive groups (aware and unaware) were compared for laboratory and radiograph studies and their associated patient charges, antibiotic/antiviral prescriptions, and length of stay in the emergency department.

Results. A total of 418 patients were enrolled, and 391 completed the study. Of these, 202 tested positive for influenza. Comparison of the 96 influenza-positive patients whose physician was aware of the result with the 106 influenza-positive patients whose physician was unaware of the result revealed significant reductions among the former group in: 1) numbers of complete blood counts, blood cultures, urinalyses, urine cultures, and chest radiographs performed; 2) charges associated with these tests; 3) antibiotics prescribed; and 4) length of stay in the emergency department. The number of influenza-positive patients who received prescriptions for antiviral drugs was significantly higher among those whose physician was aware of the result.

Conclusions. Physician awareness of a rapid diagnosis of influenza in the pediatric emergency department significantly reduced the number of laboratory tests and radiographs ordered and their associated charges, decreased antibiotic use, increased antiviral use, and decreased length of time to discharge.
Medicaid Participation by Private and Safety Net Pediatricians, 1993 and 2000
Authors: Tang Suk-fong S. , Yudkowsky Beth K. , Davis Jean C.
Published: August 2004

Background. Eligibility expansions and managed care growth were 2 major forces shaping the Medicaid program during the 1990s. Although Medicaid managed care was introduced to contain rising costs of growing enrollment and expenditures, it also offered states an opportunity to improve enrollees’ access to mainstream health care providers. By enrolling in commercial managed care plans, they could gain access to private office-based physicians, thus eliminating a 2-tiered health care system.

Objectives. To investigate changes in private and safety net pediatricians’ participation in Medicaid between 1993 and 2000, a period noted for eligibility expansion for children and rapid managed care growth.

Design. Survey data collected from private and safety net pediatricians in 1993 and 2000 were analyzed to investigate how pediatricians’ Medicaid caseloads were affected by 1) their practice setting, and 2) whether they accepted all Medicaid patients.

Results. Pediatricians’ Medicaid caseloads increased significantly between 1993 and 2000, with those in private practice settings reporting greater increases. More pediatricians accepted all Medicaid patients in 2000, but Medicaid caseloads remained twice as high for safety net pediatricians. Medicaid caseloads increased dramatically for those accepting all Medicaid patients, except in safety net settings, where pediatricians who were turning away some Medicaid patients had heavier Medicaid caseloads than those who accepted all Medicaid patients.

Conclusions. Although Medicaid children were still disproportionately served in the safety net in 2000, their access to private pediatricians had improved since 1993. But a ceiling in the safety net’s capacity to absorb more Medicaid patients was suggested by the finding that safety net pediatricians turned away Medicaid patients as their Medicaid caseloads increased. Combined with decreasing participation by commercial plans in the Medicaid managed care market, increasing hospital emergency department overloads, and growing Title XXI Medicaid enrollments, interventions may be needed to avert a looming pediatric provider shortage for publicly insured low-income children.
Treating Exacerbations of Asthma in Children: The Role of Systemic Corticosteroids
Authors: Rachelefsky Gary
Published: August 2004

Objective. To review the use of systemic corticosteroids to treat recurrent, acute asthma episodes in children, with a focus on the role of oral corticosteroids.

Methods. A comprehensive review of the literature was performed using the Medline database (January 1966–October 2002) and the Embase database (January 1980–August 2002).

Results. The significant findings of 17 selected, controlled clinical trials of oral corticosteroids (OCSs) for acute exacerbations of asthma in children, compared with placebo or with other formulations of corticosteroids, can be summarized as follows: 1) OCSs are effective for the outpatient treatment of acute asthma, 2) pulmonary function tests may not be the best means of assessing the efficacy of OCSs for acute asthma, 3) early administration of OCSs for acute asthma reduces hospitalizations, 4) the critical factor for a positive outcome is early administration of the corticosteroid, and 5) OCSs are preferred for the outpatient treatment of acute asthma.

