bluuebunny/crossref_metadata_2025 huggingface dataset:
Congenital Cutaneous Candidiasis: Clinical Presentation, Pathogenesis, and Management Guidelines
Authors: Darmstadt Gary L. , Dinulos James G. , Miller Zachary
Published: August 2004

We describe a term infant with congenital cutaneous candidiasis (CCC), and review all cases in the English literature that reported birth weight and outcome. Presence of an intrauterine foreign body was a predisposing factor for development of CCC and subsequent preterm birth. The most common presentation of CCC in neonates weighing >1000 g was a generalized eruption of erythematous macules, papules, and/or pustules that sometimes evolved to include vesicles and bullae. Extremely low birth weight, premature neonates weighing <1000 g most often presented with a widespread desquamating and/or erosive dermatitis (10 of 15 [67%]), and were at greater risk for systemic infection with Candidaspp (10 of 15 [67%]) and death (6 of 15 [40%] than those weighing >1000 g (5 of 48 [10%]; 4 of 48 [8%], respectively). Systemic antifungal therapy is recommended for neonates with burn-like dermatitis attributable to Candida spp, or positive blood, urine, and/or cerebrospinal fluid cultures. Systemic treatment also should be considered for all infants with CCC who have respiratory distress in the immediate neonatal period and/or laboratory signs of sepsis such as an elevated leukocyte count with an increase in immature forms or persistent hyperglycemia and glycosuria.
The Pediatrician and Childhood Bereavement
Authors:   Committee on Psychosocial Aspects of Child and Family Health
Published: August 2004

This Policy statement was revised. See https://doi.org/10.1542/peds.2016-2147.

Pediatricians should understand and evaluate children's reactions to the death of a person important to them by using age-appropriate and culturally sensitive guidance while being alert for normal and complicated grief responses. Pediatricians also should advise and assist families in responding to the child's needs. Sharing, family support, and communication have been associated with positive long-term bereavement adjustment.
Prevention and Management of Pain and Stress in the Neonate
Authors:   Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery,   Canadian Paediatric Society, Fetus and Newborn Committee
Published: August 2004

This Policy Statement was revised. See https://doi.org/10.1542/peds.2015-4271.

This statement is intended for health care professionals caring for neonates (preterm to 1 month of age). The objectives of this statement are to:

1.  Increase awareness that neonates experience pain; 2.  Provide a physiological basis for neonatal pain and stress assessment and management by health care professionals; 3.  Make recommendations for reduced exposure of the neonate to noxious stimuli and to minimize associated adverse outcomes; and 4.  Recommend effective and safe interventions that relieve pain and stress.
Fatal Hypermagnesemia in a Child Treated With Megavitamin/Megamineral Therapy
Authors: McGuire John K. , Kulkarni Mona Shah , Baden Harris P.
Published: August 2004

We report a case of fatal hypermagnesemia resulting from the unsupervised use of high doses of magnesium oxide administered as part of a regimen of megavitamin and megamineral therapy to a child with mental retardation, spastic quadriplegia, and seizures. The treatment regimen was given at the recommendation of a dietician working as a private nutritional consultant without the involvement or notification of the child's pediatrician. Hypermagnesemia is an uncommon but serious side effect of the use of magnesium containing compounds. These compounds are widely used as laxatives and dietary supplements, and serious side effects are uncommon when used in appropriate dosages and with adequate supervision.

The use of alternative medical therapies, including megavitamin/megamineral therapy, is widespread. Many patients use alternative medicine or seek care from alternative medicine practitioners without the recommendation or knowledge of their primary physicians. Despite unproved benefit, many alternative therapies may be safe. However, unsupervised use of generally safe treatments can result in serious side effects. This case report serves to illustrate the characteristic pathophysiologic changes of severe hypermagnesemia, an entity rarely seen in pediatric practice, and more importantly, it alerts primary care and subspecialty pediatricians to be aware of and monitor the use of alternative medical therapies in their patients.
The Impact of Dosing Frequency on the Efficacy of 10-Day Penicillin or Amoxicillin Therapy for Streptococcal Tonsillopharyngitis: A Meta-analysis
Authors: Lan Andrew J. , Colford John M. , MD Jr,
Published: August 2004

Objective.

The recommended dosing frequency of oral penicillin for the treatment of acute streptococcal tonsillopharyngitis has long been 3 to 4 times daily. In 1994, treatment guidelines included twice-daily (BID) dosing for the first time, a recommendation that could significantly increase the ease of compliance. This meta-analysis was performed to determine whether overall cure rates differed between BID or once-daily (QD) versus more frequent dosing schedules in the treatment of streptococcal tonsillopharyngitis.

Data Sources.

Candidate studies for this meta-analysis included all clinical trials of therapy for streptococcal tonsillopharyngitis published through August 1998 and identified using Medline, Dissertation Abstracts, conference proceedings, and bibliographies of all retrieved articles.

Study Selection.

A study was eligible for inclusion if it was a randomized clinical trial that compared the efficacies of different dosing frequencies of 10-day penicillin or amoxicillin in the treatment of streptococcal tonsillopharyngitis. Of the 30 articles initially identified, 6 studies met eligibility criteria.

Outcome Measure.

