bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Early Newborn Discharge Legislation and Early Follow-up Visits on Infant Outcomes in a State Medicaid Population
Authors: Meara Ellen , Kotagal Uma R. , Atherton Harry D. , Lieu Tracy A.
Published: August 2004

Objective. Scant information exists on the effects of legislation mandating coverage of minimum postnatal hospital stays on infant health outcomes. There are also gaps in knowledge regarding the effectiveness of early follow-up visits for newborns. The objective of this study was to determine the impact of 1) legislation mandating coverage of minimum postnatal hospital stays and 2) early follow-up visits by the age of 4 days on infant outcomes during the first month of life.

Methods. A retrospective analysis was conducted of Ohio Medicaid claims data linked with birth certificate data for the period 1991-1998. The impact of the legislation was evaluated using interrupted time-series analysis of health-related utilization. The effects of early follow-up visits for vaginally delivered newborns with short stays were analyzed using the day of the week on which the birth occurred (eg, Monday, Tuesday) as an instrumental variable to account for potential confounding. A total of 155 352 full-term newborns who were born to mothers who receive Medicaid were studied. The main outcomes measured were rehospitalizations, emergency department (ED) visits, and diagnoses of dehydration and infection within 10 and 21 days of birth.

Results. Few outcomes exhibited significant changes after legislation mandating coverage of minimum postnatal hospital stays. Rates of rehospitalization for jaundice within 10 days of birth fell from 0.78% to 0.47% in the year after legislation was introduced but leveled off after the legislation took effect. Rates of ED visits within 21 days increased from 6.0% to 10.4% during periods of increasing short stay but fell to 8.0% during the year after introduction of the legislation and leveled off when the legislation took effect. Rates of all-cause rehospitalization, dehydration, and infection diagnoses showed no consistent relationship to Ohio's legislation. Using instrumental variable analysis, newborns who received early follow-up visits were significantly less likely to have rehospitalizations within the first 10 days of life than those who did not.

Conclusions. In this state Medicaid population, legislation mandating coverage of minimum postnatal hospital stays was associated with reductions in the rates of rehospitalization for jaundice and ED visits. For newborns with short stays, early follow-up visits may reduce rehospitalizations in the early postpartum period.
Evaluation of a New Transcutaneous Bilirubinometer
Authors: Maisels M. Jeffrey , Ostrea Enrique M. , Touch Suzanne , Clune Sarah E. , Cepeda Eugene , Kring Elizabeth , Gracey Karin , Jackson Cheryl , Talbot Deborah , Huang Raywin
Published: August 2004

Objective. The objective of this study was to evaluate the Minolta/Hill-Rom Air-Shields Transcutaneous Jaundice Meter model JM-103.

Methods. We studied a convenience sample of 849 newborns ≥35 weeks of gestation in 3 hospitals. These infants had total serum bilirubin (TSB) levels measured on clinical indication, and transcutaneous bilirubin (TcB) levels were obtained within 1 hour of the TSB levels. The population was 59.2% white, 29.8% black, 4.5% East Asian, 3.8% Middle Eastern, 1.6% Indian/Pakistani, and 1.1% Hispanic.

Results. There was a close correlation between TSB and TcB values in all of the population groups: white (n = 503, r = .949); black (n = 253, r = .822); and East Asian, Indian/Pakistani, and Hispanic (n = 93, r = .926). In the black population, the correlation was less close than in the other groups, and differences between the TcB and TSB measurements tended to increase with rising TSB values. JM-103 values differed from TSB values by 3 mg/dL or more in 2% of white, 3.2% of other, and 17.4% of black infants. In these black infants, the JM-103 value was always greater than the TSB value.

Conclusions. We conclude that TcB measurements using the JM-103 jaundice meter correlate very closely with TSB levels over the range of TSB encountered in this study. Because only 3.3% of our infants had TSB values >15 mg/dL (257 μmol/L), more data are needed in this range of TSB concentration. The correlation in black infants is not as close as in other groups, but because the tendency in blacks is for the JM-103 to overestimate serum bilirubin levels, dangerous clinical errors are unlikely to occur. The measurement technique is rapid and simple, and it is easy to perform repeated measurements over time, thus reducing the likelihood of error. TcB measurements with the JM-103 jaundice meter should obviate the need for most serum bilirubin levels in newborn infants ≥35 weeks of gestation, although serum bilirubin measurements are still required when treatment with phototherapy or exchange transfusion is being considered.
Transcutaneous Bilirubin Measurements and Serum Total Bilirubin Levels in Indigenous African Infants
Authors: Slusher Tina M. , Angyo Ishaya A. , Bode-Thomas Fidela , Akor Francis , Pam Sunday D. , Adetunji Adedotun A. , McLaren Donald W. , Wong Ronald J. , Vreman Hendrik J. , Stevenson David K.
Published: August 2004

Objective. The objective of this study was to determine whether transcutaneous bilirubin (TcB) measurements correlate with serum total bilirubin (STB) levels in indigenous, darkly pigmented African newborns with varying degrees of skin pigmentation, some of which had developed kernicterus.

Methods. Jaundiced infants who were ≤2 weeks of age and admitted to Baptist Medical Center-Eku (Eku; n = 29) and Jos University Teaching Hospital (Jos; n = 98) in Nigeria were studied. TcB measurements using the BiliChek were made simultaneously with blood sampling for STB measurements by spectrophotometry before phototherapy.