Conclusions. Early treatment of acute asthma symptoms with OCSs in children with a pattern of recurrent acute asthma may decrease the severity of acute asthma episodes and reduce the likelihood of subsequent relapses. Attention should be given to identifying these children and standardizing a treatment approach based on accepted, consistent definitions of what constitutes an asthma exacerbation and recurrence. A suggested protocol is described.
Recombinant Granulocyte Colony-Stimulating Factor Administered Enterally to Neonates Is Not Absorbed
Authors: Calhoun Darlene A. , Maheshwari Akhil , Christensen Robert D.
Published: August 2004

Granulocyte colony-stimulating factor (G-CSF) is present in liquids swallowed by the fetus and neonate; specifically, amniotic fluid, colostrum, and human milk. The swallowed G-CSF has local effects on enteric cells, which express the G-CSF receptor. However, some portion of the G-CSF ingested by the fetus and neonate might be absorbed into the circulation and have systemic actions, such as stimulating neutrophil production. To assess this possibility we sought to determine if circulating G-CSF concentrations of neonates increase after enteral administration of recombinant human granulocyte colony-stimulating factor (rhG-CSF). This was a single-center, prospective, blinded, randomized, 2 × 2 crossover study, with each infant receiving 1 dose of rhG-CSF (100 μg/kg) and 1 dose of placebo. Plasma G-CSF concentrations were measured at 2 and 4 hours after administration of the test solution. No significant change in plasma G-CSF concentration was observed after the enteral administration of rhG-CSF. On this basis, we conclude that orally administered rhG-CSF is not absorbed in significant quantities, and we speculate that the G-CSF swallowed by the fetus and neonate has local but not systemic effects.
Prevention of Pediatric Overweight and Obesity
Authors:   Committee on Nutrition
Published: August 2004

The dramatic increase in the prevalence of childhood overweight and its resultant comorbidities are associated with significant health and financial burdens, warranting strong and comprehensive prevention efforts. This statement proposes strategies for early identification of excessive weight gain by using body mass index, for dietary and physical activity interventions during health supervision encounters, and for advocacy and research.
Prevention of Medication Errors in the Pediatric Inpatient Setting
Authors:   Committee on Drugs and Committee on Hospital Care
Published: August 2004

This Policy Statement was retired May 2011.

Although medication errors in hospitals are common, medication errors that result in death or serious injury occur rarely. Even before the Institute of Medicine reported on medical errors in 1999, the American Academy of Pediatrics and its members had been committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults. This commitment includes designing health care systems to prevent errors and emphasizing the pediatrician’s role in this system. Human and device errors can lead to preventable morbidity and mortality. National and state legislative actions have heightened public awareness of these events. All involved persons, beginning with the physician and including every member of the health care team, must be better educated about and engaged in the several steps recommended to decrease these errors. The safe administration of medications to hospitalized infants and children requires additional specific safeguards that are above and beyond those for adult patients. Pediatricians should help hospitals develop effective programs for safely providing medications, reporting medication errors, and creating an environment of medication safety for all hospitalized pediatric patients.
Prevention of Drowning in Infants, Children, and Adolescents
Authors:   Committee on Injury, Violence, and Poison Prevention
Published: August 2004

Drowning is a leading cause of injury-related death in children. In 2000, more than 1400 US children younger than 20 years drowned. A number of strategies are available to prevent these tragedies. Pediatricians play an important role in prevention of drownings as educators and advocates.
Prevention of Drowning in Infants, Children, and Adolescents
Authors: Brenner Ruth A. ,   Committee on Injury, Violence, and Poison Prevention
Published: August 2004

Drowning is a leading cause of injury-related death in children. In 2000, more than 1400 US children younger than 20 years drowned. Most (91%) of these deaths were unintentional and were not related to boating. For each drowning death, it is estimated that at least 1 to 4 children suffer a serious nonfatal submersion event, many of which leave children with permanent disabilities. Environmental strategies, such as installation of 4-sided fences around swimming pools, and behavioral strategies, such as increased supervision of children while around water, are needed to prevent these tragedies.
Vitamin D, Cod-Liver Oil, Sunlight, and Rickets: A Historical Perspective
Authors: Rajakumar Kumaravel
Published: August 2004

