bluuebunny/crossref_metadata_2025 huggingface dataset:
Condom Use by Adolescents
Authors:   Committee on Adolescence
Published: August 2004

The use of condoms as part of the prevention of unintended pregnancies and sexually transmitted diseases (STDs) in adolescents is evaluated in this policy statement. Sexual activity and pregnancies decreased slightly among adolescents in the 1990s, reversing trends that were present in the 1970s and 1980s, while condom use among adolescents increased significantly. These trends likely reflect initial success of primary and secondary prevention messages aimed at adolescents. Rates of acquisition of STDs and human immunodeficiency virus (HIV) among adolescents remain unacceptably high, highlighting the need for continued prevention efforts and reflecting the fact that improved condom use can decrease, but never eliminate, the risk of acquisition of STDs and HIV as well as unintended pregnancies. While many condom education and availability programs have been shown to have modest effects on condom use, there is no evidence that these programs contribute to increased sexual activity among adolescents. These trends highlight the progress that has been made and the large amount that still needs to be accomplished.
Principles of Patient Safety in Pediatrics
Authors:   National Initiative for Children's Health Care Quality Project Advisory Committee
Published: August 2004

The American Academy of Pediatrics and its members are committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults. In response to a 1999 Institute of Medicine report on building a safer health system, a set of principles was established to guide the profession in designing a health care system that maximizes quality of care and minimizes medical errors through identification and resolution. This set of principles provides direction on setting up processes to identify and learn from errors, developing performance standards and expectations for safety, and promoting leadership and knowledge.
The Effects of Environmental Tobacco Smoke on Health Services Utilization in the First Eighteen Months of Life
Authors: Lam Tai-Hing , Leung Gabriel M. , Ho Lai-Ming
Published: August 2004

Objective.

To examine the effects of environmental tobacco smoke (ETS) on health services use in Chinese infants with nonsmoking mothers.

Design.

Prospective, population-based birth cohort.

Setting.

General population of Hong Kong in 1997–1998.

Participants.

A total of 8327 parent–infant pairs who were followed up for 18 months.

Main Outcome Measures.

Doctor consultations and hospitalizations.

Results.

After adjusting for the age, education level, and employment status of mothers—as well as infants' birth weight, method of delivery, breastfeeding status, and birth order—ETS exposure through the mother in utero was positively associated with higher consultation (adjusted odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.14, 1.39) and hospitalization (OR: 1.18; 95% CI: 1.05, 1.31) use in infants with nonsmoking mothers attributable to any illness. In addition, postnatal exposure to ETS at home was linked to higher rates of hospitalizations for any illness compared with nonexposed infants (OR: 1.12; 95% CI: 1.00, 1.25), although the relationship did not hold for outpatient consultation visits. The OR for higher hospital use in infants exposed to 2 or more smokers at home was 1.30 (95% CI: 1.08, 1.58).

Conclusions.

The use of tobacco products by household members, even among nonsmoking mothers, has an enormous adverse impact on the health of children, as well as increases health services use and cost. The present data support the revision of public policy to reflect an evidence-based approach to the promotion of smoking cessation in all household members during and after pregnancy. environmental tobacco smoke, health services, infants.
Deaths Attributed to Pediatric Complex Chronic Conditions: National Trends and Implications for Supportive Care Services
Authors: Feudtner Chris , Hays Ross M. , Haynes Gerri , Geyer J. Russell , Neff John M. , Koepsell Thomas D.
Published: August 2004

Background.

Children with complex chronic conditions (CCCs) might benefit from pediatric supportive care services, such as home nursing, palliative care, or hospice, especially those children whose conditions are severe enough to cause death. We do not know, however, the extent of this population or how it is changing over time.

Objectives.

To identify trends over the past 2 decades in the pattern of deaths attributable to pediatric CCCs, examining counts and rates of CCC-attributed deaths by cause and age (infancy: <1 year old, childhood: 1–9 years old, adolescence or young adulthood: 10–24 years old) at the time of death, and to determine the average number of children living within the last 6 months of their lives.

Design/Methods.

We conducted a retrospective cohort study using national death certificate data and census estimates from the National Center for Health Statistics. Participants included all people 0 to 24 years old in the United States from 1979 to 1997. CCCs comprised a broad array of International Classification of Diseases, Ninth Revision codes for cardiac, malignancy, neuromuscular, respiratory, renal, gastrointestinal, immunodeficiency, metabolic, genetic, and other congenital anomalies. Trends of counts and rates were tested using negative binomial regression.

Results.

Of the 1.75 million deaths that occurred in 0- to 24-year-olds from 1979 to 1997, 5% were attributed to cancer CCCs, 16% to noncancer CCCs, 43% to injuries, and 37% to all other causes of death. Overall, both counts and rates of CCC-attributed deaths have trended downward, with declines more pronounced and statistically significant for noncancer CCCs among infants and children, and for cancer CCCs among children, adolescents, and young adults. In 1997, deaths attributed to all CCCs accounted for 7242 infant deaths, 2835 childhood deaths, and 5109 adolescent deaths. Again, in 1997, the average numbers of children alive who would die because of a CCC within the ensuing 6-month period were 1097 infants, 1414 children, and 2548 adolescents or young adults.

Conclusions.

