bluuebunny/crossref_metadata_2025 huggingface dataset:
Screening for Posttraumatic Stress Disorder in Children After Accidental Injury
Authors: Kenardy Justin A. , Spence Susan H. , Macleod Alexandra C.
Published: September 2006

OBJECTIVE. Children who have experienced an accidental injury are at increased risk of developing posttraumatic stress disorder. It is, therefore, essential that strategies are developed to aid in the early identification of children at risk of developing posttraumatic stress disorder symptomatology after an accident. The aim of this study was to examine the ability of the Child Trauma Screening Questionnaire to predict children at risk of developing distressing posttraumatic stress disorder symptoms 1 and 6 months after a traumatic accident.

METHODS. Participants were 135 children (84 boys and 51 girls; with their parents) who were admitted to the hospital after a variety of accidents, including car- and bike-related accidents, falls, burns, dog attacks, and sporting injuries. The children completed the Child Trauma Screening Questionnaire and the Children's Impact of Events Scale within 2 weeks of the accident, and the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Child Version, was conducted with the parents to assess full and subsyndromal posttraumatic stress disorder in their child 1 and 6 months after the accident.

RESULTS. Analyses of the results revealed that the Child Trauma Screening Questionnaire correctly identified 82% of children who demonstrated distressing posttraumatic stress disorder symptoms (9% of sample) 6 months after the accident. The Child Trauma Screening Questionnaire was also able to correctly screen out 74% of children who did not demonstrate such symptoms. Furthermore, the Child Trauma Screening Questionnaire outperformed the Children's Impact of Events Scale.

CONCLUSIONS. The Child Trauma Screening Questionnaire is a quick, cost-effective and valid self-report screening instrument that could be incorporated in a hospital setting to aid in the prevention of childhood posttraumatic stress disorder after accidental trauma.
Prospective Study of Infantile Hemangiomas: Clinical Characteristics Predicting Complications and Treatment
Authors: Haggstrom Anita N. , Drolet Beth A. , Baselga Eulalia , Chamlin Sarah L. , Garzon Maria C. , Horii Kimberly A. , Lucky Anne W. , Mancini Anthony J. , Metry Denise W. , Newell Brandon , Nopper Amy J. , Frieden Ilona J.
Published: September 2006

OBJECTIVES. Infantile hemangiomas are the most common tumor of infancy. Risk factors for complications and need for treatment have not been studied previously in a large prospective study. This study aims to identify clinical characteristics associated with complications and the need for therapeutic intervention.

PATIENTS AND METHODS. We conducted a prospective cohort study at 7 US pediatric dermatology clinics with a consecutive sample of 1058 children, aged ≤12 years, with infantile hemangiomas enrolled between September 2002 and October 2003. A standardized questionnaire was used to collect data on each patient and each hemangioma, including clinical characteristics, complications, and treatment.

RESULTS. Twenty-four percent of patients experienced complications related to their hemangioma(s), and 38% of our patients received some form of treatment during the study period. Hemangiomas that had complications and required treatment were larger and more likely to be located on the face. Segmental hemangiomas were 11 times more likely to experience complications and 8 times more likely to receive treatment than localized hemangiomas, even when controlled for size.

CONCLUSIONS. Large size, facial location, and/or segmental morphology are the most important predictors of poor short-term outcomes as measured by complication and treatment rates.
Use and Efficacy of Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room
Authors: Barber Chad A. , Wyckoff Myra H.
Published: September 2006

OBJECTIVE. Given the paucity of information regarding endotracheal epinephrine for newborn resuscitation, the objectives of this study were: (1) to determine the frequency of endotracheal epinephrine use in newborns in the delivery room, and (2) to determine whether the previously recommended dose of 0.01 to 0.03 mg/kg of endotracheal epinephrine is effective in establishing a return of spontaneous circulation.

PATIENTS AND METHODS. A retrospective review was conducted for all neonates who received ≥1 dose of epinephrine in the delivery room between January 1999 and December 2004. Infants who received ≥1 dose of endotracheal epinephrine in the delivery room during resuscitation were included in the study population whether or not they survived to be admitted to the NICU. Exclusion criteria included lethal congenital anomalies, delivery outside the hospital, and missing medical charts.

RESULTS. Of 93656 infants, 52 neonates (0.06%) received epinephrine in the delivery room, 5 of whom met exclusion criteria. Of the remaining 47 infants, 44 (94%) received the first dose via the endotracheal tube. Only 14 (32%) of 44 achieved return of spontaneous circulation after endotracheal tube administration of epinephrine. Of the 30 remaining infants, 23 (77%) had return of spontaneous circulation with intravenous epinephrine after initially failing endotracheal tube epinephrine. There were no differences in clinical characteristics between newborns who responded to endotracheal tube versus intravenous epinephrine except for a lower blood glucose on NICU admission (52 vs 113 mg%).