Results. Using linear regression analysis, we found that measurements of TcB correlated well with those of STB with r values of .90 and .88 for Eku and Jos, respectively. Mean bias and imprecision of TcB measurements as compared with STB measurements for the total population was 0.5 ± 7.6 mg/dL using the method of Bland and Altman. At STB ≥12 mg/dL, correlation (r = .84) and bias and imprecision (−1.2 ± 8.6 mg/dL) of measurements were only slightly poorer. Furthermore, when infants were grouped by degree of skin pigmentation, correlations of TcB and STB measurements remained strong.

Conclusions. From these results, we can conclude that TcB measurements are a useful and reliable index for estimating STB levels in pigmented neonates, including those with hyperbilirubinemia and kernicterus. In the absence of reliable STB measurements, the relatively simple and noninvasive TcB measurements can be an important adjunct in directing phototherapy and exchange transfusions, thereby preventing bilirubin-induced morbidity and mortality in low-technology clinical environments.
Trends in the Incidence of Severe Retinopathy of Prematurity in a Geographically Defined Population Over a 10-Year Period
Authors: Hameed Biju , Shyamanur Kallinath , Kotecha Sailesh , Manktelow Bradley N. , Woodruff G. , Draper Elizabeth S. , Field David
Published: August 2004

Objective. To examine trends in the incidence of severe (≥grade 3) retinopathy of prematurity (ROP) in infants with birth weight of ≤1250 g in a geographically defined population over a 10-year period.

Methods. An observational study was conducted of all infants who had a birth weight ≤1250 g and were born to mothers who were resident in the county of Leicestershire, United Kingdom, during the period January 1, 1990, to December 30, 1999. Cases were identified by the Trent Neonatal Survey. The incidence of severe ROP (≥grade 3) was compared in 2 successive 5-year periods: 1990–1994 and 1995–1999.

Results. Comparing the first 5-year period (1990–1994) with the second (1995–1999), the total number of live births fell (60 789 vs 56 564). However, there was a significant increase in the number of births with birth weight ≤1250 g (including live and dead; 615 vs 734; live births only: 455 vs 556). Survival to 42 weeks of infants who were born at ≤1250 g was significantly better in the latter time period (203 vs 302; odds ratio [OR] for death: 0.54; 95% confidence interval [CI]: 0.39–0.75). The number of cases of severe ROP was 4 times higher during the second time period compared with the first (9 vs 36). A significantly increased risk for the development of severe ROP was seen during the second time period (OR: 2.92; 95% CI: 1.37–6.20). Even after allowing for the change in gestation induced by the improved survival during the second time period, the increased risk remained (OR: 2.81; 95% CI: 1.27–6.21).

Conclusions. There is strong evidence that the incidence of severe ROP among infants with birth weight ≤1250 g increased in the latter half of the last decade. The increased risk seems to be independent of the increase in survival.
Does Valsalva Retinopathy Occur in Infants? An Initial Investigation in Infants With Vomiting Caused by Pyloric Stenosis
Authors: Herr Sandra , Pierce Mary C. , Berger Rachel P. , Ford Henri , Pitetti Raymond D.
Published: August 2004

Objective. Retinal hemorrhages (RHs) are 1 manifestation of child abuse, and although they often are considered to be diagnostic of abuse in a young child, there are other potential causes. RHs have been described in association with valsalva maneuver, such as forceful vomiting or coughing. Our aim was to describe the incidence of RH in infants with vomiting caused by pyloric stenosis.

Methods. A prospective, descriptive study was conducted of infants who underwent pyloromyotomy for hypertrophic pyloric stenosis (HPS). Dilated retinal examinations were performed, and the findings were documented.

Results. A total of 100 infants with HPS were evaluated. Eighty-four infants were male, 92 were white, and 21 had a family history of pyloric stenosis. Thirty-seven examinations were performed in the operating room. Eighteen examinations were confirmed by a second investigator, and 3 children had dilated eye examinations documented independently by a pediatric ophthalmologist. No RHs were identified (0 of 100; 95% confidence interval: 0%–3%). One patient had facial petechiae, and 2 had subconjunctival hemorrhage. Electrolyte levels were abnormal in 63 patients. In 89 cases, the emesis was described as projectile. Patients varied in the number of episodes of emesis, with 30% of patients having >100 episodes of emesis before diagnosis. One patient had a respiratory arrest associated with vomiting in the emergency department and required bag-valve mask ventilation.

Conclusions. No RHs were identified in 100 infants with vomiting caused by HPS. These results suggest that RHs do not result from forceful vomiting in infants.
Serious Bacterial Infections in Febrile Infants 1 to 90 Days Old With and Without Viral Infections
Authors: Byington Carrie L. , Enriquez F. Rene , Hoff Charles , Tuohy Richard , Taggart E. William , Hillyard David R. , Carroll Karen C. , Christenson John C.
Published: August 2004

Objective. The risk of serious bacterial infection (SBI) in febrile infants who are classified as low risk (LR) or high risk (HR) by the Rochester criteria has been established. LR infants average a 1.4% occurrence of SBI, whereas HR infants have an occurrence of 21%. The occurrence of SBI in Rochester LR or HR infants with confirmed viral infections is unknown. The objective of this study was to determine the occurrence of SBI in Rochester LR and HR infants with and without viral infections.

