bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving Adolescent Preventive Care in Community Health Centers
Authors: Klein Jonathan D. , Allan Marjorie J. , Elster Arthur B. , Stevens David , Cox Christopher , Hedberg Viking A. , Goodman Rita A.
Published: August 2004

Objective.

To evaluate implementation of the Guidelines for Adolescent Preventive Services (GAPS) in Community and Migrant Health Centers (CMHCs).

Design.

Before and after comparison of health center policy, clinician and adolescent self-report, and chart reviews in 5 CMHCs.

Participants.

Eighty-one preintervention and 80 one-year postintervention providers and 318 preintervention and 331 postintervention 14- to 19- year-old adolescent patients being seen for well visits at 5 CMHCs.

Intervention.

Health center staff were trained to implement GAPS and were provided resource materials, patient questionnaires, and clinician manuals.

Main Outcome Measures.

Delivery of and receipt of preventive services and perceived access to care.

Results.

CMHC systems changes were related to stronger leadership commitment to adolescent care. Providers reported high levels of preventive services delivery before and after guideline implementation. After guideline implementation, adolescents reported increases in having discussed prevention content with providers in 19 of 31 content areas, including increased discussion of physical or sexual abuse (10% before to 22% after), sexual orientation (13% to 27%), fighting (6% to 21%), peer relations (37% to 52%), suicide (7% to 22%), eating disorders (11% to 28%), weapons (5% to 22%), depression (16% to 34%), smokeless tobacco (10% to 29%), and immunizations (19% to 48%). Adolescents were also more likely to report knowing where to get reproductive or mental health services and were more likely to have received health education materials. Implementation also increased documentation of recommended screening and counseling in 51 of 79 specific content areas assessed in chart reviews.

Conclusion.

Implementing GAPS increased the receipt of preventive services at these health centers. Adolescents received more comprehensive screening and counseling, more health education materials, and had greater access to care after implementation. GAPS implementation may help improve the quality of care for adolescents.
Human Immunodeficiency Virus-Related Mortality in Infants and Children: Data From the Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV (P2C2) Study
Authors: Langston Claire , Cooper Ellen R. , Goldfarb Johanna , Easley Kirk A. , Husak Scott , Sunkle Susan , Starc Thomas J. , Colin Andrew A. ,   for the P2C2 HIV Study Group
Published: August 2004

Objectives.

To identify the causes of mortality in children with vertically transmitted human immunodeficiency virus (HIV) infection and to study age-related mortality trends.

Methods.

In the multicenter P2C2HIV Study, 816 children born to HIV-infected mothers were followed for a median of 3.6 years. Two hundred five study participants with HIV infection were enrolled at a median age of 23 months; 611 were enrolled either prenatally or in the neonatal period before their HIV infection status was known. There were 121 deaths in study patients. The cause of death for all patients, its relationship to HIV infection, and pulmonary or cardiac involvement were determined. Age trends in disease-specific mortality were summarized for the HIV-related deaths.

Results.

Ninety-three children died of HIV-related conditions. Infection was the most prevalent cause of death for children under 6 years of age with 32.3% caused by pulmonary infection and another 16.9% caused by nonpulmonary infection. The frequency of pulmonary disease as the underlying cause of death decreased significantly with increasing age: 5/9 (55.6%) by age 1, 1/12 (8.3%) after age 10 years. The frequency of chronic cardiac disease as the underlying cause increased with age—0% by age 1 year, 3/12 (25.0%) after age 10 years, as did the frequency of wasting syndrome with disseminated Mycobacterium avium complex—0% by age 1 year, 6/12 (50.0%) after age 10 years.

Conclusions.

Children with HIV who survive longer are less likely to die of pulmonary disease or infection and more likely to die of cardiac causes or with wasting syndrome. pediatric acquired immunodeficiency syndrome, mortality, human immunodeficiency virus.
Continuous Subcutaneous Insulin Infusion Therapy for Children and Adolescents: An Option for Routine Diabetes Care
Authors: Maniatis Aristides K. , Klingensmith Georgeanna J. , Slover Robert H. , Mowry Cathy J. , Chase H. Peter
Published: August 2004

Objective.

The purpose of this study was to determine the feasibility of continuous subcutaneous insulin infusion (CSII) (insulin pump) therapy in routine pediatric diabetes care by comparing the HbA1c, body mass index (BMI), and hypoglycemic episodes before and after initiation of CSII therapy.

Research Design and Methods.

