bluuebunny/crossref_metadata_2025 huggingface dataset:
Day-to-Day Reactogenicity and the Healthy Vaccinee Effect of Measles-Mumps-Rubella Vaccination
Authors: Virtanen Martti , Peltola Heikki , Paunio Mikko , Heinonen Olli P.
Published: August 2004

Objective.

Revaccination policies adopted in many countries to control measles have raised various safety issues including those concerning the second vaccine dose. We performed a prospective, double-blind, crossover trial among twins receiving a measles-mumps-rubella (MMR) vaccine.

Study Design.

The study comprised 1162 monozygous and heterozygous twins, each of whom randomly received placebo and then vaccine, or vice versa, 3 weeks apart, at 14 to 83 months of age. Most of the oldest children had previously been vaccinated against measles, and one half of the remainder of children had had the disease. Symptoms and signs were recorded daily on structured forms. Statistical methods included a complex analysis of the vaccine attributability of the symptoms and conditional logistic regression.

Results.

Vaccination-attributable events occurred in 6% overall. At 14 to 18 months of age, reactions developed between days 6 and 14, peaking at day 10. The clearest vaccine-attributable effect was fever exceeding 101.3 °F (38.5°C; odds ratio: 3.28; 95% confidence interval: 2.23–4.82; P < .001), but the same trend was found for rash, arthralgia, conjunctivitis, staying in bed, drowsiness, and irritability. At 6 years of age, systemic reactions occurred 5 to 15 times less frequently, only arthralgia being associated with vaccination. Zygocity, gender, history of allergy, or infections did not modify reactions. Instead, respiratory symptoms developed within days postinjection to a level of 15% to 20% without subsequent decline and with no difference between vaccinees and placebo recipients.

Conclusion.

Vaccination was avoided during infections, but many small children became mildly ill within a week or so with no relation to vaccination (the healthy vaccinee effect). MMR vaccine was virtually nonreactogenic when given at 6 years of age. vaccine, measles, mumps, rubella, reactogenicity, adverse events, zygocity, healthy vaccinee effect.
Major Factors Influencing Breastfeeding Rates: Mother's Perception of Father's Attitude and Milk Supply
Authors: Arora Samir , McJunkin Cheryl , Wehrer Julie , Kuhn Phyllis
Published: August 2004

Objective.

To determine factors influencing feeding decisions, breastfeeding and/or bottle initiation rates, as well as breastfeeding duration.

Setting.

A family medicine practice of a 530-bed community-based hospital in northwestern Pennsylvania.

Participants.

All mothers whose infants received well-child care from birth to 1 year of age.

Outcome Measure.

A survey of 28 simple questions was developed and mailed to 245 mothers. The survey assessed: 1) demographics, 2) prenatal and postnatal care, 3) sources of breastfeeding information, 4) timing of decision, 5) preference, 6) type of feeding selected, 7) duration of breastfeeding, 8) factors influencing decisions to breastfeed and/or to bottle-feed, and 9) factors that would have encouraged bottle-feeding mothers to breastfeed.

Results.

The breastfeeding initiation rate was 44.3%. By the time the infant was 6 months old, only 13% of these were still breastfeeding. The decision to breastfeed or to bottle-feed was most often made before pregnancy or during the first trimester. The most common reasons mothers chose breastfeeding included: 1) benefits the infant's health, 2) naturalness, and 3) emotional bonding with the infant. The most common reasons bottle-feeding was chosen included: 1) mother's perception of father's attitude, 2) uncertainty regarding the quantity of breast milk, and 3) return to work. By self-report, factors that would have encouraged bottle-feeding mothers to breastfeed included: 1) more information in prenatal class; 2) more information from TV, magazines, and books; and 3) family support.

Conclusions.

To overcome obstacles, issues surrounding perceived barriers, such as father's attitude, quantity of milk, and time constraints, need to be discussed with each parent. To achieve the goal of 75% of breastfeeding mothers, extensive education regarding the benefits must be provided for both parents and optimally the grandmother by physicians, nurses, and the media before pregnancy or within the first trimester.
Targeting Lead Screening: The Ohio Lead Risk Score
Authors: Litaker David , Kippes Christopher M. , Gallagher Timothy E. , O'Connor Mary E.
Published: August 2004

Objective.

Annual blood lead (BPb) screening is recommended for children ≤2 years of age residing in high-risk areas. Strategies for identifying these areas exist but lack specificity. We sought to develop an efficient method for identifying risk factors for undue lead exposure in children by using community variables.

Design.

Logistic regression for model development in one half of the sample followed by validation of the model in the remaining half.

Methods.

The association between selected census tract characteristics from 19 Ohio counties and the BPb test results of children living in those census tracts was evaluated. The dependent variable, high-risk status, was defined as a census tract with ≥12% of BPb test results ≥10 μg/dL.

Results.

