bluuebunny/crossref_metadata_2025 huggingface dataset:
Bicycle Helmet Assessment During Well Visits Reveals Severe Shortcomings in Condition and Fit
Authors: Parkinson Gregory W. , Hike Kelly E.
Published: August 2004

Background. Improper bicycle helmet fit increases the risk of head injury.1 Information on the rate of proper use of bicycle helmets is lacking. Promotion of helmet use is recommended at well-child and adolescent visits.2 Actual helmet assessment during such visits has not been reported.

Objectives. The primary goal of this study is to measure the proportion of children whose helmets are in proper condition and can be made to fit properly by the child and/or parent. The secondary goal is to begin to assess the value and practicality of helmet inspection during well-child and adolescent visits.

Methods. The study took place at a private pediatric office in Falmouth, Massachusetts, from June 1 through August 31, 2001. Eligible children and adolescents were those aged 4 to 18 years presenting for well examination, along with siblings present at the visit. Eligible families completed a questionnaire, then had a timed attempt to fit a helmet, followed by an assessment of helmet fit and condition against a predetermined standard.

Results. Eighty-four percent (395/473) of eligible families participated. A total of 479 participants were assessed. Eighty-eight percent of participants (419/478) owned a helmet. Reported helmet use “always” or “almost always” was 73% for bicycling (317/434), 69% for in-line skating (193/279), 58% for scootering (179/310), and 50% for skateboarding (79/158). Compared with younger children, teenagers were less likely to wear helmets for all activities. Complete pass rate for every aspect of condition and fit was 4% (20/478, 95% confidence interval: 3–6). The pass rate when the parent alone fit the helmet was 0% (0/52). Three individual aspects of fit were most problematic: 1) helmet ‘resting position’ too high on the forehead (pass rate 249/479; 52%), 2) improper strap position (pass rate 157/476; 33%), and 3) excessive movement of the helmet from front to back of the head (pass rate 247/479; 52%). Mean time for questionnaire completion was 4 (standard deviation: ±1) minutes, and 7 (standard deviation: ±3) minutes for helmet assessment.

Conclusions. Ninety-six percent of children and adolescents wore helmets in inadequate condition and/or with inadequate fit. This occurred despite a high acceptance of helmet use by this population. Initial evidence suggests that helmet assessment during well visits may be practical and valuable.
Transcranial Doppler Ultrasonography and Neurocognitive Functioning in Children With Sickle Cell Disease
Authors: Kral Mary C. , Brown Ronald T. , Nietert Paul J. , Abboud Miguel R. , Jackson Sherron M. , Hynd George W.
Published: August 2004

Objective. We examined the relationship between cerebral blood flow velocity, measured by transcranial Doppler (TCD) ultrasonography, and neurocognitive functioning.

Methods. Participants were 60 children who had sickle cell disease (HbSS) and had no documented history of stroke. Children were classified according to Stroke Prevention Trial in Sickle Cell Anemia criteria (normal, conditional, and abnormal), and their performance was compared on measures of intellectual abilities, academic achievement, sustained attention/concentration, executive function, and parent and teacher ratings of executive function.

Results. Children with abnormal TCD values performed more poorly than children with conditional TCD values on measures of verbal intelligence and executive function. Children with conditional TCD values performed more poorly than children with normal TCD values on measures of sustained attention/concentration and executive function. TCD values also were a significant predictor of auditory working memory in exploratory analyses.

Conclusions. Our findings support the hypothesis that neurocognitive functions subserved by the frontal systems (eg, sustained attention/concentration and executive function) seem to be the most useful indices of progressive cerebrovasculopathy in children with HbSS disease.
Mortality and Neurologic, Mental, and Psychomotor Development at 2 Years in Infants Born Less Than 27 Weeks’ Gestation: The Leiden Follow-Up Project on Prematurity
Authors: Rijken Monique , Stoelhorst Gerlinde M. S. J. , Martens Shirley E. , van Zwieten Paul H. T. , Brand Ronald , Maarten Wit Jan , Veen Sylvia
Published: August 2004

Objective. To determine the outcome of infants with a gestational age (GA) <27 weeks, born in the mid-1990s.

Design. Regional, prospective study; part of the Leiden Follow-Up Project on Prematurity.

Setting. Three health regions in The Netherlands.

Patients. A total of 266 live born infants (1996/1997) with GA <32 weeks; 46 infants were <27 weeks.

Main outcome measures. Neurologic examination (according to Hempel) and assessment of mental and psychomotor development using the Bayley Scales of Infant Development I, at the corrected age of 2 years.

Results. Mortality was 35% (16 of 46) <27 weeks, compared with 6% (14 of 220) in infants with GA 27 to 32 weeks; withdrawal of treatment in 60% and 43%, respectively. Below 27 weeks mortality was higher after extra-uterine transport and pregnancy induction. Neonatal morbidity was higher in infants <27 weeks compared with infants 27 to 32 weeks. Below 27 weeks postnatal use of dexamethasone and being hospitalized at term were associated with abnormal neurologic outcome; there was a higher incidence in (mild) mental developmental delay compared with the older infants. Adverse outcome (dead or abnormal neurologic, psychomotor, or mental development) in infants 23 to 24, 25, 26, and 27 to 32 weeks GA was, respectively, 92% (11 of 12), 64% (7 of 11), 35% (8 of 23), and 18% (40 of 220).

