bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Three Courses of Maternally Administered Dexamethasone at 0.7, 0.75, and 0.8 of Gestation on Prenatal and Postnatal Growth in Sheep
Authors: Kutzler Michelle A. , Ruane Erin K , Coksaygan Turhan , Vincent Stella E. , Nathanielsz Peter W.
Published: August 2004

Objectives. To evaluate the effects of repeated low doses of maternally administered dexamethasone (DM) on growth in sheep during fetal life and the first 2 years of postnatal life.

Methods. Ewes received 3 courses of DM (1 course: four 2-mg intramuscular injections at 12-hour intervals) or saline beginning at 103, 110, and 117 days of gestation (dGA). At 119 dGA, fetal BW and organ weight were recorded. Total placentome number, weight, and morphologic distributions were recorded. Placentome glucocorticoid receptor expression was determined by immunocytochemistry. Newborn BW and organ weight were recorded within 12 hours of birth. Duration of gestation was recorded. Measurements were collected on body weight (BW), biparietal diameter (BPD), crown-to-rump length, thoracic girth circumference, abdominal girth circumference, and radial bone length for 2 months. Maternal estradiol and progesterone levels were measured daily from 135 dGA.

Results. At 119 dGA, DM significantly decreased BW. Placentome glucocorticoid receptor expression increased after DM exposure. DM did not significantly decrease BW at birth but did prolong gestation length. DM decreased maternal estradiol before lambing. DM decreased newborn brain weight and BPD. After 2 weeks of age, no effect of DM on postnatal growth could be found.

Conclusions. This study shows that repeated maternal DM treatment at doses threefold lower than what women in preterm labor receive results in decreased fetal BW, prolonged gestation length, decreased newborn brain weight, and BPD.
The Association Between Adverse Childhood Experiences and Adolescent Pregnancy, Long-Term Psychosocial Consequences, and Fetal Death
Authors: Hillis Susan D. , Anda Robert F. , Dube Shanta R. , Felitti Vincent J. , Marchbanks Polly A. , Marks James S.
Published: August 2004

Objectives. Few reports address the impact of cumulative exposure to childhood abuse and family dysfunction on teen pregnancy and consequences commonly attributed to teen pregnancy. Therefore, we examined whether adolescent pregnancy increased as types of adverse childhood experiences (ACE score) increased and whether ACEs or adolescent pregnancy was the principal source of elevated risk for long-term psychosocial consequences and fetal death.

Design, Setting, and Participants. A retrospective cohort study of 9159 women aged ≥18 years (mean 56 years) who attended a primary care clinic in San Diego, California in 1995–1997.

Main Outcome Measure. Adolescent pregnancy, psychosocial consequences, and fetal death, compared by ACE score (emotional, physical, or sexual abuse; exposure to domestic violence, substance abusing, mentally ill, or criminal household member; or separated/divorced parent).

Results. Sixty-six percent (n = 6015) of women reported ≥1 ACE. Teen pregnancy occurred in 16%, 21%, 26%, 29%, 32%, 40%, 43%, and 53% of those with 0, 1, 2, 3, 4, 5, 6, and 7 to 8 ACEs. As the ACE score rose from zero to 1 to 2, 3 to 4, and ≥5, odds ratios for each adult consequence increased (family problems: 1.0, 1.5, 2.2, 3.3; financial problems: 1.0, 1.6, 2.3, 2.4; job problems: 1.0, 1.4, 2.3, 2.9; high stress: 1.0, 1.4, 1.9, 2.2; and uncontrollable anger: 1.0, 1.6, 2.8, 4.5, respectively). Adolescent pregnancy was not associated with any of these adult outcomes in the absence of childhood adversity (ACEs: 0). The ACE score was associated with increased fetal death after first pregnancy (odds ratios for 0, 1–2, 3–4, and 5–8 ACEs: 1.0, 1.2, 1.4, and 1.8, respectively); teen pregnancy was not related to fetal death.

Conclusions. The relationship between ACEs and adolescent pregnancy is strong and graded. Moreover, the negative psychosocial sequelae and fetal deaths commonly attributed to adolescent pregnancy seem to result from underlying ACEs rather than adolescent pregnancy per se.
The Effects of Obesity, Gender, and Ethnic Group on Left Ventricular Hypertrophy and Geometry in Hypertensive Children: A Collaborative Study of the International Pediatric Hypertension Association
Authors: Hanevold Coral , Waller Jennifer , Daniels Stephen , Portman Ronald , Sorof Jonathan
Published: August 2004

Objective. To determine the prevalence of left ventricular hypertrophy (LVH) in a multiethnic group of children and adolescents with hypertension.

Design/Methods. Pooled data from 1998 to 2001 from 3 sites belonging to the International Pediatric Hypertension Association were reviewed. Patients undergoing echocardiography to detect LVH as part of the evaluation for hypertension were included for analysis. Left ventricular mass was calculated from 2-dimensional guided M-mode echocardiographic measurements of the left ventricle. Left ventricular mass index (LVMI) was calculated as left ventricular mass/height2.7. LVH by adult criteria was defined as LVMI > 51 g/m2.7 and by pediatric criteria as LVMI > 38.6 g/m2.7. Left ventricle geometry was classified as concentric, concentric remodeling, eccentric, or normal.

