bluuebunny/crossref_metadata_2025 huggingface dataset:
A Cost-Effectiveness Analysis of Bacterial Endocarditis Prophylaxis for Febrile Children Who Have Cardiac Lesions and Undergo Urinary Catheterization in the Emergency Department
Authors: Caviness A. Chantal , Cantor Scott B. , Allen Coburn H. , Ward Mark A.
Published: August 2004

Objective. To prevent bacterial endocarditis (BE) in those at risk, the American Heart Association recommends antibiotics for patients who have a known urinary tract infection and are about to undergo urinary catheterization (UC). In young children who have cardiac lesions and undergo UC for fever without a source, the problem with prophylaxis only in the presence of infected urine is that the presence of urinary tract infection is unknown before testing. This study was conducted to determine the cost-effectiveness of BE prophylaxis before UC in febrile children aged 0–24 months with moderate-risk cardiac lesions.

Methods. We evaluated the cost-effectiveness of BE prophylaxis compared with no prophylaxis from the societal perspective. Clinical outcomes were based on BE incidence and quality-adjusted life years (QALYs). Probabilities were derived from the medical literature. Costs were derived from national and local sources in US dollars for the reference year 2000, using a discount rate of 3%.

Results. On the basis of the analysis, prophylaxis prevents 7 BE cases per 1 million children treated. When antibiotic-associated deaths were included, the no-prophylaxis strategy was more effective and less costly than the prophylaxis strategy. When antibiotic-associated deaths were excluded, amoxicillin cost $10 million per QALY gained and $70 million per case prevented. For vancomycin, it was $13 million per QALY gained and $95 million per case prevented. The results were robust to variations in the prophylactic efficacy of antibiotics, incidence of bacteremia after UC, incidence of BE after bacteremia, and costs associated with BE prophylaxis and treatment.

Conclusion. In the emergency department, BE prophylaxis before UC in febrile children who are aged 0 to 24 months and have moderate-risk cardiac lesions is not a cost-effective use of health care resources.
Outcomes in Children and Young Adults Who Are Hospitalized for Firearms-Related Injuries
Authors: DiScala Carla , Sege Robert
Published: August 2004

Objectives. To compare outcomes by intent of nonfatal firearms-related injuries in a hospitalized population, newborn to 19 years of age, and estimate the national incidence of ensuing disability.

Methods. Descriptive statistics and comparative analysis using χ2, odds ratio, and t test were applied to data from the National Pediatric Trauma Registry (NPTR) and the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission. Demographics, preinjury medical history, scene of injury, primary body part injured, severity of injury, utilization of resources, short-term and long-term disability, medical cause of disability, and disposition at discharge were studied.

Results. NPTR unintentional (n = 268) and assault-related firearms-related injuries (n = 506) were compared. In both groups, the majority of patients were male (80%). Compared with the unintentionally injured, the assaulted children were older and more frequently black (59.3% vs 32.5%). Approximately 17% in both groups had a preinjury history of medical/psychosocial problems. Unintentional injuries occurred mainly in private dwellings (75.7%), and assaults occurred in public places/street (53.8%). In both groups, injuries to multiple body regions were prevalent, and a substantial proportion sustained injuries of serious to critical level. Most children were transported by ambulance, but a significant proportion in the unintentional group were transported by helicopter. The rate of admission to the intensive care unit was ∼40% for both groups. The unintentionally injured had a higher rate of surgical intervention (66.8% vs 50.8%) and stayed in the hospital longer than the assaulted ones (median: 5 days vs 3 days). Almost half of the children in both groups were discharged with disability, and ∼87% returned to their home. Applying the NPTR disability rate to National Electronic Injury Surveillance System estimates of hospitalization suggests that ∼3200 children nationwide develop disability from firearms-related injuries annually.

Conclusions. Nonfatal firearms-related injuries in a pediatric population are associated with a high use of medical resources and lasting disability. Public policies should be developed and implemented to reduce the occurrence of these catastrophic events.
Depressive Symptoms and Health Risk Among Rural Adolescents
Authors: Burns James J. , Cottrell Lesley , Perkins Kathaleen , Pack Robert , Stanton Bonita , Hobbs Gerald , Hobby Lela , Eddy Derrick , Hauschka Andrew
Published: August 2004

Objective. To determine the stability of depression and its relationship with health risk factors among rural adolescents.

Methods. A clinic-based longitudinal study was conducted to test for depression and risk factors in 64 participants who attended a rural, primary care, adolescent medicine clinic. The primary measure of risk and depression was the Perkins Adolescent Risk Screen (PARS). Adolescent patients who were aged 12 to 18 years and had PARS assessments during a previous visit to the adolescent clinic were invited to complete a follow-up PARS assessment.

Results. The mean age of adolescents at baseline was 12.79 years; 14.59 years at follow-up. With age and gender being controlled, adolescent depression and various adolescent risk indices were significantly related at baseline. Longitudinally, baseline depression score on PARS were related to follow-up: depression, school problems, substance abuse, tobacco use, sexual activity, and violent behavior scores and a history of physical/sexual abuse. On multivariate analysis controlling for other significantly associated variables, the relationship persisted for baseline depression and follow-up: tobacco, substance abuse, depression, and history of physical/sexual abuse.