CONCLUSIONS. Endotracheal epinephrine is frequently used when intensive resuscitation is required in the delivery room. The previously recommended endotracheal epinephrine dose of 0.01 to 0.03 mg/kg is often ineffective. Higher endotracheal doses will likely be needed to improve efficacy. A prospective study is needed to determine the best endotracheal epinephrine dosing regimen. Until such information is available, intravenous administration should be the preferred route of delivery.
Effect of Hospital Characteristics on Outcomes From Pediatric Cardiopulmonary Resuscitation: A Report From the National Registry of Cardiopulmonary Resuscitation
Authors: Donoghue Aaron J. , Nadkarni Vinay M. , Elliott Michael , Durbin Dennis ,   for the American Heart Assocation National Registry of Cardiopulmonary Resuscitation Investigators
Published: September 2006

OBJECTIVE. Cardiac arrest is uncommon among pediatric patients. Prehospital data demonstrate differences in care processes between children and adults receiving cardiopulmonary resuscitation and advanced life support. We sought to evaluate whether children receiving in-hospital cardiopulmonary resuscitation would attain superior 24-hour survival in hospitals with a higher level of pediatric physician staffing, greater intensity of pediatric care services, and higher pediatric patient volume.

METHODS. A retrospective cohort of 778 hospital inpatients aged <18 years receiving cardiopulmonary resuscitation was identified from the National Registry of Cardiopulmonary Resuscitation from January 2000 to December 2002. Data on hospital pediatric facilities were obtained via telephone survey. Univariate analyses comparing 24-hour survivors and nonsurvivors were conducted using Wilcoxon rank-sum testing for continuous variables and χ2 analysis for dichotomous variables. Multivariate regression analysis was done to examine hospital characteristics as independent predictors of 24-hour survival.

RESULTS. Complete data were available for 677 patients. Univariate analyses showed an association between several pediatric-specific facility characteristics and 24-hour survival. After accounting for indicators of pre-event clinical condition and monitoring, multivariate analysis showed improved 24-hour survival in hospitals staffed by pediatric residents and surgeons and pediatric residents, surgeons, and fellows than for hospitals with no pediatric physician staffing or pediatric surgeons alone. Measures of available facilities and patient volume were not associated with improved outcome.

CONCLUSIONS. Improved 24-hour survival for children receiving in-hospital cardiopulmonary resuscitation is associated with the presence of pediatric residents and fellows.
National Impact of Universal Childhood Immunization With Pneumococcal Conjugate Vaccine on Outpatient Medical Care Visits in the United States
Authors: Grijalva Carlos G. , Poehling Katherine A. , Nuorti J. Pekka , Zhu Yuwei , Martin Stacey W. , Edwards Kathryn M. , Griffin Marie R.
Published: September 2006

BACKGROUND. Since introduction of the heptavalent pneumococcal conjugate vaccine in the United States in 2000, rates of invasive pneumococcal disease have declined. However, the national impact of heptavalent pneumococcal conjugate vaccine on pneumonia and otitis media remains unknown.

OBJECTIVES. We compared national rates of outpatient visits for pneumonia and otitis media in children before and after heptavalent pneumococcal conjugate vaccine introduction.

METHODS. Rates of ambulatory visits for pneumococcal and nonspecific pneumonia, otitis media, and other acute respiratory infections were compared before (1994–1999) and after (2002–2003) heptavalent pneumococcal conjugate vaccine introduction using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. To evaluate vaccine effects while accounting for temporal variability, ratios of pneumococcal-related disease rates in children <2 years old (vaccine target population) and in children 3 to 6 years old (not routinely vaccinated) were evaluated using a Poisson regression analysis. For children <2 years old, the differences between observed and expected rates were the estimated vaccine effects.

RESULTS. After the introduction of heptavalent pneumococcal conjugate vaccine, otitis media visit rates declined by 20% in children aged <2 years. This decline represented 246 fewer otitis media visits per 1000 children aged <2 years annually. There were no significant decreases in outpatient visit rates for pneumonia or other acute respiratory infections for children aged <2 years.

CONCLUSIONS. After heptavalent pneumococcal conjugate vaccine introduction, national rates of otitis media visits declined significantly in children <2 years old. Persistence of this trend will produce a significant reduction of the otitis media burden and further enhance the cost-effectiveness of heptavalent pneumococcal conjugate vaccine.
Detection of Impaired Growth of the Corpus Callosum in Premature Infants
Authors: Anderson Nigel G. , Laurent Isabelle , Woodward Lianne J. , Inder Terrie E.
Published: September 2006

OBJECTIVE. There is an urgent need for a bedside method to assess the effectiveness of neonatal therapies designed to improve cerebral development in very low birth-weight infants. The aim of this study was to assess the impact of preterm birth on the serial growth of the corpus callosum and how soon it could be detected after birth with cranial ultrasound.

METHODS. We recruited 61 very low birth-weight infants admitted to a single regional level III NICU from 1998 to 2000. Study infants had 2 cranial sonograms ≥7 days apart in the first 2 weeks of life and further sonograms at 6 weeks and at term equivalent. At each time point, the length of the corpus callosum and cerebellar vermis was measured on midline sagittal images, with growth rates calculated in millimeters per day. We compared growth of corpus callosum and cerebellar vermis in individuals, between birth age groups, and with corrected gestational age. We used antenatal growth rate of the corpus callosum of 0.2 to 0.27 mm/day as a reference. Relationships between corpus callosum growth rates and neurodevelopmental outcome at 2 years of age (corrected) were also examined.