Population-based planning of pediatric supportive care services should use measures that best inform our need to provide care for time-limited events (perideath or bereavement care) versus care for ongoing needs (home nursing or hospice). Pediatric supportive care services will need to serve patients with a broad range of CCCs from infancy into adulthood.
Reducing Antibiotic Use in Children: A Randomized Trial in 12 Practices
Authors: Finkelstein Jonathan A. , Davis Robert L. , Dowell Scott F. , Metlay Joshua P. , Soumerai Stephen B. , Rifas-Shiman Sheryl L. , Higham Margaret , Miller Zachary , Miroshnik Irina , Pedan Alex , Platt Richard
Published: August 2004

Objective.

To test whether an educational outreach intervention for families and physicians, based on the Centers for Disease Control and Prevention (CDC) principles of judicious antibiotic use, decreases antimicrobial drug prescribing for children younger than 6 years old.

Setting.

Twelve practices affiliated with 2 managed care organizations (MCOs) in eastern Massachusetts and northwest Washington State.

Patients.

All enrolled children younger than 6 years old.

Methods.

Practices stratified by MCO and size were randomized to intervention or control groups. The intervention included 2 meetings of the practice with a physician peer leader, using CDC-endorsed summaries of judicious prescribing recommendations; feedback on previous prescribing rates were also provided. Parents were mailed a CDC brochure on antibiotic use, and supporting materials were displayed in waiting rooms. Automated enrollment, ambulatory visit, and pharmacy claims were used to determine rates of antibiotic courses dispensed (antibiotics/person-year) during baseline (1996–1997) and intervention (1997–1998) years. The primary analysis (for children 3 to <36 months and 36 to <72 months) assessed the impact of the intervention among children during the intervention year, controlling for covariates including patient age and baseline prescription rate. Confirmatory analyses at the practice level were also performed.

Results.

The practices cared for 14 468 and 13 460 children in the 2 study years, respectively; 8815 children contributed data in both years. Sixty-two percent of antibiotic courses were dispensed for otitis media, 6.5% for pharyngitis, 6.3% for sinusitis, and 9.2% for colds and bronchitis. Antibiotic dispensing for children 3 to <36 months old decreased 0.41 antibiotics per person-year (18.6%) in intervention compared with 0.33 (11.5%) in control practices. Among children 36 to <72 months old, the rate decreased by 0.21 antibiotics per person-year (15%) in intervention and 0.17 (9.8%) in control practices. Multivariate analysis showed an adjusted intervention effect of 16% in the younger and 12% in the older age groups. The direction and approximate magnitude of effect were confirmed in practice-level analyses.

Conclusions.

A limited simultaneous educational outreach intervention for parents and providers reduced antibiotic use among children in primary care practices, even in the setting of substantial secular trends toward decreased prescribing. Future efforts to promote judicious prescribing should continue to build on growing public awareness of antibiotic overuse.
Effects of Medicaid Managed Care on Health Care Use: Infant Emergency Department and Ambulatory Services
Authors: Alessandrini Evaline A. , Shaw Kathy N. , Bilker Warren B. , Perry Katherine A. , Baker M. Douglas , Schwarz Donald F.
Published: August 2004

Objective.

Many urban children rely on emergency departments (ED) for ambulatory care. The objective of this study was to determine whether enrollment in Medicaid managed care (MMC) alters ED or other ambulatory care compared with fee-for-service Medicaid (FFSM).

Methods.

A prospective cohort study of infants born between May 1994 and April 1995 with a 6-month follow-up period was conducted in an urban, teaching hospital and surrounding ambulatory settings. A consecutive sample of 644 infants enrolled in MMC or FFSM was studied; 92% of eligible patients were enrolled, and 94% completed follow-up. The main outcome measures were 1) proportion of patients in each group visiting an ED, primary care practitioner (PCP), or specialist; 2) mean number of visits per group; and 3) ED reliance (EDR) defined as the proportion of all ambulatory visits occurring in an ED.

Results.

Fifty-six percent of MMC and 54% of FFSM patients visited an ED (relative risk: 1.03; 95% confidence interval [CI]: 0.83, 1.27). More MMC patients had a sick visit to their PCP (relative risk: 1.34; 95% CI: 1.03, 1.74); no difference in proportion with well-child or specialty visits was found. Although the mean number of total ambulatory, ED, and specialty visits was the same, MMC patients had fewer well-child and more sick visits to the PCP than FFSM patients (P = .01). EDR was 21% for both groups (P = .95). After adjustment for other factors in multivariate analysis, insurance status remained unassociated with EDR (adjusted odds ratio [OR]: 0.91; 95% CI: 0.56, 1.69). Factors associated with EDR included United States-born mother (OR: 5.34; 95% CI: 1.61, 17.68) and use of a hospital-based primary care physician (OR: 2.00; 95% CI: 1.34, 2.98). Variables that characterized infants who were less likely to be ED reliant included adequate maternal prenatal care (OR: 0.52; 95% CI: 0.34, 0.78) and having a mother who completed high school (OR: 0.67; 95% CI: 0.45, 0.99).

Conclusions.

Enrollment in MMC did not alter ED usage patterns when compared with FFSM. Some variation in use of other ambulatory services was detected.
School Difficulties in 20-Year-Olds Who Were Born Small for Gestational Age at Term in a Regional Cohort Study
Authors: Larroque Béatrice , Bertrais Sandrine , Czernichow Paul , Léger Juliane
Published: August 2004

Objective.