The measure of interest was the difference in proportion cured between the BID or QD dosing group and the comparison group with more frequent dosing.

Results.

The results of this analysis suggest that BID dosing of 10-day penicillin is as efficacious as more frequent dosing regimens in the treatment of streptococcal tonsillopharyngitis. This result also holds true in a subgroup analysis confined to pediatric cases and does not vary with total daily dose of the regimen. QD dosing of penicillin is associated with a cure rate that is 12 percentage points lower than more frequent dosing (95% confidence interval: 3–21). In contrast, this decreased efficacy is not found with QD dosing of amoxicillin.

Conclusions.

This meta-analysis supports current recommendations for BID dosing of penicillin in treating streptococcal tonsillopharyngitis. QD penicillin is associated with decreased efficacy and should not be used. Simplified regimens of amoxicillin of shorter duration or of less frequent dosing should be further investigated.
Evaluation of a Pediatric Hospitalist Service: Impact on Length of Stay and Hospital Charges
Authors: Bellet Paul S. , Whitaker Robert C.
Published: August 2004

Objectives.

Inpatient medical services supervised by pediatric hospitalist physicians are a new development in academic medical centers in the United States. In a large pediatric teaching hospital, we compared length of stay, readmission rates, and hospital charges for children admitted to medical services with and without a hospitalist system of care.

Design.

This retrospective observational study compared a baseline year of a traditional ward service (TS) with a subsequent year of a new hospitalist system of care called the Generalist Inpatient Service (GIS). Data were obtained from the hospital's clinical, demographic, and financial databases and from selected record review. All hospitalizations were at least 24 hours long and did not involve a stay in an intensive care unit.

Results.

The average length of stay was longer for the 627 TS hospitalizations than for the 813 GIS hospitalizations (2.7 ± 2.0 vs 2.4 ± 1.7 days). Total hospital charges were significantly lower on the GIS ($3002 ± $2160 vs $2720 ± $1933) because of lower room and respiratory therapy charges. Three readmissions to the TS and 8 to the GIS occurred within 24 hours of hospital discharge and were, therefore, considered potentially preventable by a longer initial hospital stay.

Conclusions.

In a large pediatric teaching hospital, a system of inpatient care provided by hospitalists can reduce length of stay. This model has the potential to control hospital charges in a period of increasing health care costs.
Pediatricians' Attitudes, Beliefs, and Practices Regarding Clinical Practice Guidelines: A National Survey
Authors: Flores Glenn , Lee Mina , Bauchner Howard , Kastner Beth
Published: August 2004

Background.

Clinical practice guidelines are increasingly being used for a wide variety of medical conditions, but not enough is known about physicians' attitudes and beliefs about guidelines, how often and under what circumstances they are used, and factors associated with their acceptance.

Objective.

To determine practice guideline attitudes, beliefs, practices, and factors associated with use among a representative national sample of general pediatricians.

Study Design.

Cross-sectional mail survey.

Subjects.

Random sample of general pediatrician members of the American Academy of Pediatrics residing in all 50 states and Puerto Rico.

Survey Instrument.

Twenty-four multiple-choice, Likert scale, yes–no, and open-ended questions about pediatric clinical practice guidelines.

Results.

From 1088 respondents, 461 specialists were excluded; the remaining 627 general pediatricians were mostly male (61%), white (81%), and in group practice (62%) in a suburban location (48%). Practice guidelines are used by 35% of pediatricians, in part by 44%, and not at all by 21%. Over 100 different practice guidelines are used, most commonly for asthma (77%), hyperbilirubinemia (27%), and otitis media (19%). Common reasons for use of practice guidelines include standardization of care (17%) and helpfulness (10%). Commonly cited problems with practice guidelines include failure to allow for clinical judgment (54%), use in litigation (16%), and limitation of autonomy (5%). In multivariate analysis, the odds of practice guideline use were greater among pediatricians in health maintenance organization practices (odds ratio [OR]: 9.1; 95% confidence interval [CI]: 1.2–68.0) and those who were nonwhite (OR: 2.3; 95% CI: 1.1–4.8), but lower in those with more weekly patient visits (OR: .7; 95% CI: .5–.9). Features most likely to lead to practice guideline use include simplicity (16%), feasibility (12%), and evidence of improved outcomes (10%). Most pediatricians agree that practice guidelines improve outcomes (89%), are motivated by a desire to improve quality (94%), and should not be used in litigation (82%) or disciplinary actions (77%), nor be motivated by a desire to reduce costs (73%).

Conclusions.

Most general pediatricians use practice guidelines, but no specific guidelines, except those for asthma, are used by >27% of pediatricians. The results of this study suggest that practice guidelines are most likely to be followed if they are simple, flexible, rigorously tested, not used punitively, and are motivated by desires to improve quality, not reduce costs.
Reevaluation of Outpatients WithStreptococcus pneumoniaeBacteremia
Authors: Bachur Richard , Harper Marvin B.
Published: August 2004

Background.

The reevaluation process for outpatients recalled for Streptococcus pneumoniae bacteremia has not been standardized. Children who return ill or with new serious focal infections require admission and parenteral antibiotic therapy. Limited data exist to guide the follow-up management of those patients identified as having occult pneumococcal bacteremia.

Objectives.