Conclusion. This study confirms a strong longitudinal relationship between baseline depressive symptoms and several important risk behaviors/factors measured at follow-up in a clinic population of rural adolescents. Also, longitudinal stability of depression over time is supported.
Comparison of Two Educational Interventions on Pediatric Resident Auscultation Skills
Authors: Mahnke C. Becket , Nowalk Andrew , Hofkosh Dena , Zuberbuhler James R. , Law Yuk M.
Published: August 2004

Objective. Multiple cross-sectional physician surveys have documented poor cardiac auscultation skills. We evaluated the impact of 2 different educational interventions on pediatric resident auscultation skills.

Methods. The auscultation skills of all first-year (PGY1; n = 20) and second-year pediatric residents (PGY2; n = 20) were evaluated at the beginning and end of the academic year. Five patient recordings were presented: atrial septal defect, ventricular septal defect, pulmonary valve stenosis, bicuspid aortic valve with insufficiency, and innocent murmur. Residents were asked to classify the second heart sound, identify a systolic ejection click, describe the murmur, and provide a diagnosis. All PGY1 and most PGY2 (14 of 20) participated on the inpatient cardiology service for 1 month. PGY2 on the cardiology service also attended outpatient clinic. PGY1 did not attend outpatient clinic but were allotted 2 hours/week to use a self-directed cardiac auscultation computer teaching program.

Results. Resident auscultation skills on initial evaluation were dependent on training level (PGY1: 42 ± 15% correct; PGY2: 53 ± 13% correct), primarily as a result of better classification of second heart sound (PGY1: 45%; PGY2: 63%) and diagnosis of an innocent murmur (PGY1: 35%; PGY2: 65%). There was no difference in the ability to identify correctly a systolic ejection click (20% vs 23%) or to arrive at the correct diagnosis (35% vs 40%). At the end of the academic year, the PGY1 scores improved by 21%, primarily as a result of improved diagnostic accuracy of the innocent murmur (35% to 65%). PGY2 scores remained unchanged (53% vs 51%), regardless of participation in a cardiology rotation (cardiology rotation: 50%; no cardiology rotation: 51%). Combined, diagnostic accuracy was best for ventricular septal defect (55%) and innocent murmur (60%) and worst for atrial septal defect (18%) and pulmonary valve stenosis (15%). However, 40% identified the innocent murmur as pathologic and 21% of pathologic murmurs were diagnosed as innocent.

Conclusions. Pediatric resident auscultation skills were poor and did not improve after an outpatient cardiology rotation. Auscultation skills did improve after the use of a self-directed cardiac auscultation teaching program. These data have relevance given the American College of Graduate Medical Education's emphasis on measuring educational outcomes and documenting clinical competencies during residency training.
Does Pediatric Surgical Specialty Training Affect Outcome After Ramstedt Pyloromyotomy? A Population-Based Study
Authors: Langer Jacob C. , To Teresa
Published: August 2004

Objective. Ramstedt pyloromyotomy is a common operation in infants and is often done by general surgeons. We wished to determine whether there are any differences in outcome when this procedure is done by subspecialist pediatric general surgeons as compared with general surgeons.

Methods. All Ramstedt pyloromyotomies in the province of Ontario between 1993 and 2000 were reviewed. Children with complex medical conditions or prematurity were excluded. Cases done by general surgeons were compared with those done by pediatric surgeons, specifically examining hospital stay and complications.

Results. Of 1777 eligible infants, 67.9% were operated on by pediatric surgeons and 32.1% by general surgeons. Total and postoperative lengths of stay were longer in the general surgeon group compared with the pediatric surgeons (4.31 vs 3.50 days for length of stay; 2.95 vs 2.25 days for postoperative length of stay). The general surgeons had a higher overall complication rate (4.18% vs 2.58%). The incidence of duodenal perforation among general surgeons was almost 4 times that of pediatric surgeons (relative risk: 3.65; 95% confidence interval: 1.43-9.32). Of the 4 infants who required repeat surgery because of an incomplete pyloromyotomy, all were originally operated on by a general surgeon. Analysis of the effect of surgeon volume on outcomes suggested that higher volume resulted in better outcome in both groups.

Conclusion. Subspecialist pediatric general surgeons achieve superior outcomes for children who undergo Ramstedt pyloromyotomy.
Placenta Growth Factor Elevation in the Cord Blood of Premature Neonates Predicts Poor Pulmonary Outcome
Authors: Tsao Po-Nien , Wei Shu-Chen , Su Yi-Ning , Lee Chien-Nan , Chou Hung-Chieh , Hsieh Wu-Shiun , Hsieh Fon-Jou
Published: August 2004

Objective. To determine whether an elevated placenta growth factor (PlGF) level in cord blood is associated with increased risk for preterm infants to develop bronchopulmonary dysplasia (BPD).

