bluuebunny/crossref_metadata_2025 huggingface dataset:
Acute Human Immunodeficiency Virus Syndrome in an Adolescent
Authors: Aggarwal Mridula , Rein Jeffrey
Published: August 2004

Acute human immunodeficiency virus (HIV) seroconversion illness is a difficult diagnosis to make because of its nonspecific and protean manifestations. We present such a case in an adolescent. A 15-year-old boy presented with a 5-day history of fever, sore throat, vomiting, and diarrhea. The patient also reported a nonproductive cough, coryza, and fatigue. The patient’s only risk factor for HIV infection was a history of unprotected intercourse with 5 girls. Physical examination was significant for fever, exudative tonsillopharyngitis, shotty cervical lymphadenopathy, and palpable purpura on both feet. Laboratory studies demonstrated lymphopenia and mild thrombocytopenia. Hemoglobin, serum creatinine, and urinalysis were normal. The following day, the patient remained febrile. Physical examination revealed oral ulcerations, conjunctivitis, and erythematous papules on the thorax; the purpura was unchanged. Serologies for hepatitis B, syphilis, HIV, and Epstein-Barr virus were negative. Bacterial cultures of blood and stool and viral cultures of throat and conjunctiva showed no pathogens. Coagulation profile and liver enzymes were normal. Within 1 week, all symptoms had resolved. The platelet count normalized. Repeat HIV serology was positive, as was HIV DNA polymerase chain reaction. Subsequent HIV viral load was 350 000, and the CD4 lymphocyte count was 351/mm3. HIV is the seventh leading cause of death among people aged 15 to 24 in the United States, and up to half of all new infections occur in adolescents. Our patient presented with many of the typical signs and symptoms of acute HIV infection: fever, fatigue, rash, pharyngitis, lymphadenopathy, oral ulcers, emesis, and diarrhea. Other symptoms commonly reported include headache, myalgias, arthralgias, aseptic meningitis, peripheral neuropathy, thrush, weight loss, night sweats, and genital ulcers. Common seroconversion laboratory findings include leukopenia, thrombocytopenia, and elevated transaminases. The suspicion of acute HIV illness should prompt virologic and serologic analysis. Initial serology is usually negative. Diagnosis therefore depends on direct detection of the virus, by assay of viral load (HIV RNA), DNA polymerase chain reaction, or p24 antigen. Both false-positive and false-negative results for these tests have been reported, further complicating early diagnosis. Pediatricians should play an active role in identifying HIV-infected patients. Our case, the first report of acute HIV illness in an adolescent, emphasizes that clinicians should consider acute HIV seroconversion in the appropriate setting. Recognition of acute HIV syndrome is especially important for improving prognosis and limiting transmission. It is imperative that we maintain a high index of suspicion as primary care physicians for adolescents who present with a viral syndrome and appropriate risk factors.
Keeping Children Out of Hospitals: Parents’ and Physicians’ Perspectives on How Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions Can Be Avoided
Authors: Flores Glenn , Abreu Milagros , Chaisson Christine E. , Sun Donglin
Published: August 2004

Background. Avoidable hospitalization conditions (AHCs) are hospitalizations that potentially can be avoided with timely, appropriate outpatient care. The specific reasons for avoidability, and parents and physicians’ perspectives on the proportion of actually avoidable pediatric AHCs, have not been examined adequately.

Objectives. To identify how pediatric hospitalizations might be avoided, and to determine the proportion of avoidable AHCs according to parents and physicians of hospitalized children.

Methods. Cross-sectional survey of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of children who were admitted with AHCs to an urban hospital in a 14-month period.

Results. The 554 hospitalized children had a median age of 4 years; most were poor (median annual family income: $12 000), nonwhite (91%), and had public (73%) or no (16%) health insurance. The most frequent AHC diagnoses were asthma (43%), dehydration/gastroenteritis (16%), pneumonia (11%), seizure disorder (8%), and skin infections (8%). Only 25% of parents said that their child’s admission was avoidable, compared with 29% of PCPs and 32% of IAPs. The proportion of AHC hospitalizations assessed as avoidable varied according to the source or combination of sources, from 13% for agreement among all 3 sources to 46% as identified by any 1 of the 3 sources. PCPs (71%) and IAPs (48%) significantly more often than parents (35%) cited parent/patient-related reasons for how hospitalizations could have been avoided, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (48%) significantly more often than PCPs (18%) and IAPs (37%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child’s condition, and better quality of care. Multivariate analyses revealed that an age ≥11 years, an asthma diagnosis, working poor family income, and having no health insurance were associated with approximately double to triple the odds of an avoidable hospitalization.

Conclusions. The proportion of AHCs assessed as avoidable varies from 13% to 46%, depending on the source. Adolescents, children with asthma, children from working-poor families, and uninsured children are at greatest risk for avoidable hospitalizations. Many pediatric hospitalizations might be avoided if parents and children were better educated about the child’s condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers. Direct assessment by parents and physicians of hospitalized children can be an informative way to examine the proportion of avoidable pediatric hospitalizations and how they can be prevented.
Bedside Procalcitonin and C-Reactive Protein Tests in Children With Fever Without Localizing Signs of Infection Seen in a Referral Center
Authors: Galetto-Lacour Annick , Zamora Samuel A. , Gervaix Alain
Published: August 2004

Objective. To assess the value of bedside tests for predicting the occurrence of severe bacterial infections (SBIs) in children with fever without source.