RESULTS. Growth of the corpus callosum was normal in most infants during the first 2 weeks of life but slowed after this (0.21 mm/day from 0–2 weeks vs 0.11 mm/day for weeks 2–6). Slowing of corpus callosum growth below expected reference range was consistently detectable by age 6 weeks for 96% of infants born between 23 and 33 weeks' gestation. Although some improvement in growth rate was observed for 15% of infants after 6 weeks, this was confined to infants born after 28 weeks. Vermis length correlated strongly with corpus callosum length. By 2 years of age, serious motor delay and cerebral palsy were associated with poorer growth of the length of the corpus callosum between 2 and 6 weeks after birth.

CONCLUSIONS. The effect of preterm birth on growth of the corpus callosum is detectable by 6 weeks after delivery in preterm infants born at gestations of 23 to 33 weeks. Reduced growth of the corpus callosum in weeks 2 to 6, places these infants at elevated risks of later psychomotor delay and cerebral palsy.
Ex Uno Plures: The Concealed Complexity of Bilirubin Species in Neonatal Blood Samples
Authors: McDonagh Antony F.
Published: September 2006

Blood from jaundiced neonates often contains several isomers of bilirubin in addition to the biosynthetic isomer that causes kernicterus. These isomers are generated during phototherapy or during normal exposure of infants to ambient light. Their presence is generally overlooked or ignored in clinical measurements of circulating bilirubin concentrations and the interpretation of these values. Whether this is justified or clinically important is presently uncertain. However, the presence of isomers may complicate the accurate measurement of free bilirubin concentrations in blood and the use of such values for identifying jaundiced infants at most risk of kernicterus.
Single Kidney and Sports Participation: Perception Versus Reality
Authors: Grinsell Matthew M. , Showalter Sharon , Gordon Katherine A. , Norwood Victoria F.
Published: September 2006

OBJECTIVES. Physician opinions and practice patterns regarding the participation of children and adolescents with single, normal kidneys in contact/collision sports are widely varied. We hypothesize that limitation of participation from play based only on the presence of a single kidney is not supported by available data. We sought to determine recommendations of pediatric nephrologists regarding the participation of patients with single, normal kidneys in contact/collision sports and review the literature to determine the rate of sports-related kidney injury compared with other organs.

METHODS. Members of the American Society of Pediatric Nephrology were surveyed regarding their recommendations for participation of patients with single, normal kidneys in contact/collision sports. Medical and sports literature databases were searched to determine sports-related kidney, brain, spinal cord, and cardiac injury rates and the sports associated with kidney injury.

RESULTS. Sixty-two percent of respondents would not allow contact/collision sports participation. Eighty-six percent of respondents barred participation in American football, whereas only 5% barred cycling. Most cited traumatic loss of function as the reason for discouraging participation. The literature search found an incidence of catastrophic sports-related kidney injury of 0.4 per 1 million children per year from all sports. Cycling was the most common cause of sports-related kidney injury causing >3 times the kidney injuries as football. American football alone accounted for 0.9 to 5.3 fatal brain injuries and 4.9 to 7.3 irreversible spinal cord injuries per 1 million players per year. Commotio cordis causes 2.1 to 9.2 deaths per year.

CONCLUSIONS. Most pediatric nephrologists prohibit contact/collision sports participation by athletes with a single kidney, particularly football. The available evidence suggests that cycling is far more likely to cause kidney injury. In addition, kidney injury from sports is much less common than catastrophic brain, spinal cord, or cardiac injury. Restricting participation of patients with a single, normal kidney from contact/collision sports is unwarranted.
Neonatal Screening for Very Long-Chain Acyl-CoA Dehydrogenase Deficiency: Enzymatic and Molecular Evaluation of Neonates With Elevated C14:1-Carnitine Levels
Authors: Liebig Michaela , Schymik Ina , Mueller Martina , Wendel Udo , Mayatepek Ertan , Ruiter Jos , Strauss Arnold W. , Wanders Ronald J.A. , Spiekerkoetter Ute
Published: September 2006

OBJECTIVE. Neonatal screening programs for very long-chain acyl-coenzyme A dehydrogenase deficiency have been implemented recently in various countries. Mildly elevated C14:1-carnitine on day 3 of life strongly suggests very long-chain acyl-coenzyme A dehydrogenase deficiency.

DESIGN. We characterized 11 neonates with elevated C14:1-carnitine by enzyme and molecular analyses. Palmitoyl-coenzyme A oxidation was measured in lymphocytes. Sequencing of all 20 exons of the VLCAD gene was performed from genomic DNA.

RESULTS. Palmitoyl-coenzyme A oxidation revealed significantly decreased residual activities consistent with very long-chain acyl-coenzyme A dehydrogenase deficiency in 7 neonates. In 2 individuals, residual activities of 48% and 44%, respectively, suggested heterozygosity. Two disease-causing mutations were detected in 6 of 7 neonates with very long-chain acyl-coenzyme A dehydrogenase deficiency; in the remaining 1 patient, only 1 mutation was identified. Of 2 individuals with residual activities consistent with heterozygosity, 1 was heterozygous for a VLCAD mutation. The other child and both individuals with normal palmitoyl-coenzyme A oxidation had normal genotypes.