Conclusions. Mortality and neonatal morbidity were higher in infants with GA <27 weeks compared with infants born between 27 and 32 weeks. The high adverse outcome of infants <25 weeks suggests that one should carefully weigh whether or not to aggressively resuscitate and treat these extremely premature infants.
Clinical Tolerance to Lactose in Children With Cow’s Milk Allergy
Authors: Fiocchi Alessandro , Restani Patrizia , Leo Gualtiero , Martelli Alberto , Bouygue Gabriel R. , Terracciano Luigi , Ballabio Cristina , Valsasina Renato
Published: August 2004

Objective. Adverse reactions following the ingestion of lactose have been reported in children with cow’s milk (CM) allergy. Whether this is attributable to the contamination of lactose with CM proteins is unknown. In this paper, we assessed clinical tolerance of lactose derived from CM whey in children hypersensitive to CM from 2 university hospital pediatric departments.

Design. Twenty-four children (5 girls and 19 boys, median 25 months old; range: 2–107 months) with immediate CM allergy confirmed at history or during double-blind, placebo-controlled food challenge (DBPCFC) were enrolled. DBPCFC with CM could be conducted in 11 of 24 patients. Children with a history of immediate/delayed reactions to soy formula (SF) were excluded. Clinical tolerance to CM, SF, and SF + lactose was assessed by: 1) skin prick test with casein, lactalbumin, soy commercial allergen preparations, fresh CM, SF, SF and lactose, lactose (Official Pharmacopoeia) in 4 concentrations (0.01%, 0.1%, 1%, 10%); 2) specific serum immunoglobulin E determination by CAP system technology; 3) DBPCFC in 8 incremental doses of SF + lactose and using SF as a placebo to make up a total of 240 mL of reconstituted formula.

Results. With a positive cutoff point of ≥3 mm wheal diameter at SPT, all patients were sensitized to fresh CM, lactalbumin, and/or casein. Twenty-three of 24 patients (95.8%) were SPT-positive to CM formula, 16 of 24 to lactalbumin (66.6%), 14 of 24 to casein (58.3%), and none to SF, SF + lactose, or lactose alone at all dilutions. Complexed immunoglobulin E determinations were positive for CM in 23 of 24 cases and negative in all cases for soy. Challenge with SF + lactose was negative in all cases.

Conclusions. Even children hypersensitive to CM are clinically tolerant to lactose and can safely consume foods and drugs with lactose from bovine sources as an ingredient. Lactose exclusion is unwarranted from soy preparations on grounds of potential allergic reactions to CM protein residue.
Developing Circadian Rhythmicity in Infants
Authors: Rivkees Scott A.
Published: August 2004

Circadian rhythms are endogenously generated rhythms with a period length of approximately 24 hours. Evidence gathered during the past decade indicates that the circadian timing system develops prenatally and the suprachiasmatic nuclei, the site of a circadian clock, is present by midgestation in primates. Recent evidence also shows that the circadian system of primate infants is responsive to light at very premature stages and that low-intensity lighting can regulate the developing clock. After birth, there is progressive maturation of the circadian system outputs, with pronounced rhythms in sleep-wake and hormone secretion generally developing after 2 months of age. Showing the importance of photic regulation of circadian phase in infants, exposure of premature infants to low-intensity cycled lighting results in the early establishment of rest-activity patterns that are in phase with the 24-hour light-dark cycle. With the continued elucidation of circadian system development and influences on human physiology and illness, it is anticipated that consideration of circadian biology will become an increasingly important component of neonatal care.
A Cohort Study of Health Effects of Human T-Cell Lymphotropic Virus Type I Infection in Jamaican Children
Authors: Maloney Elizabeth M. , Wiktor Stefan Z. , Palmer Paulette , Cranston Beverley , Pate Ernest J. , Cohn Sylvia , Kim Norma , Miley Wendell , Thomas Terry L. , Blattner William A. , Hanchard Barrie
Published: August 2004

Objective. Human T-cell lymphotropic virus type I (HTLV-I) infection in childhood is believed to play an important role in risk for adult T-cell leukemia/lymphoma. Although HTLV-I is known to be associated with infective dermatitis in childhood, other HTLV-I-associated morbidity in children has not been well studied. We sought to determine the HTLV-I-associated health effects in Jamaican children.

Methods. We compared incidence rates of several health outcomes in 28 HTLV-I-infected and 280 uninfected children clinically followed from age 6 weeks to a maximum of 10 years. Cox proportional hazards regression analysis was used to analyze these prospectively collected data, adjusting for confounding effects of other variables as necessary.

Results. HTLV-I-infected children had significantly higher incidence rates of seborrheic dermatitis (rate ratio [RR] = 4.8, 95% confidence interval [CI] = 1.9–12.5), eczema (RR = 3.1, CI = 1.2–7.9) and persistent hyperreflexia (RR = 3.7, CI = 1.6–8.2). Additionally, HTLV-I infected children had increased rates of severe anemia (RR = 2.5, CI = 0.8–7.9) and abnormal lymphocytes (RR = 2.4, CI = 0.8–7.6) that were of borderline statistical significance.