Methods. Sixty-three preterm infants who were born at 34 weeks' gestation or earlier were enrolled. Two infants who died before 28 days' postnatal age could not be assigned a BPD status and were excluded. PlGF levels in cord blood were measured using enzyme-linked immunosorbent assay. Mann-Whitney rank sum test, Spearman correlation coefficients, and multivariable linear or logistic regression analyses were used for statistical analysis.

Results. The BPD group had a higher PlGF level, lower gestational age, lower birth weight (BW), higher incidence of endotracheal tube intubation, and longer duration of intubation. The PlGF levels in cord blood correlated negatively with gestational age and BW. However, multivariable logistic regression analyses revealed that only elevated cord blood PlGF levels and BW were associated with BPD after adjusting for all contributing factors. Furthermore, an increased PlGF level in cord blood was significantly correlated with the clinical severity of BPD, as measured by duration of intubation. At 17 mg/dL, the specificity of cord blood PlGF level in predicting BPD was 95%, the sensitivity was 53%, the positive predictive value was 83%, and the negative predictive value was 82%.

Conclusions. Measuring cord blood PlGF level at birth might be a biological marker for predicting the occurrence of BPD and allowing early therapeutic intervention.
Initial and Follow-up Costs by Treatment Outcome for Children With Respiratory Infections
Authors: Howard David H. , McGowan John E.
Published: August 2004

Objective. To estimate the initial and follow-up costs of treatment of respiratory infections among pediatric patients and the relationship between costs and outcomes.

Methods. A total of 3677 episodes of care from 2328 patients who were <17 years of age and had respiratory or ear infections that were treated with an antibiotic initially. The sample was drawn from the Medical Expenditure Panel Surveys for the years 1996 through 1999. Treatment failure was defined as the receipt of a second antibiotic, different from the first, in a 4-week window. We compared follow-up costs by outcome (treatment failure vs success) using a 2-part model of medical costs. We also performed a paired analysis by selecting 2 episodes, one in which the outcome was failure and the other in which the outcome was success, for patients with at least 1 of each type and computing the difference in costs.

Results. Follow-up costs for provider visits for episodes for which the patient experienced treatment failure were $216 versus $53 for episodes for which the patient did not experience treatment failure. Follow-up drug costs, including the cost of the second antibiotic, were $75 for children who experienced treatment failure versus $23, respectively. Cost estimates from the paired analysis were similar, confirming that results are not biased by unobserved time-invariant patient characteristics.

Conclusion. Children who have respiratory infections and experience treatment failure incur substantially higher costs.
Reactions and Needs of Tristate-Area Pediatricians After the Events of September 11th: Implications for Children's Mental Health Services
Authors: Laraque Danielle , Boscarino Joseph A. , Battista Anthony , Fleischman Alan , Casalino Marie , Hu Yue-Yung , Ramos Sandra , Adams Richard E. , Schmidt Jessica , Chemtob Claude
Published: August 2004

Objective. The terrorist attacks of September 11, 2001, caused mass destruction in Lower Manhattan, the Pentagon, and rural Pennsylvania and resulted in the death of >3000 people. Children were prominent among those affected. Given the wide impact of the attacks, we hypothesized that primary care professionals would see the broad population of affected children but would feel ill-prepared to respond to children's mental health needs.

Methods. One year after the September 11th disaster, a hyperlink to a web-based 42-item survey was sent to all New York, Connecticut, and New Jersey American Academy of Pediatrics members with e-mail addresses (N = 4330), and a paper version of the survey was sent via postal mail to a random sample of those without e-mail (N = 1320). The survey requested demographic data, personal and practice experience of 9/11, perceived knowledge and skills regarding mental health, and perceived barriers to accessing mental health services for their patients. Both groups were contacted a total of 3 times at 2-week intervals, resulting in 1396 completed surveys from providers who were actively seeing patients.

Results. Twenty-nine percent of respondents stated that they were seeing affected patients, and 32.6% reported seeing children who were exposed to at least 1 9/11 event. Sixty-four percent of the respondents identified behavioral problems in directly affected children: 41.6% identified acute stress disorder, and 26.3% identified posttraumatic stress disorder (PTSD). However, a majority of these professionals indicated that they either lacked or were uncertain (50.8% PTSD, 51.7% acute stress disorder) of their skills to identify children with mental health problems and that they were “not” or only “somewhat” knowledgeable (76.8% PTSD) in these areas. The majority agreed that child health professionals should be trained to screen for these 2 disorders. Generalists as compared with specialists were more likely to report seeing patients who were affected by 9/11. Gender, race/ethnicity, and geographic location were associated with reported effects of 9/11 on respondents' practice and perceived skills and knowledge related to the psychological effects of community disasters.

Conclusions. Pediatric practitioners in the tristate area reported that children/families sought care for an array of mental health–related concerns. Generalists in the areas affected and those who identified gaps in knowledge or skills in responding to the psychological effects of community disasters should be targeted for additional education.
Unmet Need for Counseling Services by Children in New York City After the September 11th Attacks on the World Trade Center: Implications for Pediatricians
Authors: Fairbrother Gerry , Stuber Jennifer , Galea Sandro , Pfefferbaum Betty , Fleischman Alan R.
Published: August 2004

Objective. The objectives of this study were to describe the prevalence of counseling services, contrasted with the need after the terrorist attacks of September 11, 2001, the types of counseling received, and the predictors of receipt of counseling services.

