bluuebunny/crossref_metadata_2025 huggingface dataset:
Changes in Upper Extremity Position Cause Migration of Peripherally Inserted Central Catheters in Neonates
Authors: Nadroo Ali M. , Glass Ronald B. , Lin Jing , Green Robert S. , Holzman Ian R.
Published: August 2004

Objective. The migration of peripherally inserted central catheters (PICCs) from the superior or inferior vena cava into the right atrium can pose a significant risk of lethal pericardial effusion and tamponade secondary to myocardial perforation. Arm movement has been reported to cause displacement of the catheter tip toward the heart and lead to ventricular tachycardia in adults. The objective of this study was to investigate whether adduction or abduction at the shoulder and flexion or extension at the elbow affect the position of PICCs placed via upper limb veins. We also hypothesized that arm movements can be used to reposition malpositioned catheters.

Methods. A total of 280 radiographs of 60 neonates with PICCs inserted via upper limb veins from July 2000 through June 2001 were reviewed. Differences in catheter tip position as a result of abduction versus adduction at the shoulder, flexion versus extension at the elbow, and combination changes in arm posture were determined by measurements in paired radiographs. Correction of malpositioned catheters was attempted in 10 patients by using arm movements without any alterations at the site of insertion.

Results. Arm movements were associated with significant displacement of catheters. Catheters that were placed via the basilic or axillary vein migrated toward the heart with adduction of the arm, whereas those that were placed via the cephalic vein moved away from the heart with adduction. Flexion of the elbow displaced catheters that were placed in the basilic or cephalic vein below the elbow toward the heart but did not have any effect on catheters that were placed via the axillary vein. For catheters that were placed in the basilic vein, simultaneous shoulder adduction and elbow flexion caused the greatest movement toward the heart (15.11 ± 1.22 mm). We were able to reposition correctly inappropriately placed catheters in 9 of 10 patients by using arm movements.

Conclusions. Arm movements significantly affect the position of the tip of the PICCs. Prevention of catheter migration into the right atrium requires radiographic determination of vein of insertion and monitoring of catheter tip position with upper extremity in position of maximum inward movement of catheter for that vein. Arm movements can be used to correct the malpositioned catheters.
Recurrent Nursemaid’s Elbow (Annular Ligament Displacement) Treatment Via Telephone
Authors: Kaplan Robert E. , Lillis Kathleen A.
Published: August 2004

Annular ligament displacement (ALD)— also termed radial head subluxation, nursemaid’s elbow, or pulled elbow—can be successfully diagnosed and treated over the telephone by properly trained medical professionals instructing nonmedical caretakers. Two case reports of successful ALD reduction via telephone are described. The pathology of ALD and techniques for its treatment are reviewed, and guidelines are given. The rationale for the introduction of the new term annular ligament displacement as well as areas for additional investigation are discussed. To our knowledge, this is the first published account of ALD reduction via telephone.
Assessment of a Transcutaneous Device in the Evaluation of Neonatal Hyperbilirubinemia in a Primarily Hispanic Population
Authors: Engle William D. , Jackson Gregory L. , Sendelbach Dorothy , Manning Denise , Frawley William H.
Published: August 2004

Objective. To compare estimates of serum bilirubin as determined by a transcutaneous device (BiliChek [BC]) with laboratory-measured total serum bilirubin (TSB) in a predominately Hispanic population in which a significant number of TSB values ≥15 mg/dL was anticipated.

Methods. A total of 248 Hispanic and 56 non-Hispanic neonates were studied. Transcutaneous measurements were performed by 1 investigator within 30 minutes of blood sampling for TSB; TSB was determined in a large clinical laboratory using the diazo Jendrassik-Grof with blank method. Agreement between BC and TSB determinations was assessed using Bland-Altman plots and the Bradley-Blackwood test. Interdevice comparisons were made among the BC devices. Predictive indices for TSB >10 mg/dL and >15 mg/dL were determined using various BC cutoff values.

Results. TSB was ≥15 mg/dL in 31% of the Hispanic neonates. BC generally tended to underestimate TSB determinations, and this trend was more pronounced when TSB was >10 mg/dL. Very high sensitivities were observed only when relatively low BC cutoff values were used to predict TSB >10 mg/dL or >15 mg/L. Relatively small numbers of infants had BC values in these low ranges.

Conclusions. The tendency of BC to underestimate TSB limits its usefulness in neonates with relatively high TSB. In this population, most infants would have required additional evaluation to ensure that TSB was not >10 mg/dL or >15 mg/dL. It seems that the discrepancy between this study and previous studies of BC is related to our relatively large number of TSB values ≥15 mg/dL.
Health Care Services Utilization in Children With Obstructive Sleep Apnea Syndrome
Authors: Reuveni Haim , Simon Tzahit , Tal Asher , Elhayany Asher , Tarasiuk Ariel
Published: August 2004

Objective. Little is known about the effects of obstructive sleep apnea syndrome (OSAS) on utilization of health care services in children. The present study compares medical service utilization by children with OSAS with that of healthy children.