Methods. We conducted a prospective study of 99 children, aged 7 days to 36 months, who were seen for fever >38°C and no localizing sign of infection at the emergency department of the University Children’s Hospital of Geneva. Blood procalcitonin (PCT), C-reactive protein (CRP), and interleukin-6 (IL-6) values were determined using rapid tests and were compared with the total white blood cell (WBC) count with differential and clinical score. Specificity, sensitivity, predictive values, and multilevel likelihood ratios (LRs) with posttest probabilities of disease were calculated.

Results. Twenty-nine (29%) children received a diagnosis of having an SBI. PCT had the best sensitivity (93%) and negative predictive value (96%). Band count had the best specificity (93%), but its positive predictive value was only 38%. Multilevel LRs revealed that a PCT concentration <0.5 ng/mL (LR: 0.093) almost ruled out SBI (posttest probability of disease: 3.7%) in 54 (54%) subjects, whereas a value >2 ng/mL (LR: 5.2) increased the probability of SBI to 68% in 19 (19%) children. For CRP, values <40 mg/L (LR: 0.263) and >100 mg/L (LR: 14.483) generated posttest probabilities for SBI of 9.7% (61 subjects) and 86.5% (14 subjects), respectively. For WBC count, the posttest probabilities of SBI were modestly changed from the pretest prevalence.

Conclusions. PCT and CRP performed better than IL-6, WBC, and/or band count in predicting the occurrence of SBI. PCT and CRP bedside tests may be useful tools for emergency and private practice doctors and should be considered in the initial work-up of children with fever without source.
Predictors of Long-Term Outcome in Very Preterm Infants: Gestational Age Versus Neonatal Cranial Ultrasound
Authors: Vollmer Brigitte , Roth Simon , Baudin Jenny , Stewart Ann L. , Neville Brian G. R. , Wyatt John S.
Published: August 2004

Objectives. To investigate the effect of gestational age at birth on the frequency of ultrasound-detected brain lesions in infants born at <33 weeks of gestation and to investigate whether the relationship between neonatal cranial ultrasound diagnosis and neurodevelopmental outcome at 8 years of age was independent of gestational age.

Methods. Eight hundred forty-seven infants born at <33 weeks of gestation, admitted to a single tertiary referral center between 1983 and 1988, underwent serial neonatal cranial ultrasound. At 8 years of age neurodevelopmental outcome was assessed by structured neurologic examination, psychometric tests (Wechsler Intelligence Scale for Children), tests of visuomotor integration (Beery) and motor impairment (Henderson-Stott). Infants were subdivided into a group born at <28 weeks and a group born at between 28 and 32 weeks. Neurodevelopmental outcome was analyzed for each ultrasound diagnosis.

Results. Hemorrhagic lesions such as germinal matrix/intraventricular hemorrhage and hemorrhagic parenchymal infarction were more frequent in infants born at <28 weeks. There was no difference in the frequency of cystic periventricular leucomalacia between the 2 groups. When neurodevelopmental outcome for each ultrasound diagnosis was compared, no significant difference was found between the 2 gestational age groups.

Conclusion. In the gestational age range studied, adverse neurodevelopmental outcome depends primarily on the type of the intracranial lesion rather than on gestational age.
Dysfunctional Elimination Syndrome: Is It Related to Urinary Tract Infection or Vesicoureteral Reflux Diagnosed Early in Life?
Authors: Shaikh Nader , Hoberman Alejandro , Wise Barbara , Kurs-Lasky Marcia , Kearney Diana , Naylor Stephanie , Haralam Mary Ann , Colborn D. K. , Docimo Steven G.
Published: August 2004

Objective. It has been suggested that urinary tract infections (UTIs) early in life predispose to dysfunctional elimination syndrome (DES). This study evaluated the relationship between early UTI, vesicoureteral reflux (VUR), and DES by comparing two cohorts of school-aged children.

Methods. The UTI cohort (n = 123) included children previously enrolled in a prospective treatment trial conducted between 1992 and 1997. All were diagnosed with a febrile UTI before 2 years of age. The comparison cohort (n = 125) included children who were evaluated for fever in the emergency department between 1992 and 1997, whose urine culture was negative. Dysfunctional elimination symptoms were compared in the two cohorts by having families complete a revised version of the Dysfunctional Voiding Scoring System.

Results. Completed questionnaires were received from 248 children. There were no significant differences in selected demographic or clinical characteristics between the two cohorts. DES was present in 22% and 21% of children with and without a history of early UTI, respectively. Among children with UTIs, 18% of those with VUR and 25% of those without VUR had DES.

Conclusions. Dysfunctional elimination is common in a general pediatric population. Neither UTI nor VUR diagnosed before 2 years of age was associated with DES in school-aged children.
Association Between Clinically Meaningful Behavior Problems and Overweight in Children
Authors: Lumeng Julie C. , Gannon Kate , Cabral Howard J. , Frank Deborah A. , Zuckerman Barry
Published: August 2004

Objective. To determine whether there is a relationship between clinically meaningful behavior problems and concurrent and future overweight in 8- to 11-year-old children.