Rickets, a disease of vitamin D deficiency, is rarely confronted by the practicing pediatrician in the United States today. At the turn of the 20th century, rickets was rampant among the poor children living in the industrialized and polluted northern cities of the United States. With the discovery of vitamin D and the delineation of the anti-rachitic properties of cod-liver oil by the 1930s, it became possible to not only treat but also eradicate rickets in the United States. Rickets was a common disease in 17th century England. Frances Glisson’s treatise on rickets published in 1650, a glorious contribution to English medicine, described the clinical and anatomic features of rickets in great detail. The exact etiology of rickets had been elusive until the 1920s. During the Glissonian era, rickets was a mysterious disease. By the late 19th and early 20th century, faulty diet or faulty environment (poor hygiene, lack of fresh air and sunshine) or lack of exercise was implicated in its etiology. Animal experiments, appreciation of folklore advocating the benefits of cod-liver oil, and the geographical association of rickets to lack of sunshine were all relevant factors in the advancement of knowledge in the conquest of this malady. In this article, the history of rickets pertaining to the discovery of vitamin D, cod-liver oil, and sunlight is reviewed.
Congenital Cytomegalovirus Infection in Twin Pregnancies: Viral Load in the Amniotic Fluid and Pregnancy Outcome
Authors: Lazzarotto Tiziana , Gabrielli Liliana , Foschini Maria Pia , Lanari Marcello , Guerra Brunella , Eusebi Vincenzo , Landini Maria Paola
Published: August 2004

Human cytomegalovirus (CMV) is the most common cause of viral intrauterine infection and fetal damage largely attributable to maternal primary infection. Most cases of congenital CMV infection in twins reported in the literature involved only 1 twin. We assessed the validity of polymerase chain reaction (PCR) and quantitative PCR on amniotic fluid (AF), at 21 to 22 weeks’ gestation and at least 6 to 8 weeks after seroconversion, to predict the outcome of newborns in twin pregnancies. Two pregnant women with twin pregnancies and 1 woman with a triple pregnancy with primary CMV infection defined by the presence of immunoglobulin (Ig) M and low IgG avidity and/or by the presence of clinical symptoms and abnormal liver enzyme values were evaluated. CMV infection was found in 6 fetuses/newborns, 3 of whom were symptomatic. In the first twin pregnancy with diamniotic-dichorionic separate placentas, CMV symptomatic infection of the female twin was demonstrated by positive virus isolation and high viral load in AF. The male fetus was not infected as demonstrated by negative CMV culture and DNA detection in AF. In the triple pregnancy, the woman had a placenta with 2 monozygotic twins (females) and a separate placenta with a heterozygotic twin (male). The quantitative PCR results were 103 genome equivalents (GE)/mL of females AF and 1.9 × 105 GE/mL of male AF. Both female twins were asymptomatic at birth, whereas the male presented petechiae, thrombocytopenia, and cerebral ventriculomegaly. In the last twin pregnancy with fused dichorionic placentas, congenital CMV infection of both twins was diagnosed at birth in contrast with prenatal diagnosis. At time of amniocentesis, the left side twin was not infected as shown by negative results of CMV culture and DNA detection in the AF. CMV infection of the right side twin was demonstrated by positive CMV DNA detection with a CMV DNA load of 4.9 × 104 GE/mL and positive virus isolation in the AF. The morphologic and histologic examinations of the placentas strongly supported a prenatal horizontal acquisition of CMV infection. These twin pregnancies showed a marked difference in the quantity of virus load documented by the prenatal diagnosis suggesting that twin fetuses may react differently to primary maternal infection despite being exposed to the same maternal influences. A high viral load is correlated with congenital CMV infections symptomatic at birth. In such cases, with fetal infection of only 1 twin (at amniocentesis) and fusion of placentas, fetal outcome of both twins needs to be evaluated for the possibility of viral transfer from one fetus to the other.
Congenital Methemoglobinemia: A Rare Cause of Cyanosis in the Newborn—A Case Report
Authors: Da-Silva Shonola S. , Sajan Imran S. , Underwood Joseph P.
Published: August 2004

Cyanosis is a physical finding that can occur at any age but presents the greatest challenge when it occurs in the newborn. The cause is multiple, and it usually represents an ominous sign, especially when it occurs in association with neonatal sepsis, cyanotic congenital heart disease, and airway abnormalities. Cyanosis caused by abnormal forms of hemoglobin can also be life-threatening, and early recognition is mandatory to prevent unnecessary investigations and delay in management. Abnormal hemoglobin, such as hemoglobin M, is traditionally discovered by electrophoresis, so the newborn screen, which is mandatory in several states, is a useful tool for the diagnosis. Although acquired methemoglobinemia, caused by environmental oxidizing agents, is common, congenital deficiency of the innate reducing enzyme is so rare that only a few cases are documented in the medical literature around the world. We present a neonate with cyanosis as a result of congenital deficiency of the reduced nicotinamide adenine dinucleotide-cytochrome b5 reductase enzyme. This infant was found to be blue at a routine newborn follow-up visit. Sepsis, structural congenital heart disease, prenatal administration, and ingestion of oxidant dyes were excluded as a cause of the cyanosis by history and appropriate tests. Chocolate discoloration of arterial blood provided a clue to the diagnosis. A normal newborn screen and hemoglobin electrophoresis made the diagnosis of hemoglobin M unlikely as the cause of the methemoglobinemia (Hb A 59.4%, A2 1.8%, and F 38.8%). Red blood cell enzyme activity and DNA analysis revealed a homozygous form of the cytochrome b5 reductase enzyme deficiency. He responded very well to daily methylene blue and ascorbic acid administration, and he has normal growth and developmental parameters, although he shows an exaggerated increase in his methemoglobin level with minor oxidant stress such as diarrhea.
Uninsured Children: How We Count Matters
Authors: Tang Suk-fong S. , Olson Lynn M. , Yudkowsky Beth K.
Published: August 2004