Methods. A cross-sectional study of 287 consecutively recruited children (1–18 years) with OSAS and no concomitant diseases and a control group matched by age, gender, and geographic location was conducted at the Clalit Health Care Services clinic in the southern region of Israel. Children in the study group underwent nocturnal polysomnography (PSG) studies. The control group (N = 1149) was randomly selected from the Clalit Health Care Services database. PSG was performed for the OSAS patients. Indices of health care utilization 1 year before the PSG study were analyzed.

Results. A 226% increase in health care utilization was noted among children with OSAS. Children up to 5 years of age consumed more health care resources than children over 5 years. Children with OSAS consumed more health care services than the control group at all ages. The leading components of this high cost are utilization of more hospital days, drugs, and visits to the emergency department. The severity of the OSAS correlates directly to total annual costs and independently to age (β = 0.19).

Conclusions. Children with OSAS are heavy consumers of health care services 1 year before any specific evaluation and treatment for apnea. Early diagnosis and intervention may be cost-effective.
Bedside Diagnosis of Influenzavirus Infections in Hospitalized Children
Authors: Poehling Katherine A. , Griffin Marie R. , Dittus Robert S. , Tang Yi-Wei , Holland Kathy , Li Haijing , Edwards Kathryn M.
Published: August 2004

Objective. For preventing nosocomial influenza infections and to facilitate prompt antiviral therapy, an accessible, rapid diagnostic method for influenzavirus is needed. We evaluated the performance of a lateral-flow immunoassay (QuickVue Influenza Test) completed at the bedside of hospitalized children during the influenza season.

Methods. All children who were evaluated at a large teaching hospital during the 1999 to 2000 influenza season were eligible if they were 1) younger than 19 years and hospitalized with respiratory symptoms or 2) younger than 3 years and hospitalized with fever. Each study child had 2 nasal swabs obtained—1 for influenzavirus culture and polymerase chain reaction (PCR) and the other for the QuickVue Influenza Test. The performance of the rapid diagnostic test was compared with the results of culture or PCR for influenza A or B.

Results. Of 303 eligible children, 233 (77%) were enrolled. In this population, 19 children had culture- and/or PCR-confirmed influenza A infection, prevalence of 8%. The QuickVue Influenza Test had a sensitivity of 74%, specificity of 98%, positive predictive value of 74%, and negative predictive value of 98%.

Conclusions. Among children hospitalized with fever/respiratory symptoms during the influenza season, negative bedside QuickVue Influenza Tests indicated very low likelihood of influenza infection, whereas positive tests greatly increased the probability of influenza-associated illness.
Forced Use Treatment of Childhood Hemiparesis
Authors: Willis John K. , Morello Ann , Davie Anita , Rice Janet C. , Bennett James T.
Published: August 2004

Objective. Forced use, or constraint-induced, movement therapy has shown some efficacy in the rehabilitation of adults with chronic hemiparesis as a result of stroke. We used restraint of the unimpaired arm to ascertain whether this would improve function of the paretic arm in children with chronic (>1 year) hemiparesis.

Methods. Twelve hemiparetic treatment children (age 1–8 years) received a plaster cast on the unimpaired arm for 1 month; 13 hemiparetic control children did not. Peabody Developmental Motor Scales (PDMS) were performed on all treatment and control children immediately before and after casting and again 6 months later when controls crossed over to receive casts. Thus, PDMS were performed at entry, then 1 month, 6 months, and 7 months after entry. Any noted change in functional ability was also elicited by parental report. The frequency of visits to physical and occupational therapy was recorded.

Results. The 12 treatment (casted) children improved 12.6 PDMS points after 1 month of casting; the 13 control children improved 2.5 points. Improved PDMS scores persisted 6 months later when 7 treatment children returned. Similar results were obtained in the crossover when 10 control children received casts. Parental report corroborated improvement in casted children (22 of 22 parents) and its persistence at follow-up (21 of 22 parents). Receiving ongoing physical/occupational therapy did not seem to account for these results: control children received more (2.1 visits/wk) than treatment children (1.4 visits/wk).

Conclusions. Forced use can be an effective rehabilitation technique in children with chronic hemiparesis.
Pagers Combined With Telephones Improve Successful Follow-up From a Pediatric Emergency Department
Authors: Kim In K. , Lanni Karen A. , Collazo Edgar , Gracely Ed J. , Belfer Robert
Published: August 2004

Objective. To determine whether there is a significant difference in initial successful contact when attempting follow-up of patients discharged from a pediatric emergency department (ED) using either pagers or the telephone. In addition, to evaluate whether the combination of both pager and telephone follow-up is more successful than telephone follow-up alone when confined to a 2-hour period.

Design and Setting. A prospective comparison of intervention and control groups taken from convenience samples of patients seen in an ED of an urban, tertiary care children’s hospital.

Participants. One hundred eighty-five patients whose families had access to both a pager and a telephone (intervention group) and 112 patients whose families had access to only a telephone (control group) were enrolled.