Data from 897 census tracts were available. Higher risk for lead toxicity existed in areas where: 1) ≥55% of houses were built before 1950 (adjusted odds ratio [AOR]: 10.9 [6.1,19.6]); 2) ≥35% of residents were black (AOR: 3.5 [2.0,6.3]); 3) ≥35% of residents had less than a high school education (AOR: 6.1 [3.6,10.4]); and 4) ≥50% of housing units were renter-occupied (AOR: 3.6 [2.1,6.2]). Receiver operator characteristic (ROC) curves demonstrated no significant differences after applying the model in a second dataset.

Conclusions.

Several community characteristics predict risk for lead toxicity in children and may provide a useful approach to focus lead screening, especially in communities where public health resources are limited. The approach described here may also prove helpful in identifying factors within a community associated with other environmental public health hazards for children.
Providing Pediatric Subspecialty Care: A Workforce Analysis
Authors: Stoddard Jeffrey J. , Cull William L. , Jewett Ethan A. B. , Brotherton Sarah E. , Mulvey Holly J. , Alden Errol R. ,   for the AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce
Published: August 2004

Objective.

To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market.

Background.

Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies.

Methods.

Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed.

Results.

For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%–90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%–63%).

Conclusion.

This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.
Infant Feeding Mode Affects Early Growth and Body Composition
Authors: Butte Nancy F. , Wong William W. , Hopkinson Judy M. , Smith E. O'Brian , Ellis Kenneth J.
Published: August 2004

Background.

Differences in the growth pattern of breastfed (BF) and formula-fed (FF) infants are well-recognized and have been attributed to differences in nutrient intake. However, the impact of qualitative and quantitative differences in nutrient intake on the body composition of BF and FF infants has been unclear. Furthermore, it is unknown whether putative differences in body composition persist beyond weaning.

Design.

Prospective cohort study.

Methods.

Repeated anthropometric and body composition measurements were performed on 40 BF and 36 FF infants at 0.5, 3, 6, 9, 12, 18, and 24 months of age. A multicomponent body composition model based on total body water by deuterium dilution, total body potassium by whole body counting, and bone mineral content by dual-energy x-ray absorptiometry was used to estimate fat-free mass (FFM) and fat mass (FM). Independent measurements of FFM and FM were made using total body electrical conductivity and dual-energy x-ray absorptiometry. By design, infants were either exclusively BF or FF from birth to 4 months of age; thereafter, the feeding mode was at the discretion of the parents. Infant food intake was measured at 3, 6, 12, and 24 months of age using 3-day weighed-intake records. Data were analyzed by repeated measures analysis of variance.

Results.

Weight velocity was higher in FF than BF infants age 3 to 6 months, and higher in FF than BF girls 6 to 9 months of age. Adjusted for gender and baseline values, BF infants had lower total body water at 3 months, lower total body potassium at 3 to 24 months, and lower bone mineral content at 12 months. The multicomponent model indicated that FFM was lower in BF than FF infants at 3 months, and FM and %FM were higher in BF than FF infants at 3 and 6 months (boys only). Total body electric conductivity confirmed lower FFM in BF than FF infants at 3 months, as well as at 6 and 9 months; FM and %FM were higher in BF than FF at 3 and 6 months, and 9 months (boys only). Intakes of energy, protein, fat, and carbohydrate were lower in BF than FF infants at 3 and 6 months, and were positively correlated with weight gain and FFM gain, but not FM gain. No differences in nutrient intakes were observed at 12 or 24 months.

Conclusion.

Infant feeding mode is associated with differences in body composition in early infancy which do not persist into the second year of life.
Influence of Parental Gender and Self-Reported Health and Illness on Parent-Reported Child Health
Authors: Waters Elizabeth , Doyle Jodie , Wolfe Rory , Wright Martin , Wake Melissa , Salmon Louisa
Published: August 2004

Background.

Although there is clear evidence of the influence of parental factors on child health outcomes, the influence of parental perceptions of their health and illness on the reporting of child health remains primarily unknown.

Objectives.

To examine relationships between parents' reporting of their own health and illness with the reporting of their children's health and illness.

Method.

We surveyed parents of a representative population-based sample of children aged 5 to 18 years. One parent of each child completed a written questionnaire including the Child Health Questionnaire, a subjective measure of functional health and well-being, and an assessment of self-reported parental health and illness. Logistic regression models were used to examine relationships between parent and child health and illness.

Main Results.

5340 parents responded (86% mothers, 14% fathers). After adjusting for confounding effects, parents self-reporting poor health had increased odds of reporting their children with poor health (odds ratio: 7.5), although the effect was modified by parent gender. There were increased odds of mothers with self-reporting poor global health reporting their children with poor global health and illness (odds ratio: 9.0 and 2.5, respectively) that were not observed for fathers.

Conclusions.

