bluuebunny/crossref_metadata_2025 huggingface dataset:
The Role of Protein C, Protein S, and Resistance to Activated Protein C in Legg-Perthes Disease
Authors: Eldridge John , Dilley Anne , Austin Harland , EL-Jamil Muhydine , Wolstein Lori , Doris John , Hooper W. Craig , Meehan Peter L. , Evatt Bruce
Published: August 2004

Objectives.

It has been hypothesized that Legg-Perthes disease is caused by repeated vascular interruptions of the blood supply to the proximal femur, which are precipitated by coagulation system abnormalities. To test this theory, we conducted a case-control study among 57 patients with Legg-Perthes disease and an equal number of community controls. We measured protein C and protein S and resistance to activated protein C (APC-R) from plasma.

Study Design.

Participants were placed into 1 of 3 mutually exclusive categories based on the control distribution: 1) normal, defined as either above or within 1 standard deviation below the expected mean; 2) low normal, defined as between 1 and 2 standard deviations below the expected mean; and 3) low, defined as >2 standard deviations below the expected mean. DNA was analyzed to determine the presence of a point mutation in the factor V gene that causes APC-R.

Results.

We observed a statistically significant increased risk of Legg-Perthes disease with decreasing levels of protein C and a nearly significant increased risk with decreasing levels of protein S. The factor V gene defect was present in 5 (9%) of 55 cases and 3 (5%) of 56 controls (odds ratio 1.8, 95% confidence interval: 0.4–7.7), but the mean level on the APC-R plasma test was similar for cases and controls. Nine cases and 1 control had 2 low normal or low test results (odds ratio 13.0, 95% confidence interval: 2.2–75).

Conclusions.

Our results support the belief that abnormalities of the coagulation system leading to a thrombophilic state play a role in Legg-Perthes disease; however, larger studies are needed before definitive recommendations for coagulation testing can be made.
Physical Activity and Bone Measures in Young Children: The Iowa Bone Development Study
Authors: Janz Kathleen F. , Burns Trudy L. , Torner James C. , Levy Steven M. , Paulos Richard , Willing Marcia C. , Warren John J.
Published: August 2004

Objectives.

Physical activity has a beneficial effect on bone development in circumpubertal children, although its effect on younger children is uncertain. In this cross-sectional study, we examined associations between physical activity and bone measures in 368 preschool children (mean age: 5.2 years, range: 4–6 years).

Design.

Physical activity was measured using 4-day accelerometry readings, parental report of children's usual physical activity, and parental report of children's hours of daily television viewing. Total body and site-specific bone mineral content and area bone mineral density (BMD) were measured by dual energy radiograph absorptiometry.

Results.

After adjustment for age and body size, accelerometry measures of physical activity and parental report of usual physical activity were consistently and positively associated with bone mineral content and BMD in both boys and girls (r = 0.15–0.28). Television viewing was inversely associated with hip BMD in girls (r = −0.15). The proportion of variance in bone measures explained by physical activity in linear regression models ranged fromr2 = 1.5% to 9.0%. In all of these models except total body BMD, at least 1 and often several of the physical activity variables entered as independent predictors. Activity variables most likely to enter the regression models were vigorous physical activity (as determined by accelerometry) and parental ranking of child's usual physical activity.

Conclusions.

Findings indicate that there are statistically significant and, perhaps important, associations between physical activity and bone measures during early childhood, well ahead of the onset of peak bone mass. This would suggest that intervention strategies to increase physical activity in young children could contribute to optimal bone development.
A Randomized Trial Comparing Povidone-Iodine to a Chlorhexidine Gluconate-Impregnated Dressing for Prevention of Central Venous Catheter Infections in Neonates
Authors: Garland Jeffery S. , Alex Colleen P. , Mueller Chris D. , Otten Dewey , Shivpuri Chandra , Harris Mary C. , Naples Mary , Pellegrini James , Buck Rosanne K. , McAuliffe Timothy L. , Goldmann Donald A. , Maki Dennis G.
Published: August 2004

Neonates who require a central venous catheter (CVC) for prolonged vascular access experience high rates of catheter-related bloodstream infection (CRBSI).

Purpose. A multicenter randomized clinical trial was undertaken to ascertain the efficacy of a novel chlorhexidine-impregnated dressing (Biopatch Antimicrobial Dressing) on the CVC sites of neonates for the prevention of catheter tip colonization, CRBSI, and bloodstream infection (BSI) without a source.

Setting. Six level III neonatal intensive care units.

Patients Studied. Neonates admitted to study units who would require a CVC for at least 48 hours.

Methods. Eligible infants were randomized before catheter placement to 1 of the 2 catheter site antisepsis regimens: 1) 10% povidone-iodine (PI) skin scrub, or 2) a 70% alcohol scrub followed by placement of a chlorhexidine-impregnated disk over the catheter insertion site. A transparent polyurethane dressing (Bioclusive Transparent Dressing) was used to cover the insertion site in both study groups. Primary study outcomes evaluated were catheter tip colonization, CRBSI, and BSI without an identified source.