Characterize the outcomes of outpatients with pneumococcal bacteremia based on their evaluation at follow-up. For patients who are well-appearing without serious focal infection, propose a management scheme for reevaluation.

Methods.

Retrospective review of outpatients with pneumococcal bacteremia. Patients with immunocompromise, those identified with focal bacterial infection at the initial visit, or those admitted at the initial visit were excluded. Data were collected from the initial visit (when blood culture drawn) and follow-up visit with regard to clinical parameters, laboratory data, diagnoses, and any antibiotic treatment. Decision tree analysis was used to generate a model to predict children at high risk for persistent bacteremia (PB).

Results.

A total of 548 episodes of pneumococcal bacteremia were studied. Seventy-three children received no antibiotic, 239 oral antibiotic, and 236 parenteral antibiotic at the initial visit. Median age, temperature, and white blood cell (WBC) count were 13.5 months, 40.0°C, and 20 400/mm3. Forty-one patients had PB or new focal infections (15 with PB alone, 4 had focal infection and PB). Eight patients had meningitis at follow-up. Ninety-two percent returned because of notification of the positive blood culture result. A repeat blood culture was obtained in 92%, 23% had a lumbar puncture, 33% had a chest radiograph, and 12% were admitted. PB was associated with the antibiotic treatment group, elevation of temperature, and WBC count at follow-up. A simple management scheme using 2 sequential decision nodes of antibiotic treatment (none vs any) and then temperature at follow-up (>38.8°C) would have predicted 16/19 patients with PB (sensitivity = .84 and specificity = .86).

Conclusions.

All patients with pneumococcal bacteremia need prompt reevaluation. For well-appearing patients without new focal infection, the utility of diagnostic testing (specifically repeat blood cultures) and the need for admission may be determined by the use of antibiotics at the initial evaluation and the presence of fever at follow-up. The majority of patients can be managed as outpatients entirely. Patients who did not receive antibiotics at the initial evaluation and those treated with oral antibiotics but remain febrile are at the highest risk for persistent bacteremia.
Magnetic Resonance Imaging of Intestinal Necrosis in Preterm Infants
Authors: Maalouf Elia F. , Fagbemi Andrew , Duggan Philip J. , Jayanthi Subramanyam , Counsell MRCS‡; Serena J. , Lewis Helen J. , Fletcher Alison M. , Lakhoo Kokila , Edwards FRCS‡; and A. David
Published: August 2004

Background and Objective.

Noninvasive diagnosis of intestinal necrosis is important in planning surgery in preterm infants with necrotizing enterocolitis (NEC). We aimed to assess the potential of magnetic resonance imaging (MRI) for the diagnosis of intestinal necrosis.

Study Participants and Methods.

Abdominal MRI scans were performed in a group of preterm infants with suspected NEC and compared with surgical findings and to MRI results in a group of control infants. In addition, MRI was performed in 2 preterm infants with suspected NEC who did not require surgery.

Results.

Six infants with a median birth weight of 1220 g (range, 760-1770 g) and median gestational age at birth of 30 weeks (range, 28–34 weeks) were studied at a median postnatal age of 10 days (range, 4–19 days). Four infants had a bubble-like appearance in part of the intestinal wall, intramural gas, and an abnormal fluid level within bowel lumen. At surgery, NEC was found in 5 infants and sigmoid volvulus in 1. The site of the bubble-like appearance corresponded to the site of intestinal necrosis at surgery. Four control infants with a median birth weight of 1500 g (range, 730-2130 g) and a median gestational age of 31 weeks (range, 26–36 weeks) had abdominal MRI at a median postnatal age of 8 days (range, 4–70 days). None of the above findings were seen in any control infant. The bubble-like appearance was not seen in the 2 infants with suspected NEC who did not require surgery.

Conclusion.

Abdominal MRI allows the noninvasive diagnosis of bowel necrosis. This may aid the timing of surgical intervention in preterm infants with a clinical diagnosis of NEC. gangrene, ischemia, MRI, necrotizing enterocolitis.
Systemic to Pulmonary Collaterals in Very Low Birth Weight Infants: Color Doppler Detection of Systemic to Pulmonary Connections During Neonatal and Early Infancy Period
Authors: Acherman Ruben J. , Siassi Bijan , Pratti-Madrid Gilma , Luna Carlos , Lewis Alan B. , Ebrahimi Mahmoud , Castillo William , Kamat Pradip , Ramanathan Rangasamy
Published: August 2004

Objective.

Angiographic visualization of systemic to pulmonary collaterals (SPC) has been documented in premature infants needing prolonged ventilatory support. Noninvasive identification of such communications in premature infants was reported recently. The purpose of this study was to describe: 1) incidence, 2) clinical findings and implications, and 3) short-term follow-up of SPC diagnosed by echocardiography in very low birth weight (VLBW) infants admitted to the neonatal intensive care unit.

Methods.

From December 1, 1994 to August 31, 1996, 196 infants with birth weight <1500 g were admitted to the neonatal intensive care unit; 133 of them received serial echocardiographic evaluations at 1 to 2 days, at 2 weeks, and at 1, 2, and 3 months of life. Follow-up echocardiograms were scheduled at 6 months and 1 year of age for patients with SPC persisting at 3 months of age.