Methods. All febrile infants who were 90 days or younger and evaluated at Primary Children’s Medical Center between December 1996 and June 2002 were eligible. Infants were classified as Rochester LR or HR, and discharge diagnoses were collected. Viral testing for enteroviruses, respiratory viruses, rotavirus, and herpesvirus was performed as indicated by study protocol, clinical presentation, and season of the year. Results of all bacterial cultures were reviewed.

Results. Of 1779 infants enrolled, 1385 (78%) had some form of viral diagnostic testing and 491 (35%) had 1 or more viruses identified. By the Rochester criteria, 456 (33%) infants were classified as LR and 922 (67%) infants as HR. For infants with viral infections, the occurrence of SBI was significantly lower than in infants without a viral infection (4.2% vs 12.3%). Rochester HR virus-positive (HR+) infants had significantly fewer bacterial infections than HR virus-negative (HR−) infants (5.5% vs 16.7%). When compared with HR− infants, HR+ infants were less likely to have bacteremia, urinary tract infection, or soft tissue infections, and HR+ infants had a similar occurrence of bacteremia as LR infants (0.92% vs 1.97%).

Conclusions. Febrile infants with confirmed viral infections are at lower risk for SBI than those in whom a viral infection is not identified. Viral diagnostic data can positively contribute to the management of febrile infants, especially those who are classified as HR.
How Informative Are Parent Reports of Attention-Deficit/Hyperactivity Disorder Symptoms for Assessing Outcome in Clinical Trials of Long-Acting Treatments? A Pooled Analysis of Parents’ and Teachers’ Reports
Authors: Biederman Joseph , Faraone Stephen V. , Monuteaux Michael C. , Grossbard Joel R.
Published: August 2004

Objective. The validity of parent reports of children’s attention-deficit/hyperactivity disorder (ADHD) symptoms has been questioned, especially in clinical trials. Some advocate the exclusive use of teacher reports, maintaining that parent reports are not sensitive to changes in ADHD symptoms. This study compares the ability of parent and teacher reports to document change during clinical trials of long-acting treatments.

Methods. We conducted a literature search of Medline to identify any published clinical trials in pediatric ADHD that met the following criteria: 1) used a randomized design, 2) examined the efficacy of long-acting agents or standard formulations using 3-times-a-day dosing, and 3) used both parent and teacher reports of the same measure of ADHD symptoms as a study outcome. For each measurement of ADHD symptoms, we calculated effect sizes for parent and teacher reports.

Results. Three large, randomized, controlled clinical trials were identified (N = 1445 subjects). For every outcome for which teacher reports documented significant improvement, parent reports did also. Pooled analysis revealed a larger effect captured by the parent report relative to the teacher report.

Conclusion. Results suggest that parent reports are at least as sensitive to detecting change in ADHD symptoms as teacher reports in clinical trials that assess the efficacy of long-acting agents. These results suggest that parent reports are informative for detecting change during treatment of children with ADHD.
Range of Neurologic Disorders in Patients With Celiac Disease
Authors: Zelnik Nathanel , Pacht Avi , Obeid Raid , Lerner Aaron
Published: August 2004

Objective. During the past 2 decades, celiac disease (CD) has been recognized as a multisystem autoimmune disorder. A growing body of distinct neurologic conditions such as cerebellar ataxia, epilepsy, myoclonic ataxia, chronic neuropathies, and dementia have been reported, mainly in middle-aged adults. There still are insufficient data on the association of CD with various neurologic disorders in children, adolescents, and young adults, including more common and “soft” neurologic conditions, such as headache, learning disorders, attention-deficit/hyperactivity disorder (ADHD), and tic disorders. The aim of the present study is to look for a broader spectrum of neurologic disorders in CD patients, most of them children or young adults.

Methods. Patients with CD were asked to fill in a questionnaire regarding the presence of neurologic disorders or symptoms. Their medical charts were reviewed, and those who were reported as having neurologic manifestations underwent neurologic examination and brain imaging or electroencephalogram if required. Their neurologic data were compared with that of a control group matched for age and gender.

Results. Patients with CD were more prone to develop neurologic disorders (51.4%) in comparison with control subjects (19.9%). These disorders include hypotonia, developmental delay, learning disorders and ADHD, headache, and cerebellar ataxia. Epileptic disorders were only marginally more common in CD. In contrast, no difference was found in the prevalence of tic disorders in both groups. Therapeutic benefit, with gluten-free diet, was demonstrated only in patients with transient infantile hypotonia and migraine headache.

Conclusion. This study suggests that the variability of neurologic disorders that occur in CD is broader than previously reported and includes “softer” and more common neurologic disorders, such as chronic headache, developmental delay, hypotonia, and learning disorders or ADHD. Future longitudinal prospective studies might better define the full range of these neurologic disorders and their clinical response to a gluten-free diet.
The Maternal Lifestyle Study: Cognitive, Motor, and Behavioral Outcomes of Cocaine-Exposed and Opiate-Exposed Infants Through Three Years of Age
Authors: Messinger Daniel S. , Bauer Charles R. , Das Abhik , Seifer Ron , Lester Barry M. , Lagasse Linda L. , Wright Linda L. , Shankaran Seetha , Bada Henrietta S. , Smeriglio Vincent L. , Langer John C. , Beeghly Marjorie , Poole W. Kenneth
Published: August 2004

Objective. To evaluate the direct effects of prenatal cocaine exposure and prenatal opiate exposure on infant mental, motor, and behavioral outcomes longitudinally between 1 and 3 years old.