A mother's self-reported health is strongly associated with her reporting of her child's health; this was not observed for fathers. These results suggest that parental gender should be considered as a mediating factor in the reporting of child health.
Role of Carbon Monoxide and Nitric Oxide in Newborn Infants With Postasphyxial Hypoxic-Ischemic Encephalopathy
Authors: Shi Yuan , Pan Feng , Li Huaqiang , Pan Jie , Qin Shiwen , Shen Chikao
Published: August 2004

Objective.

To investigate the role of carbon monoxide (CO) and nitric oxide (NO) in the pathogenesis of neonatal hypoxic-ischemic encephalopathy (HIE).

Methods.

Plasma CO and NO levels were studied in 33 asphyxiated term neonates, and 30 healthy neonates served as controls.

Results.

Among the 33 asphyxiated term neonates, plasma CO and NO levels in 28 neonates with HIE were significantly higher than those in the 5 infants without HIE and in the normal controls. The plasma CO and NO levels in the newborn infants with HIE stage 3 were found to be significantly higher than those in the neonates with HIE stage 1 and 2. Moreover, plasma CO and NO levels were significantly increased in neonates with brain damage and adverse outcome as compared with those in patients with normal neuroimaging and normal outcome.

Conclusion.

Plasma CO and NO levels after perinatal asphyxia are related to the severity of neonatal HIE, brain damage, and neurologic outcome. The present study suggests that CO and NO might play important roles in the pathogenesis of neonatal HIE.
Carrier Testing of Children for Two X-Linked Diseases: A Retrospective Study of Comprehension of the Test Results and Social and Psychological Significance of the Testing
Authors: Järvinen Outi , Lehesjoki Anna-Elina , Lindlöf Mikael , Uutela Antti , Kääriäinen Helena
Published: August 2004

Objective.

To evaluate long-term consequences of genetic carrier testing performed in childhood in terms of awareness and comprehension of the test result, and the social and psychological significance of such testing.

Study Design.

The families of 66 young females who had been tested for carriership during childhood between 1984 and 1988 were approached. Of the 66 families, 23 young females in families affected by Duchenne muscular dystrophy (DMD), 23 young females in families affected by hemophilia A (HA), and their mothers participated in our study. We used a questionnaire including multiple-choice and open-ended questions.

Results.

Of the young female participants tested in the families affected by DMD or HA, 65% knew their test results. Only 65% of DMD mothers and 78% of HA mothers remembered correctly the test results of their daughters. The majority (83%) of the young females tested sought no genetic counseling when reaching adulthood. The reason for this was not determined. Most (78%) reported that the test result had not influenced their lives, whereas some felt relieved to know they had not been carriers. Talking about hereditary disease in the family and between friends was open, and results of the carrier test had usually been told to friends.

Conclusion.

Carrier testing was in most cases correctly understood and the matter openly discussed. Our results do not suggest that testing in childhood had caused serious harm to the young individuals tested. On the other hand, we found no obvious benefits from this early testing.
Reexamining the Association Between Child Access Prevention Gun Laws and Unintentional Shooting Deaths of Children
Authors: Webster Daniel W. , Starnes Marc
Published: August 2004

Context.

A previous study estimated that child access prevention (CAP) laws, which hold adults criminally liable for unsafe firearm storage in the environment of children, were associated with a 23% decline in unintentional firearm mortality rates among children.

Objective.

To reassess the effects of CAP laws and more fully examine the consistency of the estimated law effects across states.

Design.

A pooled time-series study of unintentional firearm mortality among children from 1979 through 1997.

Setting.

The 50 states and the District of Columbia.

Participants.

All children <15 years.

Main Outcome Measures.

Rates of unintentional deaths attributable to firearms.

Results.

When the effects of all 15 state CAP laws enacted before 1998 were aggregated, the laws were associated with a 17% decline unintentional firearm death rates among children. The laws' effects were not equal across states. Florida's CAP law was associated with a 51% decline; however, there were no statistically significant aggregate or state-specific law effects in the other 14 states with CAP laws.

Conclusions.

Florida's CAP law—1 of only 3 such laws allowing felony prosecution of violators—appears to have significantly reduced unintentional firearm deaths to children. However, there is no evidence of effects in the other 14 states with CAP laws.
Vitamin D–Deficiency Rickets in Adopted Children From the Former Soviet Union: An Uncommon Problem With Unusual Clinical and Biochemical Features
Authors: Reeves Grafton D. , Bachrach Steven , Carpenter Thomas O. , Mackenzie William G.
Published: August 2004

Rickets is an unusual disorder in international adoptees. Three international adoptees from the former Soviet Union recently presented with rickets. Their clinical and laboratory presentations were atypical, reflecting circumstances unique to children adopted from orphanages in the former Soviet Union and the early initiation of vitamin D therapy. In these children, radiographs of the long bones were diagnostic when the classically diagnostic biochemical parameters, calcium and 25OHD3 levels, were normal.
Molecular Genetic Testing in Pediatric Practice: A Subject Review
Authors:   Committee on Genetics
Published: August 2004

This Policy Statement was retired September 2016.