Conclusions. Our study suggests that HTLV-I-associated skin diseases of childhood may include seborrheic dermatitis and eczema. Additionally, these data suggest that persistent hyperreflexia of the lower limbs may be an early sign of HTLV-I-associated neurologic involvement in children. Expansion and continued clinical observation of this cohort would be valuable.
Cerebral Embolism From Atrial Myxoma in Pediatric Patients
Authors: Al-Mateen Majeed , Hood Margaret , Trippel Don , Insalaco Samuel J. , Otto Randolph K. , Vitikainen Kari J.
Published: August 2004

We describe 2 children with cerebrovascular events caused by emboli from left atrial myxomas and review 7 other pediatric cases from the literature. Transient cutaneous eruptions involving the extremities preceded the cerebrovascular events and were most likely attributable to fragmentation of the atrial tumor with peripheral embolization. Our first case demonstrates the more common presentation with acute hemiplegia caused by cerebral infarction and the second case a transient ischemic attack manifested by more subtle features as a result of involvement of the vertebrobasilar circulation. Neither child had a history or other signs of cardiac disease. Atrial myxoma should be considered in the differential diagnosis when children present with neurologic symptoms or with signs of embolization, because surgical removal of the tumor is critical and may be curative.
Hospitalization for Asthma: Atopic, Pulmonary Function, and Psychological Correlates Among Participants in the Childhood Asthma Management Program
Authors: Bacharier Leonard B. , Dawson Christopher , Bloomberg Gordon R. , Bender Bruce , Wilson Laura , Strunk Robert C. ,   for the Childhood Asthma Management Program Research Group
Published: August 2004

Background. Asthma in childhood has a significant impact on children and families, in part because of the frequent need for hospital-based care for acute exacerbations. Sensitization and exposure to inhalant allergens have been identified as risk factors for asthma hospitalization.

Objective. The Childhood Asthma Management Program (CAMP), comprised of 1041 children aged 5 to 12 with mild-to-moderate asthma, provides the opportunity to identify specific risk factors for prior hospitalization for asthma.

Methods. Data gathered during the screening period from CAMP were evaluated to elucidate differences between patients who had ever been hospitalized for asthma before enrollment in CAMP and those who had never been hospitalized.

Results. Univariate analyses indicated that prior hospitalization for asthma was associated with a younger age of asthma onset, longer duration of asthma, greater number of positive allergy skin tests, higher serum immunoglobulin E level, greater peripheral blood eosinophilia, greater recent inhaled corticosteroid use, greater airflow obstruction, greater airway hyperresponsiveness, and lower patient intelligence quotient (IQ). Gender, race, and family income did not differ between hospitalized and never-hospitalized patients. The combination of both sensitization and exposure to high levels of dog allergen (Can f1) was associated with greater likelihood of prior hospitalization. Forward multivariate logistic regression analysis identified younger age of asthma onset, longer duration of asthma, recent use of asthma controller therapy, greater airflow obstruction, and lower patient IQ as significant risk factors for prior hospitalization when all risk factors identified by univariate analysis were included in the model.

Conclusions. Children with mild-to-moderate asthma who had a past hospitalization for acute asthma had greater asthma severity, younger age of onset, and lower patient IQ at the time of entry into CAMP. They also had more markers of atopy than children without prior hospitalization, although atopy was not associated with prior hospitalization on multivariate analysis. Although we have identified these risk factors in a retrospective manner, one can speculate that the persistence of these features should alert the clinician to closely follow abnormalities on pulmonary function tests and general features of atopy to potentially identify patients at risk for future hospitalization.
The Effect of Computerized Physician Order Entry on Medication Errors and Adverse Drug Events in Pediatric Inpatients
Authors: King W. James , Paice Naomi , Rangrej Jagadish , Forestell Gregory J. , Swartz Ron
Published: August 2004

Objective. Computerized physician order entry (CPOE) has the potential to reduce patient injury resulting from medication errors. We assessed the impact of a CPOE system on medication errors and adverse drug events (ADEs) in pediatric inpatients.

Design. A retrospective cohort study.

Setting. Tertiary care pediatric hospital.

Participants. Pediatric inpatients on 3 medical and 2 surgical wards.

Intervention. CPOE system implemented on 2 medical wards and compared with 1 medical and 2 surgical wards that continued to use hand written orders.

Outcome Measures. Rate of medication error and ADEs before and after CPOE implementation.

Results. In 6 years, a total of 804 medication errors were identified with 18 ADEs, resulting in patient injury among 36 103 discharges and 179 183 patient days. The overall medication error rate (MER) was 4.49 per 1000 patient days. Before the introduction of CPOE, the MERs of the intervention versus control wards were indistinguishable (ratio = 0.93; 95% confidence interval [CI] = 0.76, 1.13). After the introduction of CPOE, the MER was 40% lower on the intervention than on the control wards (ratio = 0.60; 95% CI = 0.48, 0.74). On average, 490 patient days are required to see the benefit of one less medication error using CPOE. We did not demonstrate a similar effect of CPOE for ADEs (ratio of rate ratios = 1.30; 95% CI 0.47, 3.52).