Methods. As part of a prospective, longitudinal, multisite study, the Bayley Scales of Infant Development II were administered to 1227 infants who were exposed to cocaine (n = 474), opiates (n = 50), cocaine and opiates (n = 48), and neither substance (n = 655) at 1, 2, and 3 years of corrected age by certified, masked examiners. Hierarchic linear modeling of the 1-, 2-, and 3-year scores was conducted using cocaine and opiate exposure as predictors with and without controlling for covariates.

Results. Overall retention was 88.4% and did not differ by cocaine or opiate exposure. Overall (at 1, 2, and 3 years), cocaine-exposed infants scored 1.6 Mental Development Index points below infants who were not exposed to cocaine. Opiate-exposed infants scored 3.8 Psychomotor Development Index points below infants who were not exposed to opiates. Neither the cocaine nor the opiate effect remained significant after controlling for covariates. Neither cocaine nor opiate exposure was associated with the Behavioral Record Score during the examination. Low birth weight and indices of nonoptimal caregiving were associated with lower Mental Development Index, Psychomotor Development Index, and Behavioral Record Score scores for all groups of infants.

Conclusions. In the largest at-risk sample observed longitudinally to date, infant prenatal exposure to cocaine and to opiates was not associated with mental, motor, or behavioral deficits after controlling for birth weight and environmental risks.
Nonfatal and Fatal Firearm-Related Injuries Among Children Aged 14 Years and Younger: United States, 1993–2000
Authors: Eber Gabriel B. , Annest Joseph L. , Mercy James A. , Ryan George W.
Published: August 2004

Objective. To provide national estimates of fatal and nonfatal firearm-related (FA) injuries among children ≤14 years old and to examine the circumstances under which these injuries occurred.

Methods. For nonfatal FA injuries among children, we analyzed data on emergency department (ED) visits from the National Electronic Injury Surveillance System for 1993 through 2000. National estimates of injured children who were treated in hospital EDs were examined by selected characteristics, such as age, gender, race/ethnicity of the patient, primary body part affected, intent of the injury, the relationship of the shooter to the patient, where the injury occurred, and activity at the time of injury. For fatal FA injuries among children, we analyzed mortality data from the National Vital Statistics System for 1993 through 2000. Data from both sources were used to calculate case-fatality rates.

Results. From 1993 through 2000, an estimated 22 661 (95% confidence interval [CI]: 16 668–28 654) or 4.9 per 100 000 (95% CI: 3.6–6.2) children ≤ 14 years old with nonfatal FA injuries were treated in US hospital EDs. Assaults accounted for 41.5% of nonfatal FA injuries, and unintentional injuries accounted for 43.1%. Approximately 4 of 5 children who sustained a nonfatal, unintentional FA injury were reportedly shot by themselves or by a friend, a relative, or another person known to them. During this period, 5542, or 1.20 per 100 000 (95% CI: 1.17, 1.23), children ≤14 years old died from FA injuries; 1 of every 5 children who were wounded by a firearm gunshot died from that injury. Most FA deaths were violence related, with homicides and suicides constituting 54.7% and 21.9% of these deaths, respectively. For individuals ≤14 years old, the burden of morbidity and mortality associated with FA injuries falls disproportionately on boys, blacks, and children 10 to 14 years old. Both fatal and nonfatal injury rates declined >50% during the study period.

Conclusions. Although rates of nonfatal and fatal FA injuries declined during the period of study, FA injuries remain an important public health concern for children. Well-designed evaluation studies are needed to examine the effectiveness of potential interventions aimed at reducing FA injuries among children.
Long-Term Effect of Budesonide on Hypothalamic-Pituitary-Adrenal Axis Function in Children With Mild to Moderate Asthma
Authors: Bacharier Leonard B. , Raissy Hengameh H. , Wilson Laura , McWilliams Bennie , Strunk Robert C. , Kelly H. William
Published: August 2004

Objective. To determine the safety of long-term (36 months) administration of an inhaled corticosteroid (budesonide) on hypothalamic-pituitary-adrenal (HPA) axis function in children with mild to moderate asthma.

Methods. This was an ancillary study of the Childhood Asthma Management Program (CAMP). Sixty-three children who had mild to moderate asthma and were enrolled in CAMP underwent evaluation of HPA axis function before and 12 and 36 months after receiving continuous therapy with either an inhaled anti-inflammatory agent (budesonide 400 μg/day or nedocromil 16 mg/day) or placebo. HPA axis function was assessed by serum cortisol levels 30 and 60 minutes after 0.25 mg of adrenocorticotrophic hormone (ACTH) and 24-hour urinary free cortisol excretion.

Results. There were no differences in serum cortisol levels after ACTH stimulation between treatment groups, regardless of time after ACTH administration or months of follow-up. Urinary cortisol excretion per body surface area was similar in both treatment groups at 36 months, after adjusting for age at randomization, race, gender, and clinic. Cumulative inhaled corticosteroid exposure did not influence serum cortisol response to ACTH or urinary free cortisol excretion at 36 months.