To investigate the relation between school difficulties and being born small for gestational age (SGA) at full term in adolescents and young adults.

Methods.

A total of 236 full-term singletons who were born SGA (birth weight and/or length below the third percentile) from 1971 through 1978 and 281 full-term singletons who were born appropriate for gestational age (AGA; between the 25th and 75th percentiles) from the maternity registry of Haguenau, France. Participants were evaluated at a mean age of 20.6 (±2.1) years. The outcomes measured were late entry into secondary school (normal age: 11 years) and failure to take or pass the baccalaureate examination at the end of secondary school (normal age: 18 years).

Results.

Late entry into secondary school was more frequent for the SGA than the AGA children (odds ratio: 2.3) after adjustment for maternal age and educational level, parental socioeconomic status, family size, and gender. A significantly higher proportion of term SGA adolescents failed to take or pass the baccalaureate examination than AGA adolescents (odds ratio: 1.6). SGA participants with a smaller head circumference entered secondary school late more often than SGA participants with a larger head circumference, but the association was not significant after adjustment.

Conclusion.

Being born SGA at term is associated with poorer school performance at 12 and 18 years. Fetal adaptation to conditions that retard growth during gestation may not be successful in maintaining brain development.
A Prospective Randomized, Controlled Trial Comparing Synchronized Nasal Intermittent Positive Pressure Ventilation Versus Nasal Continuous Positive Airway Pressure as Modes of Extubation
Authors: Khalaf M. Nabeel , Brodsky Nancy , Hurley John , Bhandari Vineet
Published: August 2004

Objective.

To determine whether synchronized nasal intermittent positive pressure ventilation (SNIPPV) would decrease extubation failure compared with nasal continuous positive airway pressure (NCPAP) in preterm infants being ventilated for respiratory distress syndrome (RDS).

Methods.

Infants who were ≤34 weeks' gestational age and who were ventilated for RDS were randomized to either SNIPPV or NCPAP after extubation. The criteria for extubation were peak inspiratory pressure of ≤16 cm H2O, positive end expiratory pressure of ≤5 cm H2O, intermittent mandatory ventilation rate of 15 to 25, and fraction of inspired oxygen ≤0.35. Pulmonary function tests (PFT) were obtained before extubation. After extubation, blood gases were monitored for a minimum of 72 hours. Success was defined as remaining in the selected mode of treatment or demonstrating improvement (switching to oxyhood/nasal cannula/room air) by 72 hours.

Results.

Thirty-two (94%) of 34 infants were extubated successfully with the use of SNIPPV versus 18 (60%) of 30 with the use of NCPAP (P < .01). There was no difference in apnea/bradycardia episodes in the 2 groups during the 72-hour study period. Among 55 infants who had PFT, 80% (8 of 10) with dynamic lung compliance of ≥0.5 mL/kg/cm H2O and expiratory airway resistance of ≤70 cm H2O/L/s were extubated successfully. In infants with poor lung function (dynamic lung compliance: <0.5 mL/kg/cm H2O; expiratory airway resistance: >70 cm H2O/L/s), successful extubation was seen in 93% (27 of 29) in the SNIPPV group and 60% (15 of 25) in the NCPAP group. When weight was controlled for at the time of extubation, the odds of success in the SNIPPV group were 21.1 times higher (95% confidence interval: 3.4, 130.1) than that of the NCPAP group.

Conclusions.

SNIPPV is more effective than NCPAP in weaning infants with RDS from the ventilator. PFT may be useful in predicting successful extubation.
Attitudes of Parents and Health Care Professionals Toward Active Treatment of Extremely Premature Infants
Authors: Streiner David L. , Saigal Saroj , Burrows Elizabeth , Stoskopf Barbara , Rosenbaum Peter
Published: August 2004

Objectives.

To compare the attitudes of neonatologists, neonatal nurses, the parents of extremely low birth weight (ELBW) children, and the parents of normal birth weight children toward saving infants of borderline viability and who should be involved in the decision-making process and to compare physicians' and nurses' estimates of the proportion of infants who are born at various gestational ages with regard to survival, morbidity, and treatment.

Methods.

A questionnaire was given to 169 parents of ELBW children and 123 parents of term children, who were part of a longitudinal study of the outcome of ELBW infants. A similar questionnaire was completed by 98 Canadian neonatologists and 99 neonatal nurses.

Results.

Physicians tended to be more optimistic than nurses regarding the probability of survival and freedom from serious disabilities and would recommend to parents life-saving interventions for their child at earlier gestational ages. A significant majority of parents believed that attempts should be made to save all infants, irrespective of condition or weight at birth, compared with only 6% of health professionals who endorsed this. In contrast to parents, health professionals believed that economic costs to society should be a factor in deciding whether to save an ELBW infant. However, health professionals did not believe that the economic status of the parents should be a factor, although the stress of raising an infant with disabilities should be. Most respondents believed that the parents and physicians should make the final decision but that other bodies, such as ethics committees or the courts, should not.

Conclusion.