Conclusions. The introduction of a commercially available physician computer order entry system was associated with a significant decrease in the rate of medication errors but not ADEs in an inpatient pediatric population.
How Helpful Is Pneumatic Otoscopy in Improving Diagnostic Accuracy?
Authors: Jones Woodson S. , Kaleida Phillip H.
Published: August 2004

Background. Pneumatic otoscopy is believed to be helpful in optimally assessing the presence or absence of middle ear effusion (MEE). Although expert clinicians teach the importance of this diagnostic skill to trainees, evidence exists that many pediatric providers do not typically perform pneumatic otoscopy.

Objective. To determine if the otoscopic accuracy within a group of clinicians improves with the pneumatic assessment when compared with the static assessment using videotaped otoendoscopic examinations (VOEs).

Methods. Residents and faculty from 2 pediatric training programs served as subjects. All viewed a set of 50 video otoscopic examinations of tympanic membranes (TMs) from a validated VOE developed previously for training purposes. The video displays each TM in a static presentation and then in a pneumatic (mobile) presentation, followed by a final static presentation. Each subject first viewed the initial static presentation of each TM and responded “yes/no” to the presence of MEE, and then viewed the pneumatic presentation of the same TM and again responded “yes/no” to the presence of MEE. We compared the accuracy of assessment for both the static and the pneumatic tests.

Results. Thirty-four pediatric residents and 6 clinical faculty participated. Accuracy (percent of total test items correct) on the pneumatic test was uniformly greater than accuracy on the static test. The mean absolute improvement in the accuracy from the static test (61%) to the pneumatic test (76%) was 15% (95% confidence interval [CI] = 12%–18%). The mean relative improvement in accuracy from the static test to the pneumatic test was 26% (95% CI = 19%–32%). Higher accuracy on the VOE was associated with greater absolute (r = 0.57) and greater relative (r = 0.47) improvement. The mean relative improvement in sensitivity and specificity from static viewing to pneumatic viewing was 24% (95% CI = 15%–33%) and 42% (95% CI = 27%–58%), respectively.

Conclusions. Using a video otoendoscopic test, we found that accurate identification of both the presence and the absence of MEE improved after pneumatic assessment of TM mobility. Providers who were more accurate at otoscopy, defined by higher video total test scores, benefited more from the pneumatic component than providers with lower scores.
Trends in Otitis Media Among Children in the United States
Authors: Auinger Peggy , Lanphear Bruce P. , Kalkwarf Heidi J. , Mansour Mona E.
Published: August 2004

Background. The prevalence of repeated otitis media (OM) increased during the 1980s, but it is unknown if the increase has continued.

Objectives. To determine trends in the prevalence of OM, early-onset OM, and repeated OM among US children from 1988 to 1994 and to identify factors that may explain any observed changes.

Methods. The Third National Health and Nutrition Examination Survey was administered in 2 phases: phase I (1988–1991) and phase II (1991–1994), each comprising a national probability sample. OM (ever having had OM), early-onset OM (first episode at <12 months of age), and repeated OM (≥3 episodes) were assessed for 8261 children <6 years of age.

Results. After controlling for risk factors for OM, the prevalence of OM from phase I to phase II increased from 66.7% to 69.7% (odds ratio [OR] = 1.1; 95% confidence interval [CI] = .99, 1.1), early-onset OM increased from 41.1% to 45.8% (OR = 1.1; 95% CI = 1.03, 1.2), and repeated OM increased from 34.8% to 41.1% (OR = 1.2; 95% CI = 1.1, 1.4). This observed increase corresponds to 561 000 and 720 000 more children having early-onset OM and repeated OM, respectively. Child care use, early breastfeeding termination, asthma, and access to health care did not significantly increase from phase I to phase II. The prevalence of early-onset OM and repeated OM was higher for affluent children, but the greatest increase in prevalence was among impoverished children. There was an increase in allergic conditions from phase I to phase II for poor children (22.6% to 30.2%).

Conclusions. The prevalence of early-onset OM and repeated OM continued to increase among preschool children in the United States. Further research to investigate this increasing prevalence should explore changes in management practice and an increase in prevalence of allergic conditions among poor children.
Adverse Effects of Smoking on Respiratory Function in Young Adults Born Weighing Less Than 1000 Grams
Authors: Doyle Lex W. , Olinsky Anthony , Faber Brenda , Callanan Catherine
Published: August 2004

Objective. To determine whether active smoking has an adverse impact on respiratory function of young adults of extremely low birth weight (ELBW; birth weight <1000 g).

Methods. This was a cohort study of 60 consecutive ELBW survivors who were born during 1977–1980 at Royal Women’s Hospital, Melbourne, Australia. Respiratory function was measured on 44 (73%) of the subjects at a mean age of 20.2 years (standard deviation: 1.0 year). Respiratory function had also been measured on 42 of the 44 subjects at 8 years of age. Respiratory function was compared between the 14 smokers and the 30 nonsmokers.