Intervention. Before discharging the patient from the ED, the investigators verified a pager number and/or a best contact telephone number for a follow-up telephone call. Participants were divided into 2 groups. The intervention group consisted of caretakers with both pagers and telephones. The control group consisted of caretakers with only telephones. On even calendar days after ED visits, intervention group caretakers were paged initially from 11:00 am to 11:59 am. On odd calendar days, intervention group caretakers were telephoned initially from 11:00 am to 11:59 am. Successful contact was defined as communication with a family member or guardian over the age of 18. If the caretaker spoke only Spanish, a translator was used. In a crossover design with the intervention group, if contact was unsuccessful after 1 hour, the alternative mode of communication was used at noon. Control group caretakers were telephoned from 11:00 am to 11:59 am. If telephone contact was unsuccessful, they were called again 1 hour later.

Results. Two hundred forty-six (36%) of 685 of the convenience sample of caretakers had access to both a pager and a telephone. Fifty-two (55%) of 94 intervention caretakers were contacted initially using pagers versus 47 (52%) of 91 intervention caretakers contacted initially by telephones. Overall successful contact of intervention caretakers (telephones and pagers) was 145 (78%) of 185 when confined to a 2-hour time period. In contrast, overall successful contact of control caretakers was 68 (61%) of 112 when confined to a 2-hour time period. Successful contact was greater with the intervention caretakers than with control caretakers (78% vs 61%).

Conclusions. No significant difference in successful contact was seen whether paged or telephoned initially. The combination of both pagers and telephone follow-up was more successful than telephone follow-up alone when confined between 11:00 am to 1:00 pm.
Absolute Band Counts in Febrile Infants: Know Your Laboratory
Authors: Luxmore Brett , Powell Keith R. , Díaz Sebastián R. , Novak Robert W.
Published: August 2004

It was the impression of 1 of the authors that band counts in febrile infants ≤60 days of age were much higher as reported from the clinical laboratory at Children’s Hospital Medical Center of Akron, Ohio, than they had been at Strong Memorial Hospital in Rochester, New York. Absolute band counts (ABC) from 119 febrile infants ≤60 days of age seen in the emergency department of Children’s Hospital Medical Center of Akron for whom blood culture results were known were obtained retrospectively and compared with results from a prospective study conducted in Rochester. In Akron, 45% of the infants had elevated band counts and 16% had no other risk factor for serious bacterial infection compared with 5.9% and 1.4%, respectively, in Rochester. The ABC can vary widely from laboratory to laboratory. The clinician must use caution when using the ABC as a criterion for identifying infants at low risk for serious bacterial infection.
Relationship of Adherence to Pediatric Asthma Morbidity Among Inner-City Children
Authors: Bauman Laurie J. , Wright Elizabeth , Leickly Frederick E. , Crain Ellen , Kruszon-Moran Deanna , Wade Shari L. , Visness Cynthia M.
Published: August 2004

Objectives. Morbidity from asthma among children is one of the most important US health concerns. This study examines the relationship of baseline nonadherence to subsequent asthma morbidity among inner-city children.

Methods. A multisite, prospective, longitudinal panel study was conducted of 1199 children who were aged 4 to 9 years and had asthma and their caregivers, most of whom were parents, in emergency departments and clinics at 8 research centers in 7 US metropolitan inner-city areas. Nine morbidity indicators were collected at 3, 6, and 9 months after baseline, including hospitalizations, unscheduled visits, days of wheeze/cough, and days of reduced activities.

Results. Children whose caregivers scored high on a new measure, Admitted Nonadherence, experienced significantly worse morbidity on 8 of the 9 measures. Children who scored high on a new Risk for Nonadherence measure experienced significantly worse morbidity on all 9 morbidity measures. Multiple and logistic regressions found that the adherence measures had independent significant effects on morbidity. Combining the measures improved estimates of morbidity: children whose caregivers were poor on either adherence measure had worse morbidity than those with good adherence on both, eg, rate of hospitalization was twice as high, they missed more than twice as much school, had poorer overall functioning, and experienced more days of wheezing and more restricted days of activity.

Conclusions. Risk for Nonadherence and Admitted Nonadherence independently and jointly predicted subsequent asthma morbidity. Targeting risks for nonadherence may be an effective intervention strategy. Most risks can be controlled by physicians through reducing the complexity of asthma regimens, communicating effectively with caregivers about medication use, and correcting family misconceptions about asthma medication side effects.
Factors That Influence the Willingness of Private Primary Care Pediatricians to Accept More Medicaid Patients
Authors: Berman Steve , Dolins Judith , Tang Suk-fong , Yudkowsky Beth
Published: August 2004

Objective. State Medicaid programs are obligated by federal law to ensure that enrolled children have access to care and services to the same extent as other children in the same geographic area. Because most children in the United States receive health care from private primary care physicians, participation by private, office-based primary care pediatricians is critical to meeting this equal access obligation. The objective of this study was to document variations in Medicaid participation of private office-based primary care pediatricians across states and to examine the effects of payment levels, prevalence of capitated Medicaid payment, and paperwork concerns on participation.

Methods. Survey data collected from 3773 primary care pediatricians who practice in private office-based settings were analyzed with Medicaid physician payment data from other sources. Univariate analyses and a multiple regression were used to examine the effects of payment level, prevalence of capitated Medicaid payment, and paperwork concerns on private primary care pediatricians’ participation in state Medicaid programs.