Conclusions. We found no effects of chronic budesonide treatment at a dose of 400 μg/day on HPA axis function in children with mild to moderate asthma and demonstrated the absence of a cumulative effect on HPA axis function over a 3-year period.
Low Levels of Tissue Inhibitors of Metalloproteinases With a High Matrix Metalloproteinase-9/Tissue Inhibitor of Metalloproteinase-1 Ratio Are Present in Tracheal Aspirate Fluids of Infants Who Develop Chronic Lung Disease
Authors: Ekekezie Ikechukwu I. , Thibeault Donald W. , Simon Stephen D. , Norberg Michael , Merrill Jeffrey D. , Ballard Roberta A. , Ballard Philip L. , Truog William E.
Published: August 2004

Objective. The pathogenesis of chronic lung disease (CLD) involves inflammation with proteolytic damage to lung extracellular matrix. Matrix metalloproteinases (MMPs) are zinc-dependent endopeptidases that, acting in concert with their tissue inhibitors, tightly orchestrate extracellular matrix morphogenesis and repair after injury. Imbalances in their levels relative to that of their inhibitors have been implicated in diseases characterized by matrix disruption and remodeling. We investigated the possibility that imbalances in MMP-9 and MMP-2 relative to their tissue inhibitor of metalloproteinase-1 (TIMP-1) and TIMP-2, respectively, in tracheal aspirates of preterm infants may be involved in the development of CLD.

Methods. Serial tracheal aspirates collected from birth until extubation in 49 ventilated preterm infants (24-32 weeks’ gestations) were analyzed for MMP-2, MMP-9, TIMP-1, and TIMP-2. Data normalized by TA values of free secretory component of immunoglobulin A were compared for CLD (n = 22) versus no CLD (n = 27). Also, known clinical predictors of CLD (gestational age, birth weight, and sex) were assessed for both groups. Association of predictors with the outcome CLD was assessed by logistic regression.

Results. Mean gestational age was lower in CLD infants, but birth weight and gender were comparable for both groups. CLD infants had significantly lower TIMP-1 level with higher MMP-9/TIMP-1 ratio during the first 2 weeks of life and low TIMP-2 and MMP-2 levels during the first 3 days of life compared with no-CLD infants. Logistic regression analysis indicated that the findings are predictive of CLD.

Conclusions. We conclude that low tracheal aspirate levels of TIMPs, with a high MMP-9/TIMP-1 ratio early in life, are associated with subsequent development of CLD.
Early Childhood Computer Experience and Cognitive and Motor Development
Authors: Li Xiaoming , Atkins Melissa S.
Published: August 2004

Objectives. To explore the association between early computer experience (both accessibility and frequency of use) and cognitive and psychomotor development among young children.

Methods. The participants were 122 preschool children enrolled in a rural county Head Start program in the United States during 2001–2002. The following tests were administered to the children: the Bender Visual Motor Gestalt Test; the Boehm Test of Basic Concepts, Third Edition Preschool; the Test of Gross Motor Development, Second Edition; and a short form of the Wechsler Preschool and Primary Scales of Intelligence–Revised. Information pertaining to family characteristics and children’s early computer experience was collected from parents. Both bivariate and multivariate analyses were used to assess the association between early computer experience and cognitive and motor development.

Results. Of the participating children, 53% had a computer at home. Among families who had a computer, 83% had children’s software on the computer. According to parents’ reports, 29% of these children played on the home computer on a daily basis, and an additional 44% of the children played on the computer at least weekly. Of those families who did not have a home computer, 49% reported that their children had access to a computer somewhere outside home. Among these children, 10% had daily access to the computer and 33% had weekly access. The presence of a computer in the home was significantly associated with the family’s income and the educational attainment of the parents. There was no gender difference in computer accessibility and frequency use among the participating children. Children who had access to a computer performed better on measures of school readiness and cognitive development, controlling for children’s developmental stage and family socioeconomic status. The data in the current study did not suggest a relationship between computer experience and visual motor or gross motor skills among the participating children.

Conclusion. The findings in the present study suggest that early computer exposure before or during the preschool years is associated with development of preschool concepts and cognition among young children. However, frequency of use did not reveal such a relationship; neither did the ownership of other child electronic or video games in the household.
Usefulness of the American Academy of Pediatrics Recommendations for Identifying Youths With Hypercholesterolemia
Authors: O’Loughlin Jennifer , Lauzon Beatrice , Paradis Gilles , Hanley James , Lévy Emile , Delvin Edgar , Lambert Marie
Published: August 2004

Objective. To determine the usefulness of parent history of hypercholesterolemia and cardiovascular disease as a screening criterion for hypercholesterolemia in youths.

Methods. Data were available from a population-based survey of 3665 Quebec youths aged 9, 13, and 16 years (81.2% of eligible subjects). Blood specimens were collected from 2475 subjects (54.8% of those eligible), and questionnaire data were obtained from 3048 parents (67.5% of those eligible). Lipids were measured in a Centers for Disease Control and Prevention standardized laboratory. Usefulness of parent history in identifying borderline/high low-density lipoprotein cholesterol (LDL-C) (≥2.8 mmol/L [≥110 mg/dL]) and high LDL-C (≥3.4 mmol/L [≥130 mg/dL]) was assessed according to test performance statistics (sensitivity, specificity, positive predictive value, and negative predictive value).