CONCLUSIONS. In 4 of 11 neonates identified with elevated C14:1-carnitine, very long-chain acyl-coenzyme A dehydrogenase deficiency was excluded. A C14:1-carnitine level >1 μmol/L strongly suggests very long-chain acyl-coenzyme A dehydrogenase deficiency, whereas concentrations ≤1 μmol/L do not allow a clear discrimination among affected patients, carriers, and healthy individuals. Further diagnostic evaluation, including enzyme and molecular analyses, is essential to identify very long-chain acyl-coenzyme A dehydrogenase deficiency correctly.
Pretransport and Posttransport Characteristics and Outcomes of Neonates Who Were Admitted to a Cardiac Intensive Care Unit
Authors: Yeager Scott B. , Horbar Jeffrey D. , Greco Karla M. , Duff Julianna , Thiagarajan Ravi R. , Laussen Peter C.
Published: September 2006

OBJECTIVE. The objective for this study was to characterize the impact and the safety of transporting neonates with known or suspected cardiac abnormalities.

METHODS. We reviewed retrospectively the charts and computerized records of 192 admissions to a cardiac ICU in 2002. Patients were included when they were <28 days of age at admission and were transported from adjacent obstetric facilities (local N = 70) or other inpatient medical facilities (transport N = 122). Demographic, clinical, pharmacologic, laboratory, and diagnostic information was obtained before transport (when available) and within 3 hours of arrival. Arrival status was considered optimal when measured metabolic and clinical parameters all were within range. Outcome variables included days on ventilator, days in ICU, days in hospital, and death.

RESULTS. Of local admissions, 31 (44%) patients had 61 suboptimal arrival values, including pH <7.25 (n = 11), saturation <70% (n = 12), and temperature <36°C (n = 9). There were 69 undocumented values in 39 patients. Of transported patients, 55 (45%) had 86 suboptimal arrival values, including pH <7.25 (n = 8), saturation <70% (n = 14), and temperature <36°C (n = 13). There were 98 undocumented values in 53 patients. No in-transport deaths or catastrophic events occurred. Local admissions were more likely to have a prenatal diagnosis of heart disease and had more complex disease and higher mortality. Other outcome parameters were not significantly different between the 2 groups. Low admission arterial saturation, pH, and core temperature were not correlated with adverse outcome measures.

CONCLUSIONS. Although we did not encounter major transport complications, opportunities exist to optimize arrival status and improve surveillance and documentation.
Little Evidence for Early Programming of Weight and Insulin Resistance for Contemporary Children: EarlyBird Diabetes Study Report 19
Authors: Jeffery Alison N. , Metcalf Brad S. , Hosking Joanne , Murphy Michael J. , Voss Linda D. , Wilkin Terence J.
Published: September 2006

OBJECTIVE. The aim of this study was to evaluate whether adaptive responses made to the uterine or very early infant environment are affecting the current metabolic health of young children in the United Kingdom.

METHODS. Participants were 300 healthy children and their parents from the EarlyBird Diabetes Study cohort. Children were recruited from randomly selected schools at 5 years of age. Retrospective measures were maternal prepregnancy weight (n = 230), maternal fasting glucose levels at 28 weeks of pregnancy (n = 27), birth weight, and infant weight at ages 3 and 6 weeks. Prospective measures were insulin resistance, height, weight, and percentage of body fat (sum of 5 skinfold measurements) at ages 5, 6, 7, and 8 years.

RESULTS. Maternal third-trimester fasting glucose levels were associated positively with birth weight but were not associated with either weight or insulin resistance for the same children at 8 years. Birth weight was unrelated to insulin resistance at 8 years. There were no relationships between weight change in the first weeks of life and weight, percentage of fat, or insulin resistance at 8 years. Longer breastfeeding correlated inversely, although weakly, with percentage of body fat for boys only. Current weight was correlated with insulin resistance at 8 years.

CONCLUSIONS. For these contemporary children, neither the gestational environment nor early postnatal growth predicted insulin resistance, which was best predicted by current weight. There was no evidence that predictive adaptive responses made by the fetus or infant affected the child's weight or insulin resistance later in childhood.
Influenza Vaccination Coverage of Children Aged 6 to 23 Months: The 2002–2003 and 2003–2004 Influenza Seasons
Authors: Santibanez Tammy A. , Santoli Jeanne M. , Bridges Carolyn B. , Euler Gary L.
Published: September 2006

BACKGROUND. Beginning in 2002 the Advisory Committee on Immunization Practices encouraged, when feasible, annual influenza vaccination of all children aged 6 to 23 months and household contacts and out-of-home caregivers of children <2 years of age.

OBJECTIVE. We sought to report influenza vaccination coverage for the 2002–2003 and 2003–2004 influenza seasons among children aged 6 to 23 months according to demographic and immunization-provider characteristics.

METHODS. Data from the 2003 and 2004 National Immunization Survey were analyzed. Two measures of childhood influenza vaccination are reported: receipt of ≥1 influenza vaccination and full vaccination (ie, receipt of the appropriate number of doses on the basis of previous vaccination history). χ2 tests and logistic-regression analyses to test for associations between influenza vaccination status and demographic characteristics were performed.