Results. Data on 129 patients with a mean age of 13.6 ± 3.6 years were analyzed. The population was 67% male, 46.5% white, 38.0% African American, and 15.5% Hispanic. The prevalence of LVH was 15.5% using adult criteria and 41.1% using pediatric criteria. Increasing body mass index (BMI) was associated with a higher LVMI. Using either pediatric or adult criteria LVH was associated with BMI ≥95th percentile for age and gender. LVH and concentric hypertrophy were identified most frequently in Hispanic children.

Conclusions. LVH occurs commonly in children with hypertension and is associated with an increased BMI. LVH may be more prevalent in Hispanic children than in other ethnic groups. Prevention and treatment of obesity is important in reducing the cardiovascular risk for children with hypertension. Further evaluation of the frequency of LVH in multiethnic populations is needed.
Coping, Commitment, and Attitude: Quantifying the Everyday Burden of Enuresis on Children and Their Families
Authors: Landgraf Jeanne M. , Abidari Jennifer , Cilento Bartley G. , Cooper Christopher S. , Schulman Seth L. , Ortenberg Joseph
Published: August 2004

Objective. To develop and evaluate a parent-completed questionnaire for use by clinicians as part of routine care to assess the burden of diurnal and nocturnal enuresis on children and their families.

Methods. The questionnaire consisted of items that measure the impact on the child and his/her parent, the child’s coping ability and commitment to treatment, previous treatment success, family frustration and overall cohesion, and parental attitudes about enuresis and its treatment. Questionnaires (n = 208) were completed by parents during the child’s scheduled office visit for enuresis at 5 specialty clinics across the United States. Traditional criteria were used to assess reliability and validity of the questionnaire, including analysis of variance.

Results. Success rates provide evidence that many of the items in the child scale (79%) and all items in the parent scale (100%) met stringent criteria. α values were .62 and .77, respectively. Statistically significant differences were observed for the scales across responses on all but 1 global item, the majority of parental attitude items, whether the child urinated at bedtime, and the number of pads used. These findings suggest that the child’s coping ability and commitment and the family’s overall cohesion and frustration with the problem influence parental perceptions about the impact of enuresis on the child and the family.

Conclusions. Findings about the performance of the new measure were satisfactory and suggest that, after further refinement, it should prove as a useful tool for clinicians treating enuresis in children.
Does Environment Mediate Earlier Onset of the Persistent Childhood Asthma Phenotype?
Authors: Kurukulaaratchy Ramesh J. , Matthews Sharon , Arshad S. Hasan
Published: August 2004

Objective. We investigated the role of environmental and hereditary factors in determining whether persistent childhood wheezing phenotypes had an early or late onset.

Methods. In a whole population birth cohort (n = 1456), children were seen at birth and at 1, 2, 4, and 10 years. At each visit, information was collected prospectively regarding wheeze prevalence and used to classify subjects into wheezing phenotypes. Information on genetic and environmental risk factors in early life was also obtained prospectively, and skin-prick testing to common allergens was performed at 4 years.

Results. Early-onset persistent wheezers (n = 125) had wheeze onset in the first 4 years, still present at age 10, whereas late-onset persistent wheezers (n = 81) had wheeze onset after age 4 years that was still present at 10 years. Multivariate logistic regression analysis identified independent significance only for inherited factors (parental asthma, family history of rhinitis, eczema at 4 years, and atopic status at 4 years) in the development of late-onset persistent wheeze. However, low social class at birth, recurrent chest infections at 2 years, and parental smoking at 2 years plus inherited factors (eczema at 2 years; food allergy at 4 years; maternal asthma, sibling asthma, maternal urticaria, and atopic status at 4 years) demonstrated independent significance for early-onset persistent wheeze.

Conclusion. Inheritance seems to be of prime significance in the cause of persistent childhood wheeze. Environmental exposure in early life may combine with this tendency to produce an early onset of persistent wheeze. Absence of these environmental factors might delay but not prevent the onset of wheeze in children with atopic heredity.
Adenotonsillectomy in Children With Obstructive Sleep Apnea Syndrome Reduces Health Care Utilization
Authors: Tarasiuk Ariel , Simon Tzahit , Tal Asher , Reuveni Haim
Published: August 2004

Objective. To investigate health care utilization of children with obstructive sleep apnea syndrome (OSAS) 1 year after adenotonsillectomy (T&A).

Methods. A longitudinal, case-controlled, prospective study was conducted at Clalit Health Care Services (CHS), a health maintenance organization in the southern region of Israel. We defined 3 groups of children: 1) children who had OSAS and were treated with T&A (n = 130); 2) children who had OSAS and did not undergo surgery (n = 90); and 3) control subjects who were matched by age, sex, and area of residency (n = 520) and randomly selected from the CHS database. OSAS was verified with polysomnography studies in all patients. Indices of health care utilization were analyzed 1 year before and 1 year after T&A. Medical records in the emergency department and during hospitalization were reviewed for diagnosis before the polysomnography diagnosis.

Results. Mean age of all children with OSAS was 5.6 ± 3.6 years. Total annual health care costs were reduced by one third in children who underwent T&A, whereas there was no change in the control and untreated OSAS groups. T&A was associated with a 60% reduction in the number of new admissions, 39% reduction in emergency department visits, 47% reduction in the number of consultations, and 22% reduction in costs for prescribed drugs. In group 2, the total costs were similar in years 1 and 2.