Methods. A cross-sectional, random-digit-dial survey was conducted in New York City (NYC) of parents (N = 434) of children who were 4 to 17 years of age 4 months after the September 11th terrorist attacks on the World Trade Center.

Results. Overall, 10% of NYC children received some type of counseling after the September 11th attacks, according to parental report. Among these, 44% received counseling in schools, 36% received counseling from medical or professional providers, and 20% received counseling from other sources. However, only 27% of the children who had severe/very severe posttraumatic stress reactions (PTSR) after the attacks received counseling services. In a multivariate model, receipt of counseling before the September 11th attacks (odds ratio: 4.44) and having severe/very severe PTSR (odds ratio: 3.59) were the most important predictors of use of counseling services after the September 11th attacks. Minority status and having a parent who experienced the loss of a friend or a relative were also associated with receipt of services.

Conclusions. There was substantial disparity between apparent need (as indicated by severe/very severe PTSR) for and receipt of mental health services for children after the September 11th attacks. There is need for intensified efforts to identify, refer, and treat children in need, especially for children who are not already in a therapeutic relationship. An enhanced role for pediatricians is indicated.
West Nile Virus Infection: A Pediatric Perspective
Authors: Hayes Edward B. , O'Leary Daniel R.
Published: August 2004

West Nile virus (WNV) infection recently became a major public health concern in the western hemisphere. This article describes recent information regarding previously unrecognized mechanisms of WNV transmission and reviews clinical manifestations of WNV infection, diagnostic tests, and prevention strategies from a pediatric perspective. WNV is transmitted to humans primarily through the bite of infected mosquitoes, but during the epidemic that spread across North America in 2002, transmission of WNV through blood transfusions and organ transplantation was described for the first time. Individual case reports indicate that WNV can be transmitted also in utero and probably through breast milk. Although most WNV infections are asymptomatic, the virus causes a broad range of manifestations from uncomplicated febrile illness to meningitis, neuropathies, paralysis, and encephalitis. Severe manifestations of WNV infection are far more common in adults than in children, but 105 cases of neuroinvasive WNV disease were reported among children in the United States in 2002. The distribution of the virus in North America continues to spread. WNV infection can be diagnosed by detecting WNV-specific antibody in cerebrospinal fluid or serum, or by detecting the virus or viral nucleic acid in cerebrospinal fluid, blood, or tissues. Cornerstones of prevention include personal protection against mosquitoes, including wearing insect repellent, reducing populations of vector mosquitoes, and screening the blood supply for WNV-contaminated blood donations.
Intramedullary Hemorrhage in a Neonate After Lumbar Puncture Resulting in Paraplegia: A Case Report
Authors: Tubbs R. Shane , Smyth Matthew D. , Wellons John C. , Oakes W. Jerry
Published: August 2004

We present the case of a premature infant with decreased spontaneous movement of the lower extremities. Imaging was demonstrative of a lesion of the conus medullaris. Operatively and with histologic confirmation, the mass was determined to be a blood clot originating from the conus. Retrospectively, the patient had a known lumbar puncture. There were no clotting abnormalities in this patient. At long-term follow-up, the child continues to have lower extremity paresis and incontinence of bowel and bladder. Clinicians should consider the lower termination of the conus medullaris in the infant, especially in the preterm infant.
Fathers and Pediatricians: Enhancing Men’s Roles in the Care and Development of Their Children
Authors: Coleman William L. , Garfield Craig ,   Committee on Psychosocial Aspects of Child and Family Health
Published: August 2004

Research substantiates that fathers’ interactions with their children can exert a positive influence on their children’s development. This report suggests ways pediatricians can enhance fathers’ caregiving involvement by offering specific, culturally sensitive advice and how pediatricians might change their office practices to support and increase fathers’ active involvement in their children’s care and development.
Admission and Discharge Guidelines for the Pediatric Patient Requiring Intermediate Care
Authors: Jaimovich David G. ,   Committee on Hospital Care, and Section on Critical Care
Published: August 2004

This Policy Statement was reaffirmed February 2020.

During the past 3 decades, the specialty of pediatric critical care medicine has grown rapidly, leading to a number of pediatric intensive care units opening across the country. Many patients who are admitted to the hospital require a higher level of care than routine inpatient general pediatric care, yet not to the degree of intensity of pediatric critical care; therefore, an intermediate care level has been developed in institutions providing multidisciplinary subspecialty pediatric care. These patients may require frequent monitoring of vital signs and nursing interventions, but usually they do not require invasive monitoring. The admission of the pediatric intermediate care patient is guided by physiologic parameters depending on the respective organ system involved relative to an institution's resources and capacity to care for a patient in a general care environment. This report provides admission and discharge guidelines for intermediate pediatric care. Intermediate care promotes greater flexibility in patient triage and provides a cost-effective alternative to admission to a pediatric intensive care unit. This level of care may enhance the efficiency of care and make health care more affordable for patients receiving intermediate care.
Hospital Stay for Healthy Term Newborns
Authors:   Committee on Fetus and Newborn
Published: August 2004