Background. Because children uninsured for less than a full year are often reported as insured, they receive less attention in health policy debates than do the full-year uninsured and are underrecognized as potential users of public insurance programs.

Objective. The purpose of this study is to assess the impact on estimates of how many US children are uninsured when alternatives to the full-year uninsured definition are used.

Methods. Monthly health insurance coverage data collected from children through age 18 in the 1999 Medical Expenditure Panel Survey were analyzed to estimate prevalence of health insurance gaps among children in terms of the size of part-year and full-year uninsured child population, duration of uninsured gaps, and aggregate uninsured spells.

Results. Although 6.6 million ([M] 8.4%) children in the United States were uninsured throughout 1999, an additional 11.4M (14.4%) were uninsured for part of the year. Part-year uninsured gaps accounted for 41.7% of a total of 130M months of missing coverage experienced by all children.

Conclusions. Different definitions and measures of who are uninsured can project radically different pictures of the magnitude of the problem. As this study shows, including the part-year uninsured more than doubled the estimated uninsured child population for 1999, and increased the estimated aggregate uninsured months by 71%. As potential users of public coverage, children who have no insurance for part of the year should be included when evaluating challenges to and accomplishments by the State Children’s Health Insurance Program and other public programs. Their significant numbers and the potential burden they place on the health care delivery system argue for them to be counted and for the causes and consequences of short-term uninsured spells to be better understood.
Long-Term Neuropsychologic and Health Outcomes of Children With Facial Nerve Palsy Attributable to Lyme Disease
Authors: Vázquez Marietta , Sparrow Sara S. , Shapiro Eugene D.
Published: August 2004

Background. There is little information about the long-term outcomes of children with facial nerve palsy attributable to Lyme disease, a group putatively at high risk for poor neurologic outcomes.

Objective. The purpose of this study is to assess the long-term neuropsychologic and health outcomes of children with facial nerve palsy attributable to Lyme disease.

Methods. We conducted a matched cross-sectional study of children with facial nerve palsy in Connecticut who met the Centers for Disease Control and Prevention national surveillance case definition for Lyme disease. We identified children with facial nerve palsy attributable to Lyme disease from population-based data for the state of Connecticut from 1984 to 1991 as well as from selected clinical practices from 1984 to 1998. For each case, 2 controls without Lyme disease, matched by age, were selected by sequential digit dialing technique. Both patients and controls (or their parents) were interviewed using structured questionnaires. Outcomes included self/parents’ reports both of symptoms and of abilities to perform normal daily activities since the diagnosis was made (or for an equivalent period of time for controls). In addition, the patients with facial nerve palsy attributable to Lyme disease were evaluated with a battery of neuropsychologic tests.

Results. Of the 43 patients, 30% were female and 93% were white. Median age at diagnosis was 8 years (range: 2–18 years). Mean time to follow-up was 49 months (range: 7–161 months). Of the patients, 16% had been treated parenterally with ceftriaxone and 84% had been treated orally with either doxycycline or amoxicillin. Overall, 79% believed they were cured of Lyme disease, 9% believed they were not cured, and 12% did not know. The proportions of patients and of matched controls that reported increased problems with normal daily activities (eg, exercise, academic performance, word recall, sleeping) were similar. Patients with facial nerve palsy attributable to Lyme disease were more likely than matched controls to report symptoms of neck pain, changes in behavior, pains in joints or muscles, numbness or funny sensations in nerves, and problems with memory, but three quarters of them did not attribute these problems to Lyme disease. Twenty patients agreed to undergo neuropsychologic testing; all had average to above average scores on tests of IQ (eg, mean IQ was 110.2), memory, learning, attention, concentration, math, reading and spelling performance, executive functioning, abstract thinking, sequential processing, visuospatial scanning, and motor speed. There were no apparent differences in outcomes between children who received oral versus parenteral treatment.