Results. Seven hundred five neonates were enrolled in the trial, 335 randomized to receive the chlorhexidine dressing and 370 to skin disinfection with PI (controls). Neonates randomized to the antimicrobial dressing group were less likely to have colonized CVC tips than control neonates (15.0% vs 24.0%, relative risk [RR]: 0.6 95% confidence interval [CI]: 0.5–0.9). Rates of CRBSI (3.8% vs 3.2%, RR: 1.2, CI: 0.5–2.7) and BSI without a source (15.2% vs 14.3%, RR: 1.1, CI: 0.8–1.5) did not differ between the 2 groups. Localized contact dermatitis from the antimicrobial dressing, requiring crossover into the PI treatment group, occurred in 15 (15.3%) of 98 exposed neonates weighing ≤1000 g. No neonates in the PI group developed contact dermatitis.

Conclusion. The novel chlorhexidine-impregnated dressing, replaced weekly, was as effective as cutaneous disinfection with 10% PI and redressing the site every 3 to 7 days for preventing CRBSI and BSI without a source in critically ill neonates requiring prolonged central venous access. The risk of local contact dermatitis under the chlorhexidine dressing limits its use in low birth weight infants who require prolonged central access during the first 2 weeks of life.
Tubulointerstitial Nephritis and Uveitis Syndrome With Autoantibody Directed to Renal Tubular Cells
Authors: Wakaki Hitoshi , Sakamoto Hisato , Awazu Midori
Published: August 2004

The pathogenesis of tubulointerstitial nephritis and uveitis (TINU) syndrome remains unknown, but T cell-mediated immune response has been postulated to play a role. On the other hand, TINU syndrome is characterized by hypergammaglobulinemia and high serum immunoglobulin G (IgG) levels, suggesting an involvement of humoral immunity. We describe a case of TINU syndrome in a 13-year-old girl with multiple tubular dysfunctions including renal glucosuria, tubular proteinuria, phosphaturia, uricosuria, and concentrating and acidifying defect. IgG antibody from her serum was reactive against 125-kDa human kidney protein. Immunofluorescence study using mouse kidney revealed that the antibody was against cortical renal tubular cells. The antibody disappeared as the renal symptoms resolved. We suggest that IgG antibody may contribute to tubular dysfunction in some patients with TINU syndrome.
Strength Training by Children and Adolescents
Authors:   Committee on Sports Medicine and Fitness
Published: August 2004

Pediatricians are often asked to give advice on the safety and efficacy of strength training programs for children and adolescents. This review, a revision of a previous American Academy of Pediatrics policy statement, defines relevant terminology and provides current information on risks and benefits of strength training for children and adolescents.
Lawn Mower-Related Injuries to Children
Authors:   Committee on Injury and Poison Prevention
Published: August 2004

Lawn mower-related injuries to children are relatively common and can result in severe injury or death. Many amputations during childhood are caused by power mowers. Pediatricians have an important role as advocates and educators to promote the prevention of these injuries.
Diabetic Autoimmune Markers in Children and Adolescents With Type 2 Diabetes
Authors: Hathout Eba H. , Thomas Wendy , El-Shahawy Mohamed , Nahab Fadi , Mace John W.
Published: August 2004

Background.

There is an increase in the incidence of type 2 diabetes in children and adolescents. Absence of known diabetes autoimmune markers is sometimes required to confirm the diagnosis.

Objective.

To identify clinical and autoimmune characteristics of type 2 diabetes in a pediatric population.

Method.

We report an analysis of 48 children and adolescents with type 2 diabetes, compared with 39 randomly selected children with type 1 diabetes, diagnosed and followed at the Loma Linda University Pediatric Diabetes Center. Ethnic, familial, seasonal, and autoimmune marker characteristics are outlined. To determine the reliability of antibody testing in confirming the type of diabetes at diagnosis, we studied the incidence of positive islet cell antibodies (ICAs), glutamic acid decarboxylase antibodies (GADs), and insulin autoantibodies (IAAs) at diagnosis in both groups. ICA512, GADs, and IAAs were measured by radioimmunoassay.

Results.

The cohort with type 2 diabetes had a similar gender distribution as the group with type 1 diabetes but a significantly higher age at diagnosis. Ethnic background was significantly different between the 2 groups, predominantly Hispanic in type 2 and white in type 1. Body mass index was significantly higher in type 2 diabetes (mean = 31.24 kg/m2). Among the patients with type 2 diabetes, 33% presented in diabetic ketoacidosis, random blood glucose at diagnosis ranged from 11.4 to 22.25 mmol/L (228–445 mg/dL), fasting C-peptide levels ranged from 0.89 to 2.7 nmol/L (2.7–8.2 ng/mL; normal: <1.36 nmol/L), and hemoglobin A1C was 10.8 ± 3.5% (normal: <6.6%). None of these parameters was significantly different from the type 1 diabetes group. Although the incidence of diabetes antibody markers was significantly lower in type 2 versus type 1 diabetes, 8.1% of patients with type 2 diabetes had positive ICAs, 30.3% had positive GADs, and 34.8% had positive IAAs without ever being treated with insulin. In the type 2 diabetes group, none of the Hispanic patients had ICAs. However, there was no significant correlation between any of the diabetes antibodies and obesity, presence of acanthosis nigricans, or family history of diabetes. The frequency of thyroid antibodies was not significantly different from the group with type 1 diabetes. Daily insulin requirements 1 year after diagnosis were significantly lower in type 2 diabetes, ranging from 0 to 1.2 U/kg with a mean of 0.33.

Conclusion.