Conclusions. T&A significantly reduces health care utilization in children with OSAS. Untreated children with moderate and severe OSAS will continue to consume high levels of health care resources. Increased morbidity among children with OSAS is mainly related to upper respiratory tract infections.
Abnormal Auditory Brainstem Response Among Infants With Prenatal Cocaine Exposure
Authors: Tan-Laxa Mary Anne , Sison-Switala Consolacion , Rintelman William , Ostrea Enrique M.
Published: August 2004

Objective. To determine the auditory brainstem response (ABR) patterns in infants with prenatal cocaine exposure as detected by meconium analysis.

Methods. Meconium drug analysis was done on term infants who were at risk for antenatal illicit drug exposure. Infants who tested positive for cocaine served as the exposed group; those who tested negative served as control subjects. An ABR was done on the infants within 6 days of life. Absolute latencies at 40 and 70 decibels (dB) of waves I, III, and V and interpeak latencies between I and III, III and V, and I and V were measured.

Results. Among 58 infants in the study, 21 (35.6%) were positive, by meconium analysis, for cocaine and 5 (8.5%) were positive for cannabinoids. Four infants tested positive for cocaine, although their mothers denied illicit drug use. There was a significant difference in mean maternal age, gravidity, parity, birth weight, and head circumference among cocaine-exposed versus nonexposed infants. The ABR from cocaine-positive infants showed significantly prolonged mean absolute latencies in both ears as compared with nonexposed infants: right ear at 40 dB III (4.823 vs 4.447 milliseconds), 40 dB V (7.400 vs 6.968 milliseconds), 70 dB I (2.111 vs 1.631 milliseconds), and 70 dB III (4.122 vs 3.821 milliseconds); left ear at 40 dB III (4.820 vs 4.444 milliseconds), 40 dB V (7.460 vs 6.860 milliseconds), 70 dB I (2.063 vs 1.741 milliseconds), 70 dB III (4.026 vs 3.656 milliseconds), and 70 dB V (6.568 vs 6.258 milliseconds). The interpeak latency was not significantly different except in 1 cocaine-positive infant: left ear at 40 dB III to V (2.667 vs 2.417 milliseconds).

Conclusion. The ABR in neonates who are exposed prenatally to cocaine shows prolonged absolute peak latencies compared with nonexposed neonates and may indicate compromise of the auditory system from gestational exposure to cocaine that will need additional audiologic follow-up. Meconium analysis can more accurately detect the infants who are at risk.
Maternal Selective Serotonin Reuptake Inhibitor Use During Pregnancy and Newborn Neurobehavior
Authors: Zeskind Philip Sanford , Stephens Laura E.
Published: August 2004

Objective. This is a prospective study of the effects of maternal use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy on newborn neurobehavioral integrity, including systematic measures of behavioral state, sleep organization, motor activity, heart rate variability (HRV), tremulousness, and startles.

Methods. The sample included 17 SSRI-exposed and 17 nonexposed, full-birth-weight newborn infants who had no obvious medical problems and were matched on maternal cigarette use, social class, and maternal age. SSRI exposure was determined by medical records and maternal self-report during a standard interview. Behavioral state, startles, and tremulousness were evaluated for 1 hour between feedings. Automated recordings of motor activity and HRV were also assessed during a 15-minute subset sleep period. HRV was subjected to spectral analysis to detect rhythms in autonomic regulation. Exposed and nonexposed infant groups were compared on measures of neurobehavioral development both before and after adjustment for gestational age as a covariate.

Results. SSRI-exposed infants had a shorter mean gestational age; were more motorically active and tremulous; and showed fewer rhythms in HRV, fewer changes in behavioral state, fewer different behavioral states, and a lower peak behavioral state. SSRI-exposed infants also had significantly more rapid eye movement sleep, which was characterized by longer continuous bouts in that state and higher numbers of spontaneous startles or sudden arousals. After effects of gestational age were covaried, significant differences continued to be found in tremulousness and all measures of state and sleep organization, but effects on startles, motor activity, and rhythms in HRV were no longer significant.

Conclusions. Results provide the first systematic evidence that women who use SSRIs during pregnancy have healthy, full-birth-weight newborn infants who show disruptions in a wide range of neurobehavioral outcomes. Effects on motor activity, startles, and HRV may be mediated through the effects of SSRI exposure on gestational age. Future research can lead to a better understanding of the effects of SSRI use during pregnancy and an improved public health outcome.
Radical Reduction in the Rate of Extensive Corrective Surgery for Clubfoot Using the Ponseti Method
Authors: Morcuende Jose A. , Dolan Lori A. , Dietz Frederick R. , Ponseti Ignacio V.
Published: August 2004

Objectives. The purpose of this study was to evaluate the efficacy of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot.

Methods. Consecutive case series were conducted from January 1991 through December 2001. A total of 157 patients (256 clubfeet) were evaluated. All patients were treated by serial manipulation and casting as described by Ponseti. Main outcome measures included initial correction of the deformity, extensive corrective surgery rate, and relapses.