Results. Results revealed substantial state-to-state variation in respondents’ participation in Medicaid. Univariate analyses found that participation increased with state Medicaid payment levels but decreased as the proportion of Medicaid enrollees with primary care capitated payments rose and as paperwork concerns increased. With physician workforce held constant, a regression analysis showed that pediatrician participation in Medicaid increased significantly with Medicaid payment but decreased as the proportion of capitated Medicaid patients increased and as paperwork concerns rose.

Conclusions. This study found that low payment, capitation, and paperwork concerns all relate to low Medicaid participation by primary care office-based pediatricians. It behooves state policy makers to address these 3 factors to ensure sufficient primary care physician capacity to serve appropriately children who are enrolled in state Medicaid programs.
Survey of Adverse Drug Reactions on a Pediatric Ward: A Strategy for Early and Detailed Detection
Authors: Weiss Jutta , Krebs Sabine , Hoffmann Claudia , Werner Ulrike , Neubert Antje , Brune Kay , Rascher Wolfgang
Published: August 2004

Objective. Adverse drug reactions (ADRs) occur frequently in children. However, the exact incidence of ADRs is unknown. Therefore, we studied ADRs in 1 ward and assessed whether a general approach, eg, by a computerized monitoring system, to detect ADRs in children is feasible and likely to yield a higher rate of early detected ADRs. The aim was to assess the usefulness of a computerized monitoring system before implementing costly adaptations.

Methods. An 8-month prospective study was conducted at a 10-bed pediatric isolation ward of the University Hospital. Charts were reviewed once weekly by a pharmacoepidemiological team. Clinical signs as well as laboratory changes were documented and assessed. Algorithms were used to assess the probability and severity of each detected event.

Results. All 214 patients admitted were enrolled in the study. A total of 68 ADRs were detected in 46 of 214 patients by the pharmacoepidemiological team. Thirty-four ADRs (50%) were detected by the staff physician, and 27 (40%) were detected primarily by analyzing laboratory parameters. Antibiotics-associated ADRs (50%) predominated, followed by glucocorticoids (16%), tuberculostatic (4%), and immunosuppressive agents (4%). In 5 cases, an ADR was responsible for the prolongation of hospital stay, and in 4 children, the ADR was responsible for hospitalization.

Conclusions. The detection rate of ADRs would almost be doubled by a computerized monitoring system analyzing laboratory data. Implementation of a computer monitor system that automatically generates laboratory signals may help to identify ADRs in children, and to reduce morbidity and hospital stay, as well as costs.
The Effect of a Single Remote Course Versus Weekly Courses of Antenatal Corticosteroids on Functional Residual Capacity in Preterm Infants: A Randomized Trial
Authors: McEvoy Cindy , Bowling Susan , Williamson Kathleen , Lozano David , Tolaymat Lama , Izquierdo Luis , Maher James , Helfgott Andrew
Published: August 2004

Objective. There are no randomized data on the effect of repeat courses of corticosteroids during pregnancy on newborn pulmonary function. Our objective was to compare the effect of a single remote course of antenatal steroids (AS) with weekly courses of AS on functional residual capacity (FRC) and respiratory compliance in preterm infants.

Study Design/Methods. Pregnant women 25 to 33 weeks’ gestation, who remained undelivered 1 week after their first course of antenatal corticosteroids (two 12-mg doses of betamethasone) were randomized to weekly courses of corticosteroids versus weekly placebo until delivery or 34 weeks’ gestation. FRC was measured with the nitrogen washout technique and respiratory compliance with the single breath occlusion technique within 48 hours of life.

Results. Thirty-seven infants (mean gestational age at delivery ∼32.5 weeks) were studied. Maternal and infant demographics were similar. There was no significant difference in FRC (28.5 vs 27.5 mL/kg) or respiratory compliance between the infants who received a single remote course of antenatal corticosteroids and those who received weekly courses of corticosteroids until delivery. There was no significant difference in admission head circumference or birth weights between the groups.

Conclusions. Our results demonstrate that weekly repetitive courses of AS do not significantly increase FRC or respiratory compliance in preterm infants when compared with a single remote course of steroids given at a mean gestational age of 29 weeks.
Clinical Management of Infants With Hypoplastic Left Heart Syndrome in the United States, 1988–1997
Authors: Chang Ruey-Kang R. , Chen Alex Y. , Klitzner Thomas S.
Published: August 2004

Objectives. To evaluate changes in the clinical management of infants with hypoplastic left heart syndrome (HLHS) over a 10-year period.

Background. Orthotopic heart transplantation (OHT) and the Norwood procedure have emerged as the treatment options for HLHS over the last 2 decades.

Methods. We used 1988–1997 hospital discharge data from the National Inpatient Sample dataset. Patients ≤30 days of age with a principal diagnosis of HLHS were identified. Clinical management included the Norwood procedure, OHT, in-hospital death without surgery, discharge home without surgery, and transfer to another hospital. Multivariate logistic regression was used to evaluate variables associated with the choice of management.