Absence of diabetes autoimmune markers is not a prerequisite for the diagnosis of type 2 diabetes in children and adolescents.
Technical Report: Lawn Mower-Related Injuries to Children
Authors: Smith Gary A. ,   the Committee on Injury and Poison Prevention
Published: August 2004

In the United States, approximately 9400 children younger than 18 years receive emergency treatment annually for lawn mower-related injuries. More than 7% of these children require hospitalization, and power mowers cause a large proportion of the amputations during childhood. Prevention of lawn mower-related injuries can be achieved by design changes of lawn mowers, guidelines for mower operation, and education of parents, child caregivers, and children. Pediatricians have an important role as advocates and educators to promote the prevention of these injuries.
The Epidemiology of Mental Retardation of Unknown Cause
Authors: Croen Lisa A. , Grether Judith K. , Selvin Steve
Published: August 2004

Objective.

To describe selected infant and maternal characteristics for children with mild and severe mental retardation (MR) of unknown cause.

Study Design.

Children with MR of unknown cause born in California between 1987 and 1994 were identified through service agency records and compared with the total population of California live births for selected characteristics recorded on the birth certificate.

Results.

For both children with mild and severe MR, risk was increased among males, low birth weight children, and children born to women of black race, older age at delivery, and lower level of education. Increased risk for mild MR was found for multiple births, second or later-born children, and children whose mothers were born outside of California. Increased risk for severe MR was observed among children born to Hispanic mothers; children born to Asian mothers also had increased risk for severe MR but decreased risk for mild MR.

Conclusions.

These results provide clues for understanding the underlying causes of MR and suggest that both biological and social factors are important.
Contribution of Residential Exposures to Asthma in US Children and Adolescents
Authors: Lanphear Bruce P. , Kahn Robert S. , Berger Omer , Auinger Peggy , Bortnick Steven M. , Nahhas Ramzi W.
Published: August 2004

Context.

Residential exposures are recognized risk factors for asthma, but the relative contribution of specific indoor allergens and their overall contribution to asthma among older children and adolescents in the United States are unknown.

Objective.

To estimate the relative contributions, population-attributable risks, and costs of residential risk factors for doctor-diagnosed asthma.

Design.

Nationally representative, cross-sectional survey conducted from 1988 to 1994.

Setting and Participants.

A total of 5384 children who were 6 to 16 years old and participated in the National Health and Nutrition Examination Survey III, a survey of the health and nutritional status of children and adults in the United States.

Main Outcome Measure.

Doctor-diagnosed asthma, as reported by the parent.

Results.

Five hundred three of 5384 children and adolescents (11.4%) had doctor-diagnosed asthma. After adjusting for age, gender, race, urban status, region of country, educational attainment of the head of household, and poverty, predictors of doctor-diagnosed asthma included a history of allergy to a pet (odds ratio [OR: 2.4; 95% confidence interval [CI]: 1.7, 3.3), presence of a pet in the household (OR: 1.5; 95% CI: 1.1, 2.1), and immediate hypersensitivity to dust mite (OR: 1.5; 95% CI: 1.05, 2.0),Alternaria (OR: 1.9; 95% CI: 1.3, 2.8), and cockroach allergens (OR: 1.4; CI: 1.04, 1.9). Family history of atopy (OR: 1.7; 95% CI: 1.1, 2.7) and diagnosis of allergic rhinitis (OR: 2.1; CI: 1.1, 3.7) were also predictors for asthma. The population-attributable risk of having 1 or more residential exposures associated with doctor-diagnosed asthma was 44.4% (95% CI: 29–60), or an estimated 2 million excess cases. The attributable cost of asthma resulting from residential exposures was $405 million (95% CI: $264–$547 million) annually.

Conclusions.

The elimination of identified residential exposures, if causally associated with asthma, would result in a 44% decline in doctor-diagnosed asthma among older children and adolescents in the United States.
Safety and Immunogenicity of a Recombinant Borrelia burgdorferi Outer Surface Protein A Vaccine Against Lyme Disease in Healthy Children and Adolescents: A Randomized Controlled Trial
Authors: Sikand Vijay K. , Halsey Neal , Krause Peter J. , Sood Sunil K. , Geller Richard , Van Hoecke Christian , Buscarino Charles , Parenti Dennis ,   for the Pediatric Lyme Vaccine Study Group
Published: August 2004

Objective.

A recombinant lipoprotein outer surface protein A (OspA) Lyme disease (LD) vaccine (LYMErix) has been shown to be safe and effective in preventing LD in adults and in adolescents 15 years of age and older. Children are at risk for developing LD. This clinical study was conducted to address the safety and immunogenicity of LD vaccine in children 4 to 18 years of age.

Methods.

A randomized, placebo-controlled clinical trial was conducted at 17 investigational sites in Lyme-endemic areas in the United States. Immunogenicity data from this study also were compared with data obtained from the adult efficacy study. A total of 4090 healthy children and adolescents (age range: 4–18; mean age: 10.4 years) were randomized; 4087 were vaccinated, and a subset of 301 children participated in the immunogenicity analysis. Children were randomized to receive either 30 μg of LD vaccine (N = 3063) or placebo (N = 1024) on a 0, 1, 12-month schedule. Safety assessments evaluated both solicited (local: redness, swelling, and pain; general: fever, headache, fatigue, arthralgia, and rash) and unsolicited adverse events. Serum specimens were collected at month 0 or month 2, and months 6, 12, and 13.

Results.