Results. The prevalence of a positive parent history was 25.6%; 18.3% of subjects had borderline/high LDL-C, and 4.8% had high LDL-C. Sensitivity, specificity, positive predictive value, and negative predictive value of parent history were 33.1%, 76.0%, 23.7%, and 83.5%, respectively, for identifying borderline/high LDL-C; they were 40.7%, 75.1%, 7.7%, and 96.1% for identifying high LDL-C. Test performance statistics were not improved in subgroups defined according to age, gender, parent education, household income, family status, and family origin (French Canadian, other); neither were they improved by adding screening criteria (parent history of diabetes or hypertension, or youth overweight).

Conclusion. Parent history screening criteria offer little improvement over random population screening in identifying youths with hypercholesterolemia.
The Changing Face of Pleural Empyemas in Children: Epidemiology and Management
Authors: Schultz Karen D. , Fan Leland L. , Pinsky Jay , Ochoa Lyssa , Smith E. O’Brian , Kaplan Sheldon L. , Brandt Mary L.
Published: August 2004

Objective. Empyema remains a significant cause of morbidity in children. This study evaluates the changes that have affected the outcome in children with pleural empyema, including the emergence of resistant organisms, the introduction of the pneumococcal conjugate vaccine, and earlier treatment with video-assisted thoracoscopy (VATS).

Methods. A retrospective chart review was performed on all patients who were discharged with a diagnosis of empyema and community-acquired pneumonia over a 10-year period (1993–2002) at Texas Children’s Hospital in Houston, Texas. Data collected included demographic information, clinical presentation, radiographic studies, laboratory data including culture results, and hospital course.

Results. A total of 230 charts were available for review. The mean age of the patients was 4.0 ± 3.6 years. Of the pleural fluid cultures performed, 32% (69 of 219) were positive. An additional 27 patients had a cause identified by blood culture. The first penicillin-nonsusceptible Streptococcus pneumoniae was identified in 1995, and the first methicillin-resistant Staphylococcus aureus was identified in 1998. After the universal use of the pneumococcal conjugate vaccine, 3 major changes have occurred (1999–2000 vs 2001–2002): 1) the number of patients admitted with empyema (per 10 000 admissions) has decreased from 23 to 12.6; 2) the prevalence of S pneumoniae has decreased from 66% (29 of 44) to 27% (4 of 15); and 3) S aureus has become the most common pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant. The use of early VATS (<48 hours after admission) versus late VATS (>48 hours after admission) significantly decreased the length of hospitalization (11.49 ± 6.56 days vs 15.18 ± 8.62 days).

Conclusions. The microbiologic cause of empyema has changed with an increasing incidence of S aureus, particularly methicillin-resistant S aureus. The use of VATS for initial therapy of empyema results in decreased duration of fever and length of hospitalization.
Pediatric Patient Safety in Hospitals: A National Picture in 2000
Authors: Miller Marlene R. , Zhan Chunliu
Published: August 2004

Objective. To describe potential patient safety events for hospitalized children, examine associated factors, and explore impacts of safety events.

Methods. The newly released Patient Safety Indicators (PSIs), developed by researchers at the Agency for Healthcare Research and Quality to identify potential in-hospital patient safety problems using administrative data, were applied to hospital discharge data. All 5.7 million discharge records for children younger than 19 years from 27 states in the 2000 Healthcare Cost and Utilization Project were analyzed for PSI events. Prevalence of PSI events and associations with patient-level and hospital-level characteristics were examined. Multivariate regression adjusting for patient severity of illness was used to estimate impacts of safety events in terms of excess length of stay, charges, and in-hospital mortality.

Results. The prevalence of pediatric patient safety events is significant. PSI events occurred more frequently in the very young and those on Medicaid insurance, some of the most vulnerable hospitalized children. Regression analysis found that almost all PSIs are associated with significant and substantial increases in length of stay, charges, and in-hospital death. Using the estimates derived here and the actual number of cases identified in the 2000 data, we estimate that patient safety events incurred >$1 billion in excess charges for children alone in 2000.

Conclusions. Patient safety problems for hospitalized children occur frequently and with substantial impacts to our health care industry. Unmeasurable by this study are the additional “costs” and “burdens” of safety events that our patients are forced to handle. Additional work to describe and quantify better these outcomes in addition to ones measured here can help solidify the “business case” for patient safety efforts.
Institutional Review Board Practices Regarding Assent in Pediatric Research
Authors: Whittle Amy , Shah Seema , Wilfond Benjamin , Gensler Gary , Wendler David
Published: August 2004

Objective. To assess how Institutional Review Boards (IRBs) implement the assent requirement for research with children.

Methods. Telephone interviews were conducted with 188 chairpersons of IRBs from a range of institutions nationwide. Respondents were queried on 4 topics: 1) which children are considered capable of assent, 2) which information investigators must provide pediatric research subjects, 3) whether IRBs favor the enrollment of children who are capable of assent, and 4) how chairpersons view payment for children’s research participation.