Methods. 1998 National Longitudinal Survey of Youth interview data for 8- to 11-year-old children and their mothers were analyzed. A Behavior Problems Index score >90th percentile was considered clinically meaningful. Child overweight was defined as a body mass index (BMI) ≥95th percentile for age and sex. Multiple logistic regression was used to control for potential confounders (selected a priori): child’s sex, race, use of behavior-modifying medication, history of academic retention, and hours of television per day; maternal obesity, smoking status, marital status, education, and depressive symptoms; family poverty status; and Home Observation for Measurement of the Environment-Short Form (HOME-SF) cognitive stimulation score. In an attempt to elucidate temporal sequence, a second analysis was conducted with a subsample of normal-weight children who became overweight between 1996 and 1998 while controlling for BMI z score in 1996.

Results. The sample included 755 mother-child pairs. Of the potential confounding variables, race, maternal obesity, academic grade retention, maternal education, poverty status, and HOME-SF cognitive stimulation score acted as joint confounders, altering the relationship between behavior problems and overweight in the multiple logistic regression model. With these covariates in the final model, behavior problems were independently associated with concurrent child overweight (adjusted odds ratio: 2.95; 95% confidence interval: 1.34–6.49). The relationship was strengthened in the subsample of previously normal-weight children, with race, maternal obesity, HOME-SF cognitive stimulation score, and 1996 BMI z score acting as confounders (adjusted odds ratio: 5.23; 95% confidence interval: 1.37–19.9).

Conclusions. Clinically meaningful behavior problems in 8- to 11-year-old children were independently associated with an increased risk of concurrent overweight and becoming overweight in previously normal-weight children.
Addressing Parental Smoking in Pediatrics and Family Practice: A National Survey of Parents
Authors: Winickoff Jonathan P. , McMillen Robert C. , Carroll Bronwen C. , Klein Jonathan D. , Rigotti Nancy A. , Tanski Susanne E. , Weitzman Michael
Published: August 2004

Background. Parental smoking has been associated with increased rates of sudden infant death syndrome, low birth weight, otitis media, asthma, and decreased lung growth. No prior parent surveys have assessed national rates of screening and counseling for parental tobacco use in the context of their child’s visit to primary care.

Objective. To assess and compare rates of pediatrician and family practitioner screening and counseling for parental smoking.

Design/Methods. Data were collected by telephone survey of households from July to September 2001. The sample is weighted by race and gender based on 1999 US Census estimates to be representative of the US population.

Results. Of 3566 eligible respondents contacted, 3002 (84%) completed surveys; 902 of those were parents who had a child seen by a pediatrician (62%) or family practitioner (38%) in the past year. About half of all parents who visited a pediatrician or family practitioner reported that they had been asked about household member smoking status (52% vs 48%). More parents who visited pediatricians had been asked if they had rules prohibiting smoking in the home than those who visited family practitioners (38% vs 29%). Of 190 (21%) parents who were smokers, fewer than half reported being counseled by either specialty about dangers of second-hand smoke (41% vs 33%) or risks of modeling smoking behavior (31% vs 28%). Similarly, fewer than half of parental smokers received advice to quit (36% vs 45%).

Conclusion. Overall rates of screening and counseling for parental smoking in pediatric and family practice are low. Despite some differences between specialties, significant opportunities exist to improve tobacco control activities in primary care settings that serve children.
Poison Treatment in the Home
Authors:   Committee on Injury, Violence, and Poison Prevention
Published: August 2004

This Policy Statement was retired June 2010.

The ingestion of a potentially poisonous substance by a young child is a common event, with the American Association of Poison Control Centers reporting approximately 1.2 million such events in the United States in 2001. The American Academy of Pediatrics (AAP) has long concerned itself with this issue and has made poison prevention an integral component of its injury prevention initiatives. A key AAP recommendation has been to keep a 1-oz bottle of syrup of ipecac in the home to be used only on the advice of a physician or poison control center. Recently, there has been interest regarding activated charcoal in the home as a poison treatment strategy. After reviewing the evidence, the AAP believes that ipecac should no longer be used routinely as a home treatment strategy, that existing ipecac in the home should be disposed of safely, and that it is premature to recommend the administration of activated charcoal in the home. The first action for a caregiver of a child who may have ingested a toxic substance is to consult with the local poison control center.
Consent by Proxy for Nonurgent Pediatric Care
Authors: Berger Jan Ellen ,   Committee on Medical Liability
Published: August 2004