Solicited reactogenicity data revealed a higher incidence of local injection site reactions and general symptoms (fever, headache, fatigue, and arthralgia) in vaccine than placebo recipients. The majority of events were limited in duration (mean: 2–3 days) and were mild to moderate in severity. The total IgG anti-OspA geometric mean titer (GMT) in the pediatric vaccine recipients at month 13 was as good as and statistically higher than the GMT in the adult cohort at month 13 (27 485 enzyme-linked immunosorbent assay units [EL.U]/mL vs 8216 EL.U /mL). All of the pediatric vaccine recipients attained a level of antibody concentration ≥1400 EL.U/mL (proposed seroprotective level) compared with 90% of adults attaining levels ≥1400 EL.U/mL in the efficacy trial.

Conclusions.

LD vaccine administered on a 0, 1, 12-month schedule generally is well tolerated and immunogenic in children 4 to 18 years of age. The safety profile consists of mild to moderate local injection site reactions and flu-like symptoms of limited duration and did not worsen with subsequent injections. IgG GMT at month 13 was threefold higher than the month 13 GMT obtained in the adult efficacy study. This higher immune response in children should provide protection against LD.
Experience With the Ketogenic Diet in Infants
Authors: Nordli Douglas R. , Kuroda Maxine M. , Carroll Joanne , Koenigsberger Dorcas Y. , Hirsch Lawrence J. , Bruner Harlan J. , Seidel William T. , De Vivo Darryl C.
Published: August 2004

Objective.

To evaluate the effectiveness, tolerability, and adverse effects of the ketogenic diet in infants with refractory epilepsy.

Methods.

A retrospective review of 32 infants who had been treated with the ketogenic diet at a large metropolitan institution.

Results.

Most infants (71%) were able to maintain strong ketosis. The overall effectiveness of the diet in infants was similar to that reported in the literature for older children; 19.4% became seizure-free, and an additional 35.5% had >50% reduction in seizure frequency. The diet was particularly effective for patients with infantile spasms/myoclonic seizures. There were concomitant reductions in antiepileptic medications. The majority of parents reported improvements in seizure frequency and in their child's behavior and function, particularly with respect to attention/alertness, activity level, and socialization. The diet generally was well-tolerated, and 96.4% maintained appropriate growth parameters. Adverse events, all reversible and occurring in one patient each, included renal stone, gastritis, ulcerative colitis, alteration of mentation, and hyperlipidemia.

Conclusion.

The ketogenic diet should be considered safe and effective treatment for infants with intractable seizures.
Sedation of Children for Electroencephalograms
Authors: Olson Donald M. , Sheehan Maureen G. , Thompson William , Hall Phyllis T. , Hahn Jin
Published: August 2004

Objective.

Sedation sometimes is necessary to perform an electroencephalogram (EEG) on a child. A dramatic decline in the need to use conscious sedation in our EEG laboratory prompted this review of our sedation experience. The purpose of this review was to determine the incidence of adverse sedation effects and to determine why the need for sedation had declined.

Methods.

All 513 attempts to administer sedation to children who were undergoing EEG studies during a 4-year period were reviewed retrospectively. Parameters studied included type and amount of the sedative agents, need for repeated dosing, successful completion of the EEG, and complications attributed to the sedative.

Results.

Sedation was attempted in 513 (18%) of 2855 EEGs performed during the 4-year period. Ninety-one percent of the EEGs performed with sedation were completed successfully. Chloral hydrate was the most frequently administered sedative. Complications (transient oxygen desaturation) occurred in 3 children, all of whom had recognized risk factors for airway compromise. The proportion of children who required sedation decreased from 32% to just 2% during that time period.

Conclusion.

Sedation of children who are undergoing EEG examinations is effective and safe. Complications are infrequent. The need for sedation can be decreased greatly by adequate preparation and by creating a less-threatening, child-friendly environment in which to perform the study.
Developmental Surveillance and Screening of Infants and Young Children
Authors:   Committee on Children With Disabilities
Published: August 2004

Early identification of children with developmental delays is important in the primary care setting. The pediatrician is the best-informed professional with whom many families have contact during the first 5 years of a child's life. Parents look to the pediatrician to be the expert not only on childhood illnesses but also on development. Early intervention services for children from birth to 3 years of age and early childhood education services for children 3 to 5 years of age are widely available for children with developmental delays or disabilities in the United States. Developmental screening instruments have improved over the years, and instruments that are accurate and easy to use in an office setting are now available to the pediatrician. This statement provides recommendations for screening infants and young children and intervening with families to identify developmental delays and disabilities.
Prediction of Hyperbilirubinemia in Near-Term and Term Infants
Authors: Stevenson David K. , Fanaroff Avroy A. , Maisels M. Jeffrey , Young Betty W. Y. , Wong Ronald J. , Vreman Hendrik J. , MacMahon James R. , Yeung Chap Y. , Seidman Daniel S. , Gale Rena , Oh William , Bhutani Vinod K. , Johnson Lois H. , Kaplan Michael , Hammerman Cathy , Nakamura Hajime
Published: August 2004

Objective.

The purpose of this study was to determine whether end-tidal carbon monoxide (CO) corrected for ambient CO (ETCOc), as a single measurement or in combination with serum total bilirubin (STB) measurements, can predict the development of hyperbilirubinemia during the first 7 days of life.

Methods.