Results. Half of IRBs have a method that they require investigators to follow when determining which children are capable of assent, most commonly an age cutoff. Half of IRBs do not have a method, and the majority rely on investigators’ clinical judgment. IRBs largely follow the adult research regulations when determining which information should be provided to an assenting child. A total of 58% of IRBs would enroll a child who is incapable of assent in a nonbeneficial study, even if children who are capable of assent could be enrolled instead. Almost half (46%) of chairpersons believe that it sometimes or always acceptable to offer incentive payments to children, and more than one third (35%) thought it acceptable to offer payment to the parents.

Conclusion. When possible, IRBs follow the federal regulations for research with adults when implementing the assent requirement. For considerations that do not have analogs in the adult regulations, IRB practices vary widely. These data suggest that IRBs need guidance on how to implement the assent requirement in a way that provides appropriate protections for pediatric research subjects.
Factors Associated With Difficult Toilet Training
Authors: Schonwald Alison , Sherritt Lon , Stadtler Ann , Bridgemohan Carolyn
Published: August 2004

Objective. To identify temperament and behavioral patterns in children with difficult toilet training and to compare those children with same-aged toilet-trained children.

Methods. We compared 46 referred clinic patients who were difficult toilet trainers (DTT) with 62 comparison children (CC) using the Carey-McDevitt Behavioral Style Questionnaire, the Parenting Scale, and a questionnaire of toilet-training history.

Results. CC were more likely to have easy temperaments (odds ratio [OR]: 33.51). DTT were more likely to be less adaptable (OR: 3.12), more negative in mood (OR: 2.79), less persistent (OR: 2.97), and lower in approach (OR: 1.85). DTT were more likely than CC to be constipated (OR: 3.52), although 55% of CC were constipated. DTT were likely to hide to stool (74%) and to ask for pull-ups in which to leave stool (37%). Parenting styles did not differ between the groups.

Conclusions. Although the referral population may be inherently biased, these data suggest that difficult toilet training is associated with difficult temperamental traits and constipation in affected children.
Population-Based Surveillance for Hospitalizations Associated With Respiratory Syncytial Virus, Influenza Virus, and Parainfluenza Viruses Among Young Children
Authors: Iwane Marika K. , Edwards Kathryn M. , Szilagyi Peter G. , Walker Frances J. , Griffin Marie R. , Weinberg Geoffrey A. , Coulen Charmaine , Poehling Katherine A. , Shone Laura P. , Balter Sharon , Hall Caroline B. , Erdman Dean D. , Wooten Karen , Schwartz Benjamin ,   for the New Vaccine Surveillance Network
Published: August 2004

Objective. Respiratory syncytial virus (RSV), influenza virus, and parainfluenza viruses (PIV) cause significant morbidity in young children. Although only influenza virus infection and illness is currently vaccine-preventable, vaccines are under development for RSV and PIV. We established a prospective, active population-based surveillance network to provide precise estimates of hospitalization rates for viral acute respiratory illness (ARI) in young children and to measure the potential impact of enhanced vaccine usage on these rates.

Methods. Prospective, active population-based surveillance was conducted in young children who were hospitalized for ARI from October 1, 2000, to September 30, 2001, in Monroe County, New York (Rochester area) and Davidson County, Tennessee (Nashville area). Eligible children younger than 5 years were those who resided in surveillance counties and were hospitalized for febrile or acute respiratory illness. Viral culture and polymerase chain reaction identified viruses from nasal and throat samples obtained from all surveillance children. We measured population-based rates of hospitalization for RSV, influenza virus, and PIV as well as demographic, clinical, and risk factor assessment for each virus.

Results. Of 812 eligible hospital admissions, 592 (73%) children were enrolled. Of the enrolled children, RSV was identified in 20%, influenza in 3%, PIV in 7%, other respiratory viruses in 36%, and no detectable virus in 39%. Population-based rates of ARI hospitalizations in children younger than 5 years were 18 per 1000. Virus-positive hospitalization rates per 1000 children were 3.5 for RSV, 1.2 for PIV, and 0.6 for influenza virus. Younger age (particularly <1 year), black and Hispanic race/ethnicity, male gender, and presence of chronic underlying illness were associated with higher hospitalization rates.

Conclusions. This study confirms that children younger than 5 years and particularly children younger than 1 year have a high burden of hospitalization from RSV, influenza, and PIV. The enhanced use of influenza vaccine and the development of RSV and PIV vaccines have the potential to reduce markedly the pediatric morbidity from ARIs.
Violence and Suffering in Television News: Toward a Broader Conception of Harmful Television Content for Children
Authors: van der Molen Juliette H. Walma
Published: August 2004

Traditionally, the public and professional debate about the inappropriateness of media violence for children focuses mainly on the negative effects of violence in entertainment programming. However, since the terrorist attacks on September 11th and the recent coverage of the war in Iraq, the suitability of real-life news violence for children may be doubted more than ever. To draw attention to the potential harmful effects of violence presented in news programs, it is argued in the present article that health care professionals should advocate a broader conception of media violence than thus far has been used. On the basis of recent research, potential effects of violent news content, such as fear, aggression, and desensitization, are discussed and recommendations are provided on how to abate these outcomes.
Ethical Concerns About Federal Approval of Risky Pediatric Studies
Authors: Kopelman Loretta M. , Murphy Timothy F.
Published: August 2004