Results.

SPC were demonstrated in 88 patients (66%) at 1 to 90 days of life (mean 28 days). In most cases, the SPC originated at the distal aortic arch or the proximal descending aorta. Ten patients (11%) were treated for congestive heart failure. The symptoms improved and anticongestive therapy was discontinued in 9. One patient with persistent congestive heart failure underwent therapeutic cardiac catheterization and 1 prominent SPC was embolized.

Conclusions.

The incidence of SPC in VLBW infants is much higher than previously reported. We postulate that SPC are bronchopulmonary communications that enlarge and/or proliferate in response to a given stimulus. These communications are associated with increased time on positive pressure ventilation and length of stay in the hospital. SPC may lead to pulmonary edema and should be searched for in VLBW infants with a more complicated course.

Echocardiographic examination with color Doppler performed in premature infants to evaluate left to right shunts should include careful search for systemic to pulmonary collaterals. echocardiography, systemic to pulmonary collaterals, aortopulmonary collaterals, prematurity, pulmonary edema.
Population-Based Estimates of Surfactant Protein B Deficiency
Authors: Cole F. Sessions , Hamvas Aaron , Rubinstein Pablo , King Erin , Trusgnich Michelle , Nogee Lawrence M. , deMello Daphne E. , Colten Harvey R.
Published: August 2004

Objective.

Surfactant protein B deficiency is a lethal cause of respiratory distress in infancy that results most commonly from a homozygous frameshift mutation (121ins2). Using independent clinical ascertainment and molecular methods in different populations, we sought to determine allele frequency.

Study Design.

Using clinical characteristics of the phenotype of affected infants, we screened the Missouri linked birth–death database (n = 1 052 544) to ascertain potentially affected infants. We used molecular amplification and restriction enzyme digestion of DNA samples from a metropolitan New York birth cohort (n = 6599) to estimate allele frequency.

Results.

The point estimate and 95% confidence interval of the 121ins2 allele frequency in the Missouri cohort are 1/1000 individuals (.03–5.6/1000) and in the New York cohort are .15/1000 (.08–.25/1000). These estimates are not statistically different.

Conclusions.

The close approximation of these independent estimates suggests accurate gene frequency (approximately one 121ins2 mutation per 1000–3000 individuals) despite its rare occurrence and that this mutation does not account for the majority of full-term infants with lethal respiratory distress.
Training of Pediatricians in Care of Physical Disabilities in Children With Special Health Needs: Results of a Two-State Survey of Practicing Pediatricians and National Resident Training Programs
Authors: Sneed Raphael C. , May Warren L. , Stencel Christine S.
Published: August 2004

Objective.

One goal of the American Academy of Pediatrics' Future of Pediatric Education II Project is to establish guidelines in training physicians to care for children with special health care needs (CWSN). Assessment of current practices in prescribing therapies and devices is necessary to meet this goal. Although much has been written about CWSN, there is a paucity of literature describing pediatricians' preparedness in prescribing such therapies and devices to children with physical disabilities. In an effort to assess physician preparedness, we surveyed pediatric residents nationwide and practicing pediatricians from 2 states, 1 urban and 1 rural.

Methods.

A questionnaire aimed at identifying areas of concern regarding preparedness of physicians in practice and in training was prepared and mailed to prospective participants in Ohio and Mississippi. After follow-up mailings to nonresponders, ∼59% responded. Summary statistics were reported as proportions with 95% confidence intervals.

Results.

Among those polled, >70% reported no training in prescribing certain durable medical equipment and over 50% reported no training in prescribing certain therapies. In addition, at least 20% reported no training in treating some of the more common childhood physical disabilities. Nearly three fourths of the respondents indicated that they did not believe that they were adequately prepared to take an active role in prescribing therapies and durable medical equipment. Fewer respondents believed that they should be the sole providers of these therapies and durable medical equipment.

Conclusions.

The results of the survey indicate a lack of specific training and physician confidence in prescribing therapies and devices to CWSN, establishing the necessity of expanding training programs to better ensure quality health care for special needs children. Although additional ongoing research is necessary to fully evaluate the preparedness of physicians in caring for CWSN, this survey does help to identify areas of physician training that require improvement to provide quality health care for CWSN.
High-Risk Periods for Childhood Injury Among Siblings
Authors: Johnston Brian D. , Grossman David C. , Connell Frederick A. , Koepsell Thomas D.
Published: August 2004

Objective.

To determine whether the risk of unintentional injury requiring emergency department (ED) or inpatient care in children is transiently increased over a 90-day period after injury to a sibling.

Design.

Retrospective cohort.

Setting.

King County, Washington.

Participants.

A total of 41 242 children 0 to 15 years of age continuously enrolled in Medicaid and living in King County during the period October 1, 1992 through September 30, 1993 (27 450 child-years).

Outcome Measures.

The outcome was an unintentional injury treated in the ED or inpatient setting. Incidence rates and hazard ratios were calculated for children whose sibling had been injured in the previous 90 days, compared with children without such exposure. Multivariate analysis was used to adjust for age, gender, race, sibling group size, and noninjury ED use.

Results.