Results. Several respiratory function variables reflecting airflow (the forced expired volume in 1 second [FEV1]/forced vital capacity [FVC] ratio; flow rates at 75%, 50%, and 25% of vital capacity; and mid-expiratory flow from 25% to 75% of vital capacity) were significantly diminished in smokers. The proportion with a clinically important reduction in the FEV1/FVC ratio (<75%) was significantly higher in smokers (64%) than in nonsmokers (20%). There was a significantly larger decrease in the FEV1/FVC ratio between ages 8 and 20 years in the smokers (mean change: −8.2%; 95% confidence interval: −14.1% to −2.4%)

Conclusions. Active smoking by young adult survivors of ELBW is associated with reduced respiratory function.
Longitudinal Changes in Growth Parameters Are Correlated With Changes in Pulmonary Function in Children With Cystic Fibrosis
Authors: Peterson Michelle L. , Jacobs David R. , Milla Carlos E.
Published: August 2004

Objective. Nutritional status is associated with pulmonary health and survival in children with cystic fibrosis (CF). This study evaluated the weight gain pattern of children with CF in relation to the longitudinal trends of their pulmonary function. Our hypothesis was that children who experience continuous weight gain at a given rate will have better average forced expiratory volume in 1 second (FEV1) and change in FEV1 than children who have weight gain patterns that deviate from this rate, even when total weight gain seems adequate.

Methods. Prospectively collected data were examined in 319 children, aged 6 to 8, who were routinely followed at the Minnesota Cystic Fibrosis Center. One to 67 measurements of weight (kg), height (cm), and FEV1 (mL) were taken per child during this 2-year period. The data were analyzed by repeated measure regression analysis and by growth pattern analysis.

Results. At baseline, a 1-kg higher initial weight was associated with a 55-mL higher average FEV1. During the follow-up period, a 1-kg gain in weight was associated with an increase in FEV1 by 32 mL. Children who had a steady weight gain tended to experience greater increases in FEV1 than children who experienced periodic losses in weight.

Conclusions. We established that children who weigh more and who gain weight at an appropriate and uninterrupted rate have a better FEV1 trajectory. Aggressive nutritional support to maintain growth in these children may therefore improve FEV1, which can be taken as a surrogate for better lung health, and may ultimately lead to better survival.
Reduction in Antibiotic Use Among US Children, 1996–2000
Authors: Finkelstein Jonathan A. , Stille Christopher , Nordin James , Davis Robert , Raebel Marsha A. , Roblin Douglas , Go Alan S. , Smith David , Johnson Christine C. , Kleinman Kenneth , Chan K. Arnold , Platt Richard
Published: August 2004

Background. High rates of antibiotic prescribing to children contribute to antibiotic resistance in the community. The Centers for Disease Control and Prevention, in collaboration with other national and state level organizations, have actively promoted more judicious prescribing for children.

Objective. We sought to assess changes in the rate of antibiotic prescribing from 1996–2000 in 9 US health plans, patterns of diagnosis and treatment responsible for these trends, and changes in the use of first-line antimicrobial agents.

Design/Methods. We analyzed claims data for dispensed medications and physician visits from 9 health plans. Each provided data on 25 000 children aged 3 months to <18 years enrolled between September 1, 1995, and August 31, 2000. Antibiotic dispensings were linked with an ambulatory visit claim to assign diagnosis. Antibiotic dispensings per person-year (antibiotics/p-y) were calculated for the age groups 3 months to <3 years, 3 years to <6 years, and 6 years to <18 years. The contribution of each diagnosis to changes in the overall rate of antibiotic use was determined. Generalized linear mixed models were used to test for trend and assess differences in rates by site.

Results. From 1996–2000, antibiotic rates for children 3 months to <3 years decreased from 2.46 to 1.89 antibiotics/p-y (24%); for children 3 years to <6 years from 1.47 to 1.09 antibiotics/p-y (25%); and for children 6 to <18 years from 0.85 to 0.69 antibiotics/p-y (16%). The reduction varied among health plans from 6% to 39% for children 3 months to <3 years. A decrease in prescriptions for otitis media accounted for 59% of the total decrease, and was primarily accounted for by a decrease in the rate of diagnosis of this condition. The proportion of first-line penicillins increased from 49% to 53%, with health plans with the lowest initial rates increasing most.

Conclusions. Antibiotic prescribing decreased significantly between 1996 and 2000, concurrent with decreased frequency of diagnosis of potential bacterial infections, especially otitis media. Attention by public health and professional organizations and the news media to antibiotic resistance may have contributed to changes in diagnostic thresholds, resulting in more judicious prescribing.
Neonatal Candidemia and End-Organ Damage: A Critical Appraisal of the Literature Using Meta-analytic Techniques
Authors: Benjamin Daniel K. , Poole Charles , Steinbach William J. , Rowen Judith L. , Walsh Thomas J.
Published: August 2004

Objective. Neonatal candidemia is an increasing cause of infant morbidity and mortality. We evaluated the current medical literature in an effort to critique the literature and to document the reported prevalences of end-organ damage after neonatal candidemia.

Methods. We analyzed all peer-reviewed articles of neonatal candidemia published in the English language; inclusion criteria included a cohort limited to all neonatal intensive care unit admissions or all episodes of candidemia in neonates. Articles that also incorporated older patients, did not define a numerator and a denominator for at least 1 form of end-organ damage, included patients from other reports, or did not include all episodes of candidemia in the source population were excluded from the analysis.