Minor-aged patients are often brought to the pediatrician for nonurgent acute medical care or health supervision visits by someone other than their custodial parent or guardian. These surrogates can be members of the child’s extended family, such as a grandparent or aunt. In cases of divorce and remarriage, a noncustodial parent or stepparent may accompany the patient. Sometimes, children are brought for care by adults living in the home who are not biologically or legally related to the child. In some instances, a child care professional (eg, au pair, nanny) brings the pediatric patient for medical care. This report identifies common situations in which pediatricians may encounter “consent by proxy” for nonurgent medical care for minors and explains the potential for liability exposure associated with these circumstances. The report suggests practical steps that balance the need to minimize the physician’s liability exposure with the patient’s access to health care. Key issues to be considered when creating or updating office policies for obtaining and documenting consent by proxy are offered.
Decrease in Hospital Admissions for Febrile Seizures and Reports of Hypotonic-Hyporesponsive Episodes Presenting to Hospital Emergency Departments Since Switching to Acellular Pertussis Vaccine in Canada: A Report From IMPACT
Authors: Le Saux Nicole , Barrowman Nicholas J. , Moore Dorothy L. , Whiting Sharon , Scheifele David , Halperin Scott ,   for Members of the Canadian Paediatric Society/ Health Canada Immunization Monitoring Program–Active (IMPACT)
Published: August 2004

Objective. Acellular pertussis vaccines were introduced with the promise of an improved safety profile compared with whole-cell vaccines. In 1997–1998, Canada adopted 1 combination acellular pertussis vaccine, having previously used 1 particular combination whole-cell pertussis vaccine. We hypothesized that the change would result in a decrease in hospitalization rates for seizures and reports of hypotonic-hyporesponsive episodes (HHEs) temporally related to pertussis vaccination.

Methods. Active surveillance was performed between 1995 and 2001 by the Immunization Monitoring Program–Active monitors at 12 hospitals using standard case definitions. Seizures had to occur within 72 hours after immunization with a pertussis-containing vaccine or 5 to 30 days after immunization with measles-mumps-rubella vaccine. HHE episodes had to occur within 48 hours of receipt of a pertussis-containing vaccine. Poisson regression models were used to compare the average number of monthly admissions for seizures and HHEs before and after introduction of the acellular pertussis vaccine.

Results. We found a 79% decrease in febrile seizures associated with receipt of pertussis vaccine but no significant decrease in febrile seizures temporally related to measles-mumps-rubella between 1995–1996 and 1998–2001. There was a 60% to 67% reduction in HHEs associated with pertussis-containing vaccines between the same time periods, depending on case definition.

Conclusions. The risks of febrile seizures and HHEs after pertussis-containing vaccine declined significantly with the introduction of acellular pertussis vaccine in Canada. Active surveillance systems are important for detecting trends in uncommon adverse events after routine immunizations.
Indoor and Outdoor Environmental Exposures, Parental Atopy, and Physician-Diagnosed Asthma in Taiwanese Schoolchildren
Authors: Lee Yung-Ling , Lin Ying-Chu , Hsiue Tzuen-Ren , Hwang Bing-Fang , Guo Yueliang Leon
Published: August 2004

Objective. Parental atopy and environmental exposures are recognized risk factors for childhood asthma. However, the relative contributions of specific risk factors and the overall contributions of indoor and outdoor exposures remain unexplored. This study was undertaken to identify risk factors, estimate the population attributable risk of each exposure, and compare the data for boys versus girls for physician-diagnosed asthma in Taiwanese schoolchildren.

Methods. During a February to June 2001 cross-sectional national survey, 35 036 6- to 15-year-old schoolchildren were chosen from 22 elementary and 22 middle schools located within 1-km catchment areas of 22 air-monitoring stations in Taiwan. The main outcome measure was physician-diagnosed asthma, as reported by the parents. We investigated hereditary and indoor and outdoor environmental factors for childhood asthma by questionnaire. The adjusted prevalences of questionnaire-determined outdoor indicators were also compared with air-monitoring data.

Results. Outdoor air pollutants were associated with parent-reported perceived ambient air pollution. Physician-diagnosed asthma was reported for 8.1% of the boys (1330 of 16 441) and 5.6% of the girls (894 of 16 056). The risk of physician-diagnosed asthma was significantly associated with parental atopy and perceived ambient air pollution in both sexes. The presence of visible cockroaches (odds ratio [OR]: 1.30; 95% confidence interval [CI]: 1.07–1.59), mold on walls at home (OR: 1.20; 95% CI: 1.01–1.41), and water damage (OR: 1.33; 95% CI: 1.02–1.70) were also associated with asthma in girls; however, only visible mold on walls at home was related to asthma in boys. Mutually adjusted analytical models produced statistically significant associations between any indoor factor and asthma in girls (OR: 1.24; 95% CI: 1.00–1.56) but not in boys (OR: 1.04; 95% CI: 0.87–1.25). For all hereditary and environmental factors, the total population attributable risk was 44.31% in boys and 60.61% in girls.

Conclusions. Parental atopy contributed more to childhood asthma than indoor or outdoor environmental factors. Girls may be more susceptible to indoor factors than boys.
Intrathoracic Disease From Nontuberculous Mycobacteria in Children: Two Cases and a Review of the Literature
Authors: Nolt Dawn , Michaels Marian G. , Wald Ellen R.
Published: August 2004