Results. There were 1986 cases of HLHS with 812 in-hospital deaths, yielding a mortality rate 40.9%. The in-hospital mortality rate decreased from 54.4% in 1988 to 38.1% in 1997. The proportion of patients treated with the Norwood procedure increased from 8% in 1988 to 34% in 1997. The proportion of patients who died in the hospital without surgery decreased over time while the percentage discharged from the hospital without surgery or transferred to another hospital remained relatively unchanged. The in-hospital mortality rate was significantly lower in the OHT group compared with the Norwood group (26.2% vs 46.0%). We found no differences in gender, race, type of insurance, or home income between patients treated with the Norwood procedure compared with those who received comfort care. Patients from a later era, in the South, and in teaching hospitals were more likely to undergo the Norwood procedure.

Conclusions. Between 1988 and 1997, the proportion of infants with HLHS treated with the Norwood procedure increased while the use of comfort care decreased. Gender, race/ethnicity, type of medical insurance, and home income did not correlate with treatment choices.
When Children Die: A Seminar Series for Pediatric Residents
Authors: Bagatell Rochelle , Meyer Robyn , Herron Sandra , Berger Alice , Villar Rodrigo
Published: August 2004

Objective. Our goals were to assist residents in acquiring skills needed to care for children at the end of life and to increase their comfort level regarding critical aspects of caring for dying children.

Methods. We designed and implemented a 6-part seminar series for pediatric residents in their postgraduate year-2 at the University of Arizona Pediatric Residency Program. The series consisted of small group sessions regarding medical and legal issues facing physicians at the time of a pediatric patient’s death, symptom management in dying children, approaches to limitation of care and discussion of impending death of a child, cultural and developmental factors impacting on the care of children at the end of life, parent and sibling bereavement after the death of a child, and physician’s personal responses to the death of pediatric patients. The sessions were conducted on weekday evenings away from patient care settings and included input from community-based individuals as well as academic pediatric subspecialists. To promote active discussion, size was limited to 12 participants. Pretests and posttests were used to evaluate the success of this program. Residents’ level of comfort with important issues in end-of-life care was measured using a 5-point Likert scale.

Results. Although most of the residents taking part in the seminar series had previously participated in discussions of limitation of care of a child and/or had performed advanced life support measures on a child, few had any previous training in end-of-life care. Responses of the 8 participants who completed both the pretests and posttests were evaluated for assessment of changes in comfort level in areas pertinent to end-of-life care. We found that on completion of this program, residents were significantly more comfortable with logistic issues and symptom management, discussing death and limitation of medical care with families, discussing end-of-life care with colleagues and families, handling conflicts within the health care team, working with families of varying ethnic backgrounds, guiding developmentally appropriate discussions of death, identifying and seeking out advice from a role model regarding end-of-life care, and coping with their own responses to a child’s death. Costs of this seminar series were minimal.

Conclusions. An inexpensive, discussion-based seminar series successfully provided pediatric residents with basic information regarding end-of-life care and significantly increased their confidence as clinicians caring for seriously ill and dying children.
Small Thymus at Birth: A Predictive Radiographic Sign of Bronchopulmonary Dysplasia
Authors: De Felice Claudio , Latini Giuseppe , Del Vecchio Antonio , Toti Paolo , Bagnoli Franco , Petraglia Felice
Published: August 2004

Objective. Emerging evidence indicates a relationship between bronchopulmonary dysplasia (BPD) and chorioamnionitis. Recent data provide evidence of an acute thymic involution in very low birth weight (VLBW) preterm infants and fetuses with histologic chorioamnionitis. We tested the hypothesis that a small thymus detected at birth on the routine chest radiograph is a predictor of BPD in VLBW infants.

Methods. A prospective study was conducted on 400 VLBW preterm infants who survived >4 weeks (mean gestational age: 27.5 weeks [range: 24–30]; mean birth weight: 1010 g [range: 450-1450]). Thymic size was measured on routine chest radiographs taken in the first 6 hours after birth and expressed as the ratio between the transverse diameter of the cardiothymic image at the level of the carina and that of the thorax (CT/T). The accuracy of CT/T for identifying infants with BPD was tested using receiver operating characteristic curve analyses and multivariate logistic regression.

Results. Fifty-one VLBW infants (12.7%) subsequently developed BPD. A small thymus (CT/T <0.28) was observed in 94.1% of the infants with BPD versus 2.9% of the infants without BPD. A small thymus at birth identified infants with BPD with 94.1% sensitivity and 98.3% specificity (odds ratio: 17.8; 95% confidence interval: 5.7–55.4).

Conclusions. A small thymus at birth on the standard chest radiograph can accurately identify VLBW infants who subsequently develop BPD.
Vaccination Coverage of Foreign-Born Children 19 to 35 Months of Age: Findings From the National Immunization Survey, 1999–2000
Authors: Strine Tara W. , Barker Lawrence E. , Mokdad Ali H. , Luman Elizabeth T. , Sutter Roland W. , Chu Susan Y.
Published: August 2004

Objective. To compare coverage estimates of foreign-born children 19 to 35 months old with those of US-born children of the same age group.