From 9 multinational clinical sites, 1370 neonates completed this cohort study from February 20, 1998, through February 22, 1999. Measurements of both ETCOc and STB were performed at 30 ± 6 hours of life; STB also was measured at 96 ± 12 hours and subsequently following a flow diagram based on a table of hours of age-specific STB. An infant was defined as hyperbilirubinemic if the hours of age-specific STB was greater than or equal to the 95th percentile as defined by the table at any time during the study.

Results.

A total of 120 (8.8%) of the enrolled infants became hyperbilirubinemic. Mean STB in breastfed infants was 8.92 ± 4.37 mg/dL at 96 hours versus 7.63 ± 3.58 mg/dL in those fed formula only. The mean ETCOc at 30 ± 6 hours for the total population was 1.48 ± 0.49 ppm, whereas those of nonhyperbilirubinemic and hyperbilirubinemic infants were 1.45 ± 0.47 ppm and 1.81 ± 0.59 ppm, respectively. Seventy-six percent (92 of 120) of hyperbilirubinemic infants had ETCOc greater than the population mean. An ETCOc greater than the population mean at 30 ± 6 hours yielded a 13.0% positive predictive value (PPV) and a 95.8% negative predictive value (NPV) for STB ≥95th percentile. When infants with STB >95th percentile at <36 hours of age were excluded, the STB at 30 ± 6 hours yielded a 16.7% PPV and a 98.1% NPV for STB >75th percentile. The combination of these 2 measurements at 30 ± 6 hours (either ETCOc more than the population mean or STB >75th percentile) had a 6.4% PPV with a 99.0% NPV.

Conclusions. 

This prospective cohort study supports previous observations that measuring STB before discharge may provide some assistance in predicting an infant's risk for developing hyperbilirubinemia. The addition of an ETCOc measurement provides insight into the processes that contribute to the condition but does not materially improve the predictive ability of an hours of age-specific STB in this study population. The combination of STB and ETCOc as early as 30 ± 6 hours may identify infants with increased bilirubin production (eg, hemolysis) or decreased elimination (conjugation defects) as well as infants who require early follow-up after discharge for jaundice or other clinical problems such as late anemia. Depending on the incidence of hyperbilirubinemia within an institution, the criteria for decision making should vary according to its unique population.
Intussusception, Rotavirus Diarrhea, and Rotavirus Vaccine Use Among Children in New York State
Authors: Chang Hwa-Gan H. , Smith Perry F. , Ackelsberg Joel , Morse Dale L. , Glass Roger I.
Published: August 2004

Objective.

To describe epidemiologic features of intussusception and rotavirus diarrhea in New York, to examine the baseline incidence and trends over time, and to ascertain whether an excess of cases occurred in the 9 months of vaccination with the newly licensed rotavirus vaccine.

Methods.

Hospital discharge data from 1989 through 1998 were reviewed for children (<1 year old) whose primary or secondary diagnosis was coded as intussusception or rotavirus diarrhea. Characteristics of patients admitted for intussusception and rotavirus diarrhea were compared, and trends over time were examined. For a subset of patients, medical records and vaccine histories for intussusception hospitalizations from October 1998 through June 1999 were analyzed. The number of intussusception cases attributable to rotavirus vaccine was calculated based on the penetration of the vaccine (21%) and a range of excess risks of intussusception among vaccinated children as estimated by the National Immunization Program (NIP).

Results.

From 1989 through 1998, 1450 intussusception-associated hospitalizations were reported in children <1 year old (average annual incidence 5.4/10 000). Among these children, 47% were treated medically and 53% had surgery, with 9% needing surgical resection. The incidence of intussusception declined over time from 6.1 per 10 000 in 1989 to 3.9 per 10 000 in 1998. Intussusception hospitalizations occurred throughout the year, whereas rotavirus-associated hospitalizations peaked from February to April. Of 20 patients with intussusception whose hospitalization charts were reviewed, 5 had received rotavirus vaccine. All 5 were hospitalized after their first dose of vaccine, were admitted before 7 months of age, were white, and had private insurance. A total of 81 cases of intussusception occurred during the 9-month period of rotavirus vaccination, compared with 78 during the same period in the prevaccination year. The number of excess intussusception cases observed (n = 3) was lower than expected using the NIP estimate of excess risk (1.8) among rotavirus vaccinated children (n = 12) but not significantly different from the risks identified in the NIP cohort studies (1 in 12 000).

Conclusion.

Our data suggest that in New York the rate of intussusception has declined, and approximately 1 child in 2600 develops intussusception before 1 year of age. The different seasonality between intussusception and rotavirus-related hospitalizations suggests that if any causal association exists, it must be small. Unlike other studies, analysis of New York hospitalized discharge data failed to show an appreciable increase in the incidence of intussusception after introduction of the rotavirus vaccine.
Utilization and Cost of Health Care Services for Children With Attention-Deficit/Hyperactivity Disorder
Authors: Guevara James , Lozano Paula , Wickizer Thomas , Mell Loren , Gephart Harlan
Published: August 2004

Background.

Despite an increasing prevalence of diagnosed attention-deficit/hyperactivity disorder (ADHD) among children, the impact of ADHD on utilization and costs of health care services is largely unknown.

Objective.

To examine differences in health care utilization and costs between children with and without ADHD.

Design.

Retrospective matched cohort study conducted from January 1 to December 31, 1997.