Results. Thirty-four articles reported episodes of candidemia and mortality; 21 articles reported prevalence for at least 1 form of end-organ damage. Only 4 (19%) of 21 articles reported prevalence for >4 forms of end-organ damage from the following list: endophthalmitis, meningitis, brain parenchyma invasion, endocarditis, renal abscesses, positive cultures from other normally sterile body fluids, or hepatosplenic abscesses. The median reported prevalence of endophthalmitis was 3% (interquartile range [IQR]: 0%–17%), of meningitis was 15% (IQR: 3%–23%), of brain abscess or ventriculitis was 4% (IQR: 3%–21%), of endocarditis was 5% (IQR: 0%–13%), of positive renal ultrasound was 5% (IQR: 0%–14%), and of positive urine culture was 61% (IQR: 40%–76%). The medical literature concerning end-organ evaluation after episodes of neonatal candidemia is heterogeneous and consists largely of single-center retrospective studies. Year that the data were collected and prevalence of neonates infected with Candida albicans were associated with observed heterogeneity.

Conclusions. Given the heterogeneity of the medical literature, precise estimates of the frequencies of end-organ damage are not possible and a prospective multicenter trial is warranted, but the data from the published literature suggest that the prevalence of neonates with end-organ damage not only is greater than 0 but also is high enough that until such a prospective trial is completed, end-organ studies should be considered before the conclusion of antifungal therapy.
Family-Centered Care and the Pediatrician’s Role
Authors:   Committee on Hospital Care
Published: August 2004

Drawing on several decades of work with families, pediatricians, other health care professionals, and policy makers, the American Academy of Pediatrics provides a definition of family-centered care. In pediatrics, family-centered care is based on the understanding that the family is the child’s primary source of strength and support. Further, this approach to care recognizes that the perspectives and information provided by families, children, and young adults are important in clinical decision making. This policy statement outlines the core principles of family-centered care, summarizes the recent literature linking family-centered care to improved health outcomes, and lists various other benefits to be expected when engaging in family-centered pediatric practice. The statement concludes with specific recommendations for how pediatricians can integrate family-centered care in hospitals, clinics, and community settings as well as in more broad systems of care.
Fatal Lumbar Puncture: Fact Versus Fiction—An Approach to a Clinical Dilemma
Authors: Oliver William J. , Shope Thomas C. , Kuhns Lawrence R.
Published: August 2004

Recent reports and commentaries have emphasized the alleged risk of cerebral herniation complicating lumbar puncture performed to diagnose acute bacterial meningitis. Instead, knowledge of facts relevant to the disease process can provide a rational and reassuring approach to management. All cases of purulent meningitis are associated with increased intracranial pressure, but herniation is a rare complication (5%). Despite suggestions to the contrary, cranial computed tomography (CT) is normal in most cases of purulent meningitis, including those with subsequent herniation. Additionally, CT may be associated with long-term radiation effects. An accurate clinical history combined with recognition of the early systemic and neurologic findings of bacterial meningitis will indicate a safe setting for performance of a diagnostic lumbar puncture with little likelihood of complicating herniation. In contrast, in patients in whom the disease process has progressed to the neurologic findings associated with impending cerebral herniation, a delay of the diagnostic procedure is indicated. In this latter circumstance, a different approach in management can be developed.
Partial Pressure of Carbon Dioxide in Extremely Low Birth Weight Infants Supported by Nasal Prongs Continuous Positive Airway Pressure
Authors: Nguyen An T. , Aly Hany , Milner Joshua , Patel Kantilal M. , El-Mohandes Ayman
Published: August 2004

Objective. Traditionally, delivery room management of extremely low birth weight (ELBW) infants consisted of immediate intubation and mechanical ventilation. There have been recent reports of success using nasal prongs continuous positive airway pressure (NCPAP) in this population. Data on the partial pressure of carbon dioxide (Pco2) in spontaneously breathing ELBW infants is very limited. The objective of this study was to determine the trend of the average Pco2 in the spontaneously breathing ELBW infants, while on NCPAP, during the first week of life and to determine whether a brief period of mechanical ventilation affects the Pco2 levels after extubation.

Methods. This is a retrospective cohort study of infants who had birth weights <1000 g and were admitted to the neonatal intensive care unit at our institution. These ELBW infants were divided into groups on the basis of whether they were never intubated (group 1) or were intubated for <48 hours (group 2). Average daily Pco2 levels while on NCPAP were compared between the 2 groups. Minimum and maximum Pco2 levels were also compared with a third group of infants (group 3), who were intubated for >48 hours and treated mainly with mechanical ventilation during the first week of life.

Results. Sixty-two ELBW infants were included in this study: 24 infants in group 1, 19 infants in group 2, and 19 infants in group 3. There was no significant difference between the average Pco2 levels of group 1 and group 2 during the first week of life. The daily Pco2 level during the first week of life for infants who were breathing spontaneously on NCPAP had a mean value of 39.73 ± 1.78 mm Hg. There was no difference between the daily average minimum Pco2 levels among the 3 groups. Group 3, however, had significantly higher maximum Pco2 levels compared with the first 2 groups during days 2 through 7 of life.