Pulmonary disease caused by nontuberculous mycobacteria (NTM) is a relatively rare occurrence in immunocompetent children. Two cases of endobronchial NTM infection in immunocompetent children are described. In addition, 41 other children with NTM pulmonary disease reported in the English literature between 1930 and 2003 are reviewed. Clinical manifestations are either purely respiratory or respiratory with more widespread systemic symptoms. Compared with children with only respiratory complaints, children with constitutional symptoms from NTM pulmonary disease 1) had symptoms for a shorter period before presentation (10 vs 28 days), 2) had more radiographic evidence of pulmonary disease, and 3) were treated longer with antimycobacterial agents (11.5 months vs 6 months). The most common causative organism was Mycobacterium avium complex. Pediatricians should be increasingly aware of NTM in the differential diagnosis of persistent pulmonary disease in previously healthy children.
Evaluation of a Rapid Urine Antigen Assay for the Detection of Invasive Pneumococcal Disease in Children
Authors: Neuman Mark I. , Harper Marvin B.
Published: August 2004

Objective. Streptococcus pneumoniae remains the most common cause of occult bacteremia, bacterial pneumonia, and meningitis in young febrile children. We sought to determine the utility of a pneumococcal urine antigen assay among young febrile children at varying risk of invasive pneumococcal disease.

Methods. We prospectively enrolled 5 groups of children, 3 months to 5 years of age, who presented to an urban pediatric emergency department or hospital-based clinic between January 1, 2000, and April 1, 2001. The groups enrolled included 1) children with pneumococcal bacteremia, 2) febrile children with pneumonia, 3) febrile nonbacteremic children with leukocytosis, 4) febrile nonbacteremic children with normal white blood cell (WBC) counts, and 5) afebrile children with no evidence of current or recent bacterial infection.

Results. Of 346 children enrolled, positive assay results were found in 23 (95%) of 24 with pneumococcal bacteremia (95% confidence interval [CI]: 77%–100%), 47 (76%) of 62 with lobar pneumonia (95% CI: 63%–85%), 28 (15%) of 181 nonbacteremic children with fever (95% CI: 11%–22%) with no difference among patients with elevated WBC counts (18%; 95% CI: 11%–27%) compared with those with normal WBC counts (11%; 95% CI: 5%–21%), and 6 of 79 patients without fever (8%; 95% CI: 3%–16%).

Conclusions. This S pneumoniae antigen detection assay demonstrated high sensitivity for proven (bacteremic) and suspected (focal pneumonia) invasive pneumococcal infections. The rate of false-positive test results among febrile children without identified pneumococcal infection is approximately 15%. Although not ideal, this combination of sensitivity and specificity compares favorably with other available tests, such as the WBC or absolute neutrophil count used to screen children for clinically unsuspected pneumococcal infections.
Importance of Parental Conceptual Model of Illness in Severe Recurrent Abdominal Pain
Authors: Crushell Ellen , Rowland Marion , Doherty Mairin , Gormally Siobhan , Harty Sinead , Bourke Billy , Drumm Brendan
Published: August 2004

Objectives. Recurrent abdominal pain (RAP) affects up to 15% of children. A biopsychosocial approach to the treatment of children with RAP has been proposed as an alternative to the traditional medical model. The aim of this study was to examine whether the parental conceptual model of illness is a factor in the long-term outcome of children with severe RAP.

Methods. The study was undertaken in 2 parts: 1) a review of the medical and psychiatric records (including Child Behavior Checklist [CBCL]) of all children with RAP of sufficient severity to necessitate hospitalization during a 5-year period and 2) a structured telephone interview to collect information on ongoing abdominal pain, other somatic symptoms, school attendance, and the parents’ opinion as to the cause of the child’s pain.

Results. Twenty-eight of 30 children who were identified were available for follow-up. Twenty-three (82%) were tertiary referrals from other pediatric services, and 20 had pain for >6 months. On admission 7 (25%) of 28 had a depressive disorder, and 8 (29%) had an anxiety/depressive disorder. Twenty-one of 28 parents completed the CBCL, and on analysis of the CBCL, 11 (52%) children had scores in the clinical range (>65). At follow-up (mean: 3.56 years; standard deviation: 1.59), 14 (50%) of 28 continued to complain of pain. These children also complained of multiple other somatic complaints and had repeated school absences. Only 1 (7%) of 14 parents of children with ongoing pain believed that there was a psychological cause for their child’s pain, whereas 11 (78%) of 14 parents of the children who had recovered believed that the cause was attributable to psychological factors (odds ratio: 47.67; 95% confidence interval: 3.56–1511.6).

Conclusions. The acceptance by parents of a biopsychosocial model of illness is important for the resolution of recurrent abdominal pain in children.
Addressing Parents’ Concerns: Do Vaccines Contain Harmful Preservatives, Adjuvants, Additives, or Residuals?
Authors: Offit Paul A. , Jew Rita K.
Published: August 2004

Vaccines often contain preservatives, adjuvants, additives, or manufacturing residuals in addition to pathogen-specific immunogens. Some parents, alerted by stories in the news media or information contained on the World Wide Web, are concerned that some of the substances contained in vaccines might harm their children. We reviewed data on thimerosal, aluminum, gelatin, human serum albumin, formaldehyde, antibiotics, egg proteins, and yeast proteins. Both gelatin and egg proteins are contained in vaccines in quantities sufficient to induce rare instances of severe, immediate-type hypersensitivity reactions. However, quantities of mercury, aluminum, formaldehyde, human serum albumin, antibiotics, and yeast proteins in vaccines have not been found to be harmful in humans or experimental animals.
A School-Based Exercise Intervention Elicits Substantial Bone Health Benefits: A 2-Year Randomized Controlled Trial in Girls
Authors: MacKelvie Kerry J. , Khan Karim M. , Petit Moira A. , Janssen Patricia A. , McKay Heather A.
Published: August 2004