Methods. The National Immunization Survey is a multistage, random-digit dialing survey designed to measure vaccination coverage estimates of US children 19 to 35 months old. Data from 1999–2000 were combined to permit comparison of vaccination coverage among foreign- and US-born children.

Results. Foreign-born and US-born children 19 to 35 months of age had comparable 3:3:1 series coverage (3 or more doses of diphtheria and tetanus toxoids and pertussis vaccine [DTP/DTaP/DT], 3 or more doses of poliovirus vaccine, and 1 or more doses of measles-containing vaccine), the standard in most countries. However, coverage for a US standard, 4:3:1:3 series (4 or more doses of DTP/DTaP/DT, 3 or more doses of poliovirus vaccine, 1 or more doses of measles-containing vaccine, and an adequate number of Haemophlius influenzae type b [Hib] doses based on age at first dose) was lower among foreign-born children because of markedly lower Hib cover and marginally lower DTP/DTaP/DT coverage. In addition, hepatitis B coverage was markedly lower in foreign-born children.

Conclusion. Lower vaccination coverage among foreign-born children, especially against Hib and hepatitis B, is of concern because foreign-born children often live in households and communities characterized by more intense exposure to these diseases, and many originate from countries with much higher prevalence rates of these diseases than the United States. The differences in Hib and hepatitis B coverage suggest a need for increased culturally competent public health immunization interventions to increase coverage among foreign-born children.
Underascertainment of Child Maltreatment Fatalities by Death Certificates, 1990–1998
Authors: Crume Tessa L. , DiGuiseppi Carolyn , Byers Tim , Sirotnak Andrew P. , Garrett Carol J.
Published: August 2004

Objective. Child fatality review teams have emerged across the United States in the past decade to address the concern that systems of child protection, law enforcement, criminal justice, and medicine do not adequately assess the circumstances surrounding child fatality as a result of maltreatment.

Methods. We compared data collected by a multidisciplinary child fatality review team with vital records for all children who were aged birth to 16 years and died in Colorado between January 1, 1990, and December 1, 1998. Odds ratios and 95% confidence intervals for ascertainment by the death certificate were estimated using logistic regression.

Results. Only half of the children who died as a result of maltreatment had death certificates that were coded consistently with maltreatment. Black race and female gender were associated with higher ascertainment, whereas death in a rural county was associated with lower ascertainment. Deaths resulting from violent causes (eg, shaking, blunt force trauma, striking) were more likely to be ascertained than those that involved acts of omission (eg, neglect and abandonment, drowning, fire). The most common perpetrators of maltreatment were parents. However, maltreatment by an unrelated perpetrator was 8.71 times (95% confidence interval: 3.52–21.55) more likely to be ascertained than maltreatment by a parent.

Conclusions. The degree of underascertainment found in this study is of concern because most national estimates of child maltreatment fatality in the United States are derived from coding on death certificates. In addition, the patterns recognized in this study raise concern about systematic underascertainment that may affect children of specific sociodemographic groups.
Persistent Sterile Leukocyturia Is Associated With Impaired Renal Function in Human Immunodeficiency Virus Type 1-Infected Children Treated With Indinavir
Authors: van Rossum Annemarie M. C. , Dieleman Jeanne P. , Fraaij Pieter L. A. , Cransberg Karlien , Hartwig Nico G. , Burger David M. , Gyssens Inge C. , de Groot Ronald
Published: August 2004

Background. Prolonged administration of indinavir is associated with the occurrence of a variety of renal complications in adults. These well-documented side effects have restricted the use of this potent protease inhibitor in children.

Design. A prospective study to monitor indinavir-related nephrotoxicity in a cohort of 30 human immunodeficiency virus type 1-infected children treated with indinavir.

Methods. Urinary pH, albumin, creatinine, the presence of erythrocytes, leukocytes, bacteria and crystals, and culture were analyzed every 3 months for 96 weeks. Serum creatinine levels were routinely determined at the same time points. Steady-state pharmacokinetics of indinavir were done at week 4 after the initiation of indinavir.

Results. The cumulative incidence of persistent sterile leukocyturia (≥75 cells/μL in at least 2 consecutive visits) after 96 weeks was 53%. Persistent sterile leukocyturia was frequently associated with a mild increase in the urine albumin/creatinine ratio and by microscopic hematuria. The cumulative incidence of serum creatinine levels >50% above normal was 33% after 96 weeks. Children with persistent sterile leukocyturia more frequently had serum creatinine levels of 50% above normal than those children without persistent sterile leukocyturia. In children younger than 5.6 years, persistent sterile leukocyturia was significantly more frequent than in older children. A higher cumulative incidence of persistent leukocyturia was found in children with an area under the curve >19 mg/L*h or a peak serum level of indinavir >12 mg/L. In 4 children, indinavir was discontinued because of nephrotoxicity. Subsequently, the serum creatinine levels decreased, the urine albumin/creatinine ratios returned to zero, and the leukocyturia disappeared within 3 months.