Results. Clubfoot correction was obtained in all but 3 patients (98%). Ninety percent of patients required ≤5 casts for correction. Average time for full correction of the deformity was 20 days (range: 14–24 days). Only 4 (2.5%) patients required extensive corrective surgery. There were 17 (11%) relapses. Relapses were unrelated to age at presentation, previous unsuccessful treatment, or severity of the deformity (as measured by the number of Ponseti casts needed for correction). Relapses were related to noncompliance with the foot-abduction brace. Four patients (2.5%) underwent an anterior tibial tendon transfer to prevent further relapses.

Conclusions. The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. This technique can be used in children up to 2 years of age even after previous unsuccessful nonsurgical treatment.
Care of the Dying Adolescent: Special Considerations
Authors: Freyer David R.
Published: August 2004

More than 3000 adolescents in the United States die annually from the effects of chronic illness. Providing appropriate end-of-life care for these patients is particularly challenging because of several developmental, ethical, and legal considerations relevant to this age group. Developmental issues relate to the ways in which life-threatening illness alters the normal physical and psychological changes associated with adolescence, including attainment of independence, social skills, peer acceptance, and a healthy self-image. Ethical and legal issues arise from the fact that many terminally ill adolescents <18 years of age lack ordinary legal authority to make binding medical decisions (including discontinuation of their treatment), yet they meet functional criteria for having the competence to do so. In such situations, a broad medical, ethical, and legal consensus supports giving decisional authority to the minor patient. Even when full decisional authority is not appropriate, strong moral arguments exist for taking serious account of the young adolescent’s treatment preferences. In supporting the dying adolescent, an atmosphere promoting excellent communication and sound decision-making should be fostered as early as possible during preterminal care and maintained thereafter. Once palliative-care strategies become the clinical focus, psychosocial support sensitive to the adolescent’s developmental stage must be provided. Using these principles, clinicians can play a crucial role in helping the adolescent, in the face of death, to experience richness of life and the dignity of self-determination.
Management of a Severe Carbamazepine Overdose Using Albumin-Enhanced Continuous Venovenous Hemodialysis
Authors: Askenazi David J. , Goldstein Stuart L. , Chang I-Fen , Elenberg Ewa , Feig Daniel I.
Published: August 2004

Carbamazepine intoxication is common in the pediatric population. Highly protein-bound, carbamazepine is not removed efficiently through conventional hemodialysis. We describe the use of albumin-enhanced continuous venovenous hemodialysis (CVVHD) in a 10-year-old girl who developed coma and respiratory depression due to an intentional carbamazepine overdose (peak drug level of 44.8 μg/ml; therapeutic range: 8–12 μg/ml). Without intervention, the half-life of drug elimination is 25 to 60 hours in patients who are naive to carbamazepine and 12 to 20 hours in children on chronic carbamazepine therapy. In contrast, with albumin-enhanced CVVHD, we observed a half-life of 7 to 8 hours. The patient recovered rapidly and was discharged from hospital <4 days from the time of ingestion with no complications or neurologic impairment. Because the cost-benefit analysis was also favorable relative to other therapeutic options, albumin-enhanced CVVHD may be the optimal treatment of toxic-level ingestion of carbamazepine.
Ipsilateral Hemangioma and Aortic Arch Anomalies in Posterior Fossa Malformations, Hemangiomas, Arterial Anomalies, Coarctation of the Aorta, and Cardiac Defects and Eye Abnormalities (PHACE) Anomaly: Report and Review
Authors: Bronzetti Gabriele , Giardini Alessandro , Patrizi Annalisa , Prandstraller Daniela , Donti Andrea , Formigari Roberto , Bonvicini Marco , Picchio Fernando Maria
Published: August 2004

Posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta, and cardiac defects and eye abnormalities (PHACE) is a rare congenital anomaly with a broad spectrum of clinical manifestations with a striking female predominance. We describe an infant with PHACE anomaly and aortic coarctation who underwent cardiac catheterization to clearly define the complex anatomy of the aortic lesion before surgical repair. Review of the literature documents a highly significant association between ipsilateral hemangiomas and cerebrovascular and aortic arch anomalies. We conclude that cardiac catheterization is required to define the complex anatomy of aortic lesions and should be performed in all patients with PHACE and evident aortic involvement to plan appropriate and safe surgical repair.
An Evidence-Based Approach to Predicting Low IQ in Very Preterm Infants From the Neurological Examination: Outcome Data From the Indomethacin Intraventricular Hemorrhage Prevention Trial
Authors: Pleacher Michael D. , Vohr Betty R. , Katz Karol H. , Ment Laura R. , Allan Walter C.
Published: August 2004