Health care professionals must recognize that their attitudes toward saving ELBW infants differ from those of parents. Parents, whether of term or extremely premature children, are more in favor of intervening to save the infant irrespective of its weight or condition at birth than are professionals. It therefore is imperative that there be joint decision making, combining the knowledge of the physician with the wishes of the parents.
Congenital Autoimmune Neutropenia in Two Premature Neonates
Authors: Calhoun Darlene A. , Rimsza Lisa M. , Burchfield David J. , Millsaps Melinda , Christensen Robert D. , Budania Jyoti , McCullough Jeffrey
Published: August 2004

Autoimmune neutropenia (AIN) has been reported in infants and children, but not in neonates. AIN is caused by antibodies produced by the patient against their own neutrophils; therefore, it differs from the more common alloimmune neonatal neutropenia and the neonatal neutropenia because of a maternal autoimmune disease in which antineutrophil antibodies of maternal origin cross the placenta. We observed 2 cases of congenital AIN in premature neonates. These are the youngest reported cases, and indicate that AIN can have a prenatal onset. Examination of the bone marrow biopsies revealed an increase in B lymphocytes and myeloperoxidase-positive cells with a maturation arrest at the myelocyte stage. Recombinant human granulocyte colony-stimulating factor effectively treated the neutropenia, as it does in infantile AIN. Ten months after the diagnosis, 1 of the patients still requires recombinant human granulocyte colony-stimulating administration.
Allopurinol Neurocardiac Protection Trial in Infants Undergoing Heart Surgery Using Deep Hypothermic Circulatory Arrest
Authors: Clancy Robert R. , McGaurn Susan A. , Goin James E. , Hirtz Deborah G. , Norwood William I. , Gaynor J. William , Jacobs Marshall L. , Wernovsky Gil , Mahle William T. , Murphy John D. , Nicolson Susan C. , Steven James M. , Spray Thomas L.
Published: August 2004

Objective.

This pharmacologic protection trial was conducted to test the hypothesis that allopurinol, a scavenger and inhibitor of oxygen free radical production, could reduce death, seizures, coma, and cardiac events in infants who underwent heart surgery using deep hypothermic circulatory arrest (DHCA).

Design.

This was a single center, randomized, placebo-controlled, blinded trial of allopurinol in infant heart surgery using DHCA. Enrolled infants were stratified as having hypoplastic left heart syndrome (HLHS) and all other forms of congenital heart disease (non-HLHS). Drug was administered before, during, and after surgery. Adverse events and the clinical efficacy endpoints death, seizures, coma, and cardiac events were monitored until infants were discharged from the intensive care unit or 6 weeks, whichever came first.

Results.

Between July 1992 and September 1997, 350 infants were enrolled and 348 subsequently randomized. A total of 318 infants (131 HLHS and 187 non-HLHS) underwent heart surgery using DHCA. There was a nonsignificant treatment effect for the primary efficacy endpoint analysis (death, seizures, and coma), which was consistent over the 2 strata. The addition of cardiac events to the primary endpoint resulted in a lack of consistency of treatment effect over strata, with the allopurinol treatment group experiencing fewer events (38% vs 60%) in the entire HLHS stratum, compared with the non-HLHS stratum (30% vs 27%). In HLHS surgical survivors, 40 of 47 (85%) allopurinol-treated infants did not experience any endpoint event, compared with 27 of 49 (55%) controls. There were fewer seizures-only and cardiac-only events in the allopurinol versus placebo groups. Allopurinol did not reduce efficacy endpoint events in non-HLHS infants. Treated and control infants did not differ in adverse events.

Conclusions.

Allopurinol provided significant neurocardiac protection in higher-risk HLHS infants who underwent cardiac surgery using DHCA. No benefits were demonstrated in lower risk, non-HLHS infants, and no significant adverse events were associated with allopurinol treatment.congenital heart defects, hypoplastic left heart syndrome, induced hypothermia, ischemia-reperfusion injury, neuroprotective agents, allopurinol, xanthine oxidase, free radicals, seizures, coma.
Effectiveness of Compliance With Pediatric Preventive Care Guidelines Among Medicaid Beneficiaries
Authors: Hakim Rosemarie B. , Bye Barry V.
Published: August 2004

Objective.

Because research has not confirmed a relationship between compliance with health supervision in infancy and improved health outcomes, we examined the association between adherence to prevailing guidelines for periodic health supervision and adverse health outcome indicated by incidence of avoidable hospitalizations.

Methods.

This was a historic cohort study of 308 131 children enrolled in Medicaid at birth in California, Georgia, and Michigan in 1990 using Medicaid records linked across 3 years. We used avoidable hospitalizations as indicators of health in a survival analysis. The analysis used variables that represented completeness and timeliness of well-child visits and immunizations using AAP guidelines for health supervision as the gold standard.

Results.

When the children in this cohort were up-to-date for age on their schedule of well-child visits, they were less likely to have an avoidable hospitalization (race, illness, and level of poverty adjusted hazard ratios 0.52 [95% confidence interval (CI): 0.50–0.55] in California, 0.54 [95% CI: 0.50–0.55] in Georgia, and 0.7 [95% CI: 0.69–0.79] in Michigan). Among children who were not up-to-date with well-child visits, a sporadic preventive care visit conferred a mild benefit. Immunizations and race/ethnicity had no consistent relationship with incidence of avoidable hospitalizations.

Conclusions.