Data from 56 patients (7–23 years old) were collected during regularly scheduled visits at a frequency similar to non-CSII patients.

Results.

The data were analyzed for the entire cohort and 3 subgroups (decreased, stable, or increased HbA1c) stratified according to a ≥0.5% change in HbA1c. The total cohort demonstrated a decrease in HbA1c from 8.5% to 8.3%. The decreased cohort (39.4% of the total cohort) demonstrated a significant decrease in HbA1c from 8.6% to 7.6%. The mean HbA1c of the stable cohort (41.0%) was 8.7%. The increased cohort (19.6%) had an increase in HbA1c from 7.8% to 8.8%. Thirty-six patients (64.3%) maintained or achieved a HbA1c <8.0% or achieved a HbA1c at least 1% lower than their pre-CSII level. Of concern, 6 patients (10.7%) demonstrated a clinically significant increase in HbA1c from 8.3% to 9.6%. For the entire cohort, the rate of severe hypoglycemia before and on CSII therapy was 12.3 and 9.5 events per 100 patient-years, respectively. A statistically significant proportion of patients reported a decrease in seizure frequency versus an increase (17.9% vs 1.8%) as well as a decrease in overall hypoglycemic frequency versus an increase (41.1% vs 17.9%). There was not a clinically significant increase in BMI, even in the decreased HbA1c cohort.

Conclusions.

CSII therapy is an appropriate option for some children in routine pediatric diabetes care. It can effectively decrease the HbA1c and reduce hypoglycemic episodes, without producing an abnormal increase in BMI.
IsHelicobacter pyloriInfection in Childhood a Risk Factor for Gastric Cancer?
Authors: Imrie Cameron , Rowland Marion , Bourke Billy , Drumm Brendan
Published: August 2004

Helicobacter pylori infection is associated with chronic gastritis and peptic ulcer disease. Furthermore, the World Health Organization has classified this organism as a carcinogen for gastric cancer. H pylori infection is mainly acquired in childhood. Children with H pyloriinfection are asymptomatic except for a very small number that develop peptic ulcer disease. However, if H pylori gastritis is associated with gastric cancer, do pediatricians need to screen children for this infection and treat those who are infected? In an attempt to determine the significance of the association betweenH pylori and gastric cancer, we have reviewed all of the English language literature on this topic. H pyloriinfection seems to be associated with an increased risk of developing gastric cancer. However, only a small number of infected individuals (∼1%) will develop gastric cancer. Furthermore, there are potential cofactors other than H pylori that could be equally important. The effect of the eradication of H pylorialone on the development of gastric cancer is unknown. Based on our knowledge to date, we suggest that it is not indicated to treat all children with H pylori infection because of the risk of developing gastric cancer or to institute a screening and treatment program.
A Case of Protein-Losing Enteropathy Caused by Intestinal Lymphangiectasia in a Preterm Infant
Authors: Salvia Gennaro , Cascioli Concetta F. , Ciccimarra Filippo , Terrin Gianluca , Cucchiara Salvatore
Published: August 2004

Intestinal lymphangiectasia is characterized by obstruction of lymph drainage from the small intestine and lacteal dilation that distorts the villus architecture. Lymphatic vessel obstruction and elevated intestinal lymphatic pressure in turn cause lymphatic leakage into the intestinal lumen, thus resulting in malabsorption and protein-losing enteropathy. Intestinal lymphangiectasia can be congenital or secondary to a disease that blocks intestinal lymph drainage. We describe the first case of intestinal lymphangiectasia in a premature infant. The infant presented with peripheral edema and low serum albumin; high fecal concentration of α1-antitrypsin documented intestinal protein loss. Endoscopy showed white opaque spots on the duodenal mucosa, which indicates dilated lacteal vessels. Histology confirmed dilated lacteals and also showed villus blunting. A formula containing a high concentration of medium chain triglycerides resulted in a rapid clinical improvement and normalization of biochemical variables. These features should alert neonatologists to the possibility of intestinal lymphangiectasia in newborns with hypoalbuminemia and peripheral edema. The intestinal tract should be examined for enteric protein losses if other causes (ie, malnutrition and protein loss from other sites) are excluded. The diagnosis rests on jejunal biopsy demonstrating dilated lymphatic lacteal vessels.
Blue Rubber Bleb Nevus Syndrome
Authors: Ertem Deniz , Acar Yesim , Kotiloglu Esin , Yucelten Deniz , Pehlivanoglu Ender
Published: August 2004