We evaluated whether the degree of cerebral palsy (CP) at age 3 in very preterm children is predictive of full-scale intelligence quotient (FSIQ) <70 at age 8 by calculating likelihood ratios (LRs) for findings on the neurologic examination. Data from the follow-up phase of the Indomethacin Intraventricular Hemorrhage Prevention Trial, which includes periodic neurologic examination and neuropsychometric testing, were used. Information was available on 366 of 440 (83%) children with birth weight of 600 to 1250 g who survived. Neurologic examination at age 3 was grouped by presence and type of CP, and the Weschler Intelligence Scale for Children–Third Edition FSIQ at age 8 was grouped dichotomously (<70 or ≥70). CP was identified in 35 of 366 3-year-olds (9.5%). An FSIQ <70 was identified in 47 of 366 children at 8 years old (12.8%). FSIQ <70 occurred in 14 of 17 children with tri- or quadriplegia (82%), 8 of 18 children with di- or hemiplegia (44%), and 25 of 331 children without CP (7.5%). Useful LRs were calculated for tri- or quadriplegia (30), di- or hemiplegia (5.7), and children without CP (0.55). These LRs have greater impact on posttest odds for FSIQ <70 than those for birth weight <1000 g, history of bronchopulmonary dysplasia, and Stanford-Binet Intelligence Score <70 at age 3. We conclude that the neurologic examination at 3 years old predicts FSIQ <70 at age 8 with LRs that allow evidence-based parental counseling and intervention planning.
Central Nervous System Side Effects of First- and Second-Generation Antihistamines in School Children With Perennial Allergic Rhinitis: A Randomized, Double-Blind, Placebo-Controlled Comparative Study
Authors: Ng Kar Hui , Chong Daniel , Wong Chin Khoon , Ong Hian Tat , Lee Chien Yee , Lee Bee Wah , Shek Lynette Pei-Chi
Published: August 2004

Objective. Allergic rhinitis is common and on the rise. Antihistamines are the mainstay of treatment and are the most commonly prescribed drugs in Singapore. Treatment-related sedation and its effect on cognition are a major concern. First- and second-generation antihistamines show varying degrees of sedation, but to date, objective studies in children are lacking. The objective of this study was to assess the sedating effect of cetirizine (second-generation antihistamine) and chlorpheniramine (first-generation antihistamine) compared with placebo using an objective neurophysiological test.

Methods. This was a prospective, double-blind, placebo-controlled, randomized, single-dose, 3-way crossover study. Twenty-four children aged 7 to 14 years with allergic rhinitis completed the study. All children were randomly allocated to medication sequences and received 3 different drugs on 3 different days, at least 1 week apart. The P300 event-related potential was used as an objective test of sedation. Subjective assessment was by a visual analog scale.

Results. Chlorpheniramine and cetirizine increased P300 latency when compared with baseline. No significant increase was obtained with placebo. The significant increase in P300 latency was not accompanied by significant change in subjective somnolence as measured by the visual analog scale.

Conclusion. We have shown that cetirizine has sedative properties in children. The lack of correlation between P300 latency and the visual analog scale indicates that sedation induced by these drugs may not be subjectively noted.
Gastroesophageal Reflux: A Critical Review of Its Role in Preterm Infants
Authors: Poets Christian F.
Published: August 2004

There is widespread concern about gastroesophageal reflux (GER) in preterm infants. This article reviews the evidence for this concern. GER is common in infants, which is related to their large fluid intake (corresponding to 14 L/day in an adult) and supine body position, resulting in the gastroesophageal junction’s being constantly “under water.” pH monitoring, the standard for reflux detection, is of limited use in preterm infants whose gastric pH is >4 for 90% of the time. New methods such as the multiple intraluminal impedance technique and micromanometric catheters may be promising alternatives but require careful evaluation before applying them to clinical practice. A critical review of the evidence for potential sequelae of GER in preterm infants shows that 1) apnea is unrelated to GER in most infants, 2) failure to thrive practically does not occur with GER, and 3) a relationship between GER and chronic airway problems has not yet been confirmed in preterm infants. Thus, there is currently insufficient evidence to justify the apparently widespread practice of treating GER in infants with symptoms such as recurrent apnea or regurgitation or of prolonging their hospital stay, unless there is unequivocal evidence of complications, eg, recurrent aspiration or cyanosis during vomiting. Objective criteria that help to identify those presumably few infants who do require treatment for GER disease are urgently needed.
Abnormal Retinal Vascular Morphology in Young Adults Following Intrauterine Growth Restriction
Authors: Hellström Ann , Dahlgren Jovanna , Maršál Karel , Ley David
Published: August 2004

Objective. Intrauterine growth restriction (IUGR) resulting in low birth weight for gestational age may predispose one to development of cardiovascular disease later in life. Abnormal fetal blood flow in the presence of fetal growth restriction helps to distinguish infants with true fetal growth impairment from small but normal infants. Our goal was to investigate associations between IUGR with abnormal fetal blood flow and abnormal retinal vascular morphology at 18 years of age.

Methods. A prospective study was performed with 21 subjects with IUGR (abnormal fetal aortic blood flow velocity; birth weight small for gestational age; median birth weight deviation from the population mean of −31% [range: −22% to −42%] and in 23 subjects with birth weight appropriate for gestational age [normal fetal aortic blood flow velocity; median birth weight deviation of −2% (range: −10% to 22%)]). The retinal vessel morphology was evaluated by digital image analysis.

Result. Subjects with IUGR (n = 21) had significantly less retinal vascularization as evidenced by a lower number of vascular branching points (median: 26; range: 20–31) as compared with the subjects who were born appropriate for gestational age (median: 28; range: 26–32). Within the entire group (N = 44), increasing negative birth weight deviation was associated with a reduced number of vascular branching points (r = 0.36.