A series of well-child visits maintained during the first 2 years of life has a positive effect on health outcomes as indicated by a decrease in avoidable hospitalizations among poor and near-poor children, regardless of race, level of poverty, or health status. National efforts to improve the quality of child health services for young children should focus on increasing compliance with periodic preventive care for young children in addition to improving immunization levels.
Children Who Return Home From Foster Care: A 6-Year Prospective Study of Behavioral Health Outcomes in Adolescence
Authors: Taussig Heather N. , Clyman Robert B. , Landsverk John
Published: August 2004

Objective.

Returning children to their biological families after placement in foster care (ie, reunification) has been prioritized with legislation. Comprehensive studies of child behavioral health functioning after reunification, however, have not been conducted. This study examined outcomes for youth who were reunified after placement in foster care as compared with youth who did not reunify.

Design.

Prospective cohort.

Setting.

Children who entered foster care in San Diego, California, and who remained in foster care for at least 5 months.

Participants.

A cohort of 149 ethnically diverse youth, 7 to 12 years old, who entered foster care between May 1990, and October 1991. Seventy-five percent of those interviewed at Time 1 were interviewed at Time 2 (6 years later).

Outcome Measures.

1) Risk behaviors: delinquent, sexual, self-destructive, substance use, and total risk behaviors; 2) Life-course outcomes: pregnancy, tickets/arrests, suspensions, dropping out of school, and grades; 3) Current symptomatology: externalizing, internalizing, total behavior problems, and total competence.

Results.

Compared with youth who were not reunified, reunified youth showed more self-destructive behavior (0.15 vs −0.11), substance use (0.16 vs −0.11), and total risk behavior problem standardized scores (0.12 vs −0.09). Reunified youth were more likely to have received a ticket or have been arrested (49.2% vs 30.2%), to have dropped out of school (20.6% vs 9.4%), and to have received lower grades (6.5 vs 7.4). Reunified youth reported more current problems in internalizing behaviors (56.6 vs 53.0), and total behavior problems (59.5 vs 55.7), and lower total competence (41.1 vs 45.0). There were no statistically significant differences between the groups on delinquency, sexual behaviors, pregnancy, suspensions, or externalizing behaviors. Reunification status was a significant predictor of negative outcomes in 8 of the 9 regression equations after controlling for Time 1 behavior problems, age, and gender.

Conclusions.

These findings suggest that youth who reunify with their biological families after placement in foster care have more negative outcomes than youth who do not reunify. The implications of these findings for policy and practice are discussed.
Leptin Levels in Preterm Human Breast Milk and Infant Formula
Authors: Resto Migdalia , O'Connor Darlise , Leef Kathleen , Funanage Vicky , Spear Michael , Locke Robert
Published: August 2004

Objective.

Leptin, a hormone present in breast milk, is involved in energy regulation and metabolism. The purpose of this investigation was to determine whether leptin is present in either preterm breast milk (PBM) or preterm formula (PF). The effects of delivery methods and pasteurization on leptin levels also were evaluated.

Methods.

PBM samples were obtained from 29 mothers who delivered infants at between 23 and 34 weeks' gestation. Leptin levels were measured in PBM and PF with the use of a radioimmunoassay specific for human and bovine leptin, respectively. Milk samples were pasteurized by fast- and slow-heating methods. PBM and PF spiked with human leptin were delivered through catheters by bolus and continuous administration to determine the effects of delivery method on recoverable leptin levels.

Results.

Median PBM leptin concentration was 5.28 ng/mL (intraquartile range: 24.79). Birth gestational age, birth weight, and gender of the infant did not significantly influence PBM leptin levels. Neither bolus nor continuous feeding practices affected leptin levels in PBM or spiked PF. However, pasteurization significantly reduced the amount of detectable leptin in PBM.

Conclusions.

PBM leptin levels were highly variable and similar to levels reported for term breast milk. There was no effect of postnatal age on PBM leptin concentrations. Sterilization decreased detectable leptin levels, whereas feeding practices had no adverse effect on the quantity of leptin delivered. Although no infant formula contained leptin, leptin could be added to formula and delivered through various feeding methods without loss.
Recovery of Anaerobic Bacteria From Four Children With Postthoracotomy Sternal Wound Infection
Authors: Brook Itzhak
Published: August 2004

The cases of 4 children who developed postthoracotomy sternal wound infection caused by anaerobic bacteria are presented. The predominate anaerobes werePeptostreptococcus species and pigmentedPrevotella species. Polymicrobial infection was present in all cases, and aerobic bacteria also were recovered in 2 instances. All patients responded to surgical debridement and antimicrobials effective against the isolated aerobic and anaerobic bacteria. These findings highlight the potential importance of anaerobic bacteria in postthoracotomy sternal wound infection.
Hypokalemic Salt-Losing Tubulopathy With Chronic Renal Failure and Sensorineural Deafness
Authors: Jeck Nikola , Reinalter Stephan C. , Henne Thomas , Marg Wolfgang , Mallmann Rudolf , Pasel Katharina , Vollmer Martin , Klaus Günter , Leonhardt Andreas , Seyberth Hannsjörg W. , Konrad Martin
Published: August 2004

Objective.

To characterize a rare inherited hypokalemic salt-losing tubulopathy with linkage to chromosome 1p31.

Methods.

We conducted a retrospective analysis of the clinical data for 7 patients in whom cosegregation of the disease with chromosome 1p31 had been demonstrated. In addition, in 1 kindred, prenatal diagnosis in the second child was established, allowing a prospective clinical evaluation.

Results.