Decisions regarding the length of hospital stays for newborns and their mothers became driven by financial reimbursement from third-party payers in the 1990s. The Newborns' and Mothers' Health Protection Act of 1996 and a report from the Secretary's Advisory Committee on Infant Mortality acknowledge the importance of physician assessment in determining the timing of each newborn's discharge. The pediatrician's primary role is to ensure the health and well-being of the newborn in the context of the family. It is within this context that this revised statement addresses the short hospital stay (<48 hours after birth) for healthy term newborns.
Application of the Resource-Based Relative Value Scale System to Pediatrics
Authors:   Committee on Coding and Nomenclature
Published: August 2004

In today's rapidly changing health care environment, it is crucial to understand the genesis and principles behind the Medicare Resource-Based Relative Value Scale (RBRVS) physician fee schedule. Many third-party payers, including state Medicaid programs, BlueCross BlueShield, and managed care organizations, use variations of the Medicare RBRVS to determine physician reimbursement and capitation rates. Because the RBRVS fee schedule was created originally for Medicare only, pediatric-specific Current Procedural Terminology (CPT) codes and pediatric practice expense calculations were not included. The American Academy of Pediatrics supports the use of CPT codes and the RBRVS physician fee schedule and continues to work to rectify certain inequities of the RBRVS system as they pertain to pediatrics.
Diagnosis and Management of Acute Otitis Media
Authors:   Subcommittee on Management of Acute Otitis Media
Published: August 2004

This evidence-based clinical practice guideline provides recommendations to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM).

The American Academy of Pediatrics and American Academy of Family Physicians convened a committee composed of primary care physicians and experts in the fields of otolaryngology, epidemiology, and infectious disease. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to AOM. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM.

The guideline provides a specific definition of AOM. It addresses pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures. Decisions were made based on a systematic grading of the quality of evidence and strength of recommendations, as well as expert consensus when definitive data were not available. The practice guideline underwent comprehensive peer review before formal approval by the partnering organizations.

This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.
The Temporal Relationship Between the Onset of Type 1 Diabetes and Celiac Disease: A Study Based on Immunoglobulin A Antitransglutaminase Screening
Authors: Peretti Noel , Bienvenu Françoise , Bouvet Charlotte , Fabien Nicole , Tixier Frédérique , Thivolet Charles , Levy Emile , Chatelain Pierre G. , Lachaux Alain , Nicolino Marc
Published: August 2004

Objective. The association of celiac disease (CD) and type 1 diabetes is now clearly documented. Immunoglobulin A (IgA) antitransglutaminase antibodies were measured to determine the prevalence of celiac disease in a diabetic population of children and to determine the temporal relationship between type 1 diabetes onset and CD.

Methods. We measured IgA antitransglutaminase antibodies using human recombinant antigen in parallel with classical markers (IgA and IgG antigliadin, IgA antiendomysium) in 284 children with diabetes.

Results. In the population studied, the prevalence of CD was 3.9% (11 of 284). Two cases of CD were diagnosed before the onset of diabetes, and in 8 patients, the diagnoses of CD and diabetes were concomitant, suggesting that CD was present before the onset of diabetes. In 1 case, a girl who presented with thyroiditis, serology for CD became positive after diabetes had been diagnosed.

Conclusion. An excellent correlation was observed between IgA antiendomysium and IgA antitransglutaminase antibodies. We therefore propose using IgA antitransglutaminase as a screening test for practical reasons. Furthermore, IgA antitransglutaminase levels and mucosa abnormalities were closely correlated. The presence of antitransglutaminase antibodies should alert pediatricians to the atypical forms of CD. This study indicates that CD is most often present before the onset of diabetes.
Living With Classical Galactosemia: Health-Related Quality of Life Consequences
Authors: Bosch Annet M. , Grootenhuis Martha A. , Bakker Henk D. , Heijmans Hugo S.A. , Wijburg Frits A. , Last Bob F.
Published: August 2004

Objective. Classical galactosemia (McKusick 230400) is an autosomal recessive disorder of galactose metabolism caused by a deficiency of galactose-1-phosphate uridyltransferase (EC 2.7.712). Treatment, consisting of a severe restriction of dietary galactose, is life saving, but most patients develop abnormalities despite this diet. The aim of this study was to study the influence of galactosemia on the patients’ health-related quality of life (HRQoL), on educational levels, and on the specific galactosemia-related concerns of these families.

Methods. Age-specific HRQoL questionnaires, a classical galactosemia-specific questionnaire designed by the authors, and a list of questions regarding educational attainment were handed out or sent to all 75 members of the Dutch Galactosemia Society and their families.