There were 4921 injuries treated only in the ED and 82 hospital admissions. The incidence of ED treated injury was 305 per 1000 child-years among children whose sibling had been injured in the previous 90 days and 174 per 1000 child-years among children without this exposure (relative risk: 1.75; 95% confidence interval: 1.56–1.95). The incidence of injury-related hospitalization was 1.7 per 1000 child-years among children whose sibling had been injured in the previous 90 days, compared with 3.0 per 1000 child-years among children without this exposure (relative risk: .57; 95% confidence interval: .07–2.12). Injury risk peaked in the period 4 to 10 days after a sibling's injury and returned toward, but did not attain, baseline risk over the subsequent 2½ months. The magnitude of this effect depended on the child's age; the relative risk of injury was higher among older children.

Conclusions.

Injuries treated in the ED or inpatient setting appear to cluster within sibling groups over brief periods of time. Shared social or environmental exposures may contribute to this clustering and may be amenable to targeted, time-limited prevention interventions.
Beliefs About Diagnosing Asthma in Young Children
Authors: Werk Lloyd N. , Steinbach Suzanne , Adams William G. , Bauchner Howard
Published: August 2004

Objectives.

To determine what factors primary care pediatricians believe are important in establishing the initial diagnosis of childhood asthma and to identify variations in physicians' beliefs concerning this clinical decision.

Study Design.

Massachusetts American Academy of Pediatrics Fellows were surveyed about their beliefs concerning the importance of 20 clinical factors associated with establishing the initial diagnosis of asthma.

Results.

Most clinicians considered recurrent wheeze (96%), symptomatic improvement with a bronchodilator (90%), recurrent cough (89%), exclusion of alternative diagnoses (87%), and suggestive peak flow findings (82%) as important in diagnosing asthma. However, there was substantial heterogeneity among clinicians as to which combinations of factors they each considered relevant; for example, only 60% identified all 5 of the above factors to be necessary or important. Further, <50% identified presence of any of the 20 factors as necessary. Although national guidelines cite objective assessment of pulmonary function as essential, spirometry and peak expiratory flow testing were identified as necessary by only 8% and 10%, respectively. Two factors believed to contribute to establishing the asthma diagnosis contradicted the National Asthma Education and Prevention Program guidelines and expert opinion (age >2 years and absence of fever during episodes) and these beliefs were more likely held by those clinicians in practice for >5 years.

Conclusions.

The majority of pediatricians believe several common clinical factors establish a diagnosis of childhood asthma, but disagree over what combinations of these factors are important. Some misconceptions persist despite wide dissemination of clinical practice guidelines. We believe that future asthma guidelines will need to organize diagnostic criteria in an easily understood format, like a decision tree, to facilitate early recognition of asthma in young children.
Informed Proxy Consent: Communication Between Pediatric Surgeons and Surrogates About Surgery
Authors: Lashley Myrna , Talley William , Lands Larry C. , Keyserlingk Edward W.
Published: August 2004

Objective.

Informed consent for surgical procedures requires that the procedures are explained and that the patient understands the procedures and risks and agrees to undergo them. Proxy consent occurs when an individual is provided with the legal right to make decisions on behalf of another. This study was conducted to determine how surgeons communicate information to obtain an informed proxy consent, and to investigate how that information is received and processed by surrogates responsible for providing such consent.

Study Design.

Twenty English-speaking parents or legal guardians and 5 surgeons in an urban pediatric hospital were interviewed before, and 2 to 4 weeks after, the surgical procedure. In addition, the interview between the surgeon and surrogate, when consent was obtained, was audiotaped and subsequently analyzed. Semistructured interviews were used to elicit the motivations and influences on the surrogates to consent to the procedure. The same methodology was used to elicit the corresponding impressions of the surgeons. The data were analyzed using descriptive statistics and crosstabulations.

Results.

Demographic data did not influence the results. Although there was concordance between the surrogate's understanding of the procedure and the surgeon's impression of this understanding, only 3 of 17 surrogates could recall any specifics of the explained procedure. Contrary to the stated belief of surgeons, surrogates consulted with a variety of others, including medical and paramedical professionals, family members, and spiritual leaders.

Conclusions.

Communication plays an important role within the surrogate-surgeon dyad. Psychologic variables such as expectations, and the perception of both the surrogates and the surgeons, influence the amount of information that is proffered and the manner in which it is received. Improved communication may be achieved by use of visual aids, discussion of anesthesia and the postoperative course, recognition of the circumstances around the discussion, such as timing and location of the discussion, and personalization of the discussion.
Childhood Encephalopathies and Myopathies: A Prospective Study in a Defined Population to Assess the Frequency of Mitochondrial Disorders
Authors: Uusimaa Johanna , Remes Anne M. , Rantala Heikki , Vainionpää Leena , Herva Riitta , Vuopala Katri , Nuutinen Matti , Majamaa Kari , Hassinen Ilmo E.
Published: August 2004

Objectives.

To assess the frequency of mitochondrial abnormalities in muscle histology, defects in respiratory chain enzyme activities, and mutations in mitochondrial DNA (mtDNA) in children with unexplained psychomotor retardation in the population of Northern Finland.

Background.

The frequency of mitochondrial diseases among patients with childhood encephalopathies and myopathies is not known. Frequencies are difficult to estimate because the clinical presentation of these disorders is variable.