Clinical presentation of the patients was homogeneous and included premature birth attributable to polyhydramnios, severe renal salt loss, normotensive hyperreninemia, hypokalemic alkalosis, and excessive hyperprostaglandin E-uria, which suggested the diagnosis of hyperprostaglandin E syndrome/antenatal Bartter syndrome. However, the response to indomethacin was only poor, accounting for a more severe variant of the disease. The patients invariably developed chronic renal failure. The majority had extreme growth retardation, and motor development was markedly delayed. In addition, all patients turned out to be deaf.

Conclusion.

The hypokalemic salt-losing tubulopathy with chronic renal failure and sensorineural deafness represents not only genetically but also clinically a disease entity distinct from hyperprostaglandin E syndrome/antenatal Bartter syndrome. A pleiotropic effect of a single gene defect is most likely causative for syndromic hearing loss.
Fetal Surgery for Posterior Urethral Valves: Long-Term Postnatal Outcomes
Authors: Holmes Nicholas , Harrison Michael R. , Baskin Laurence S.
Published: August 2004

Objective.

Fetal intervention for obstructive uropathy was first performed at the University of California, San Francisco in 1981. Indications for treatment were bilateral hydronephrosis with oligohydramnios. Preintervention criteria included fetal urinary electrolytes with β-microglobulin levels, karyotyping, and detailed sonography specifically looking for renal cortical cysts. We reviewed the outcomes of children who underwent fetal intervention with specific long-term follow-up in patients who were found postnatally to have posterior urethral valves.

Methods.

A retrospective review of the University of California, San Francisco fetal surgery database was performed for patients with a prenatal diagnosis of obstructive uropathy. Medical records from 1981 to 1999 were reviewed. Long-term follow-up was documented if the cause of the urinary tract obstruction was posterior urethral valves. We collected data points, focusing on time and type of intervention, fetal urinary electrolytes, appearance of fetal kidneys, present renal function, length of follow-up, and present status of the urinary tract.

Results.

Forty patients were evaluated for fetal intervention; 36 fetuses underwent surgery during this time period. Postnatal confirmation of posterior urethral valves was demonstrated in 14 patients. All patients had favorable fetal urinary electrolytes. Mean gestational age at intervention was 22.5 weeks. The procedures performed included creation of cutaneous ureterostomies in 1, fetal bladder marsupialization in 2, in utero ablation of valves in 2, and placement of vesicoamniotic catheter in 9. Six deaths occurred before term delivery with premature labor and the newborns succumbing to respiratory failure. One pregnancy was terminated electively because of shunt failure and declining appearance of fetal lungs and kidney. The remaining 8 living patients had a mean follow-up of 11.6 years. Chronic renal disease with abnormal serum creatinine was present in 5 patients. Two patients have undergone renal transplantation, and 1 is awaiting organ donation. Five of the 8 living patients have had urinary diversion with vesicostomy, cutaneous ureterostomy, or augmentation cystoplasty with later reconstruction.

Conclusions.

Fetal intervention for posterior urethral valves carries a considerable risk to the fetus with fetal mortality rate of 43%. The long-term outcomes indicate that intervention may not change the prognosis of renal function or be a predictor for possible urinary diversion. Despite all of these patients' having favorable urinary electrolytes, this did not seem to have any implication postnatally. When counseling families about fetal intervention, efforts should be focused on that intervention may assist in delivering the fetus to term and that the sequelae of posterior urethral valves may not be preventable. Fetal surgery for obstructive uropathy should be performed only for the carefully selected patient who has severe oligohydramnios and “normal”-appearing kidneys.
Pediatric Residency Training on Tobacco
Authors: Hymowitz Norman , Schwab Joseph , Eckholdt Haftan
Published: August 2004

Objective.

Pediatricians have a unique role to play in the antismoking arena. However, few pediatric residency training programs prepare residents to meet the tobacco challenge. This study evaluates the effects of a comprehensive pediatric residency training program on tobacco on resident tobacco intervention behaviors, as well as on changes in the behavior of patients and their parents/guardians.

Methods.

Pediatric residents were exposed to a comprehensive training program on tobacco. Baseline and follow-up surveys of residents, parents/guardians, and patients were used to assess the effects of the training program. A quasi-experimental design permitted unambiguous evaluation of the program's effects on resident intervention behaviors.

Results.

The comprehensive training program on tobacco led to marked and significant changes in resident intervention on tobacco. Many of these changes were supported by parents' and patients' reports. In turn, resident intervention on tobacco led to a significant increase in the likelihood that parents would maintain a “smoke-free household.” Significant changes in the prevalence of parental smoking were not found, although the trend during 3 years of follow-up was in the desired direction. A high proportion of residents reported that they intervened on tobacco in patients at baseline and follow-up, but too few patients were sampled to permit analysis of the impact on changes in smoking.

Conclusions.

Comprehensive training on tobacco had a positive and powerful effect on the tobacco intervention behavior of pediatric residents. In turn, intervention on tobacco by pediatric residents may have a significant impact on patients and their parents. These findings underscore the efficacy of pediatric residency training on tobacco, and it is hoped that they will serve as an impetus for other pediatric residency programs to introduce training on tobacco.
Evidence Assessment of Management of Acute Otitis Media: I. The Role of Antibiotics in Treatment of Uncomplicated Acute Otitis Media
Authors: Takata Glenn S. , Chan Linda S. , Shekelle Paul , Morton Sally C. , Mason Wilbert , Marcy S. Michael
Published: August 2004

Context.