Although many types of diagnostic and carrier testing for genetic disorders have been available for decades, the use of molecular methods is a relatively recent phenomenon. Such testing has expanded the range of disorders that can be diagnosed and has enhanced the ability of clinicians to provide accurate prognostic information and institute appropriate health supervision measures. However, the proper application of these tests may be difficult because of their scientific complexity and the potential for negative, sometimes unexpected, consequences for many patients. The purposes of this subject review are to provide background information on molecular genetic tests, to describe specific testing modalities, and to discuss some of the benefits and risks specific to the pediatric population. It is likely that pediatricians will use these testing methods increasingly for their patients and will need to evaluate critically their diagnostic and prognostic implications.
Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants
Authors: Kaplan Ron L. , Harper Marvin B. , Baskin Marc N. , Macone Ann B. , Mandl Kenneth D.
Published: August 2004

Objective.

To determine the time to detection of positive blood, urine, and cerebrospinal fluid (CSF) cultures among febrile 28- to 90-day-old infants.

Study Design.

Retrospective cohort of consecutive 28- to 90-day-old infants presenting with a temperature of ≥38°C to an urban pediatric emergency department. Positive cultures and times to detection were noted. Patients were categorized as being at high risk for serious bacterial illness (SBI) based on clinical and laboratory criteria.

Results.

Of the 3166 febrile infants seen in the emergency department during the study, 2733 had blood (86%), 2517 had urine (80%), and 2361 had CSF (75%) specimens obtained for culture, and 2190 had all 3 cultures (69%) sent. There were 224 positive cultures in 214 patients; of these, 191 had all 3 cultures (89%) sent. Subsequent analyses were confined to those who had all 3 cultures sent. The detected rate of SBI was 8.7% (191/2190). There were 28 positive blood cultures (1.3%), 165 positive urine cultures (7.5%), and 8 positive CSF cultures (.4%). Median time to detection of positive cultures was 16 hours for blood, 16 hours for urine, and 18 hours for CSF. Four blood cultures (.1%), 20 urine cultures (.9%), and 0 CSF cultures were noted to have growth of a pathogen >24 hours after the specimen was obtained. All 4 blood cultures and 17 of 20 urine cultures with growth noted after 24 hours occurred among high-risk patients.

Conclusions.

The risk of identifying SBI after 24 hours is 1.1% among all 28- to 90-day-old febrile infants and .3% in low-risk infants.
Predicting HIV Disease Progression in Children Using Measures of Neuropsychological and Neurological Functioning
Authors: Pearson Deborah A. , McGrath Nuala M. , Nozyce Molly , Nichols Sharon L. , Raskino Claire , Brouwers Pim , Lifschitz Marta C. , Baker Carol J. , Englund Janet A. ,   for the Pediatric AIDS Clinical Trials 152 Study Team
Published: August 2004

Background.

Neuropsychological testing and 2 measures of neurological status, cortical atrophy, and motor dysfunction were assessed for their usefulness in predicting human immunodeficiency virus (HIV) disease progression in infants, children, and adolescents who participated in Pediatric AIDS Clinical Trials Group Protocol 152 (PACTG 152).

Methods.

A cohort of 722 antiretroviral therapy-naive children with symptomatic HIV infection were assessed at study entry and at later intervals. Assessments included neurodevelopmental testing, neuroradiologic imaging, and neurological examination of motor function. CD4 cell count and plasma RNA viral load also were measured.

Results.

Children with the lowest neuropsychological functioning (IQ < 70) at baseline had the highest risk for later HIV disease progression (56%), compared with those with borderline/low (IQ = 70–89) functioning (26%), or with average or above (IQ > 90) functioning (18%). This was also true of week 48 neuropsychological functioning. Motor dysfunction (especially reduced muscle mass) at entry also predicted disease progression. Furthermore, motor dysfunction and week 48 neuropsychological functioning provided predictive information beyond that obtainable from surrogate markers of HIV disease status (eg, CD4 count, HIV RNA level). Children with cortical atrophy also were at higher risk for later disease progression, but when CD4 count and RNA viral load were known, cortical atrophy information provided no additional predictive information.

Conclusions.

Measures of neuropsychological and motor function status provide unique information regarding pediatric HIV disease progression. As such, these findings have important implications for predicting long-term outcomes (eg, longevity) in pediatric patients.
Morbidity Among Human Immunodeficiency Virus-1-Infected and -Uninfected African Children
Authors: Taha Taha E. , Graham Stephen M. , Kumwenda Newton I. , Broadhead Robin L. , Hoover Donald R. , Markakis Diane , van der Hoeven Len , Liomba George N. , Chiphangwi John D. , Miotti Paolo G.
Published: August 2004

Objective.

To assess patterns of morbidity and associated factors in late infancy and early childhood among human immunodeficiency virus (HIV)-infected and -uninfected African children.

Design.

Prospective study.

Setting.

The Queen Elizabeth Central Hospital, Blantyre, Malawi.