Blue rubber bleb nevus syndrome is a rare disorder characterized by distinctive cutaneous and gastrointestinal venous malformations that usually cause massive or occult gastrointestinal hemorrhage and iron deficiency anemia secondary to the bleeding episodes. It is even a rare cause of gastrointestinal hemorrhage during childhood. We describe a 6-year-old boy who had multiple venous malformations all over his body. He also suffered from several episodes of melena, chronic anemia, and growth retardation. The endoscopic examination of the gastrointestinal tract revealed multiple bluish-black sessile and polypoid venous malformations in various sizes. It was possible to remove the largest venous malformations causing massive bleeding during colonoscopy.
Thrombus in the Left Ventricle of a Child With Systemic Emboli: An Unusual Presentation of Hereditary Protein C Deficiency
Authors: Matitiau Abraham , Tabachnik Elvan , Sthoeger Dalia , Birk Einat
Published: August 2004

We present a case of left ventricular thrombus in a child with a normal functioning left ventricle. The diagnosis was made by 2-dimensional echocardiography after 2 episodes of systemic emboli.

Hereditary protein C deficiency diagnosed in the patient provides the probable pathogenesis of the thrombus formation.

Systemic emboli necessitates cardiac examination, and in cases of unusual thrombi, hereditary or acquired thrombophilic risk factors should be considered.
Children, Adolescents, and Television
Authors:   Committee on Public Education
Published: August 2004

This statement describes the possible negative health effects of television viewing on children and adolescents, such as violent or aggressive behavior, substance use, sexual activity, obesity, poor body image, and decreased school performance. In addition to the television ratings system and the v-chip (electronic device to block programming), media education is an effective approach to mitigating these potential problems. The American Academy of Pediatrics offers a list of recommendations on this issue for pediatricians and for parents, the federal government, and the entertainment industry.
Abused Boys, Battered Mothers, and Male Involvement in Teen Pregnancy
Authors: Anda Robert F. , Felitti Vincent J. , Chapman Daniel P. , Croft Janet B. , Williamson David F. , Santelli John , Dietz Patricia M. , Marks James S.
Published: August 2004

Background.

The relationship between boyhood exposure to physical abuse, sexual abuse, or to a battered mother and subsequent risk of impregnating a teenage girl has not previously been examined.

Methods.

In a retrospective cohort study set in a primary care clinic for adult members of a large health maintenance organization, questionnaire responses from 4127 men were analyzed. Respondents provided the age of the youngest female whom they had impregnated, their own ages at the time, and information regarding childhood exposure to physical or sexual abuse and battered mothers. We calculated the prevalence and adjusted odds ratio (OR) for having impregnated a teenage girl according to these 3 adverse childhood experiences, regardless of the male's age at the time of impregnation. Using logistic regression, ORs were adjusted for the male's age at time of survey, race, and education.

Results.

Nineteen percent of the men reported that they had ever impregnated a teenage girl. During childhood, 32% of respondents had been physically abused, 15% sexually abused, and 11% had battered mothers. Compared with respondents reporting no abuse, frequent physical abuse or battering of mothers increased the risk of involvement in teen pregnancy by 70% (OR: 1.7; 95% confidence interval [CI]: 1.2–2.5) and 140% (OR: 2.4; 95% CI: 1.1–5.0), respectively. Sexual abuse as a boy at age 10 years or younger increased the risk of impregnating a teenage girl by 80% (OR: 1.8; 95% CI: 1.3–2.4); sexual abuse with violence increased the risk by 110% (OR: 2.1; 95% CI: 1.2–3.4). We found a dose–response relationship between the number of types of exposures and the risk of impregnating a teenage girl; men who reported all 3 types of exposures were more than twice as likely to have been involved than those with no exposures (OR: 2.2; 95% CI: 1.4–3.5).

Conclusions.

Boyhood exposure to physical or sexual abuse or to a battered mother is associated with an increased risk of involvement in a teen pregnancy—during both adolescence and adulthood. Because these exposures are common and interrelated, boys and adult men who have had these experiences should be identified via routine screening by pediatricians and other health care providers and counseled about sexual practices and contraception. Such efforts may prevent teen pregnancy and the intergenerational transmission of child abuse and domestic violence.
Hopkins Teen Central: Assessment of an Internet-Based Support System for Children With Cystic Fibrosis
Authors: Johnson Kevin B. , Ravert Russell D. , Everton Andrea
Published: August 2004

Support groups are an important therapeutic intervention for patients with chronic debilitating illnesses. Patients who are difficult to assemble in one physical location may benefit from participating in an electronic support group (ESG). ESGs for adolescents have not been evaluated, although studies have shown a benefit to adult ESGs. Our goals were to create a web-based support service for adolescents with cystic fibrosis (CF) and to qualitatively and quantitatively measure the effects that such a support site could have on patients' relationships with the clinic faculty and staff, access to and interaction with peers with CF, and understanding of CF.