Results. Sixty-three (84%) patients with classical galactosemia from 58 families returned the questionnaire. Concerning HRQoL, significant differences between patients aged 1 to 5 and healthy children were found on the domains of abdominal complaints and communication. Patients aged 8 to 15 years differed from their healthy peers on the domain of cognitive function. Mothers of patients aged 6 to 15 reported a significantly lower HRQoL on the domains of motor and cognitive function. Patients 16 years and older had significant lower scores on the domains of cognitive and social function. The percentage of patients who attend special schools is significantly higher than in the general population, and the educational attainment is significantly lower in patients with classical galactosemia.

Conclusions. This is the first study to describe the HRQoL of patients with classical galactosemia using well-developed and validated instruments in different age groups. The results of the present study indicate that having galactosemia negatively influences the HRQoL. Early and regular evaluation and support of possible cognitive problems should be a major part of the protocol for the follow-up of patients with classical galactosemia.
Exposure to Di-(2-Ethylhexyl) Phthalate Among Premature Neonates in a Neonatal Intensive Care Unit
Authors: Calafat Antonia M. , Needham Larry L. , Silva Manori J. , Lambert George
Published: August 2004

Objective. Premature neonates who spend time in a neonatal intensive care unit may be at increased risk of adverse health effects from exposure to di-(2-ethylhexyl) phthalate (DEHP) because of their increased risk of high exposure, their small body size, and their physical condition. DEHP, a reproductive toxicant in animals, is a major component in polyvinyl chloride (PVC) plastics, which are frequently used in medical tubing and blood storage bags. DEHP is not covalently bound to PVC, and it may be easily released from the PVC medical devices. The objective of this study was to determine whether premature infants who undergo medical procedures, such as blood transfusions, intravenous therapy, enteral and parenteral nutrition support, and dialysis, are at increased risk of exposure to DEHP than the general population. Because of their smaller size, children and especially premature and small infants may receive a larger dose of DEHP on a milligram per kilogram basis than adults when the same-size medical device is used for all ages.

Methods. Premature neonates who seemed to have the potential to be on intravenous infusion for >2 weeks and were expected to survive were eligible for enrollment in the study. We assessed exposure to DEHP in 6 premature newborns by measuring in 41 urine samples the levels of 3 DEHP metabolites: mono-(2-ethylhexyl) phthalate (mEHP), mono-(2-ethyl-5-hydroxyhexyl) phthalate (mEHHP), and mono-(2-ethyl-5-oxohexyl) phthalate (mEOHP).

Results. mEHHP and mEOHP were detected in all 41 urine samples, and mEHP was detected in 33. Because only 33 of the samples had detectable amounts for all 3 metabolites, statistical analyses were limited to those 33. The levels of all 3 DEHP metabolites varied widely, and the urinary mean and median concentrations of mEOHP and mEHHP were 1 order of magnitude higher than those for mEHP. Furthermore, the geometric mean urinary concentrations of mEOHP (1617 ng/mL), mEHHP (2003 ng/mL), and mEHP (100 ng/mL) in these 6 premature infants who underwent intensive therapeutic interventions were found to be severalfold higher than in the US general population (for mEHP, geometric mean in those 6 years and older was 3.43 ng/mL).

Conclusions. This study provides the first quantitative evidence confirming that newborns who undergo intensive therapeutic medical interventions are exposed to higher concentrations of DEHP than the general population. Although the overall benefits of medical procedures using PVC devices outweigh the risks associated with exposure to DEHP, more research is needed to determine whether infants and children who undergo intensive therapeutic interventions using DEHP-containing devices are at higher risk for altered health outcomes than infants and children who undergo similar treatments but are not potentially exposed to DEHP.
Breastfeeding and the Risk of Postneonatal Death in the United States
Authors: Chen Aimin , Rogan Walter J.
Published: August 2004

Objective. Breastfed infants in the United States have lower rates of morbidity, especially from infectious disease, but there are few contemporary studies in the developed world of the effect of breastfeeding on postneonatal mortality. We evaluated the effect of breastfeeding on postneonatal mortality in United States using 1988 National Maternal and Infant Health Survey (NMIHS) data.

Methods. Nationally representative samples of 1204 infants who died between 28 days and 1 year from causes other than congenital anomaly or malignant tumor (cases of postneonatal death) and 7740 children who were still alive at 1 year (controls) were included. We calculated overall and cause-specific odds ratios for ever/never breastfeeding among all children, conducted race and birth weight–specific analyses, and looked for duration–response effects.

Results. Overall, children who were ever breastfed had 0.79 (95% confidence interval [CI]: 0.67–0.93) times the risk of never breastfed children for dying in the postneonatal period. Longer breastfeeding was associated with lower risk. Odds ratios by cause of death varied from 0.59 (95% CI: 0.38–0.94) for injuries to 0.84 (95% CI: 0.67–1.05) for sudden infant death syndrome.

Conclusions. Breastfeeding is associated with a reduction in risk for postneonatal death. This large data set allowed robust estimates and control of confounding, but the effects of breast milk and breastfeeding cannot be separated completely from other characteristics of the mother and child. Assuming causality, however, promoting breastfeeding has the potential to save or delay ~720 postneonatal deaths in the United States each year.
Failure to Thrive and Cognitive Development in Toddlers With Infantile Anorexia
Authors: Chatoor Irene , Surles Jaclyn , Ganiban Jody , Beker Leila , Paez Laura McWade , Kerzner Benny
Published: August 2004

Objective. The goal of this study was to examine the relative contributions of growth deficiency and psychosocial factors to cognitive development in toddlers with infantile anorexia.