The US Federal Code limits research with healthy children to no more than a minimal risk of harm; it restricts research with children who have some disorder or condition to no more than a minor increase over minimal risk, unless potential harms are offset by potential benefits to them, as in therapeutic studies. Higher risk studies require “407 approval,” named after the relevant section of the code describing requirements. Rarely used until recently, 407 approval requirements include Institutional Review Board approval and authorization by the Secretary of the Department of Health and Human Services after consultation with a panel of experts; a period for public comment; and assurances that there are adequate permission, consent, and assent. This 407-approval mechanism contains both procedural and interpretative ambiguities, which raise ethical concerns about 1) the expertise represented on advisory panels, 2) the scope of the information offered to the public for comment and its potential conflicts with investigators’ intellectual property or commercial interests, 3) whether any upper level of risk exists, and 4) how it conforms with other policies such as the best interest of the child standard in the law or in medical decision making.
Cushing’s Syndrome After Intra-articular and Intradermal Administration of Triamcinolone Acetonide in Three Pediatric Patients
Authors: Kumar Seema , Singh Ravinder J. , Reed Ann M. , Lteif Aida N.
Published: August 2004

Background. Intra-articular and intradermal steroids are often used for their antiinflammatory effect. There is limited experience with intra-articular and intralesional administration of corticosteroids in the pediatric age group.

Design/Methods. We performed a retrospective chart review of 3 pediatric patients who developed Cushing’s syndrome after local administration of triamcinolone acetonide (TCA).

Results. Two females 9 and 17 years old, received intra-articular injections of TCA. One patient received multiple injections of TCA into the interphalangeal joints (cumulative dose: 120 mg), whereas the other received a single injection of 40 mg, a dose that is considered to be in the therapeutic range, into the hip joint. The third patient, a 7-year-old female, received multiple intralesional injections of TCA. These patients developed signs and symptoms of hypercortisolism that appeared 4 to 6 weeks after local administration of TCA and lasted for 4 to 6 months after the last dose of TCA. TCA was detectable in the plasma and urine by the liquid chromatography/tandem mass spectrometry method 4 to 5 months after the last dose of the steroid.

Conclusions. We noted evidence for Cushing’s syndrome in 3 pediatric patients after intra-articular or intradermal administration of TCA. One of them had received a therapeutic dose of TCA. The possibility of hypothalamic-pituitary-adrenal axis suppression should be considered in patients who have received intra-articular or intradermal steroid injections, particularly in those who have had multiple or relatively high doses.
Legalization of Marijuana: Potential Impact on Youth
Authors:   Committee on Substance Abuse and Committee on Adolescence
Published: August 2004

As experts in the health care of children and adolescents, pediatricians may be called on to advise legislators concerning the potential impact of changes in the legal status of marijuana on adolescents. Parents, too, may look to pediatricians for advice as they consider whether to support state-level initiatives that propose to legalize the use of marijuana for medical purposes or to decriminalize possession of small amounts of marijuana. This policy statement provides the position of the American Academy of Pediatrics on the issue of marijuana legalization, and the accompanying technical report (available online) reviews what is currently known about the relationship between adolescents’ use of marijuana and its legal status to better understand how change might influence the degree of marijuana use by adolescents in the future.
Sexual Orientation and Adolescents
Authors: Frankowski Barbara L. ,   and Committee on Adolescence
Published: August 2004

The American Academy of Pediatrics issued its first statement on homosexuality and adolescents in 1983, with a revision in 1993. This report reflects the growing understanding of youth of differing sexual orientations. Young people are recognizing their sexual orientation earlier than in the past, making this a topic of importance to pediatricians. Pediatricians should be aware that some youths in their care may have concerns about their sexual orientation or that of siblings, friends, parents, relatives, or others. Health care professionals should provide factual, current, nonjudgmental information in a confidential manner. All youths, including those who know or wonder whether they are not heterosexual, may seek information from physicians about sexual orientation, sexually transmitted diseases, substance abuse, or various psychosocial difficulties. The pediatrician should be attentive to various potential psychosocial difficulties, offer counseling or refer for counseling when necessary and ensure that every sexually active youth receives a thorough medical history, physical examination, immunizations, appropriate laboratory tests, and counseling about sexually transmitted diseases (including human immunodeficiency virus infection) and appropriate treatment if necessary.

Not all pediatricians may feel able to provide the type of care described in this report. Any pediatrician who is unable to care for and counsel nonheterosexual youth should refer these patients to an appropriate colleague.
Guidelines for Pediatric Cancer Centers
Authors:   Section on Hematology/Oncology
Published: August 2004

This Policy Statement was revised. See https://doi.org/10.1542/peds.2014-1526.

Since the American Academy of Pediatrics published guidelines for pediatric cancer centers in 1986 and 1997, significant changes in the delivery of health care have prompted a review of the role of tertiary medical centers in the care of pediatric patients. The potential effect of these changes on the treatment and survival rates of children with cancer led to this revision. The intent of this statement is to delineate personnel and facilities that are essential to provide state-of-the-art care for children and adolescents with cancer. This statement emphasizes the importance of board-certified pediatric hematologists/oncologists, pediatric subspecialty consultants, and appropriately qualified pediatric medical subspecialists and pediatric surgical specialists overseeing the care of all pediatric and adolescent cancer patients and the need for facilities available only at a tertiary center as essential for the initial management and much of the follow-up for pediatric and adolescent cancer patients.