Participants.

Children with known HIV status from an earlier perinatal intervention trial were enrolled during the first year of life and followed to ∼36 months of age.

Outcome Measures.

Morbidity and mortality information was collected every 3 months by a questionnaire. A physical examination was conducted every 6 months. Blood to determine CD4+ values was also collected. Age-adjusted and Kaplan-Meier analyses were performed to compare rates of morbidity and mortality among infected and uninfected children.

Results.

Overall, 808 children (190 HIV-infected, 499 HIV-uninfected but born to infected mothers, and 119 born to HIV-uninfected mothers) were included in this study. Of these, 109 died during a median follow-up of 18 months. Rates of childhood immunizations were high among all children (eg, lowest was measles vaccination [87%] among HIV-infected children). Age-adjusted morbidity rates were significantly higher among HIV-infected than among HIV-uninfected children. HIV-infected children were more immunosuppressed than were uninfected children. By 3 years of age, 89% of the infected children died, 10% were in HIV disease category B or C, and only ∼1% were without HIV symptoms. Among HIV-infected children, median survival after the first occurrence of acquired immunodeficiency syndrome-related conditions, such as splenomegaly, oral thrush, and developmental delay, was <10 months. These same conditions, in addition to frequent bouts of fever, were the main morbidity predictors of mortality.

Conclusions.

The frequency of diseases was high, and progression from asymptomatic or symptomatic HIV disease to death was rapid. Management strategies that effectively reduce morbidity for HIV-infected children are needed.
Hyperbaric Oxygen Therapy for Cerebral Palsy: Two Complications of Treatment
Authors: Nuthall Gabrielle , Seear Michael , Lepawsky Michael , Wensley David , Skippen Peter , Hukin Juliette
Published: August 2004

There is growing interest in the use of hyperbaric oxygen therapy (HBO2) for children with cerebral palsy. Although there is no rigorous evidence to support this management, private hyperbaric centers have been established throughout the United States and Canada. There is likely to be increasing pressure on pediatricians and other health professionals to prescribe HBO2. We describe 2 children with cerebral palsy who suffered significant morbidity immediately after treatment with hyperbaric oxygen. Both the temporal association and pathologic findings suggest that the hyperbaric treatment is likely to have been responsible for the resulting complications. As with any new therapy, we suggest waiting for the results of a randomized, controlled trial before recommending this treatment.
The Pivotal Role of Deep Vein Thrombophlebitis in the Development of Acute Disseminated Staphylococcal Disease in Children
Authors: Gorenstein Arkadi , Gross Eitan , Houri Sion , Gewirts Gabriella , Katz Schmuel
Published: August 2004

Deep vein thrombophlebitis (DVT) and septic pulmonary emboli (PE) are rare in children. The association of DVT and acute disseminated staphylococcal disease (DSD) during childhood has not been previously reported. We report 3 children who developed a triad of DVT, septic PE, and acute osteomyelitis withStaphylococcus aureus cultured from blood and bone. One child succumbed, while 2 survived following prolonged, morbid hospitalizations. The rapid clinical deterioration observed in these patients might be caused by the aggressiveness of staphylococcal infection combined with an ongoing showering of septic emboli from the ileo-femoral DVT. We suggest that infected DVT with septic PE had a pivotal role in the development of DSD in these children. The presence of this triad should prompt aggressive treatment with the appropriate antibiotics, anticoagulation, surgical drainage, and assisted ventilation when indicated.
Technical Report: Precautions Regarding the Use of Aerosolized Antibiotics
Authors: Prober Charles G. , Walson Philip D. , Jones Jim ,   the Committee on Infectious Diseases and Committee on Drugs
Published: August 2004

This Technical Report was retired August 2010.

In 1998, the Food and Drug Administration (FDA) approved the licensure of tobramycin solution for inhalation (TOBI). Although a number of additional antibiotics, including other aminoglycosides, β-lactams, antibiotics in the polymyxin class, and vancomycin, have been administered as aerosols for many years, none are approved by the FDA for administration by inhalation.

TOBI was approved by the FDA for the maintenance therapy of patients 6 years or older with cystic fibrosis (CF) who have between 25% and 75% of predicted forced expiratory volume in 1 second (FEV1), are colonized with Pseudomonas aeruginosa, and are able to comply with the prescribed medical regimen. TOBI was not approved for the therapy of acute pulmonary exacerbations in patients with CF nor was it approved for use in patients without CF. Currently, no other antibiotics are approved for administration by inhalation to patients with or without CF.