Conclusions. Daily average Pco2 levels in the spontaneously breathing ELBW infants during the first week of life remains at approximately 40 mm Hg. These levels seem to be unaffected by an initial brief period of mechanical ventilation. Infants who are treated with longer periods of mechanical ventilation have higher daily maximum Pco2 levels during the first week of life. Additional studies are required to detect neurodevelopmental outcomes of these 3 groups.
Nelfinavir Pharmacokinetics in Stable Human Immunodeficiency Virus-Positive Children: Pediatric AIDS Clinical Trials Group Protocol 377
Authors: Floren Leslie Carstensen , Wiznia Andrew , Hayashi Sandra , Jayewardene Anura , Stanley Kenneth , Johnson George , Nachman Sharon , Krogstad Paul , Aweeka Francesca T. ,   the Pediatric ACTG 377 Protocol Team
Published: August 2004

Objective. Pharmacokinetic data obtained from children who have human immunodeficiency virus (HIV) infection are essential for the safe and effective use of antiretroviral agents in pediatric populations. The objective of this study was to assess the impact of body weight on the pharmacokinetic disposition of nelfinavir (NFV) in the absence and presence of nevirapine (NVP) and compare the pharmacokinetic profiles of twice-daily (BID) and three-times-daily (TID) NFV regimens.

Methods. This was an intensive pharmacokinetic substudy nested in a phase II, multicenter, randomized, open-label trial. Forty-five HIV-infected children receiving NFV 30 mg/kg TID and 6 HIV-infected children receiving NFV 55 mg/kg BID were enrolled in this study and assigned to 1 of 4 stavudine-containing regimens, 3 containing NFV and 2 containing NVP. Area under the plasma concentration-time curves from 0 to 8 hours (AUC0–8 hours) and from 0 to 12 hours (AUC0–12 hours) for the TID and BID regimens, respectively, were determined. For comparative purposes, the AUC0–24 hours was also calculated for each regimen.

Results. NFV exposure in the absence of NVP was decreased in children who were <25 kg compared with those who were >25 kg (a 2.6-fold difference in median AUC0–8 hours). NFV pharmacokinetics in the presence of NVP did not differ between the <25 kg and >25 kg groups. The AUC0–24 hours for children who were <30 kg and on NFV BID was comparable to the AUC0–24 hours for children who were >25 kg and on NFV TID but was 2.7-fold greater than AUC0–24 hours for children who were <25 kg and on NFV TID.

Conclusions. NFV in the absence of NVP resulted in less than half the drug exposure in children who were <25 kg compared with children who were >25 kg. NFV dosed at 55 mg/kg BID in children who are <30 kg provides comparable exposure to that measured in children who are >25 kg and receiving NFV 30 mg/kg TID.
Neuroimaging of Intraparenchymal Lesions Predicts Outcome in Shaken Baby Syndrome
Authors: Bonnier Christine , Nassogne Marie-Cécile , Saint-Martin Christine , Mesples Bettina , Kadhim Hazim , Sébire Guillaume
Published: August 2004

Objective. Studies of long-term outcome on nonaccidental head injury (NAHI) in young children have shown severe neurodevelopmental sequelae in most cases. For improving the knowledge of outcome and for identifying prognostic factors, additional clinical and cerebral imaging data are needed. The aim of this study was to describe clinical and imaging features over time and to consider their value for predicting neurodevelopmental outcome.

Methods. A retrospective medical record review was conducted of 23 children with confirmed NAHI, for whom an extended follow-up of 2.5 to 13 years (mean: 6 years) was contemplated. Glasgow Coma Scale scores, severity of retinal hemorrhages, presence of skull fractures, cranial growth deceleration, and sequential neuroimaging data (computed tomography and/or magnetic resonance imaging) were compared with patterns of clinical evolution assessed by the Glasgow Outcome Scale.

Results. Clinical outcome showed that 14 (61%) children had severe disabilities, 8 (35%) had moderate disabilities, and 1 (4%) was normal. A low initial Glasgow Coma Scale score, severe retinal hemorrhages, presence of skull fracture, and cranial growth deceleration were significantly associated with poor developmental outcome. Eighteen of the 23 patients had abnormal magnetic resonance imaging scans. This examination disclosed atrophy when performed beyond 15 days of injury. Atrophy seemingly resulted from various brain lesions, namely, contusions, infarcts, and other lesions within the white matter. Presence of intraparenchymal brain lesions within the first 3 months was significantly associated with neurodevelopmental impairment. Severity of motor and cognitive dysfunctions was related to the extent of intraparenchymal lesions.

Conclusions. Early clinical and radiologic findings in NAHI are of prognostic value for neurodevelopmental outcome.
Are Minority Children Under- or Overrepresented in Pediatric Research?
Authors: Walsh Catherine , Ross Lainie F.
Published: August 2004

Objectives. There is extensive documentation that minority adults are underrepresented in medical research, but there are scant data regarding minority children and their parents.

Methods. All full-length articles published in the paper edition of 3 general pediatric journals between July 1999 and June 2000 were collected and reviewed. Articles were excluded when they did not include at least 1 US researcher, all subjects at US institutions, parents or children as subjects, some prospective data collection, or between 8 and 10 000 subjects. We recorded the number and race/ethnicity (R/E) of all subjects, the type of research, and the type of data collected. Corresponding authors were surveyed to clarify R/E data.

Results. A total of 192 studies qualified. R/E data were reported in 114 (59%) studies, and survey data provided additional or new information in 25 studies resulting in R/E data in 128 (67%) articles accounting for 75% of the subjects. R/E was described by >10 different labels. There was an overrepresentation of black subjects and an underrepresentation of white and Hispanic subjects compared with the census data. When compared with research participation of child subjects, generally, black children were overrepresented and Hispanic children were underrepresented in clinical trials, and both were underrepresented in therapeutic research. Black and Hispanic children were overrepresented in potentially stigmatizing research.