RESULTS. In the 2002–2003 and 2003–2004 influenza seasons only 7.4% and 17.5%, respectively, of children aged 6 to 23 months received ≥1 influenza vaccination, whereas only 4.4% and 8.4%, respectively, were fully vaccinated. In both seasons, adjusted influenza vaccination coverage was significantly lower among children living below the poverty level; non-Hispanic black children; older children; children with less-educated mothers; children vaccinated only at public clinics; and children not residing in a metropolitan statistical area.

CONCLUSIONS. During the first 2 years of the Advisory Committee on Immunization Practices' encouragement for children aged 6 to 23 months to receive influenza vaccination, coverage was low, with significant demographic differences in receipt of vaccination. Beginning with the 2004–2005 influenza season, they replaced the encouragement with a recommendation that children aged 6 to 23 months receive annual influenza vaccination. Substantial work remains to fully and equitably implement this new recommendation and ensure vaccination with 2 doses for previously unvaccinated children.
Stimulants and Sudden Death: What Is a Physician to Do?
Authors: Wilens Timothy E. , Prince Jefferson B. , Spencer Thomas J. , Biederman Joseph
Published: September 2006

OBJECTIVE. Recently, a US Food and Drug Administration advisory committee raised concerns about cardiovascular risks and sudden death in children and adolescents with attention-deficit/hyperactivity disorder who are receiving stimulants.

METHODS. We comment on the risk of sudden death in children/adolescents taking stimulants compared with population rates, biological plausibility, and known cardiovascular effects of stimulants to determine specific risk.

RESULTS. There does not seem to be higher risk of sudden death in stimulant-treated individuals compared with the general population. Although there is evidence of biological plausibility, the known effects of the stimulants on cardiovascular electrophysiology and vital signs seem to be benign.

CONCLUSIONS. There does not seem to be compelling findings of a medication-specific risk necessitating changes in our stimulant treatment of children and adolescents with attention-deficit/hyperactivity disorder. The use of existing guidelines on the use of stimulants (and psychotropic agents) may identify children, adolescents, and adults who are vulnerable to sudden death.
Chemical-Biological Terrorism and Its Impact on Children
Authors:   Committee on Environmental Health and Committee on Infectious Diseases
Published: September 2006

Children remain potential victims of chemical or biological terrorism. In recent years, children have even been specific targets of terrorist acts. Consequently, it is necessary to address the needs that children would face after a terrorist incident. A broad range of public health initiatives have occurred since September 11, 2001. Although the needs of children have been addressed in many of them, in many cases, these initiatives have been inadequate in ensuring the protection of children. In addition, public health and health care system preparedness for terrorism has been broadened to the so-called all-hazards approach, in which response plans for terrorism are blended with plans for a public health or health care system response to unintentional disasters (eg, natural events such as earthquakes or pandemic flu or manmade catastrophes such as a hazardous-materials spill). In response to new principles and programs that have appeared over the last 5 years, this policy statement provides an update of the 2000 policy statement. The roles of both the pediatrician and public health agencies continue to be emphasized; only a coordinated effort by pediatricians and public health can ensure that the needs of children, including emergency protocols in schools or child care centers, decontamination protocols, and mental health interventions, will be successful.
Lactose Intolerance in Infants, Children, and Adolescents
Authors: Heyman Melvin B. ,   for the Committee on Nutrition
Published: September 2006

This Clinical Report was reaffirmed November 2024.

The American Academy of Pediatrics Committee on Nutrition presents an updated review of lactose intolerance in infants, children, and adolescents. Differences between primary, secondary, congenital, and developmental lactase deficiency that may result in lactose intolerance are discussed. Children with suspected lactose intolerance can be assessed clinically by dietary lactose elimination or by tests including noninvasive hydrogen breath testing or invasive intestinal biopsy determination of lactase (and other disaccharidase) concentrations. Treatment consists of use of lactase-treated dairy products or oral lactase supplementation, limitation of lactose-containing foods, or dairy elimination. The American Academy of Pediatrics supports use of dairy foods as an important source of calcium for bone mineral health and of other nutrients that facilitate growth in children and adolescents. If dairy products are eliminated, other dietary sources of calcium or calcium supplements need to be provided.
The Use of Systemic Fluoroquinolones
Authors:   Committee on Infectious Diseases
Published: September 2006

The only indications for which a fluoroquinolone (ie, ciprofloxacin) is licensed by the US Food and Drug Administration for use in patients younger than 18 years are complicated urinary tract infections, pyelonephritis, and postexposure treatment for inhalation anthrax. Nonetheless, approximately 520 000 prescriptions for fluoroquinolones were written in the United States for patients younger than 18 years in 2002; 13 800 were written for infants and children 2 to 6 years of age, and 2750 were written for infants younger than 2 years. Clinical trials of fluoroquinolones in pediatric patients with various diagnoses have been published and are reviewed. Fluoroquinolones cause arthrotoxicity in juvenile animals and have been associated with reversible musculoskeletal events in both children and adults. Other adverse events associated with fluoroquinolones include central nervous system disorders, photosensitivity, disorders of glucose homeostasis, prolongation of QT interval with rare cases of torsade de pointes (often lethal ventricular arrhythmia in patients with long QT syndrome), hepatic dysfunction, and rashes. The increased use of fluoroquinolones in adults has resulted in increased bacterial resistance to this class of antibacterial agents. This report provides specific guidelines for the systemic use of fluoroquinolones in children. Fluoroquinolone use should be restricted to situations in which there is no safe and effective alternative to treat an infection caused by multidrug-resistant bacteria or to provide oral therapy when parenteral therapy is not feasible and no other effective oral agent is available.
Immunization Information Systems
Authors:   Committee on Practice and Ambulatory Medicine
Published: September 2006