Setting.

Health maintenance organization in western Washington State.

Participants.

Children aged 3 through 17 years who were continuously enrolled in the health maintenance organization and used services during 1997 were eligible. Children were identified with ADHD if they had a diagnosis of ADHD or a prescription for a stimulant medication using automated patient files. Children without ADHD were randomly selected as controls and matched 4:1 to children with ADHD on age and sex.

Outcome Measure.

Utilization and costs of specific categories of health care services.

Results.

A total of 2992 children (5.2%) were identified with ADHD. Children with ADHD incurred significantly greater per capita total costs ($1465 vs $690) than children without ADHD. Children with ADHD had 9.9 times more outpatient mental health visits (1.35/year vs 0.14/year), 3.4 times more pharmacy fills (11.25/year vs 3.30/year), and 1.6 times more primary care visits (3.84/year vs 2.36/year) than children without ADHD. The adjusted incremental costs were estimated to be $375 (95% confidence interval: $336–$416) for children with ADHD alone and $812 (95% confidence interval: $671–$973) for children with ADHD plus coexisting mental health disorders.

Conclusions.

Children with ADHD use significantly more health care resources and incur significantly higher costs than children without ADHD. Coexisting mental health disorders substantially increase the cost of treating ADHD. Resource allocation decisions should consider the contributions of primary care, outpatient mental health, and pharmacy costs to the overall costs of care for children with ADHD.
Adult Outcomes of Pediatric Recurrent Abdominal Pain: Do They Just Grow Out of It?
Authors: Campo John V. , Di Lorenzo Carlo , Chiappetta Laurel , Bridge Jeff , Colborn D. Kathleen , Gartner J. Carlton , Gaffney Paul , Kocoshis Samuel , Brent David
Published: August 2004

Objective.

To determine whether medically unexplained recurrent abdominal pain (RAP) in childhood predicts abdominal pain, irritable bowel syndrome (IBS), other somatic complaints, and psychiatric symptoms and disorders in young adulthood.

Methods.

A sample of 28 young adults evaluated for RAP between the ages of 6 and 17 years were compared with 28 individually matched former childhood participants in a study of tonsillectomy and adenoidectomy. RAP caseness was established by structured retrospective chart review requiring agreement by 2 independent reviewers. Standardized assessments of abdominal pain, IBS, other somatic symptoms, psychopathology, perceived health, and history of maltreatment were performed an average of 11.1 years after the index visit.

Results.

Former RAP patients were significantly more likely than controls to endorse anxiety symptoms and disorders, hypochondriacal beliefs, greater perceived susceptibility to physical impairment, poorer social functioning, current treatment with psychoactive medication, and generalized anxiety in first degree relatives. There were trends suggesting associations between childhood RAP and lifetime psychiatric disorder, depression, migraine, and family history of depression, but group differences on abdominal pain, IBS, other somatic symptoms, and history of maltreatment were not statistically significant.

Conclusions.

There is a strong and relatively specific association between childhood RAP and anxiety in young adulthood. Affected children may be at special risk to perceive physical symptoms as threatening, and should be evaluated for psychiatric disorder on initial presentation.
Obsessive-Compulsive Scale of the Child Behavior Checklist: Specificity, Sensitivity, and Predictive Power
Authors: Nelson Elliot C. , Hanna Gregory L. , Hudziak James J. , Botteron Kelly N. , Heath Andrew C. , Todd Richard D.
Published: August 2004

Objective.

To create an obsessive-compulsive disorder subscale (OCS) of the Child Behavior Checklist (CBCL) and to determine its internal consistency, sensitivity, specificity, and positive and negative predictive power to identify obsessive-compulsive disorder (OCD) in children and adolescents.

Methods.

Three samples of equal size (n = 73) of children and adolescents, matched for age, gender, and race, were selected for these analyses: 1) a clinically ascertained OCD group, 2) a psychiatrically treated group whose records revealed no evidence of OCD, and 3) a general population control group. An OCS was created by applying factor analysis to 11 CBCL items. Examinations of internal consistency, sensitivity, specificity, and positive and negative predictive value were undertaken.

Results.

Of 11 items hypothesized to predict OCD, 8 items were retained after factor analyses (smallest factor loading: 0.49) and used to calculate OCS scores. The retained items displayed excellent internal consistency (Cronbach's α coefficient = 0.84). OCD participants had significantly higher OCS scores than either psychiatrically treated or general population control groups. With the use of the 2 cutoff scores closest to the true rate of OCD in the overall sample, sensitivity was 75.3% to 84.9%, specificity was 82.2% to 92.5%, positive predictive value was 70.5% to 83.3%, and negative predictive value was 88.2% to 91.6%.

Conclusion.

The performance of the proposed CBCL OCS compares favorably with that of the only previously studied screening instrument for OCD, the Leyton Obsessional Inventory–Child Version. Unlike the Leyton Obsessional Inventory–Child Version, the CBCL is already in widespread use as a screen for most other forms of psychopathology. As the performance of the CBCL OCS will need to be replicated in other sample populations, data with various cutoff levels are provided to enable investigators and clinicians to tailor its use to specific study populations.
Rational Testing of the HIV-Exposed Infant
Authors: Benjamin Daniel K. , Miller William C. , Fiscus Susan A. , Benjamin Daniel K. , Morse Michele , Valentine Megan , McKinney Ross E.
Published: August 2004

Objectives.