Methods. Eighty-eight toddlers, ranging in age from 12 to 33 months, were enrolled in this study. Toddlers were evaluated by 2 child psychiatrists and placed into 1 of 3 groups: infantile anorexia, picky eater, and healthy eater. All 3 groups were matched for age, race, gender, and socioeconomic status (SES). Toddlers underwent nutritional evaluations and cognitive assessments with the Bayley Scales of Infant Development. Toddlers and their mothers were also videotaped during feeding and play interactions, which later were rated independently by 2 observers.

Results. On average, toddlers with infantile anorexia performed within the normal range of cognitive development. However, the Mental Developmental Index (MDI) scores of the healthy eater group (MDI = 110) were significantly higher than those of the infantile anorexia (MDI = 99) and picky eater (MDI = 96) groups. Within the infantile anorexia group, correlations between MDI scores and the toddlers' percentage of ideal body weight approached statistical significance (r = .32). Across all groups, the toddlers' MDI scores were associated with the quality of mother–child interactions, SES level, and maternal education level. Collectively, these variables explained 22% of the variance in MDI scores.

Conclusions. This study demonstrated that psychosocial factors, such as mother–toddler interactions, maternal education level, and SES level, are related to the cognitive development of toddlers with feeding problems and explain more unique variance in MDI scores than nutritional status.
Trichotillomania in Childhood: Case Series and Review
Authors: Tay Yong-Kwang , Levy Moise L. , Metry Denise W.
Published: August 2004

Trichotillomania is a relatively common cause of childhood alopecia. We report our observations of 10 children with trichotillomania seen over a 2-year period at Texas Children's Hospital. Patient ages ranged from 9 to 14 years (mean: 11.3 years) with an equal gender ratio. The duration of hair-pulling ranged from 1 month to 10 years (median: 4.6 months). The scalp alone was affected in 8 cases, the scalp and eyelashes in 1 case, and the eyelashes alone in 1 case. The frontal scalp and vertex were the most common sites affected. Associated findings included nail-biting in 2 cases, “picking” of the skin in 1 case, and headaches in another case. Noted precipitating factors in 3 patients included “stress” at home and school. Associated psychopathology included major depression in 1 case, attention-deficit/hyperactivity disorder in 1 case, and an “anxious and nervous personality” in 1 case. The most important differential diagnosis to exclude from trichotillomania is alopecia areata, which was seen concomitantly in 1 patient and preceded the onset of hair-pulling by 11 months. Eight patients were referred to a child psychologist for additional management, of which 2 were subsequently treated with antidepressant medication. Trichotillomania is a disorder of multifaceted pathology, and an interdisciplinary approach to management is often helpful. The common prepubertal age of onset provides an important opportunity for the pediatrician to lend support to affected patients and their families.
Grand Mal Seizure in a Child 30 Minutes After Cyclogyl (Cyclopentolate Hydrochloride) and 10% Neo-Synephrine (Phenylephrine Hydrochloride) Eye Drops Were Instilled
Authors: Demayo Alan P. , Reidenberg Marcus M.
Published: August 2004

A grand mal seizure is an unexpected, rare adverse event in a child receiving eye drops to dilate the pupils for an eye examination. A case is reported of a convulsion in a 23-month-old boy after he received Cyclogyl (cyclopentolate) and Neo-Synephrine (phenylephrine) eye drops before ophthalmoscopy. His serum sodium was 125 mEq/L, and he had low plasma pseudocholinesterase activity. Children exposed to organophosphate insecticides and other pseudocholinesterase inhibitors may be at risk for cyclopentolate toxicity.
Unilateral Negative-Pressure Pulmonary Edema in an Infant During Bronchoscopy
Authors: Hannania Shai , Barak Michal , Katz Yeshayahu
Published: August 2004

We report here a case of a 3-week-old infant with a lung disease of unknown origin who underwent diagnostic fiber-optic bronchoscopy. During the procedure, she developed unilateral pulmonary edema. Factors that contributed to this complication are discussed along with means to reduce its occurrence.
Intestinal Pseudoobstruction in Kawasaki Disease
Authors: Akikusa Jonathan D. , Laxer Ronald M. , Friedman Jeremy N.
Published: August 2004

Intestinal pseudoobstruction is an uncommon but important manifestation of Kawasaki disease. Its occurrence at the onset or during the course of the disease may confuse the clinical picture and cause delay in diagnosis and treatment. This delay may be responsible for the high rate of coronary artery abnormalities that have been reported in patients with this complication. We suggest that Kawasaki disease be considered in the differential diagnosis of any child presenting with intestinal pseudoobstruction and fever without definable cause.
Fetal Infants: The Fate of 4172 Infants With Birth Weights of 401 to 500 Grams—The Vermont Oxford Network Experience (1996–2000)
Authors: Lucey Jerold F. , Rowan Cherise A. , Shiono Patricia , Wilkinson Andrew R. , Kilpatrick Sarah , Payne Nathaniel R. , Horbar Jeffrey , Carpenter Joseph , Rogowski Jeannette , Soll Roger F.
Published: August 2004

Objective. Improvement in the survival of extremely low birth weight infants requires that we evaluate the limits of our care and assess the impact of treatment on a population of infants who previously rarely survived.