The American Academy of Pediatrics continues to support the development and implementation of immunization information systems, previously referred to as immunization registries, and other systems for the benefit of children, pediatricians, and their communities. Pediatricians and others must be aware of the value that immunization information systems have for society, the potential fiscal influences on their practice, the costs and benefits, and areas for future improvement.
Evaluating Infants and Young Children With Multiple Fractures
Authors: Jenny Carole ,   for the Committee on Child Abuse and Neglect
Published: September 2006

Infants and toddlers with multiple unexplained fractures are often victims of inflicted injury. However, several medical conditions can also cause multiple fractures in children in this age group. In this report, the differential diagnosis of multiple fractures is presented, and diagnostic testing available to the clinician is discussed. The hypothetical entity “temporary brittle-bone disease” is examined also. Although frequently offered in court cases as a cause of multiple infant fractures, there is no evidence that this condition actually exists.
Occurrence of Photoprotective Compounds in Yeasts from Freshwater Ecosystems of Northwestern Patagonia (Argentina)
Authors: Libkind Diego , Diéguez María C. , Moliné Martín , Pérez Patricia , Zagarese Horacio E. , van Broock María
Published: September 2006

In this paper we present the results of research on the occurrence, induction and role of photoprotective compounds (PPCs) present in native aquatic yeasts from freshwater Patagonian ecosystems. We focus on the effect of UV radiation (UVR) as a factor that controls the level of photoprotection of yeasts, and explore its potential significance in shaping yeast distributional patterns. The research presented here combines field surveys and laboratory work, including the isolation and culture of native yeasts strains, and laboratory assays under different radiation conditions. The results obtained suggest that yeasts are common dwellers of oligotrophic Patagonian water bodies, and provide the first evidence of the distribution of PPC (carotenoid and mycosporine)‐producing yeasts in temperate freshwaters. A greater proportion of carotenogenic yeasts were observed in high‐elevation lakes. The yeast strains isolated from these environments were found to produce higher amounts of mycosporines (MYCs), and to present higher tolerance to UVB exposure than those from piedmont lakes. Patagonian yeasts have only one type of MYC, mycosporine‐glutaminol‐glucoside (myc‐glu‐glu), which seems common to all other yeasts. By analyzing the production of myc‐glu‐glu in a large number of yeasts belonging to different taxonomic groups, we propose that this compound may have potential use as a chemotaxonomic marker in yeast systematics. Collectively, our work reveals that in Patagonian freshwater yeasts there is an apparent relationship between the ability to produce PPCs, their tolerance to UV exposure and their success in colonizing habitats highly exposed to UVR.
Simulation of Ozone Depletion Using Ambient Irradiance Supplemented with UV Lamps
Authors: Díaz S. , Camilión C. , Escobar J. , Deferrari G. , Roy S. , Lacoste K. , Demers S. , Belzile C. , Ferreyra G. , Gianesella S. , Gosselin M. , Nozais C. , Pelletier E. , Schloss I. , Vernet M.
Published: September 2006

In studies of the biological effects of UV radiation, ozone depletion can be mimicked by performing the study under ambient conditions and adding radiation with UV‐B lamps. We evaluated this methodology at three different locations along a latitudinal gradient: Rimouski (Canada), Ubatuba (Brazil) and Ushuaia (Argentina). Experiments of the effect of potential ozone depletion on marine ecosystems were carried out in large outdoor enclosures (mesocosms). In all locations we simulated irradiances corresponding to 60% ozone depletion, which may produce a 130–1900% increase in 305 nm irradiance at noon, depending on site and season. Supplementation with a fixed percentage of ambient irradiance provides a better simulation of irradiance increase due to ozone depletion than supplementation with a fixed irradiance value, particularly near sunrise and sunset or under cloudy skies. Calculations performed for Ushuaia showed that, on very cloudy days, supplementation by the square‐wave method may produce unrealistic irradiances. Differences between the spectra of the calculated supplementing irradiance and the lamp for a given site and date will be a function of the time of day and may become more or less pronounced according to the biological weighting function of the effect under study.
On the Role of Iron and one of its Chelating Agents in the Production of Protoporphyrin IX Generated by 5‐Aminolevulinic Acid and its Hexyl Ester Derivative Tested on an Epidermal Equivalent of Human Skin
Authors: Uehlinger Pascal , Ballini Jean‐Pierre , van den Bergh Hubert , Wagnières Georges
Published: September 2006