The objectives of this study were 1) to evaluate testing regimens of human immunodeficiency virus (HIV)-exposed infants and 2) to determine optimal methods of follow-up by enzyme-linked immunosorbent assay (ELISA) testing.

Methods.

We reviewed the results from 742 HIV-exposed infants in the state of North Carolina; 2474 samples were tested for HIV by DNA polymerase chain reaction (PCR) at the University of North Carolina Retrovirology Core Laboratory. We then reviewed the utility and costs of ELISA testing of all HIV-exposed infants who were seen at the Duke University Pediatric Infectious Disease Clinic between January 1, 1993, and May 5, 1998. We used likelihood ratios to model probability of HIV infection given 3 negative DNA (PCR) tests and to provide recommendations on the use of ELISA follow-up.

Results.

The overall sensitivity of the DNA PCR was 87.1%, and its specificity was 99.9%. We evaluated 224 HIV-exposed infants who were seen at Duke University and who had at least 3 negative diagnostic tests using either DNA PCR tests or HIV blood cultures. All 178 infants who subsequently underwent ELISA testing ultimately demonstrated seroreversion. The Duke University Pediatric Infectious Disease Clinic transferred the care of 65 patients to primary care physicians before ELISA testing and retained the care of the remaining 159 patients. Children who remained in Duke's care were more likely to have documentation of seroreversion (158 of 159 vs 20 of 65). We reviewed costs of travel, physician appointment, and HIV antibody testing in a tertiary care setting. Given 3 negative PCR tests, the expected cost per case of HIV detected by a positive ELISA assay is $23.8 million.

Conclusions.

Documentation of seroreversion in this cohort was nearly complete in the multidisciplinary subspecialty clinic but not when such responsibility was left to the primary care physician. Given the low probability of disease in patients who have had 3 negative PCR tests, documentation of a negative ELISA may not be an appropriate use of medical resources.
The Decision to Breastfeed in the United States: Does Race Matter?
Authors: Forste Renata , Weiss Jessica , Lippincott Emily
Published: August 2004

Objectives.

To estimate the effects of maternal and birth characteristics on the decision to breastfeed and to relate breastfeeding practices to racial differences in infant mortality.

Methods.

Using a sample of women with young children from the National Survey of Family Growth (NSFG), Cycle V, 1995, the likelihood of breastfeeding was modeled using logistic regression techniques. In addition, single, live births from the NSFG 1988 and 1995 surveys were analyzed to model the effects of race and breastfeeding on infant mortality using Cox regression methods.

Results.

After controlling for socioeconomic background and birth characteristics, race remained a strong predictor of breastfeeding. Black women were less likely to breastfeed than nonblack women were, and the primary reason indicated by black women for not breastfeeding was that they “preferred to bottle-feed.” Analyses of infant mortality indicated that breastfeeding accounts for the race difference in infant mortality in the United States at least as well as low birth weight does.

Conclusions.

Race is an important predictor of breastfeeding, with most black women reporting that they “preferred bottle-feeding.” Efforts to increase breastfeeding of infants in the black community should help narrow the racial gap in infant mortality.
Driveway Injuries in Children: Risk Factors, Morbidity, and Mortality
Authors: Nadler Evan P. , Courcoulas Anita P. , Gardner Mary J. , Ford Henri R.
Published: August 2004

Background/Purpose.

Injuries that occur around the driveway are not typically regarded as reportable to the police and thus are often underrecognized. The aim of this study was to characterize the pattern and consequences of motor vehicle collisions that occur in the driveway.

Methods.

Over the past 13 years, 64 patients admitted to the Children's Hospital of Pittsburgh sustained motor vehicle-related injuries in a driveway. These injuries resulted from a vehicle driven by an adult driver striking a child (group 1) or a child shifting an idle vehicle out of gear (group 2). We compared demographic variables and outcome measures between the 2 groups.

Results.

There was no difference in gender, injury pattern, Injury Severity Score, length of stay, or operations performed between the groups. Patients in group 1 were younger, smaller, had a lower Glasgow Coma Scale, and had poorer outcomes. The majority of collisions (∼65%) in group 1 resulted from a truck or sport-utility vehicle going in reverse.

Conclusions.

Younger children are more severely injured in driveway-related crashes, which are most likely to be caused by a truck or sport-utility vehicle going in reverse. These vehicles should be equipped with additional safety features such as extended mirrors to visualize small children.
Comparative Practice Patterns of Emergency Medicine Physicians and Pediatric Emergency Medicine Physicians Managing Fever in Young Children
Authors: Isaacman Daniel J. , Kaminer Kimberly , Veligeti Hari , Jones Michael , Davis Paris , Mason Jon D.
Published: August 2004

Background/Objective.

The management of fever in young children is a controversial topic. This study seeks to compare the management approaches between general emergency medicine physicians (GEMPs) and pediatric emergency medicine physicians (PEMPs) and correlate them to existing practice guidelines.

Design/Methods.

All charts of children age 3 to 36 months presenting with the complaint of fever at both a children's hospital emergency department (ED) and a general ED from June 1, 1998 to September 1, 1998; December 1, 1998 to April 1, 1999; and June 1, 1999 to September 1, 1999 were retrospectively reviewed. Fever was defined as ≥39°C. Patients with a history of immunodeficiency, chronic illness, ventriculoperitoneal shunt, antibiotic use in the past 48 hours, or focal infection noted on examination were excluded. Data collected included focal exam findings, laboratory tests, diagnosis, treatment, and disposition. Variances from the practice guidelines were tabulated and compared.