Conclusion. Our findings show that IUGR with abnormal fetal blood flow is associated with abnormal retinal vascular morphology in young adult life.
Does Breastfeeding Protect Against Pediatric Overweight? Analysis of Longitudinal Data From the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System
Authors: Grummer-Strawn Laurence M. , Mei Zuguo
Published: August 2004

Objective. To examine whether increasing duration of breastfeeding is associated with a lower risk of overweight in a low-income population of 4-year-olds in the United States.

Methods. Visit data were linked to determine prospectively the duration of breastfeeding (up to 2 years of age) and weight status at 4 years of age. Overweight among 4-year-old children was defined as a body mass index (BMI)-for-age at or above the 95th percentile based on the 2000 Centers for Disease Control and Prevention growth charts. Logistic regression was performed, controlling for gender, race/ethnicity, and birth weight. In a subset of states, links to maternal pregnancy records also permitted regression analysis controlling for mother’s age, education, prepregnancy BMI, weight gain during pregnancy, and postpartum smoking. Data from the Pediatric Nutrition Surveillance System, which extracts breastfeeding, height, and weight data from child visits to public health programs, were analyzed. In 7 states, data were linked to Pregnancy Nutrition Surveillance System data. A total of 177 304 children up to 60 months of age were included in our final pediatric-only analysis, and 12 587 were included in the pregnancy-pediatric linked analysis.

Results. The duration of breastfeeding showed a dose-response, protective relationship with the risk of overweight only among non-Hispanic whites; no significant association was found among non-Hispanic blacks or Hispanics. Among non-Hispanic whites, the adjusted odds ratio of overweight by breastfeeding for 6 to 12 months versus never breastfeeding was 0.70 (95% confidence interval: 0.50–0.99) and for >12 months versus never was 0.49 (95% confidence interval: 0.25–0.95). Breastfeeding for any duration was also protective against underweight (BMI-for-age below the 5th percentile).

Conclusion. Prolonged breastfeeding is associated with a reduced risk of overweight among non-Hispanic white children. Breastfeeding longer than 6 months provides health benefits to children well beyond the period of breastfeeding.
Twelve-Month Safety and Efficacy of Inhaled Fluticasone Propionate in Children Aged 1 to 3 Years With Recurrent Wheezing
Authors: Bisgaard Hans , Allen David , Milanowski Janusz , Kalev Ilia , Willits Lisa , Davies Patricia
Published: August 2004

Objective. Our aim was to compare the 12-month safety and efficacy of fluticasone propionate (FP) and sodium cromoglycate (SCG) in children aged 1 to 3 years with mild to moderate recurrent wheeze.

Methods. The study was a randomized, parallel-group, open-label multicenter study of 625 children, aged 1 to 3 years, with recurrent wheeze randomized in a 3:1 ratio to treatment for 52 weeks with FP (100 μg twice daily) via metered-dose inhaler and Babyhaler spacer device or SCG (5 mg 4 times daily) via metered-dose inhaler and Nebuhaler spacer device, respectively.

Results. There was no significant difference in mean adjusted growth rates between the 2 groups: 84.0 mm/year in the FP group versus 86.4 mm/year in the SCG group (difference FP-SCG: −2.4 mm/year; 95% confidence interval: −6.6 to 1.8). Growth comparisons were independent of age, gender, previous use of steroid, or whether measured as length and/or height. Serum and urinary cortisol concentrations showed a statistically significant suppression of 10% and 14%, respectively, but the number of patients with serum cortisol levels below the lower normal limit was reduced during the trial. Both treatments were well tolerated. The most common drug-related adverse events were cough (2% FP vs 1% SCG) and hoarseness (1% FP vs 0% SCG). One incident of cataract was observed at baseline and 1 after FP treatment; the latter had resolved after 12 months. The efficacy of FP was superior to SCG with fewer cases of symptom worsening, exacerbations, and requirements for oral steroid treatment and more symptom-free days and days without use of rescue treatment.

Conclusions. Twelve months of treatment with inhaled FP (100 μg twice daily) in preschool children aged 1 to 3 years with recurrent wheeze has no effect on growth and no other clinically important side effects but is more efficacious than SCG.
Cost-Utility Analysis of Orthoptic Screening in Kindergarten: A Markov Model Based on Data From Germany
Authors: König Hans-Helmut , Barry Jean-Cyriaque
Published: August 2004

Objective. To estimate the long-term cost-effectiveness of a hypothetical screening program for untreated amblyopia in 3-year-old children conducted by orthoptists in all German kindergartens in the year 2000.

Methods. A cost-utility analysis was performed for which a decision tree was combined with a Markov model. Incremental costs and effects during the children’s remaining lifetime were estimated. The model took into account the probability of treatment without screening, age-specific treatment success rates, costs of screening and treatment, as well as effects of unilateral and bilateral visual impairment caused by amblyopia and other eye diseases coming along later in life on quality of life (utility). Model parameter values were obtained from a field study of orthoptic screening in kindergarten, from the literature, and from expert interviews. Costs were estimated from a third-party payer perspective. Uncertainty was assessed by univariate and probabilistic sensitivity analysis (Monte Carlo simulation).