Objective. Childhood weight-bearing physical activity is recognized as an important determinant of peak bone mass, and physical activity intervention may represent a feasible strategy for primary prevention of osteoporosis. Previous school-based exercise interventions have all been of <10 months in duration. We implemented a high-impact, circuit-based, jumping intervention (10 minutes, 3 times a week) over 2 school years and compared changes in bone mineral content (BMC) over 20 months (2 school years) in 9.9 ± 0.6-year-old intervention girls (N = 32) and controls (10.3 ± 0.4 years, N = 43).

Methods. We measured BMC for the total body, lumbar spine, proximal femur (and femoral neck and trochanteric subregions), and lean and fat mass by dual-energy radiograph absorptiometry (Hologic QDR 4500), and height, sitting height, leg length, and weight at baseline and 20 months. We assessed Tanner stage, general physical activity, and calcium intake by questionnaire.

Results. Girls were Tanner breast stage 1 to 3 at baseline. There were no significant differences in baseline or 20-month change in body size or composition, average physical activity, or calcium intake between groups. There were substantially greater gains in lumbar spine (41.7% vs 38.0%) and femoral neck (24.8% vs 20.2%) BMC in intervention than in control girls (P < .05, analysis of covariance; covariates were baseline BMC and height, change in height, physical activity, and final Tanner stage).

Conclusion. Three brief sessions of high-impact exercise per week implemented over 2 consecutive years within the elementary school curriculum elicited a substantial bone mineral accrual advantage in pubertal girls.
Injection-Site Reactions to Booster Doses of Acellular Pertussis Vaccine: Rate, Severity, and Anticipated Impact
Authors: Skowronski Danuta M. , Remple Valencia P. , Macnabb Jane , Pielak Karen , Patrick David M. , Halperin Scott A. , Scheifele David
Published: August 2004

Background. Acellular pertussis (aP)-containing vaccines cause fewer adverse events than whole-cell versions for primary doses. Booster doses, however, may be followed by extensive injection-site reactions. This study compares the frequency, severity, and impact of local reactions among children receiving 5 consecutive doses of an aP combination vaccine (including inactivated polio virus, conjugated Haemophilus influenzae type b antigen, and diphtheria and tetanus toxoids) to children receiving a mixed series of whole-cell and aP combination vaccines.

Methods. Participants were parents or guardians of children 4 to 6 years old immunized at public health clinics across British Columbia, Canada. This included 398 children receiving the fifth consecutive dose of an aP combination vaccine and 402 receiving the fifth dose in a mixed series consisting of at least 1 prior dose of whole-cell pertussis combination vaccine with the remainder as aP combination vaccine. A cross-sectional telephone survey evaluated the extent of local reactions 48 to 96 hours after immunization by asking participants to compare the size of redness and swelling with familiar household items such as Oreo cookies or coins. Associated discomfort and impact on recreational activities, health care utilization, parental time off work, and attitudes toward immunization were also assessed.

Results. Children who received the fifth consecutive dose of an aP combination vaccine more often experienced redness (24%) or swelling (16%) the size of an Oreo cookie or larger (≥46 mm) than children given a mixed series (10% and 9%, respectively) but less often experienced tenderness or limitation of movement at the injection site. Related health care utilization was low. There was no discernible effect on participation in recreational activities or parental attitudes toward vaccine; 90% would recommend the same vaccine to others with children of the same age.

Conclusions. We conclude that injection-site reactions are more extensive after the fifth consecutive dose of an aP combination vaccine compared with the fifth dose in a mixed series of whole-cell and aP combination vaccines. These reactions are unlikely to affect parental acceptance of immunization recommendations or health care utilization.
Soft Drinks in Schools
Authors:   Committee on School Health
Published: August 2004

This statement is intended to inform pediatricians and other health care professionals, parents, superintendents, and school board members about nutritional concerns regarding soft drink consumption in schools. Potential health problems associated with high intake of sweetened drinks are 1) overweight or obesity attributable to additional calories in the diet; 2) displacement of milk consumption, resulting in calcium deficiency with an attendant risk of osteoporosis and fractures; and 3) dental caries and potential enamel erosion. Contracts with school districts for exclusive soft drink rights encourage consumption directly and indirectly. School officials and parents need to become well informed about the health implications of vended drinks in school before making a decision about student access to them. A clearly defined, district-wide policy that restricts the sale of soft drinks will safeguard against health problems as a result of overconsumption.
The Effect of Birth Hospital Type on the Outcome of Very Low Birth Weight Infants
Authors: Warner Barbara , Musial M. Judith , Chenier Thomas , Donovan Edward
Published: August 2004

Objective. To test the hypothesis that the likelihood of death or major morbidity is reduced for very low birth weight (VLBW; <1500 g) infants who are born at hospitals with subspecialty perinatal and neonatal care compared with other available birth sites.