Photodynamic therapy (PDT) with 5‐aminolevulinic acid (ALA) or its derivatives as precursors of protoporphyrin IX (PPIX) is routinely used in dermatology for the treatment of various pathologies. However, this methodology suffers to some extent from a limited efficacy. Therefore, the main goal of this study was to investigate the modulation and pharma‐cokinetics of PPIX buildup after a 5 h incubation with ALA (1.5 mM) and one of its derivatives, the hexyl ester of ALA (h‐ALA) (1.5 mM), on the human epidermal equivalent Epidex™. PPIX production was modulated with (L+) ascorbic acid iron (II) salt (LAI) or the iron (II)‐specific chelating agent deferoxamine (DFO). PPIX fluorescence from the Epidex™ layers was measured up to 150 h after the precursor administration using a microspectrofluorometer (λex: 400 ± 20 nm; λdet: 635 nm). The maximum PPIX fluorescence intensity induced by h‐ALA was about 1.7x larger than that induced by ALA. The addition of DFO resulted in a more than 50% increase in PPIX fluorescence for both precursors. The decay half life measured for PPIX fluorescence is 30 and 42.5 h, respectively, for ALA and h‐ALA. These half lives are doubled when the samples contain DFO. In the samples with the highest fluorescence intensity, a modified fluorescence spectrum was observed after 10 h, with the emergence of a peak at 590 nm, which is attributed to zinc protoporphyrin IX (Zn PPIX).
International Adoption: Issues in Infectious Diseases
Authors: Staat Dana D. , Klepser Michael E.
Published: September 2006

International adoptions have become increasingly common in the United States. Children awaiting international adoption and families traveling to adopt these children can be exposed to a variety of infectious diseases. Compared with the United States, foreign countries often have different immunization practices and methods of diagnosing, treating, and monitoring disease. Reporting of medical conditions can also differ from that of the United States. The prevalence of infectious diseases varies from country to country and may or may not be common among adopted children. The transmission of tuberculosis, hepatitis B, and measles from adopted children to family members has been documented. Furthermore, infectious organisms (e.g., intestinal parasites), bacterial pathogens (e.g., Bordetella pertussis and Treponema pallidum), and viruses (e.g., human immunodeficiency virus and hepatitis viruses) may cause clinically significant morbidity and mortality among infected children. Diseases such as severe acute respiratory syndrome or avian influenza have not been reported among international adoptees, but transmission is possible if infection is present. Family members may be infected by others during travel or by their adopted child after returning home. Families preparing to adopt a child from abroad should pay special attention to the infectious diseases they may encounter and to the precautions they should take on returning home.
Development and Validation of the Pediatric Nausea Assessment Tool for Use in Children Receiving Antineoplastic Agents
Authors: Dupuis L. Lee , Taddio Anna , Kerr Elizabeth N. , Kelly Andrea , MacKeigan Linda
Published: September 2006

Study Objective. To develop and validate an instrument to assess nausea intensity in children aged 4–18 years.

Design. Prospective, descriptive study.

Setting. Tertiary‐quaternary, university‐affiliated pediatric hospital.

Patients. Four pediatric inpatient groups (177 patients): group 1 (107), those receiving cancer chemotherapy; group 2 (24), those receiving cancer chemotherapy before hematopoietic stem cell transplantation; group 3 (23), those with cancer who were not receiving cancer chemotherapy; and group 4 (23), those without cancer.

Intervention. We developed a scale with a standard script for administration, the Pediatric Nausea Assessment Tool (PeNAT). Revisions were made after face validity testing with clinicians and parents, and pilot testing with 15 inpatients undergoing chemotherapy.

Measurements and Main Results. The PeNAT scores were obtained 4–24 hours after chemotherapy in groups 1 and 2. Dietary intake scores and number of emetic episodes were recorded for the 4 hours before PeNAT administration for all patients in group 2 and 36 patients in group 1. Parents of a subset of patients made an independent assessment of their child's nausea and pain intensities immediately before PeNAT administration. Reliability was evaluated in groups 1 and 2 by correlating the first and second (obtained 1 hr after the first) PeNAT scores. Construct validity was evaluated by comparing PeNAT scores in groups 1–4. Criterion‐related validity was evaluated by correlating PeNAT scores with emetic episodes and dietary intake. Convergent and discriminant validity were evaluated by correlating PeNAT scores with parental assessments of nausea and pain. Significant differences in PeNAT scores were noted among the study groups (p=0.035). Moderate correlation was noted between the first and second PeNAT scores (Spearman ρ = 0.649). The PeNAT scores correlated modestly with emetic episodes (Spearman ρ = 0.322) but not with dietary intake (Spearman ρ = −0.217). Children's PeNAT scores correlated moderately with their parents' assessment of nausea (Spearman ρ = 0.442), whereas little correlation was seen between children's PeNAT scores and parents' assessment of pain (Spearman ρ = 0.167).

Conclusion. The PeNAT is a new instrument that can be used by children to assess nausea intensity.
Limited Sampling Strategy for Predicting Area Under the Concentration‐Time Curve of Mycophenolic Acid in Adult Lung Transplant Recipients
Authors: Ting Lillian S. L. , Partovi Nilufar , Levy Robert D. , Riggs K. Wayne , Ensom Mary H. H.
Published: September 2006

Study Objective. To develop limited sampling strategies for estimation of mycophenolic acid exposure (by determining area under the concentration‐time curve [AUC]) in lung transplant recipients by using sampling times within 2 hours after drug administration and a maximum of three plasma samples.

Design. Prospective, open‐label clinical study.

Setting. Lung transplant clinic in Vancouver, British Columbia, Canada.