In 1995, >5 million episodes of acute otitis media (AOM) accounted for $3 billion in health care expenditures.

Objectives.

To synthesize the literature on the natural history of AOM, the effectiveness of antibiotic treatment in uncomplicated AOM, and the relative effectiveness of specific antibiotic regimens.

Data Sources.

Seven electronic databases for articles published between 1966 and March 1999 and reference lists in proceedings, published articles, reports, and guidelines.

Study Selection.

Two physicians independently assessed each article. Studies addressing AOM in children 4 weeks to 18 years old were included; those addressing children with immunodeficiencies or craniofacial abnormalities were excluded. Randomized, controlled trials (RCTs) were used to assess antibiotic effectiveness, and RCTs and cohort studies were used to assess the natural history of AOM. Among the 3491 citations identified, 80 (2.3%) met our inclusion criteria.

Data Extraction.

Two physicians independently abstracted data and assessed the quality of studies using a validated scale for RCTs and 8 quality components for cohort studies.

Data Synthesis.

Random-effects estimates of pooled absolute rate differences of outcomes were derived, and heterogeneity of both the rates and rate differences was assessed. Children with AOM not treated with antibiotics experienced a 1- to 7-day clinical failure rate of 19% (95% confidence interval: 0.10–0.28) and few suppurative complications. When patients were treated with amoxicillin, the 2- to 7-day clinical failure rate was reduced to 7%, a 12% (95% confidence interval: 0.04–0.20) reduction. Adverse effects, primarily gastrointestinal, were more common among children on cefixime than among those on ampicillin or amoxicillin. They were also more common among children on amoxicillin-clavulanate than among those on azithromycin.

Conclusions.

The majority of uncomplicated cases of AOM resolve spontaneously without apparent suppurative complications. Ampicillin or amoxicillin confers a limited therapeutic benefit. There is no evidence to support any particular antibiotic regimens as more effective at relieving symptoms. Certain antibiotics are more likely than others to cause diarrhea and other adverse events.
Recent Skin Injuries in Normal Children
Authors: Labbé Jean , Caouette Georges
Published: August 2004

Objective.

The objective of our study was to collect data on the totality of recent skin injuries in normal children and adolescents, and to determine the relationship between the number of injuries, the age of the child, and the time of year in a temperate climate.

Methods.

The participants in this study were children and adolescents seen successively for a reason other than trauma over a period of 1 year, by the first author (J.L.), in a university medical center in Québec City, Canada. The total body surface, with the exception of the anal-genital area, was examined systematically. The characteristics and location of all recent injuries (bruises, abrasions, scratches, cuts, burns, etc) were recorded. Scars from old injuries were ignored. The statistical method used for comparison was the Fisher's exact test.

Results.

Two thousand forty examinations were done on 1467 youngsters from 0 to 17 years of age. Nine hundred thirty-one examinations were done on boys and 1109 on girls. The majority of children 9 months and older (76.6%) had at least 1 recent skin injury, without a significant difference between the sexes. Seventeen percent of the total sample of children had at least 5 injuries, whereas 4% had 10 or more, <1% had 15 or more, and 0.2% had 20 or more. The sites involved were mostly the lower limbs. Less than 2% of the total sample of children had injuries to the thorax, abdomen, pelvis, or buttocks, and <1% to the chin, ears, or neck. The majority of injuries observed were bruises, regardless of the time of year. There were, however, more skin injuries during the summer and the proportion of abrasions was higher at this time of the year. The 0- to 8-month age group was unique from all points of view. Skin injuries were rare in this age group (11.4%); they did not vary with the season, and they were mainly on the head and the face. Their injuries were mostly scratches. Bruises were found in only 1.2% of this group.

Conclusions.

The majority of normal children (after the age of 9 months) and adolescents, who do not consult for trauma, had 1 or more recent skin injuries. These injuries, mostly bruises, are more prevalent in the summer in a region with a temperate climate and can be present on all parts of the body, although they are most frequently observed on the limbs, especially on the shins and knees. Even if there are no recognizable marks on the skin, physicians must pay particular attention to children who have injuries with other unusual characteristics (uncommon location, ≥15 injuries, bruises in a child <9 months of age, numerous injuries elsewhere than the lower limbs, numerous injuries in the cold seasons in a temperate climate, injuries other than bruises, abrasions or scratches) because they could be a sign of a bleeding disorder or physical abuse.bruising, child abuse, accidental injury.
Risk Factors for Positive Mantoux Tuberculin Skin Tests in Children in San Diego, California: Evidence for Boosting and Possible Foodborne Transmission
Authors: Besser Richard E. , Pakiz Bilge , Schulte Joann M. , Alvarado Sonia , Zell Elizabeth R. , Kenyon Thomas A. , Onorato Ida M.
Published: August 2004

Objectives.

Source case finding in San Diego, California, rarely detects the source for children with tuberculosis (TB) infection or disease. One third of all pediatric TB isolates in San Diego are Mycobacterium bovis, a strain associated with raw dairy products. This study was conducted to determine risk factors for TB infection in San Diego.

Design.