Methods.

A total of 116 consecutive patients with undefined encephalopathies and myopathies were enrolled during a 7-year period in a hospital serving as the only neurologic unit for a pediatric population of 97 609 and as the only tertiary level neurologic unit for a pediatric population of 48 873. Biochemical and morphologic investigations were performed on muscle biopsy material, including oximetric and spectrophotometric analyses of oxidative phosphorylation, histochemistry, electron microscopy, and molecular analysis of mtDNA.

Results.

Ultrastructural changes in the mitochondria were the most common finding in the muscle biopsies (71%). Ragged-red fibers were found in 4 cases. An oxidative phosphorylation defect was found in 26 children (28%), complex I (n = 15) and complex IV (n = 13) defects being the most common. Fifteen percent of patients (n = 17/116) with unexplained encephalomyopathy or myopathy had a probable mitochondrial disease. Common pathogenic mutations were found in the mtDNA of only 1 patient (.9%).

Conclusions.

The common known mutations in mtDNA are rarely causes of childhood encephalomyopathies, which is in contrast to the considerable frequency of the common MELAS mutation observed among adults in the same geographical area. Biochemically and morphologically verified mitochondrial disorders were nevertheless common among the children, making the analysis of a muscle biopsy very important for clinical diagnostic purposes.
Use of the National Institutes of Health Criteria for Diagnosis of Neurofibromatosis 1 in Children
Authors: DeBella Kimberly , Szudek Jacek , Friedman Jan Marshall
Published: August 2004

Objective.

The National Institutes of Health (NIH) Diagnostic Criteria for neurofibromatosis 1 (NF1) are very useful clinically, but some individuals who are later shown to have NF1 cannot be diagnosed in early childhood using these criteria. The aim of this study is to determine the value of the NIH Diagnostic Criteria for NF1 in early childhood, to determine the age at which diagnosis can confidently be made, and to clarify the age at onset of the cardinal clinical features used in the NIH Diagnostic Criteria.

Methods.

We studied 1893 NF1 patients under 21 years old from the National Neurofibromatosis Foundation International Database to determine the age at which the features included in the NIH Diagnostic Criteria appear.

Results.

Approximately 46% of sporadic NF1 cases fail to meet the NIH Diagnostic Criteria by 1 year of age. Nearly all (97%; 95% confidence interval: 94–98) NF1 patients meet the criteria for diagnosis by 8 years old, and all do so by 20 years old. The usual order of appearance of the clinical features listed as NIH criteria is café-au-lait macules, axillary freckling, Lisch nodules, and neurofibromas. Symptomatic optic glioma is usually diagnosed by 3 years old, and characteristic osseous lesions are usually apparent within the first year of life.

Conclusion.

The diagnosis of NF1 cannot always be made in young children using the NIH Diagnostic Criteria. Modification of these criteria may be necessary for children under 8 years old.
Snowmobile Injuries and Deaths in Children: A Review of National Injury Data and State Legislation
Authors: Rice Manda R. , Alvanos Lynn , Kenney Brian
Published: August 2004

Background.

Snowmobiling is a popular family sport, with annual expenditures over $9 billion. The size and speed of snowmobiles make them potentially dangerous to children. Pediatric snowmobile-related trauma has not been studied in the United States.

Methods.

We analyzed 291 pediatric snowmobile- related injuries and 75 deaths reported to the Consumer Product Safety Commission from 1990 to 1998. We reviewed snowmobile legislation in the states that reported at least 1 death to the Consumer Product Safety Commission during this time period.

Results.

The most common sites of injury were the extremities (48.8%) and the head, neck, and face (28.2%). Head and neck injuries were the predominant cause of death (66.7%). The most common diagnosis was contusion/abrasion (30.9%), followed by laceration (22%), fracture (20.3%), and strain/sprain (14.4%). Nonfatal injuries most often involved ejection from the snowmobile (26.1%), but striking a stationary object was the most common mechanism in fatal crashes. The review of state legislation revealed that few age restrictions or helmet laws exist. Children as young as 8 years old may legally operate a snowmobile in some states. Often, restrictions do not apply to snowmobile use on private property, where 43% of pediatric snowmobile-related injuries occurred.

Conclusions.

Head, neck, and face injuries are common nonfatal injuries and are the most common cause of death. State legislation often lacks age restrictions on private property, and laws requiring helmet use are rare. Legislators have not addressed the dangers of pediatric snowmobile-related injuries. Helmet laws and age restrictions similar to those enacted for motorcycle riders are necessary and appropriate.
Health Appraisal Guidelines for Day Camps and Resident Camps
Authors:   Committee on School Health
Published: August 2004

The American Academy of Pediatrics recommends that specific guidelines be established for pre-camp health appraisals of young people in day and resident camps. Camp guidelines also should include reference to health maintenance, storage and administration of medication, and emergency medical services.

Although camps have diverse environments, there are general guidelines that apply to all situations, and specific recommendations are appropriate under special conditions.
Injuries in Youth Soccer: A Subject Review
Authors:   Committee on Sports Medicine and Fitness
Published: August 2004

The current literature on injuries in youth soccer, known as football worldwide, has been reviewed to assess the frequency, type, and causes of injuries in this sport. The information in this review serves as a basis for encouraging safe participation in soccer for children and adolescents.
The Highly Protective Effect of Newborn Circumcision Against Invasive Penile Cancer
Authors: Schoen Edgar J. , Oehrli Michael , Colby CTR‡; Christopher J. , Machin Geoffrey
Published: August 2004

Objective.