Patients. Nineteen adult (mean age 48.3 yrs) lung transplant recipients who were receiving mycophenolate mofetil therapy along with cyclosporine (9 patients) or tacrolimus (10 patients).

Intervention. Eleven blood samples were collected from each of the 19 patients over 12 hours: immediately before (0 hr) and 0.3, 0.6, 1, 1.5, 2, 4, 6, 8, 10, and 12 hours after administration of mycophenolate mofetil.

Measurements and Main Results. Mycophenolic acid levels in plasma were determined by a high‐performance liquid chromatography–ultraviolet detection method. The 19 patients were randomly divided into index (10 patients) and validation (9 patients) groups. Limited sampling strategies were developed with multiple regression analysis by using data from the index group. Data from the validation group were used to test each strategy. Bias and precision of each limited sampling strategy were determined by calculating the mean prediction error and the root mean square error, respectively. The correlation between AUC and single concentrations was generally poor (r2= 0.18–0.73). Two single‐concentration strategies, eight two‐concentration strategies, and eight three‐concentration strategies matched our criteria. However, the best overall limited sampling strategies (and their predictive performance) were the following: log AUC = 0.241 log C0+ 0.406 log C2+ 1.140 (bias −5.82%, precision 5.97%, r2= 0.828) and log AUC = 0.202 log C0+ 0.411 log C1.5+ 1.09 (bias −5.71%, precision 6.94%, r2= 0.791), where Cxis mycophenolic acid concentration at time x hours.

Conclusion. Two‐concentration limited sampling strategies provided minimally biased and highly precise estimation of mycophenolic acid AUC in lung transplant recipients. These optimal and most clinically feasible limited sampling strategies are based collectively on the number of blood samples required, r2value, bias, and precision.
Electrocardiographic and Blood Pressure Effects of the Ephedra‐Containing TrimSpa Thermogenic Herbal Compound in Healthy Volunteers
Authors: Caron Michael F. , Dore David D. , Min Bokyung , Kluger Jeffrey , Boguk Irena , White C. Michael
Published: September 2006

Study Objective. To determine the effect of an ephedra‐containing thermogenic herbal compound (TrimSpa) on rate‐corrected QT (QTc) interval duration and systolic blood pressure.

Design. Randomized, double‐blind, placebo‐controlled, crossover, intent‐to‐treat study.

Setting. Student laboratory at a college of pharmacy.

Subjects. Thirteen healthy volunteers (eight men, five women).

Intervention. Participants were given TrimSpa, which contains more than 30 ingredients including ephedra 15 mg and caffeine 60 mg, or matching placebo 3 times/day for 7 days in a crossover fashion with a 7‐day washout period between treatments.

Measurements and Main Results. Each subject's QTc interval and systolic blood pressure were measured on days 1, 4, and 7. These measurements were performed immediately before study drug ingestion (baseline) and 0.5, 1, and 3 hours after ingestion. No differences in these variables were found between the TrimSpa and placebo groups. In one subject taking TrimSpa, the QTc interval increased 96 msec from baseline, more than double the largest increase in the placebo group.

Conclusion. Standard doses of TrimSpa did not induce changes in subjects' QTc intervals or systolic blood pressures. However, because the QTc interval dramatically changed in one subject taking TrimSpa, a large study is needed to determine if the effect is an artifact or if the subject represents a subset of people for whom the drug may pose a risk.
Effect of Quercetin on the Plasma and Intracellular Concentrations of Saquinavir in Healthy Adults
Authors: DiCenzo Robert , Frerichs Valerie , Larppanichpoonphol Panupong , Predko Lisa , Chen Amy , Reichman Richard , Morris Marilyn
Published: September 2006

Study Objectives. To determine if quercetin, a bioflavonoid that inhibits p‐glycoprotein, alters plasma saquinavir concentrations, and to explore the potential influence on intracellular concentrations.

Design. Prospective pharmacokinetic analysis.

Setting. University‐affiliated general clinical research center.

Subjects. Ten healthy adults (four women, six men) with a mean ± SD age of 30.7 ± 9.4 years.

Intervention. All subjects received saquinavir 1200 mg 3 times/day with food on days 1–11 and quercetin 500 mg 3 times/day with food on days 4–11.

Measurements and Main Results. On days 4 and 11, nine blood samples and four peripheral blood mononuclear cell samples were drawn during a steady‐state dosing interval. Pharmacokinetic parameters were calculated by using standard noncompartmental techniques. Plasma saquinavir concentrations were similar regardless of quercetin administration. Geometric mean ratios for the area under the concentration‐time curve during an 8‐hour dosing interval (AUC0–8), maximum concentration in the dosing interval, and minimum concentration in the dosing interval were 0.99 (95% confidence interval [CI] 0.65–1.50), 0.99 (95% CI 0.64–1.54), and 1.06 (95% CI 0.68–1.67), respectively. Intracellular saquinavir concentrations displayed substantial intra‐ and intersubject variability, which limited the ability to determine the influence of quercetin coadministration (geometric mean ratio for AUC0–8= 0.51 [95% CI 0.14–1.95], six patients).

Conclusion. Quercetin coadministration did not influence plasma saquinavir concentrations. Because of substantial inter‐ and intrasubject variability, more study is necessary to determine if saquinavir intracellular concentrations are altered by coadministration of quercetin.