Conclusions. Children treated with indinavir have a high cumulative incidence of persistent sterile leukocyturia. Children with persistent sterile leukocyturia more frequently had an increase in serum creatinine levels of >50% above normal. Younger children have an additional risk for renal complications. The impairment of the renal function in these children occurred in the absence of clinical symptoms of nephrolithiasis. Indinavir-associated nephrotoxicity must be monitored closely, especially in children with risk factors such as persistent sterile leukocyturia, age <5.6 years, an area under the curve of indinavir >19 mg/L*h, and a Cmax >12 mg/L.
Respiratory Syncytial Virus Infection in Navajo and White Mountain Apache Children
Authors: Bockova Jana , O’Brien Katherine L. , Oski Jane , Croll Janne’ , Reid Raymond , Weatherholtz Robert C. , Santosham Mathuram , Karron Ruth A.
Published: August 2004

Objective. The hospitalization rate for bronchiolitis of any cause among US children younger than 1 year is estimated at 31.2 per 1000. No data exist on respiratory syncytial virus (RSV)-specific hospitalization rates among high-risk Native Americans other than Alaska Natives, for whom the incidence of RSV hospitalization was estimated at 150 per 1000 among infants younger than 1 year. We aimed to estimate RSV hospitalization rates among Navajo and White Mountain Apache children younger than 2 years.

Methods. We conducted prospective population-level hospital-based surveillance to determine RSV hospitalization rates among Navajo and White Mountain Apache children younger than 2 years. From 1997 to 2000, all children who were admitted for acute lower respiratory tract infection between October 1 and March 31 had a nasopharyngeal aspirate obtained and tested for RSV by commercial enzyme immunoassay kits. We reviewed charts of children who tested positive for RSV antigen to determine disease severity.

Results. During 3 RSV seasons (1997–2000), 51.3% of 1837 admissions for acute lower respiratory tract infection among children younger than 2 years were attributed to RSV infection. The overall seasonal RSV hospitalization rate among children younger than 2 years was 63.6 per 1000 and 91.3 per 1000 among children younger than 1 year. In a univariate analysis, predictors of severity included age <6 months (relative risk: 6.8; 95% confidence interval: 3.1–17.0).

Conclusions. Navajo and White Mountain Apache children are at high risk for RSV disease requiring hospitalization. A lower threshold for hospitalization or underlying chronic conditions that predispose to severe RSV disease do not seem to explain high RSV hospitalization rates in this population.
Urinary Incontinence in Female Adolescents With Cystic Fibrosis
Authors: Nixon Gillian M. , Glazner Judith A. , Martin Jennifer M. , Sawyer Susan M.
Published: August 2004

Objectives. Urinary incontinence is common in healthy women and occurs with increased frequency in adult women with chronic lung disease, including cystic fibrosis (CF). This study aimed to determine the prevalence, severity, and impact on daily life of urinary incontinence in female adolescents with CF.

Methods. An interviewer-administered questionnaire was conducted with females who were aged 12 years and older and attend the CF Clinic at the Royal Children’s Hospital in Melbourne, Australia.

Results. Fifty-five (96%) of 57 eligible adolescents (age: 12–19 years) participated. Twenty-six (47%) reported ever having been incontinent of urine; 12 (22%) reported daytime incontinence twice a month or more. Median age of onset of incontinence was 13 years (range: 7–16 years). No relationship was seen with age, lung function, body mass index, or menarchal status. Coughing and laughing were the most commonly reported precipitants (affecting 84% and 68%, respectively). Of those with incontinence once a year or more, 42% reported that it sometimes prevented them from doing effective physiotherapy. Social life was affected by incontinence in approximately one third of respondents. Nearly half (42%) of affected adolescents had told no one, and only 2 had discussed the problem with their physician.

Conclusions. Urinary incontinence is common in female adolescents with CF and is not related to illness severity. Urinary incontinence has a negative impact on the performance of chest physiotherapy. Given the lack of adolescent report and knowledge of treatment availability, inquiry about symptoms of urinary incontinence should be part of the routine assessment of female adolescents with CF.
Respiratory Support in Spinal Muscular Atrophy Type I: A Survey of Physician Practices and Attitudes
Authors: Hardart M. Kathleen Moynihan , Burns Jeffrey P. , Truog Robert D.
Published: August 2004

Objective. To determine whether there is variability in the attitudes and practices of physicians regarding treatment of respiratory failure in children with spinal muscular atrophy type I (SMA type I) and, if so, whether this variation is associated with professional training.

Methods. This was a descriptive, cross-sectional survey mailed to a randomly selected subset of the Child Neurology Society, pediatric members of the Society of Critical Care Medicine and to the membership of the Pediatric Interest Section of the American Academy of Physical Medicine and Rehabilitation. A scenario of a child with SMA type I in respiratory distress was followed by questions that explored practices and attitudes regarding mechanical ventilation.