Results. The incremental cost-effectiveness ratio (ICER) of orthoptic screening was 7397 Euro (€) per quality-adjusted life year (QALY) when costs and effects were discounted at 5%. In univariate sensitivity analysis, the ICER was sensitive to the uncertainty regarding the utility of unilateral visual impairment and to the discount rate for effects; besides uncertainty regarding the prevalence of untreated amblyopia, the odds ratio of success of treatment when started late, and the probability of treatment without screening had a noticeable but much smaller effect. Monte Carlo simulation yielded a 90% uncertainty interval for the ICER of 3452 €/QALY to 72 637 €/QALY; the probability of an ICER <25 000 €/QALY was 84%.

Conclusions. The ICER of orthoptic screening seems to fall within a range that warrants careful consideration by decision-makers. Much of the uncertainty in results comes from the uncertainty regarding the effect of amblyopia on quality of life. To reduce this uncertainty, the impact of amblyopia on utility should be investigated.
The General Pediatrician: Projecting Future Workforce Supply and Requirements
Authors: Shipman Scott A. , Lurie Jon D. , Goodman David C.
Published: August 2004

Objective. Trends affecting both the supply and requirements of child health physicians call into question earlier assessments about the adequacy of the general pediatric workforce. To understand the effects of these trends over time, we developed a model that projects the national supply of practicing general pediatricians over a 20-year period (2000–2020).

Design. The model incorporates current data on the practicing pediatrician workforce in the United States, pediatric residency graduates entering general pediatrics, and gender- and age-specific measures of productivity and of retirement or death. In addition, it accounts for projected changes in the size and ethnicity of the child population and the proportion of children currently receiving outpatient care from family practitioners.

Main Outcome Measures. Time trend of the supply of general pediatricians and the number of children in the population per practicing pediatrician.

Results. The baseline model projects that the number of general pediatricians will expand by nearly 25 000 by the year 2020, a 64% increase from the year 2000, whereas the child population is projected to expand by only 9%. The increase was robust to sensitivity analyses measuring the impact of each of the model’s variables on the future supply of pediatricians. In all probable scenarios, the general pediatrician workforce will expand significantly more rapidly than the child population. In addition, the trend in pediatrics is in marked contrast to the other primary care specialties.

Conclusions. Despite a number of factors that might attenuate the growth of the general pediatrician workforce, none seems sufficient to slow its expansion in relation to the pediatric population. To maintain practice volumes comparable to today, pediatricians of the future may need to provide expanded services to the children currently under their care, expand their patient population to include young adults, and/or compete for a greater share of children currently cared for by nonpediatricians.
Decrease of Invasive Pneumococcal Infections in Children Among 8 Children’s Hospitals in the United States After the Introduction of the 7-Valent Pneumococcal Conjugate Vaccine
Authors: Kaplan Sheldon L. , Mason Edward O , Wald Ellen R. , Schutze Gordon E. , Bradley John S. , Tan Tina Q. , Hoffman Jill A. , Givner Laurence B. , Yogev Ram , Barson William J.
Published: August 2004

Objective. To monitor clinical and microbiologic features including antimicrobial susceptibility and serogroup distribution of invasive infections caused by Streptococcus pneumoniae among children before and after the introduction of routine administration of the 7-valent pneumococcal conjugate vaccine (PCV7).

Design. A 9-year (January 1, 1994 through December 31, 2002) prospective surveillance study of all invasive pneumococcal infections in children.

Patients. Infants and children cared for at 8 children’s hospitals in the United States with culture-proven invasive infections caused by S pneumoniae.

Results. When compared with the mean of the years 1994 to 2000, the annual number of invasive pneumococcal infections for children ≤24 months of age declined 58% in 2001 and 66% in 2002. If only the serogroups in the PCV7 are considered, the number of cases in children ≤24 months old declined 63% and 77% in 2001 and 2002, respectively. The greatest decrease was observed for serogroup-14 isolates. The number of isolates in nonvaccine serogroups increased 28% in 2001 and 66% in 2002 for children ≤24 months old. Nonvaccine serogroup-15 and -33 isolates had the greatest increase in number. The proportion of all isolates nonsusceptible to penicillin increased yearly from 1994 to 2000, reached a plateau in 2001 at 45%, and declined to 33% in 2002. Decrease in nonsusceptibility to penicillin occurred entirely in the isolates with penicillin minimum inhibitory concentration ≥2 μg/mL. Nonsusceptibility to penicillin increased slightly among nonvaccine-serotype isolates. Most infections after at least 2 doses of PCV7 were caused by nonvaccine-serotype isolates.

Conclusions. Since the introduction of the PCV7, the number of invasive pneumococcal infections caused by vaccine-serogroup isolates among 8 US children’s hospitals has decreased >75% among children ≤24 months old. In addition, penicillin resistance decreased in 2002 for the first time since our surveillance began in 1993–1994. However, we have noted that replacement may be developing with serogroups 15 and 33. Furthermore, penicillin resistance seems to be increasing among nonvaccine serogroups. Surveillance must be continued to detect the emergence of changes in the distribution of serotypes as well as antibiotic susceptibility.
The Effect of Point-of-Care Personal Digital Assistant Use on Resident Documentation Discrepancies
Authors: Carroll Aaron E. , Tarczy-Hornoch Peter , O’Reilly Eamon , Christakis Dimitri A.
Published: August 2004

Background. We recently found documentation discrepancies in 60% of resident daily-progress notes with respect to patient weight, medications, or vascular lines. To what extent information systems can decrease such discrepancies is unknown.