Case-control study of children ≤5 years old screened for TB as part of routine health care visit. Asymptomatic children with a positive (≥10 mm) Mantoux skin test (TST) were matched by age to 1 to 2 children with negative TST from the same clinic. We assessed risk factors for TB infection through parental interview and chart review.

Results.

A total of 62 cases and 97 controls were enrolled. Eleven cases and 25 controls were excluded from analysis because of previous positive skin tests. Compared with controls, cases were more likely to have received BCG vaccine (73% vs 7%, odds ratio [OR] 44), to be foreign born (35% vs 11%, OR 4.3), and to have eaten raw milk or cheese (21% vs 8%, OR 3.76). The median time between the most recent previous TST and the current test was 12 months for cases and 25 months for controls. Other factors associated with a positive TST included foreign travel, staying in a home while out of the country, and having a relative with a positive TST. There was no association between contact with a known TB case. In a multivariable model, receipt of BCG, contact with a relative with a positive TST, and having a previous TST within the past year were independently associated with TB infection.

Conclusions.

We identified several new or reemerging associations with positive TST including cross border travel, staying in a foreign home, and eating raw dairy products. The strong associations with BCG receipt and more recent previous TST may represent falsely positive reactions, booster phenomena, or may be markers for a population that is truly at greater risk for TB infection. Unlike studies conducted in nonborder areas, we found no association between positive TB skin tests and contact with a TB case or a foreign visitor. Efforts to control pediatric TB in San Diego need to address local risk factors including consumption of unpasteurized dairy products and cross-border travel. The interpretation of a positive TST in a young child in San Diego who has received BCG is problematic.
Smoking During Pregnancy and Infantile Colic
Authors: Søndergaard Charlotte , Henriksen Tine Brink , Obel Carsten , Wisborg Kirsten
Published: August 2004

Objective.

To evaluate the association between maternal smoking during pregnancy and infantile colic (IC).

Methods.

A follow-up study of singleton infants delivered by Danish mothers at the Aarhus University Hospital from May 1991 to February 1992 and still living in the municipality of Aarhus at the age of 8 months was conducted. A total of 1820 mothers and their infants were included. Self-administered questionnaires were used to collect data on smoking, other lifestyle factors, and sociodemographic variables at 16 and 30 weeks of gestation and 8 months postpartum. IC was defined in the 8-month questionnaire and based on Wessel's criteria, except that we used only the crying criterion.

Results.

IC was seen in 10.8% of all infants. We observed a twofold increased risk of IC among infants whose mothers smoked 15 or more cigarettes per day during their pregnancy(relative risk: 2.1; 95% confidence interval: 1.4–3.2) or in the postpartum period (relative risk: 2.0; 95% confidence interval: 1.3–3.1). Women who smoked continuously during pregnancy and the postpartum period had a relative risk of 1.5 (95% confidence interval: 1.1–2.0) of having a infant with IC compared with women who did not smoke during this period. Adjustment for maternal age, parity, marital status, alcohol intake, birth weight, gestational age, breastfeeding, caffeine intake postpartum, and paternal smoking did not change the effect measures.

Conclusion.

The results indicate that maternal smoking during pregnancy may increase the risk of IC.
The Effectiveness of a Home Visit to Prevent Childhood Injury
Authors: King W. James , Klassen Terry P. , LeBlanc John , Bernard-Bonnin Anne-Claude , Robitaille Yvonne , Pham Ba' , Coyle Douglas , Tenenbein Milton , Pless I. Barry
Published: August 2004

Objective.

To examine the effectiveness of a home visit program to improve home safety and decrease the frequency of injury in children. We examined the effects of the program on 1) parental injury awareness and knowledge; 2) the extent that families used home safety measures; 3) the rate of injury; and 4) the cost effectiveness of the intervention.

Design.

A randomized, controlled trial.

Setting.

A multicenter trial conducted at 5 hospitals in 4 Canadian urban centers.

Participants.

Children <8 years old, initially enrolled in an injury case-control study, were eligible to participate.

Intervention.

Subsequent to a home inspection conducted to determine baseline hazard rates for both groups, participants in the intervention group received a single home visit that included the provision of an information package, discount coupons, and specific instruction regarding home safety measures.

Main Results.

The median age was 2 years, with males comprising ∼60% of participants. The experimental groups were comparable at outset in terms of case-control status, age, gender, and socioeconomic status. Parental injury awareness and knowledge was high; 73% correctly identified injury as the leading cause of death in children, and an intervention effect was not demonstrated. The adjusted odds ratios (ORs) for the home inspection items indicated that significant safety modifications only occurred in the number of homes having hot water not exceeding 54°C (OR: 1.31, 95% confidence interval [CI]: 1.14, 1.50) or the presence of a smoke detector (OR: 1.45, 95% CI: 0.94, 2.22). However, the intervention group reported home safety modifications of 62% at 4 months and significantly less injury visits to the doctor compared with the nonintervention group (rate ratio: 0.75; 95% CI: 0.58, 0.96). The total costs of care for injuries were significantly lower in the intervention group compared with the nonintervention group with a cost of $372 per injury prevented.

Conclusions.

An intervention using a single home visit to improve the extent to which families use safety measures was found to be insufficient to influence the long-term adoption of home safety measures, but was effective to decrease the overall occurrence of injuries. Future programs should target a few, well-focused, evidence-based areas including the evaluation of high-risk groups and the effect of repeated visits on outcome.