The purpose of this statement is to briefly summarize the data that supported approval for licensure of TOBI and to provide recommendations for its safe use. The pharmacokinetics of inhaled aminoglycosides and problems associated with aerosolized antibiotic treatment, including environmental contamination, selection of resistant microbes, and airway exposure to excipients in intravenous formulations, will be discussed.
Collaborative Quality Improvement for Neonatal Intensive Care
Authors: Horbar Jeffrey D. , Rogowski Jeannette , Plsek Paul E. , Delmore Paula , Edwards William H. , Hocker James , Kantak Anand D. , Lewallen Patrick , Lewis William , Lewit Eugene , McCarroll Connie J. , Mujsce Dennis , Payne Nathaniel R. , Shiono Patricia , Soll Roger F. , Leahy Kathy , Carpenter Joseph H. ,   for the NIC/Q Project Investigators of the Vermont Oxford Network
Published: August 2004

Objective.

To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model.

Design.

Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997.

Setting.

Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group.

Patients.

Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738).

Interventions.

NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented “potentially better practices” developed through analysis of the processes of care, literature review, and site visits.

Main Outcome Measures.

The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g.

Results.

Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997.

Conclusion.

We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.
Severe Ethylene Glycol Ingestion Treated Without Hemodialysis
Authors: Boyer Edward W. , Mejia Mauricio , Woolf Alan , Shannon Michael
Published: August 2004

Fomepizole (4-methylpyrazole, Antizol) is being increasingly used in the treatment of ethylene glycol toxicity in adults. Little experience exists with this drug, however, in the pediatric population. We present a case of ethylene glycol poisoning in a child where use of fomepizole averted intravenous ethanol infusion and hemodialysis, limited the duration of intensive care monitoring, and decreased the overall cost of treatment.
Factitious Hypoglycemia: A Tale From the Arab World
Authors: Bappal Bhasker , George Mariam , Nair Rajendran , Khusaiby Saleh Al , De Silva Vasantha
Published: August 2004

The mother is usually the one who narrates the patient's history to the pediatrician. Listening and eliciting the parent's story is an art. One of the essential attributes of a good pediatrician is the readiness to believe the parent's story. Mothers are good historians and careful observers. The axiom that the mother is always right is true in most instances. However, occasionally the clinician is deliberately misled by the storyteller, resulting in numerous and potentially dangerous diagnostic investigations. We describe a boy with recurrent hypoglycemic coma in whom the diagnosis of factitious hypoglycemia was delayed as it is believed to be nonexistent in our community. We emphasize that in all patients with recurrent hypoglycemia, estimation of C-peptide and insulin should be performed even when the clinical settings are not in favor of the diagnosis of Munchausen syndrome by proxy.Munchausen syndrome by proxy, hypoglycemia.
Adolescents and Human Immunodeficiency Virus Infection: The Role of the Pediatrician in Prevention and Intervention
Authors:   Committee on Pediatric AIDS and Committee on Adolescence
Published: August 2004

Half of all new human immunodeficiency virus (HIV) infections in the United States occur among young people between the ages of 13 and 24. Sexual transmission accounts for most cases of HIV during adolescence. Pediatricians can play an important role in educating adolescents about HIV prevention, transmission, and testing, with an emphasis on risk reduction, and in advocating for the special needs of adolescents for access to information about HIV.
Impaired Cerebral Cortical Gray Matter Growth After Treatment With Dexamethasone for Neonatal Chronic Lung Disease
Authors: Murphy Brendan P. , Inder Terrie E. , Huppi Petra S. , Warfield Simon , Zientara Gary P. , Kikinis Ron , Jolesz Ferenc A. , Volpe Joseph J.
Published: August 2004

Objective.

The specific aim of this study was to quantify at term the influence of postnatal systemic dexamethasone treatment for neonatal chronic lung disease on subsequent brain growth and development in premature infants without evidence of severe intraventricular hemorrhage or white matter injury.

Methods.

Eighteen premature (23 to 31 weeks) infants, 7 treated with dexamethasone and 11 not treated, were studied at term, ie, 38 to 41 postconceptional weeks, by an advanced quantitative volumetric 3-dimensional magnetic resonance imaging (MRI) technique to quantify cerebral tissue volumes. Fourteen healthy term infants also were studied for comparison. A sequence of image processing algorithms was used to segment each of the MRI slices into the following separate tissue classes: cerebral cortical gray matter, basal ganglia/thalami, unmyelinated white matter, myelinated white matter, and cerebrospinal fluid, all classified based on magnetic resonance signal intensity and anatomic location. A final summing of voxels for each tissue class was performed to compute absolute volumes in milliliters.

Results.

Cerebral cortical gray matter volume in premature infants treated with dexamethasone was reduced 35% when compared with gray matter volume in premature infants not treated with dexamethasone (mean ± standard deviation, 130.3 ± 54.0 vs 200.6 ± 35.1 mL, respectively). Subcortical gray matter volumes (basal ganglia and thalami) and myelinated and unmyelinated white matter volumes were not significantly different among the treated and untreated groups. However, premature infants treated with dexamethasone exhibited a reduction (30%) in total cerebral tissue volume compared with total cerebral tissue volume in both the premature infants not treated with dexamethasone and the control term infants (312.7 ± 43.7 vs 448.2 ± 50.2 and 471.6 ± 36.4 mL respectively). This latter finding relates primarily to the decrease in cerebral cortical gray matter volume.