Conclusions. The neuropsychologic and health outcomes of children with facial nerve palsy attributable to Lyme disease 7 to 161 months earlier are comparable to those who did not have Lyme disease.
A Retrospective Cohort Study of the Association of Varicella Vaccine Failure With Asthma, Steroid Use, Age at Vaccination, and Measles-Mumps-Rubella Vaccination
Authors: Verstraeten Thomas , Jumaan Aisha O. , Mullooly John P. , Seward Jane F. , Izurieta Hector S. , DeStefano Frank , Black Steven B. , Chen Robert T. ,   the Vaccine Safety Datalink Research Group
Published: August 2004

Objective. Varicella breakthrough, the occurrence of varicella disease >42 days after vaccination, is indicative of vaccination failure. A sevenfold increased risk of breakthrough among vaccinated children with asthma was observed in a 1996 varicella outbreak in a child care center. More recent outbreak investigations have also identified age at vaccination as a potential risk factor for breakthrough. We assessed the association of varicella breakthrough with asthma, steroids, age at varicella vaccination, and timing of measles-mumps-rubella (MMR) vaccination.

Methods. We performed a retrospective cohort study among children born after 1993 and followed up through 1999 at 2 health maintenance organizations ([HMOs] A and B) in the United States. Information was obtained from automated vaccination, clinic, hospital discharge, and pharmacy records.

Results. We identified 268 and 97 breakthrough cases among 80 584 and 8181 children vaccinated against varicella at HMOs A and B, respectively. Varicella breakthrough was not associated with asthma, inhaled steroids prescribed at any time, and oral steroids prescribed before vaccination. An increased risk of varicella breakthrough was found in the 3 months immediately after prescription for oral steroids at HMO A (adjusted relative risk [aRR]: 2.4; 95% confidence interval [CI]: 1.3–4.4) and HMO B (aRR: 2.8; 95% CI: 1.0–7.8), when varicella vaccine was given before 15 months of age at HMO A (aRR: 1.4; 95% CI: 1.1–1.9), and when varicella vaccination followed MMR vaccine within 28 days at HMO A (aRR: 3.1; 95% CI: 1.5–6.4).

Conclusions. Varicella vaccine failure in children was not associated with asthma or the use of inhaled steroids, but with the use of oral steroids. Administration of varicella vaccine before the age of 15 months may be associated with a slightly increased risk of breakthrough disease. As currently recommended, varicella vaccination should not be administered for 28 days after MMR vaccination.
Kawasaki Syndrome Hospitalizations in the United States, 1997 and 2000
Authors: Holman Robert C. , Curns Aaron T. , Belay Ermias D. , Steiner Claudia A. , Schonberger Lawrence B.
Published: August 2004

Objective. To estimate the incidence and describe the epidemiologic characteristics of Kawasaki syndrome (KS) among children in the United States.

Methods. Hospital discharge records with a KS diagnosis among patients <18 years of age were obtained from the 1997 and 2000 Kids’ Inpatient Database and weighted to estimate the number and rate of KS-associated hospitalizations for the United States.

Results. In 2000, ∼4248 hospitalizations associated with KS occurred in the United States, and the median age of patients at admission was 2 years. Children <5 years of age accounted for 3277 of these KS hospitalizations (77%) and had a KS hospitalization rate of 17.1 per 100 000 children. This rate was similar to the 1997 rate of 17.6 per 100 000 children. The KS hospitalization rate was significantly higher for infants <1 year of age than for children 1 to 4 years of age (19.8 and 16.4 per 100 000 children, respectively). The rate of KS hospitalizations among children aged <5 years was highest among Asian and Pacific Islander children and was followed by the rate for black children (39.0 and 19.7 per 100 000 children, respectively). No deaths associated with KS were reported among hospitalized children. The median charge for a KS hospitalization was $7779 (mean $10 725) and the total annual charges for KS hospitalizations in 2000 were approximately $35 million among children <5 years of age.