We determined the relation between newborn circumcision and both invasive penile cancer (IPC) and carcinoma in situ (CIS) among adult male members of a large health maintenance organization.

Subjects and Methods.

Circumcision status was ascertained by a combination of pathology reports, medical record review, and questionnaires for 213 adult male members of a large prepaid health plan who were diagnosed with IPC or CIS.

Results.

Of 89 men with IPC whose circumcision status was known, 2 (2.3%) had been circumcised as newborns, and 87 were not circumcised. Of 118 men with CIS whose circumcision status was known, 16 (15.7%) had been circumcised as newborns.

Conclusions.

Our results confirm the highly protective effect of newborn circumcision against IPC and the less protective effect against CIS.
Mortality and Time to Death in Very Low Birth Weight Infants: California, 1987 and 1993
Authors: Gould Jeffrey B. , Benitz William E. , Liu Hao
Published: August 2004

Background.

Recent advances in perinatal technology have dramatically increased the survival of very low birth weight (VLBW) infants (<1500 g). The possibility that these advances may also prolong the time to death and increase pain and suffering has been of concern, but there have been no population-based evaluations of this issue.

Methods.

Infant, neonatal, and postneonatal mortality rates and time to death for infants 500 to 749 g, 750 to 999 g, 1000 to 1499 g, and all VLBW infants born during 1987 were compared with those outcomes for infants born in 1993 using statewide California linked birth/death cohort files. To assess the effects of improved survival and changes in time until death, we calculated the total days of life preceding an infant death per 1000 live born infants (TDD).

Results.

VLBW infants comprised .96% of California's live births in 1987 and .92% of those in 1993. Between 1987 and 1993, VLBW infant mortality rate decreased 28.4% (from 290.7 to 208.3 per 1000 live born VLBW infants), VLBW neonatal mortality rate decreased 30.3% (from 244.5 to 170.4), and VLBW postneonatal mortality rate decreased 25.3% (from 61.2 to 45.7 per 1000 VLBW alive at 28 days;P < .05 for each rate). Infant mortality rates decreased by 18.8% (718.1 to 583.0 per 1000) for infants 500 to 749 g, 43.3% (375.1 to 202.6) for infants 750 to 999 g, and 40.1% (127.9 to 76.7) for infants 1000 to 1449 g (P < .05 for each group). Neonatal mortality and postneonatal mortality rates also decreased in all 3 VLBW subgroups. These reductions in mortality rates were not accompanied by a significant difference in the distribution of times to death or a significant increase in the average time to death for all VLBW infants (22.0 vs 23.6 days) or for those with birth weights of 500 to 749 g (12.7 vs 71.5 days). Reduced mortality in larger infants was accompanied by an increase in the average time to death, from 24.3 to 32.5 days in infants 750 to 999 g and from 32.3 to 47.0 days in infants 1000 to 1449 g. TDD decreased from 6410 to 4908 days for all VLBW infants. TDD was also reduced 26.4% (2401 days), 24.3% (2115 days), and 22.5% (1043 days) for the 3 VLBW birth weight groups.

Conclusions.

Both mortality rate and timing of death are important when assessing the impact of advances in perinatal technology. Although the average time to death was significantly increased in VLBW infants weighing >750 g, between 1987 and 1993, advances in perinatal technology dramatically decreased VLBW mortality. In the State of California in 1993, this resulted in 452 fewer VLBW deaths and 8233 fewer days preceding a VLBW death than expected.
Clinical Safety of Iron-Fortified Formulas
Authors: Singhal Atul , Morley Ruth , Abbott Rebecca , Fairweather-Tait Susan , Stephenson Terence , Lucas Alan
Published: August 2004

Background.

Iron-fortified formulas are recommended throughout infancy and are frequently used beyond, yet safety aspects have been inadequately studied. Iron could theoretically increase pro-oxidant stress, with potential adverse effects, including infection risk, and some clinicians suspect that iron-fortified formulas induce gastrointestinal disturbance.

Objective.

A planned component of a large intervention trial has been to test the hypothesis that infants receiving iron-fortified formula do not have a higher incidence of infections (primary outcome) or gastrointestinal problems (secondary outcome) than infants on low iron-formulas or cow's milk.

Methods.

Children (n = 493) 9 months old receiving cow's milk were recruited in 3 UK centers and randomized to: 1) cow's milk as before, 2) formula containing .9 mg/L of iron, or 3) an otherwise identical formula but containing 12 mg/L of iron. Children were followed at 3 monthly intervals and the episodes of infections, diarrhea and constipation, and general morbidity to 18 months old were recorded. Hematologic indices of iron status were determined at 18 months old.

Results.

Serum ferritin concentrations were increased in infants receiving iron-fortified formula but there were no intergroup differences in incidence of infection, gastrointestinal problems, or in general morbidity or weight gain.

Conclusions.