Methods. A review was conducted of demographic and clinical data of infants who had birth weight 401 to 500 g and were entered in the Vermont Oxford Network Database between 1996 and 2000.

Results. A total of 4172 infants who weighed 401–500 g (mean gestational age: 23.3 ± 2.1 weeks) were born at 346 participating centers. Overall, 17% survived until discharge. A total of 2186 (52%) died in the delivery room (DR), and 1986 (48%) were admitted to a neonatal intensive care unit (NICU). Compared with infants who died in the DR, infants who survived the DR and were admitted to the NICU were more likely to be female (58% vs 49%), to be small for gestational age (56% vs 11%), to have received prenatal steroids (61% vs 12%), and to have been delivered by cesarean section (55% vs 5%). Thirty-six percent of NICU admissions survived to discharge. Mean gestational age of the 690 NICU survivors was 25.3 ± 2.0 weeks. These survivors experienced significant morbidity in the NICU.

Conclusions. An appreciable number of these marginally viable fetal infants survive. They experienced a high rate of serious morbidities while in the NICU. There is very little information about long-term outcomes, as the medical and developmental status of few of these infants has been followed carefully. Parents should be made aware of the high incidence of serious problems, and concerted efforts should be made to follow the status of these infants.
Long-Term Ocular Prognosis in 327 Children With Congenital Toxoplasmosis
Authors: Wallon Martine , Kodjikian Laurent , Binquet Christine , Garweg Justus , Fleury Jacques , Quantin Catherine , Peyron François
Published: August 2004

Objective. Retinochoroiditis is the most frequent consequence of congenital toxoplasmosis. Early diagnosis and treatment are believed to reduce the risk of visual impairment. We report on the clinical evolution of ocular lesions and final visual function in a prospective cohort of congenitally infected children who were identified during monthly maternal prenatal screening.

Methods. The study included 327 congenitally infected children who were monitored for up to 14 years at the Croix Rousse Hospital in Lyon, France. Data on date of maternal infection; time and type of therapy; antenatal, neonatal, and postnatal work-ups; and ocular status were analyzed.

Results. All mothers but 52 had been treated. Pyrimethamine and sulfadiazine was given in utero to 38% of children and after birth to 72% of newborns. Fansidar was given for an average duration of 337 days in all but 2 children. After a median follow-up of 6 years, 79 (24%) children had at least 1 retinochoroidal lesion. In 23 (29%) of them, at least 1 new event had been diagnosed up to 10 years after detection of the first lesions: reactivation of an existing lesion (1 case), new lesion in a previously healthy location (19 cases), or both (3 cases). Fifty-five children had lesions in 1 eye; of the 45 children for whom final visual acuity data were available, 31 (69%) had normal vision. Twenty-four children had lesions in both eyes; of the 21 for whom final visual acuity data were available, 11 had normal vision in both eyes. None had bilateral visual impairment.

Conclusions. Clinicians, parents, and elder children with congenital infection should be informed that late-onset retinal lesions and relapse can occur many years after birth but that the overall ocular prognosis of congenital toxoplasmosis is satisfactory when infection is identified early and treated accordingly.
Headache and Backache After Lumbar Puncture in Children and Adolescents: A Prospective Study
Authors: Ebinger Friedrich , Kosel Christina , Pietz Joachim , Rating Dietz
Published: August 2004

Objective. After lumbar puncture, many adults develop headaches or backaches. Postpuncture complaints are believed to be rare in children and adolescents, but their exact incidence is unclear because there is a paucity of data derived from general pediatric patients. In a prospective study of general pediatric and neuropediatric patients, we investigated the frequency of postlumbar puncture headaches or backaches and factors that might influence their occurrence.

Methods. Conducted over 12 months, the prospective study included 112 patients aged 2 to 16 years. We evaluated them for factors that might influence the rate of postpuncture complaints: age, gender, use of local anesthesia, cannula gauge, bevel orientation, number of puncture attempts, volume of cerebrospinal fluid (CSF) aspirated, and cell count in CSF.

Results. Twenty-seven percent of the patients experienced headaches (positional headache in 9%), and 40% developed backache. Frequency of complaints increased in relation to patients' age. In older children, girls reported complaints more frequently than did boys. Patients with higher cell counts in CSF had more frequent headaches than did patients without pleocytosis. Cannula gauge or bevel orientation did not influence outcome.

Conclusion. The frequency of positional and nonpositional headaches after lumbar puncture is lower in children than in adults. Backaches contribute significantly to postpuncture morbidity. With puberty, the incidences of postpuncture complaints increase, and girls start to become more prone to develop postpuncture headaches. Recommendations regarding cannula gauge or bevel orientation that derive from studies in adults are not confirmed for children.