Conclusions. Among children <5 years of age, the annual KS-associated hospitalization rates were similar for 1997 and 2000. The epidemiologic characteristics and hospitalization rates for KS at a national level were consistent with those reported from earlier studies, suggesting that the incidence for KS has not markedly changed in the United States during the past decade.
Guiding Medical Students Through the Match: Perspectives From Recent Graduates
Authors: Englander Robert , Carraccio Carol , Zalneraitis Edwin , Sarkin Richard , Morgenstern Bruce
Published: August 2004

Objective. Little has been written about the counseling of medical students as they go through the process of selecting and ranking residency programs for the National Resident Matching Program. The Association of Pediatric Program Directors (APPD) and the Council on Medical Student Education in Pediatrics jointly sought to evaluate the current status of advice and counseling for students going through the Match, and to elicit suggestions for improvement.

Methods. Surveys evaluating satisfaction with aspects of and advice received regarding the Match were sent to each of the 199 Accreditation Council for Graduate Medical Education accredited member programs of the APPD with a request that they be distributed to all first-year pediatric residents during the orientation process for the 2001–2002 academic year. Surveys were both voluntary and anonymous. Results were compiled by the administration of the APPD.

Results. We received responses from 42% of all US pediatric categorical or combined residents entering pediatric residency in July of 2001. Respondents included at least 1 representative from every US medical school. Ninety-seven percent of respondents were either very satisfied (88%) or somewhat satisfied (9%) with where they matched, whereas 82% were either very (42%) or somewhat (40%) satisfied with the advice they received regarding the match. The Fellowship and Residency Interactive Database, the faculty advisor, and resident-to-student counseling were the top 3 resources identified by the respondents. Of 12 resources listed in the survey, only the Green Book was rated as unhelpful. Four areas for improvement regarding the advising process were identified: timing, standardization, and quantity of advice and accuracy of online information resources, with specific suggestions given for each.

Conclusions. Overall, recent medical school graduates are quite satisfied with both where they matched in pediatrics and the process that got them there. However, several areas for improvement in the advising/counseling system were identified. Potential approaches to these concerns or resources to develop approaches to them were identified.
Influence of Insurance Status and Vaccine Cost on Physicians’ Administration of Pneumococcal Conjugate Vaccine
Authors: Davis Matthew M. , Ndiaye Serigne M. , Freed Gary L. , Kim Christopher S. , Clark Sarah J.
Published: August 2004

Objective. In 2000, heptavalent pneumococcal conjugate vaccine (PCV7) was recommended for children younger than 2 years, but its high cost relative to other universally recommended childhood immunizations and variability in insurance coverage for the vaccine raised concerns. We investigated the influence of PCV7 cost and insurance coverage on physician recommendation of PCV7 to their patients and administration of PCV7 in their practices.

Methods. We conducted a mail survey from April to July 2001 of a random sample of 833 pediatricians and 788 family physicians in 24 states with different vaccine financing strategies (Vaccines for Children [VFC]-only; enhanced VFC; universal purchase). Physicians specified the proportion of children in their practice with insurance coverage for PCV7, where they recommend administering PCV7, and whether they have concerns about the cost of PCV7.

Results. The response rate was 60%. Overall, 87% of physicians recommend PCV7 for children younger than 2 years (99% pediatricians; 68% family physicians). Among physicians who recommend PCV7, 98% said that they would administer the vaccine in their own practices for children whose insurance covers the vaccine. However, only 56% of physicians who recommend PCV7 reported that all children in their practices had insurance coverage for the vaccine, whereas 24% of physicians reported 86% to 99% of children with coverage and 20% reported ≤85% of children with coverage. Among physicians in the last group with the lowest PCV7 insurance coverage rates in their practices, only 44% said that they would administer the vaccine in their own practices to children without PCV7 coverage, compared with 62% of physicians who provide care to children with higher rates of PCV7 coverage. Physicians in states with VFC-only vaccine financing strategies for PCV7 are less likely to administer PCV7 in their own practices to children without coverage than physicians in states with enhanced VFC and universal purchase strategies (48% vs 64% vs 74%). Almost one third of physicians who recommend PCV7 are concerned about the cost of PCV7; those with cost concerns are more likely to recommend that children without insurance coverage for PCV7 receive the vaccine at a public health clinic rather than in their own practices (45% vs 29%). Physicians with cost concerns are also more likely to say that they now screen children for insurance coverage more than for previously recommended vaccines (52% vs 21% for physicians without cost concerns).

Conclusions. Nationwide, physician adoption of PCV7 recommendations is high, but where physicians recommend that PCV7 be administered differs significantly by children’s variable insurance coverage for the vaccine and by state vaccine financing strategies. Physicians’ concerns about the cost of PCV7 may foreshadow their responses to future children’s vaccines that may be even more expensive.