Results. Fifty-seven percent of intensivists (75 of 132), 39% physiatrists (61 of 155), and 34% of neurologists (61 of 155) responded. Specialists differed as to whether they offered and/or recommended respiratory support to patients with SMA type I. Intensivists were less likely to offer and recommend tracheostomy than physiatrists. Intensivists were also significantly less likely than physiatrists to agree with statements supporting the ethical necessity of noninvasive mechanical ventilation (NIMV) and intubation in the setting of an acute respiratory illness, and NIMV and tracheostomy in the setting of chronic respiratory failure. Although parallel differences were found between physiatrists and neurologists regarding their attitudes toward mechanical ventilation, no significant differences were detected between intensivists and neurologists. Finally, physicians who reported that a high percentage of their patients with SMA type I received “comfort care only” also tended to view mechanical ventilation, ie, use of NIMV for chronic respiratory failure, use of intubation for an acute respiratory infection, and use of tracheostomy for chronic respiratory failure as an unreasonable intervention in most circumstances.

Conclusions. We found a wide variation in physician practice regarding the mechanical ventilation of patients with SMA type I. This study suggests a wide variation not only in what is recommended but also in what is actually offered to families of these children. Furthermore, the study suggests that physician training and attitudes affect recommendations regarding mechanical ventilation and ultimately family decision making.
Perinatal Screening for Group B Streptococci: Cost-Benefit Analysis of Rapid Polymerase Chain Reaction
Authors: Haberland Corinna A. , Benitz William E. , Sanders Gillian D. , Pietzsch Jan Benjamin , Yamada Sanae , Nguyen Lan , Garber Alan M.
Published: August 2004

Objective. To evaluate the costs and benefits of a group B streptococci screening strategy using a new, rapid polymerase chain reaction test in a hypothetical cohort of expectant mothers in the United States.

Methods. Design. Cost-benefit analysis using the human capital method. We developed a decision model to analyze the costs and benefits of a hypothetical group B streptococci screening strategy using a new, rapid polymerase chain reaction test as compared with the currently recommended group B streptococci screening guidelines—prenatal culture performed at 35 to 37 weeks or risk-factor-based strategy with subsequent intrapartum treatment of the expectant mothers with antibiotics to prevent early-onset group B streptococcal infections in their infants.

Participants. A hypothetical cohort of pregnant women and their newborns.

Interventions. Screening strategies for group B streptococci using the new polymerase chain reaction technique, the 35- to 37-week culture, or maternal risk factors.

Outcome Measures. Infant infections averted, infant deaths, infant disabilities, costs, and societal benefits of healthy infants.

Results. A screening strategy using the new polymerase chain reaction test generates a net benefit of $7 per birth when compared with the maternal risk-factor strategy. For every 1 million births, 80 700 more women would receive antibiotics, 884 fewer infants would become infected with early-onset group B streptococci, and 23 infants would be saved from death or disability. The polymerase chain reaction-based strategy generates a net benefit of $6 per birth when compared with the 35- to 37-week prenatal culture strategy and results in fewer maternal courses of antibiotics (64 080 per million births), fewer perinatal infections with early-onset group B streptococci (218/million), and a reduction in 6 infant deaths and severe infant disability per million births. The benefits hold over a wide range of assumptions regarding key factors in the analysis.

Conclusions. Although additional clinical trials are needed to establish the accuracy of this new polymerase chain reaction test, initial studies suggest that strategies using this test will be superior to the other 2 strategies. Using the rapid polymerase chain reaction test becomes less attractive as the cost of the test increases. The test’s greatest strengths lie in its ability to identify women and infants at risk at the time of labor, thereby decreasing the number of false-positives and false-negatives seen with the other 2 strategies and allowing for more accurate and effective intrapartum prophylaxis.
Parental Screening for Intimate Partner Violence by Pediatricians and Family Physicians
Authors: Borowsky Iris Wagman , Ireland Marjorie
Published: August 2004

Objective. To ascertain and compare the knowledge, practices, and training needs of pediatricians and family physicians regarding intimate partner violence screening and intervention.

Methods. Surveys were mailed to national random samples of 1350 pediatricians and 650 family physicians evenly divided between senior residents, practitioners completing their residency training within the last 5 years, and practitioners completing their training >5 years ago.

Results. The overall response rate was 37% (41% for pediatricians, 30% for family physicians). Among practicing physicians, only 8% of family physicians and 5% of pediatricians routinely screened a parent for intimate partner violence during well-child and teen visits. Family medicine residents were significantly more likely to routinely screen for intimate partner violence (18%), whereas pediatric residents were not (7%). All groups demonstrated deficits in knowledge of appropriate management of situations of domestic abuse; for example, over 60% of family medicine and 75% of pediatric residents and practitioners agreed with the inappropriate response of always urging a woman to leave her abusive partner immediately. Many physicians indicated a need for more information about domestic violence, ranging from 40% of family medicine residents to 72% of pediatric residents. Residency training and continuing medical education in the prevention of child/adolescent violence and having an office protocol for managing cases involving domestic violence increased the likelihood of parental screening for intimate partner violence.

Conclusions. Few child and adolescent primary care physicians routinely screen parents for intimate partner violence and most need more information on this topic. Residency training and continuing medical education on violence prevention, including screening and intervention skills in intimate partner violence, and office protocols for managing cases of domestic violence could increase screening rates.