Objective. To determine whether a point-of-care personal digital assistant (PDA)-based patient record and charting system could reduce the number of resident progress-note documentation discrepancies in a neonatal intensive care unit (NICU).

Design/Methods. We conducted a before-and-after trial in an academic NICU. Our intervention was a PDA-based patient record and charting system used by all NICU resident physicians over the study period. We analyzed all resident daily-progress notes from 40 randomly selected days over 4 months in both the baseline and intervention periods. Using predefined reference standards, we determined the accuracy of recorded information for patient weights, medications, and vascular lines. Logistic and Poisson regression were used in analyses to control for potential confounding factors.

Results. A total of 339 progress notes in the baseline period and 432 progress notes in the intervention period were reviewed. When controlling for covariates in the regression, there were significantly fewer documentation discrepancies of patient weights in notes written by using the PDA system (14.4%–4.4% of notes; odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.15–0.56). When using the PDA system, there were no significant changes in the numbers of notes with documentation discrepancies of medications (27.7%–17.1% of notes; OR: 0.63; 95% CI: 0.35–1.13) or vascular lines (33.6%–36.1% of notes; OR: 1.11; 95% CI: 0.66–1.87).

Conclusions. The use of our PDA-based point-of-care patient record and charting system showed a modest benefit in reducing the number of documentation discrepancies in resident daily-progress notes. Further study of PDAs in information systems is warranted before they are widely adopted.
Chickenpox Outbreak in a Highly Vaccinated School Population
Authors: Tugwell Barna D. , Lee Lore E. , Gillette Hilary , Lorber Eileen M. , Hedberg Katrina , Cieslak Paul R.
Published: August 2004

Objective. We investigated a chickenpox outbreak that started in an Oregon elementary school in October 2001, after public schools began phasing in a varicella vaccination requirement for enrollment. We sought to determine the rate of varicella vaccination and effectiveness and risk factors for breakthrough disease.

Methods. A chickenpox case was defined as an acute maculopapulovesicular rash without other explanation occurring from October 30, 2001 through January 27, 2002 in a student without a prior history of chickenpox. We reviewed varicella vaccination records and history of prior chickenpox, and we calculated vaccine effectiveness. We evaluated the effects of age, gender, age at vaccination, and time since vaccination on risk of breakthrough disease (ie, chickenpox occurring >42 days after vaccination).

Results. Of 422 students, 218 (52%) had no prior chickenpox. Of these, 211 (97%) had been vaccinated before the outbreak. Twenty-one cases occurred in 9 of 16 classrooms. In these 9 classrooms, 18 of 152 (12%) vaccinated students developed chickenpox, compared with 3 of 7 (43%) unvaccinated students. Vaccine effectiveness was 72% (95% confidence interval: 3%–87%). Students vaccinated >5 years before the outbreak were 6.7 times (95% confidence interval: 2.2–22.9) as likely to develop breakthrough disease as those vaccinated ≤5 years before the outbreak (15 of 65 [23%] vs 3 of 87 [3%]).

Conclusions. A chickenpox outbreak occurred in a school in which 97% of students without a prior history of chickenpox were vaccinated. Students vaccinated >5 years before the outbreak were at risk for breakthrough disease. Booster vaccination may deserve additional consideration.
Perinatal Predictors of Atopic Dermatitis Occurring in the First Six Months of Life
Authors: Moore Megan M. , Rifas-Shiman Sheryl L. , Rich-Edwards Janet W. , Kleinman Ken P. , Camargo Carlos A. , Gold Diane R. , Weiss Scott T. , Gillman Matthew W.
Published: August 2004

Objective. Previous studies of predictors of atopic dermatitis have had limited sample size, small numbers of variables, or retrospective data collection. The purpose of this prospective study was to investigate several perinatal predictors of atopic dermatitis occurring in the first 6 months of life.

Design. We report findings from 1005 mothers and their infants participating in Project Viva, a US cohort study of pregnant women and their offspring. The main outcome measure was maternal report of a provider’s diagnosis of eczema or atopic dermatitis in the first 6 months of life. We used multiple logistic regression models to assess the associations between several simultaneous predictors and incidence of atopic dermatitis.

Results. Cumulative incidence of atopic dermatitis in the first 6 months of life was 17.1%. Compared with infants born to white mothers, the adjusted odds ratio (OR) for risk of atopic dermatitis among infants born to black mothers was 2.41 (95% confidence interval [CI]: 1.47, 3.94) and was 2.58 among infants born to Asian mothers (95% CI: 1.27, 5.24). Male infants had an OR of 1.76 (95% CI: 1.24, 2.51). Increased gestational age at birth was a predictor (OR: 1.14; 95% CI: 1.02, 1.27, for each 1-week increment), but birth weight for gestational age was not. Infants born to mothers with a history of eczema had an OR of 2.67 (95% CI: 1.74, 4.10); paternal history of eczema also was predictive, although maternal atopic history was more predictive than paternal history. Several other perinatal, social, feeding, and environmental variables were not related to risk of atopic dermatitis.

Conclusions. Black and Asian race/ethnicity, male gender, higher gestational age at birth, and family history of atopy, particularly maternal history of eczema, were associated with increased risk of atopic dermatitis in the first 6 months of life. These findings suggest that genetic and pre- and perinatal influences are important in the early presentation of this condition.