Methods. A population-based cohort study was conducted of all live births of 500 to 1499 g at the 19 hospitals in the greater Cincinnati region from September 1, 1995, through December 31, 1997 (N = 848). Primary outcome was the risk-adjusted, predischarge mortality or morbidity, including bronchopulmonary dysplasia, severe intracranial hemorrhage, severe retinopathy of prematurity, or necrotizing enterocolitis for VLBW infants who were born at subspecialty perinatal centers compared with those who were born at nonsubspecialty centers.

Results. The odds of death or major morbidity for VLBW infants who are born at nonsubspecialty perinatal centers is twice that of infants who are born at subspecialty centers despite controlling for demographic (odds ratio [OR]: 2.64; 95% confidence interval [CI]: 1.7–4.2) and practice characteristics (OR: 1.96; 95% CI: 1.2–3.2). The effect of birth hospital type on death or major morbidity was greater for infants of 1000 to 1499 g birth weight (OR: 3.42; 95% CI: 2.0–6.1) than for infants of 500 to 999 g birth weight (OR: 2.1; 95% CI: 1.0–4.8).

Conclusion. The current study lends strong support to existing Academy of Pediatrics and American College of Obstetricians and Gynecologists recommendations that deliveries at <32 weeks’ gestational age occur at subspecialty perinatal centers.
Influence of Helicobacter pylori Eradication on Gastroesophageal Reflux Symptoms and Epigastric Pain in Children and Adolescents
Authors: Levine Arie , Milo Tamir , Broide Efrat , Wine Eitan , Dalal Ilan , Boaz Mona , Avni Yona , Shirin Haim
Published: August 2004

Objective. Conflicting reports have noted a possible association linking eradication of Helicobacter pylori with aggravation of gastroesophageal reflux (GER) disease. We prospectively evaluated the effect of eradication of H pylori on GER symptoms and epigastric pain and the association among these 3 parameters in a pediatric cohort.

Methods. Patients who were referred for gastroscopy were evaluated for frequency, severity, and nocturnal presence of symptoms related to GER as well as epigastric pain. Patients who were positive for H pylori received triple antibiotic therapy. The patients were followed for at least 6 months after therapy. Patients with successful eradication had symptoms compared with their pre-eradication state and were compared with a cohort of patients without H pylori or those with persistent H pylori.

Results. Of 119 children and adolescents who were recruited, 95 patients completed the study, with a mean follow-up of 11.2 months. The distribution of outcomes for each GER symptom (better, worse, unchanged) was similar before and after eradication and did not depend on prior H pylori status. Among patients with GER and epigastric pain, improvement in epigastric pain was significantly correlated with the improvement in GER symptoms but not with eradication of H pylori.

Conclusions. Eradication of H pylori is not associated with increased symptoms of GER in children and adolescents. Improvement in epigastric pain in children is significantly correlated with the improvement in GER symptoms but not with eradication of H pylori.
Neonatal Cerebral Infarction and Neuromotor Outcome at School Age
Authors: Mercuri Eugenio , Barnett Anna , Rutherford Mary , Guzzetta Andrea , Haataja Leena , Cioni Giovanni , Cowan Frances , Dubowitz Lilly
Published: August 2004

Objective. The aim of this study was to assess neuromotor function at school age in children who had cerebral infarction on neonatal magnetic resonance imaging (MRI).

Design. Twenty-two children with evidence of cerebral infarction on neonatal brain MRI (18 with arterial infarction and 4 with border-zone lesions) were assessed at school age with a structured neurologic examination and the Movement Assessment Battery for Children, a battery of tests designed to assess motor function.

Results. Of the 22 children, 6 (30%) had hemiplegia and a further 7 (30%) showed some neuromotor abnormality such as asymmetry on the neurologic examination (n = 4) or poor scores on the neuromotor test without any sign of asymmetry (n = 3). The remaining 9 children had a normal motor outcome. Hemiplegia was found only in children who had concomitant involvement of hemisphere, internal capsule, and basal ganglia on brain MRI. Children with involvement of the internal capsule, associated either with basal ganglia or hemispheric lesions, did not show hemiplegia but still had motor difficulties.

Conclusions. Our results suggest that although hemiplegia occurs in a relatively small proportion of children with neonatal cerebral infarction, other signs of neuromotor impairment can be present, and these become more obvious at school age when a more specific assessment can be performed. These results also suggest that the involvement of the internal capsule on neonatal MRI can predict the presence of these abnormalities.
Paintball Injuries in Children: More Than Meets the Eye
Authors: Listman David A.
Published: August 2004

Objective. To describe the increasing incidence of ocular injuries in the pediatric population caused by paintballs. The awareness of this trend will help the physician who treats the child to give appropriate care as well as educate physicians, who counsel children, about this growing mechanism of pediatric injuries.

Methods. Previously unpublished data from the US Consumer Product Safety Commission were analyzed to find the frequency of ocular injuries in children. A review of the English-language literature was also conducted to describe trends with regard to age, sex, location at the time of injury, use of eye protection, types of injuries sustained, and long-term visual outcome.