Results.

One thousand three hundred twenty-three eligible children met exclusion criteria and were seen by PEMPs; 755 were eliminated because of exclusion criteria (526 because of focal infection). Twenty-two (4%) of 568 remaining patients were admitted to the hospital. Two hundred twenty-eight eligible children were seen by GEMPs; 147 were excluded (109 because of focal infection). No patients were admitted to the hospital. PEMPs ordered more complete blood counts (324/568 vs 27/81), more blood cultures (321/568 vs 27/81), and more urine cultures (208/568 vs 20/81) than GEMPs. GEMPs ordered more chest radiographs and cerebrospinal fluid analyses than PEMPs; GEMPs ordered less complete blood counts, blood cultures, and urine cultures than PEMPs. GEMPs diagnosed more focal infections (109/228 vs 526/1323), and conflicted more often with the practice guidelines (66/79 vs 225/498) than PEMPs. Patients spent an average of 2.26 ± 0.16 hours in the pediatric ED versus 3.0 hours ± 0.18 hours in the general ED.

Conclusions.

Significant differences in the management of the young child with fever and no source exist between these two groups of physicians. These variations affect both cost and standard of care. Future studies assessing whether these strategies affect patient outcomes would further elucidate their clinical implication.
Aerosol Therapy With Valved Holding Chambers in Young Children: Importance of the Facemask Seal
Authors: Amirav Israel , Newhouse Michael T.
Published: August 2004

Objective.

Masks are an essential interface between valved holding chambers (VHCs), or spacers, and a small child's face for providing aerosol therapy. Clinical experience suggests that many young children do not cooperate with the VHC treatment or tolerate a mask of any kind. This might impair the mask–face seal and reduce the dose delivered to the child. The objective of this study was to evaluate the ability of parents to provide a good mask–face seal in infants and toddlers using 3 masks provided with commonly used pediatric VHCs and compare this with the seal obtained with the Hans Rudolph pediatric anesthesia mask.

Methods.

A preliminary in vitro filter study was conducted to validate the assumption that reduced ventilation as a result of increased facemask leak reduces the drug aerosol dose delivered to the mouth. Facemask leak then was studied in vivo for NebuChamber, AeroChamber, BabyHaler, and Hans Rudolph masks by measuring ventilation with an in-line pneumotachograph while the facemask was held in place by experienced parents who were asked to demonstrate how they deliver medication to their children without any additional instruction. Thirty children (mean age: 3.2 ± 1.4 years) performed 4 repeat studies with each mask. The first 10 patients performed the tests once again within 1 month. On the second occasion, the parents were coached continuously and encouraged to hold the mask tightly against the child's face.

Results.

The AeroChamber and Hans Rudolph masks provided the best seal as reflected in the magnitude of the ventilation measured through them. The NebuChamber provided the poorest seal, with 45% less ventilation than the AeroChamber and Hans Rudolph masks. There was considerable intraindividual variability for all masks (24% to 48%); however, the variability with the NebuChamber mask was 2-fold greater than the other masks. All ventilatory volumes during the coached session were significantly greater than during the uncoached session. Variability during the coached session was significantly less (except for the BabyHaler, which remained unchanged).

Conclusions.

VHCs with masks designed for use with small children may provide a poor seal with the face, leading to reduced or more variable dose delivery. The facemask seal is critical for efficient aerosol delivery to infants and young children, and this should be stressed to parents.
Comparison of Quality of Care by Specialist and Generalist Physicians as Usual Source of Asthma Care for Children
Authors: Diette Gregory B. , Skinner Elizabeth A. , Nguyen Theresa T. H. , Markson Leona , Clark Becky D. , Wu Albert W.
Published: August 2004

Objective.

To determine whether care for children was more consistent with national asthma guidelines when a specialist rather than a generalist was the usual source of asthma care.

Design.

Cross-sectional survey.

Setting.

Two large managed care organizations in the United States.

Participants.

A total of 260 parents of children with asthma.

Interventions.

None.

Main Outcome Measures.

Parent reports of the physician primarily responsible for asthma care (specialist, generalist, or both equally) and whom they would call (specialist or generalist) for questions about asthma care were used to define usual source of care. We assessed consistency of care with 1997 National Asthma Education and Prevention Program guidelines using 11 indicators in 4 domains of asthma care: patient education, control of factors contributing to asthma symptoms, periodic physiologic assessment and monitoring, and proper use of medications.

Results.

In all 4 domains, care was more likely to be consistent with guidelines when specialists were the usual source of care. These differences remained after adjustment for symptom severity, recent care encounters, and parent demographics. Greatest differences for specialist versus generalist management were for use of controller medications (odds ratio [OR] 6.7; 95% confidence interval [CI]: 1.5–30.4), ever having a pulmonary function test (OR 6.5; 95% CI: 2.4–18.1), and having been told about asthma triggers and how to avoid them (OR 5.9; 95% CI: 1.3–26.2).

Conclusions.

In these managed care organizations, asthma care in children was more likely to be consistent with national guidelines when a specialist was the primary provider. Greater use of specialists or altering generalist physicians' care may improve the degree to which the care of children with asthma is consistent with national guidelines.