Conclusions.

The data suggest an impairment in brain growth, principally affecting cerebral cortical gray matter, secondary to systemic dexamethasone therapy. Although the premature infants who received dexamethasone were smaller with more severe respiratory disease, these findings are consistent with growing evidence of a potential deleterious effect of dexamethasone on neonatal brain and subsequent neurodevelopmental outcome. This apparent deleterious effect should be taken into consideration by clinicians when weighing the potential risks and benefits of this therapy for low birth weight infants with neonatal chronic lung disease.
Continuous Subcutaneous Glucose Monitoring in Children With Type 1 Diabetes
Authors: Chase H. Peter , Kim Laura M. , Owen Susie L. , MacKenzie Todd A. , Klingensmith Georgeanna J. , Murtfeldt Robert , Garg Satish K.
Published: August 2004

Purpose.

To determine whether the use of continuous subcutaneous glucose monitoring will help in detecting unrecognized nocturnal hypoglycemia and in lowering hemoglobin A1c (HbA1c) levels (without increasing the risk for severe hypoglycemia) in children with type 1 diabetes.

Methods.

Eleven children with type 1 diabetes and HbA1c values consistently >8.0% were randomized either to the Continuous Glucose Monitoring System (CGMS) group or to the control group. The CGMS group used 6 3-day sensors within a 30-day period. Both groups self-monitored their blood glucose levels a minimum of 4 times daily. HbA1c levels were measured at the start, at 1-month, and after 3 months of study.

Results.

The 5 children using the CGMS had 17 asymptomatic episodes (85%) of glucose levels below 60 mg/dL (3.25 mmol/L) and 3 symptomatic episodes (15%) during the night in the study month. The 6 control children had 4 symptomatic nocturnal low episodes during the month. After the 30-day period of wearing the CGMS, the 5 children had a significantly lower mean HbA1c value compared with their initial value (mean ± standard error of the mean [SEM] decrease = .36% ± .07%). The mean decrease for the controls was .2% ± .2%. After 3 months, 4 of the 5 children who used the CGMS continued to have lower HbA1c values in comparison to their initial values (mean ± SEM decrease = 1.04% ± .43%). Three of the 6 control participants also had lower HbA1c values at 3 months (mean ± SEM decrease for the group = .62% ± .44%). No severe hypoglycemic events occurred in either the CGMS or the control groups.

Conclusion.

In this pilot trial, continuous subcutaneous glucose monitoring was helpful in detecting asymptomatic nocturnal hypoglycemia as well as in lowering HbA1c values without increasing the risk for severe hypoglycemia in children with type 1 diabetes.
Routine Chest Radiographs in Pediatric Intensive Care Units
Authors: Quasney Michael W. , Goodman Denise M. , Billow Michael , Chiu Hsiaoting , Easterling Larry , Frankel Lorry , Habib David , Heitschmidt Mary , Kurachek Stephan , Moler Frank , Montgomery Vicki , Moss Michele , Murman Sheila , Rice Thomas , Richman Barbara , Tilden Samuel
Published: August 2004

Objectives.

To determine whether interventions were performed based on portable routine morning chest x-rays (CXRs) in pediatric intensive care unit (PICU) patients and to identify patient subgroups for whom the routine CXR is most useful.

Design.

Prospective multiinstitutional study.

Setting.

PICUs of 15 tertiary care hospitals.

Patients.

PICU patients who received a routine morning CXR were included in the study.

Outcome Measures.

Recorded data included: weight, diagnosis, presence of active cardiopulmonary problems, length of stay, and number and type of devices. The number and types of interventions based on the interpretation of the CXR were recorded.

Results.

Five hundred twelve routine CXRs were evaluated. The majority of the routine chest radiographs were obtained on patients who were admitted for cardiovascular disease (195/512; 38%) or respiratory failure (186/512; 36%), and 465/512 of the routine CXRs (91%) were performed on patients with one or more devices. Two hundred thirty-one of the 512 routine CXRs (45%) resulted in 1 or more interventions. One hundred fifty-five of the 284 routine CXRs (55%) obtained in children ≤10 kg resulted in one or more interventions, compared with 61/152 (40%) and 15/76 (20%) of routine CXRs obtained in children 10 to 40 kg and ≥40 kg, respectively. The frequency of interventions increased from 19% in children with no devices to >50% in children with 2 or more devices. One or more interventions were performed in 27% of routine CXRs when no active cardiopulmonary problems were present, compared with 51% of routine CXRs when active cardiopulmonary problems were present. Diagnosis and length of intensive care unit stay at the time the routine CXR was obtained did not affect the percentage of CXRs that resulted in interventions.

Conclusions.