Conclusions. Overall, we found an overrepresentation of black subjects and an underrepresentation of white and Hispanic subjects with significant variations depending on the type of research.
A Young Infant With Severe Acute Respiratory Syndrome
Authors: Sit Sou C. , Yau Eric K. C. , Lam Yuen Y. , Ng Daniel K. K. , Fong Nai C. , Hui Yim W. , Cheng Wai F. , Leung Chi W. , Chiu Man C.
Published: August 2004

Severe acute respiratory syndrome (SARS), a new contagious respiratory disease associated with a novel coronavirus, has spread worldwide and become a global health concern after its first outbreak in Guangdong Province of the People’s Republic of China in November 2002. The clinical presentation and the radiologic, hematologic, biochemical, and microbiologic findings of a 56-day-old male infant with SARS are described. Some clinical and laboratory features are similar to those reported in adult and pediatric patients. However, this infant had a more severe clinical course as compared with the older children. This is the youngest patient with symptomatic SARS reported to date.
Children Hospitalized With Severe Acute Respiratory Syndrome-Related Illness in Toronto
Authors: Bitnun Ari , Allen Upton , Heurter Helen , King Susan M. , Opavsky Mary Anne , Ford-Jones Elizabeth L. , Matlow Anne , Kitai Ian , Tellier Raymond , Richardson Susan , Manson David , Babyn Paul , Read Stanley ,   Other Members of the Hospital for Sick Children SARS Investigation Team
Published: August 2004

Objective. An outbreak of severe acute respiratory syndrome (SARS) occurred in the greater Toronto area between February and June 2003. We describe the clinical, laboratory, and epidemiologic features of children who were admitted to the Hospital for Sick Children, Toronto, with a presumptive diagnosis of suspect or probable SARS.

Methods. A prospective investigational study protocol was established for the management of children with a presumptive diagnosis of suspect or probable SARS. All were ultimately classified as having probable SARS, suspect SARS, or another cause on the basis of their epidemiologic exposure, clinical and radiologic features, and results of microbiologic investigations.

Results. Twenty-five children were included; 10 were classified as probable SARS and 5 were classified as suspect SARS, and in 10 another cause was identified. The exposure consisted of direct contact with at least 1 adult probable SARS case in 11 children, travel from a World Health Organization-designated affected area in Asia in 9 children, and presence in a Toronto area hospital in which secondary SARS spread had occurred in 5 children. The predominant clinical manifestations of probable cases were fever, cough, and rhinorrhea. With the exception of 1 teenager, none of the children developed respiratory distress or an oxygen requirement, and all made full recoveries. Mild focal alveolar infiltrates were the predominant chest radiograph abnormality. Lymphopenia; neutropenia; thrombocytopenia; and elevated alanine aminotransferase, aspartate aminotransferase, and creatine kinase were present in some cases. Nasopharyngeal swab specimens were negative for the SARS-associated coronavirus by an in-house reverse transcriptase-polymerase chain reaction in all 25 children.

Conclusions. Our results indicate that SARS is a relatively mild and nonspecific respiratory illness in previously healthy young children. The presence of fever in conjunction with a SARS exposure history should prompt one to consider SARS as a possible diagnosis in children irrespective of the presence or absence of respiratory symptoms. Reverse-transcriptase polymerase chain reaction analysis of nasopharyngeal specimens seems to be of little utility for the diagnosis of SARS during the early symptomatic phase of this illness in young children.
Parental Knowledge, Attitudes, and Practices Associated With Not Receiving Hepatitis A Vaccine in a Demonstration Project in Butte County, California
Authors: Bardenheier Barbara , González Idalia M. , Washington Michael L. , Bell Beth P. , Averhoff Francisco , Massoudi Mehran S. , Hyams Insu , Simard Edgar P. , Yusuf Hussain
Published: August 2004

Objective. To determine hepatitis A vaccination coverage and factors associated with not receiving hepatitis A vaccine among children.

Methods. A random cluster sample survey was conducted of parents of children who attended kindergarten in Butte County, California, in 2000. Because of a history of recurrent epidemics, an aggressive hepatitis A vaccination program was ongoing during the time this study was conducted. Receipt of 1 or 2 doses of hepatitis A vaccine was studied.

Results. Of 896 surveys sent, 648 (72%) were completed. The vaccination coverage for at least 1 dose of hepatitis A vaccine was 398 (62%) and for 2 doses was 272 (42%). Factors associated with not receiving the vaccine included lack of provider recommendation (vs having recommendation; odds ratio [OR]: 7.8; 95% confidence interval [CI]: 4.9–12.2), not having heard of the vaccine (OR: 2.4; 95% CI: 1.2–4.9), and parent’s not perceiving child is likely to get hepatitis A (vs perceiving child might get disease; OR: 2.1; CI: 1.6–2.9).

Conclusions. Vaccination coverage among kindergartners did not reach high levels (ie, >90%), despite aggressive vaccination efforts in this community. Lack of provider recommendation and lack of parental awareness of hepatitis A vaccine were the 2 most significant factors associated with failure to receive vaccine. These findings will facilitate the development of vaccination strategies for communities in which hepatitis A vaccination is recommended.