We were unable to identify adverse health effects in older infants and toddlers consuming a high iron-containing formula (12 mg/L) even when used in populations with a low incidence of iron deficiency.
Pediatric Milliman and Robertson Length-of-Stay Criteria: Are They Realistic?
Authors: Sills Marion R. , Huang Zhihuan J. , Shao Cheng , Guagliardo Mark F. , Chamberlain James M. , Joseph Jill G.
Published: August 2004

Objective.

Guidelines for inpatient length of stay (LOS) have been developed by several groups; among the most widely applied are those published by Milliman and Robertson (M&R). Few published reports have examined the relationship of actual practice to such guidelines, none in pediatric populations. This study was designed to compare pediatric practice in a large and defined population to M&R LOS criteria.

Methods.

Administrative data from New York State in 1995 were used to examine LOS for discharges corresponding to 16 selected pediatric diagnoses for which M&R publishes guidelines. Outliers, defined as the 2% of discharges with the longest LOS, were eliminated. The distribution of LOS for each diagnosis was compared with M&R LOS guidelines.

Results.

In New York State during 1995, pediatric LOS was markedly divergent from M&R guidelines. In general, the percentage of discharges in excess of the criterion LOS was less for nonmandatory admissions (croup: 23%, gastroenteritis: 44%, and pneumonia: 48%) than for those requiring surgery (uncomplicated appendectomy: 67%, pyloromyotomy: 62%, and major but noncritical burns: 64%) or prolonged treatment with antibiotics (bacterial meningitis: 91% and osteomyelitis: 86%).

Conclusions.

In New York State during 1995, LOS for selected pediatric conditions was generally in excess of published M&R guidelines. This raises concern about the potential effects of such guidelines on both patients and the hospitals caring for them. While endorsing the need for cost-effective practice, we call attention to the methods used to develop and validate guidelines. length of stay, pediatrics, managed health care, administrative data, practice guidelines.
Effect of Infection Control Measures on the Frequency of Diarrheal Episodes in Child Care: A Randomized, Controlled Trial
Authors: Roberts Leslee , Jorm Louisa , PhD BVSc, MSc(Epid), , Patel Mahomed , Smith Wayne , Douglas Robert M. , McGilchrist Charles
Published: August 2004

Background.

Diarrheal infections are common in children who attend child care, and preventing transmission of disease in this setting depends on actions by child care staff. We set out to discover whether transmission of gastrointestinal infections in child care could be reduced by improved infection control procedures.

Methods.

We performed a cluster randomized, controlled trial of an infection control intervention conducted in child care centers for 1 city in Australia. The intervention was training of child care staff about transmission of infection and handwashing and focused on both staff and child behavior. Implementation of the intervention was recorded by an observer. Illness was measured by parent report in telephone interviews every 2 weeks.

Results.

There were 311 child-years of surveillance for diarrheal episodes. The rate of episodes of diarrhea was 1.9 per child-year in intervention centers and 2.7 per child-year in control centers. Multivariable analysis showed that diarrheal episodes were significantly reduced in intervention center children by 50%. However, the impact of the intervention was confined to children over 24 months of age. For those centers in which children's compliance with handwashing was high, diarrheal episodes were reduced by 66%.

Conclusions.

This trial supports education about infection control, for staff and children in child care, as a means of reducing transmission of diarrhea. Reduction in episodes of diarrhea in children in child care was limited to children over 24 months of age.
Symptoms Associated With Infant Teething: A Prospective Study
Authors: Macknin Michael L. , Piedmonte Marion , Jacobs Jonathan , Skibinski Christine
Published: August 2004

Context.

Studies of infant teething have been retrospective, small, or conducted on institutionalized infants.

Objectives.

To conduct a large, prospective study of healthy infants to determine which symptoms may be attributed to teething and to attempt to predict tooth emergence from an infant's symptoms.

Design.

Prospective cohort.

Setting.

Clinic-based pediatric group practice.

Patients.

One hundred twenty-five consecutive well children of consenting Cleveland Clinic employees.

Outcome Measures.

Parents daily recorded 2 tympanic temperatures, presence or absence of 18 symptoms, and all tooth eruptions in their infants, from the 4-month well-child visit until the child turned 1 year old.

Results.

Daily symptom data were available for 19 422 child-days and 475 tooth eruptions. Symptoms were only significantly more frequent in the 4 days before a tooth emergence, the day of the emergence, and 3 days after it, so this 8-day window was defined as the teething period. Increased biting, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite for solid foods, and mild temperature elevation were all statistically associated with teething. Congestion, sleep disturbance, stool looseness, increased stool number, decreased appetite for liquids, cough, rashes other than facial rashes, fever over 102°F, and vomiting were not significantly associated with tooth emergence. Although many symptoms were associated with teething, no symptom occurred in >35% of teething infants, and no symptom occurred >20% more often in teething than in nonteething infants. No teething child had a fever of 104°F and none had a life-threatening illness.

Conclusions.

Many mild symptoms previously thought to be associated with teething were found in this study to be temporally associated with teething. However, no symptom cluster could reliably predict the imminent emergence of a tooth. Before caregivers attribute any infants' signs or symptoms of a potentially serious illness to teething, other possible causes must be ruled out. teething, tooth eruption, teeth, deciduous dentition.