Routine CXRs are more likely to result in interventions in the smaller, critically ill child with one or more devices and if active cardiopulmonary problems are present.
Who's Teaching Neonatal Resuscitation to Housestaff?: Results of a National Survey
Authors: Halamek Louis P. , Kaegi David M.
Published: August 2004

Objective.

This study was designed to investigate current patterns of training in neonatal resuscitation in US residency programs in general pediatrics.

Methods.

A questionnaire was mailed to the chief residents and directors of all US residency programs in general pediatrics to determine who provides supervision and teaching of neonatal resuscitation in the delivery room and neonatal intensive care unit. This questionnaire also inquired as to the use within these residency programs of standardized resuscitation training courses such as Pediatric Advanced Life Support and Neonatal Resuscitation Program.

Results.

Residents in their third and second years of training are most often cited as responsible for supervision and teaching of neonatal resuscitation in the delivery room, whereas attending neonatologists are cited most frequently as being responsible for these tasks in the neonatal intensive care unit. Pediatric Advanced Life Support is required by virtually all US residency programs, followed in frequency by Neonatal Resuscitation Program and Advanced Cardiac Life Support.

Conclusions.

Because those in training collectively provide much of the supervision and teaching of neonatal resuscitation, vigilance is required so that appropriate resuscitation skills are developed and maintained. Objective performance markers may be useful in assessing competency in caring for sick newborns. neonatal resuscitation, delivery room, Neonatal Resuscitation Program, Pediatric Advanced Life Support, Advanced Cardiac Life Support.
Prospective Study of Children With Cyanotic and Pallid Breath-Holding Spells
Authors: DiMario Francis J.
Published: August 2004

Objective.

In this investigation, we sought to prospectively document the natural history of severe breath-holding spells (BHS) among children with both cyanotic and pallid BHS who were referred for neurologic consultation.

Design.

Prospective cohort study.

Methods.

A structured interview was undertaken at the time of initial consultation and at subsequent 1-year intervals regarding type of BHS, frequency of spells, associated phenomenon, sequelae, family history, and age at termination of spells.

Results.

A total of 95 children (48 boys, 47 girls) with BHS were identified and followed over a 9-year interval. There were no significant differences between genders. Median onset age was between 6 and 12 months old with 15% presenting younger than 6 months. A median frequency of spells was weekly with 30% experiencing 1 or more spells per day. The median age at peak frequency was between 12 and 18 months old with a range extending from 6 months to 4 years of age. Of the patients whose BHS had remitted for >12 months' time (n = 67), the last spell occurred at a median age of 37 to 42 months. Of those children whose BHS were still occurring, the oldest age at time of latest spell was at 7 years old. Hypoxic convulsions were associated with BHS in ≤15% of all participants. A positive family history of BHS was identified in 34% of all families with equal frequency distributed between paternal and maternal sides.

Conclusions.

In this study, new data concerning the natural history of BHS have been determined. The information is important for family counseling and identifying intervention strategies, and serves as baseline data to evaluate the efficacy of future treatment approaches.
Postnatal Malnutrition and Growth Retardation: An Inevitable Consequence of Current Recommendations in Preterm Infants?
Authors: Embleton Nicolas E. , Pang Naomi , Cooke Richard J.
Published: August 2004

Background.

Nutrient intakes meeting recommended dietary intakes (RDIs) take time to establish and once established are rarely maintained throughout hospital stay in preterm infants. A nutrient deficit, therefore, accrues. RDI are based on needs for maintenance and growth, with no provision to replace this deficit. We, therefore, hypothesized that postnatal malnutrition and growth retardation were inevitable in infants fed current RDI.

Methodology.

Dietary intakes were prospectively collected, by a single observer (N.P.), on a daily basis in a group of preterm infants (n = 105; birth weight ≤1750 g; gestational age ≤34 weeks) admitted to neonatal intensive care unit over a 6-month period. Actual was subtracted from recommended energy (120 kcal/kg/day) and protein (3 g/kg/day) intakes and nutritional deficits calculated. Infants were weighed on admission and throughout hospital stay. The data were analyzed using a combination of repeated measures analysis of variance and stepwise regression analysis.

Results.

Nutrient intakes meeting current RDIs were rarely achieved during early life. By the end of the first week, cumulative energy and protein deficits were 406 ± 92 and 335 ± 86 kcal/kg and 14 ± 3 and 12 ± 4 g/kg in infants ≤30 and those at ≥31 weeks. By the end of the fifth week, cumulative energy and protein deficits were 813 ± 542 and 382 ± 263 kcal/kg and 23 ± 12 and 13 ± 15 g/kg and the zscores were −1.14 ± .6 and −.82 ± .5 for infants at ≤30 and ≥31 weeks. Stepwise regression analysis indicated that variation in dietary intake accounted for 45% of the variation in changes inz score.

Conclusions.

Preterm infants inevitably accumulate a significant nutrient deficit in the first few weeks of life that will not be replaced when current RDIs are fed. This deficit can be directly related to subsequent postnatal growth retardation. postnatal growth retardation, preterm infants.