Results. The incidence of paintball eye injuries treated in emergency departments has risen from an estimated 545 in 1998 to >1200 in 2000. The proportion of these injuries that occurred in the pediatric population may be well over 40%. These injuries are seen predominantly in boys, a growing proportion of whom are playing informally in unsupervised settings and not wearing eye protection. The cases previously reported include large numbers of hyphemas, retinal detachments, cataracts, corneal abrasions, vitreous hemorrhages, and commotio retina. Many of the patients in these cases sustained permanent visual impairment, with 43% having best vision at follow-up of 20/200 or worse.

Conclusions. Pediatric eye injuries caused by paintballs are an unrecognized cause of severe injury and permanent visual loss. The advances in eye protection for participants in “war games” have had little if any effect on the youngest population. Children and teens are unlikely to wear eye protection voluntarily when playing at undesignated or unsupervised locations. Changes should be made to restrict availability of these very dangerous but easily acquired guns and ammunition. Practitioners must counsel young people and their caregivers to avoid injuries by wearing appropriate eye protection. Parents should supervise the use of paintball equipment as they would other activities that involve high-speed projectiles.
Planning Adenotonsillectomy in Children With Obstructive Sleep Apnea: The Role of Overnight Oximetry
Authors: Nixon Gillian M. , Kermack Andrea S. , Davis G. Michael , Manoukian John J. , Brown Karen A. , Brouillette Robert T.
Published: August 2004

Objective. Obstructive sleep apnea (OSA) in children is usually effectively treated by adenotonsillectomy (T&A). However, there may be a waiting list for T&A, and the procedure is associated with an increased risk of postoperative complications in children with OSA. Needed is a simple test that will facilitate logical prioritization of the T&A surgical list and help to predict children who are at highest risk of postoperative complications. The objective of this study was to develop and validate a severity scoring system for overnight oximetry and to evaluate the score as a tool to prioritize the T&A surgical list.

Methods. This study comprised 3 phases. In phase 1, a severity score was developed by review of preoperative overnight oximetry in children who had urgent T&A in 1999–2000. In phase 2, the score was validated retrospectively in 155 children who had polysomnography (PSG) before T&A in 1992–1998. In a phase 3, a 12-month prospective evaluation of a protocol based on the score was conducted.

Results. In phase 1, a 4-level severity score was developed on the basis of the number and the depth of desaturation events (normal to severely abnormal, categories 1–4). In phase 2, the McGill oximetry score correlated with severity of OSA by PSG criteria. In phase 3, a clinical management protocol was developed based on the score. Of 230 children tested, 179 (78%) had a normal/inconclusive oximetry (category 1) and went on to have PSG. Those with a positive oximetry (categories 2–4; 22%) had no additional sleep studies before T&A. Timing of T&A was based on oximetry score, leading to a significant reduction in waiting time for surgery for those with higher oximetry scores. Postoperative respiratory complications were more common with increasing oximetry score.

Conclusions. Overnight pulse oximetry can be used to estimate the severity of OSA, to shorten the diagnostic and treatment process for those with more severe disease, and to aid clinicians in prioritization of T&A and planning perioperative care.
Identification and Recall of Children With Chronic Medical Conditions for Influenza Vaccination
Authors: Daley Matthew F. , Barrow Jennifer , Pearson Kellyn , Crane Lori A. , Gao Dexiang , Stevenson John M. , Berman Stephen , Kempe Allison
Published: August 2004

Objectives. Despite long-standing recommendations to provide annual influenza vaccination to children with chronic medical conditions, immunization rates are <10% in most primary care settings. Many obstacles impede implementation of these recommendations, including the challenge of identifying targeted children and the need to immunize yearly in a short time interval. The objective of this study was to assess the accuracy of billing data for identifying children who have high-risk conditions (HRCs) and need influenza vaccination and 2) to evaluate the efficacy of reminder/recall for children with HRCs.

Methods. The study was conducted in 4 private pediatric practices in metropolitan Denver, Colorado, that share a computerized billing system and also participate in an immunization registry. For all children aged 6 to 72 months, registry records were linked with the billing database. Patients with ≥1 encounters for an HRC in the previous 24 months were selected, with HRCs identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Using medical records as the “gold standard,” we reviewed 327 randomly selected records to determine the sensitivity, specificity, and accuracy of billing data for identifying HRCs. For children with an HRC, we then conducted a randomized, controlled trial of reminder/recall for influenza vaccination. The primary outcome of the recall trial was receipt of influenza vaccine.

Results. Billing data had a sensitivity of 72% (95% confidence interval [CI]: 48%–95%), specificity of 95% (95% CI: 90%–100%), and overall accuracy of 90% (95% CI: 84%–96%) in determining which children had an HRC. Of the 17 273 patients aged 6 to 72 months, 2007 had ≥1 HRCs (12% overall; range: 9%–14% per practice). Asthma/reactive airways disease accounted for 87% of all HRCs. Reminder/recall significantly increased influenza immunization in children with HRCs, with a vaccination rate of 42% in those recalled, compared with 25% in control subjects. Recalled subjects were more likely to have an office visit (68% vs 60%) and less likely to have a missed opportunity to immunize (28% vs 37%) compared with control subjects.

Conclusions. Diagnosis-based billing data accurately identified children who had HRCs and needed annual influenza vaccination, and registry-driven reminder/recall significantly increased influenza immunization in targeted children.