Methods. A highly interactive ESG was developed after discussions with a team of CF specialists and patients. Eighteen of 37 teenagers with CF agreed to use this site. Each patient was asked to assess his or her perceived availability of and comfort with the clinic staff and faculty, perceived support available through peers, knowledge about CF, and perceived usefulness of the Internet as a support tool.

Results. Participants logged into the site an average of 4 times each month. Teens who owned home computers accessed the site somewhat more frequently than did teens who were provided with home Internet access for the study. Most activity occurred in those sections of the site that described the participants and that allowed them to socialize. Over one half of the participants e-mailed each other at least once a week, with 77% e-mailing peers at least every other week. There was no significant difference in the participants' scores on a quiz about CF at the beginning and the end of the study; however, there was a significant decrease in perceptions about their knowledge about CF. At the conclusion of the study, participants believed that they had more friends who they could relate to than they did at the beginning of the study. Clinic staff noticed an increase in references to peers among the group who were using the site. In addition, 4 of the teens expressed a desire to get together to meet each other as a result of their interactions on the web site. There was no significant change in perceptions about the perceived availability and comfort with the clinic staff and faculty, support available through peers, knowledge about CF, and the usefulness of the Internet as a support environment. Managing the project was extremely easy, with virtually no technical or procedural issues arising during the study.

Conclusions. Teenagers with a chronic disease will actively participate in an ESG. The social and expressive aspects of their involvement with this support group hold much promise.
Hypocarbia in Preterm Infants With Periventricular Leukomalacia: The Relation Between Hypocarbia and Mechanical Ventilation
Authors: Okumura Akihisa , Hayakawa Fumio , Kato Toru , Itomi Kazuya , Maruyama Koichi , Ishihara Naoko , Kubota Tetsuo , Suzuki Motomasa , Sato Yoshiaki , Kuno Kuniyoshi , Watanabe Kazuyoshi
Published: August 2004

Objective.

The aim of this study was to elucidate the relationship between mechanical ventilation and hypocarbia in infants with periventricular leukomalacia (PVL).

Study Design.

Matched pair analysis was conducted for 26 infants with PVL and 26 with normal development, who were born between 27 and 32 weeks' gestational age and required mechanical ventilation. The time-averaged carbon dioxide (CO2) index, Paco2, and pH were calculated every 24 hours for samples obtained from indwelling arterial catheters within the first 72 hours of life. The time-averaged respiratory rate of the ventilator (RR), peak inspiratory pressure (PIP), mean airway pressure (MAP), and ventilator index (VI) were also determined. The time-averaged total respiratory rate (TRR) was determined by observing the movement of the chest wall. The patients' characteristics, antenatal and neonatal variables, and electroencephalographic findings were also compared.

Results.

The time-averaged CO2 index was larger, the time-averaged CO2 lower and the time-averaged pH higher in infants with PVL than in those with normal development on the third day of life. There was no significant difference in the time-averaged RR, PIP, MAP, or VI on any day. TRR was larger in the PVL group than in the control group on each day, but there was no significant difference. No significant difference was observed in the clinical characteristics or neonatal variables. Electroencephalographic abnormalities within 48 hours of life were more frequent in infants with PVL than in those with normal development.

Conclusion.

Hypocarbia was associated with PVL because the time-averaged CO2 index was larger and the time-averaged Paco2 lower in infants with PVL than in those with normal development. However, the ventilator settings were similar among the infants with and without PVL.
Neurologic Outcomes of 90 Neonates and Infants With Persistent Hyperinsulinemic Hypoglycemia
Authors: Menni Francesca , de Lonlay Pascale , Sevin Caroline , Touati Guy , Peigné Catherine , Barbier Valérie , Nihoul-Fékété Claire , Saudubray Jean-Marie , Robert Jean-Jacques
Published: August 2004

Objective.

To evaluate the neurologic outcomes of neonates and infants suffering from persistent hyperinsulinemic hypoglycemia of infancy (PHHI).

Methods.

The neurologic development of 90 PHHI patients was studied retrospectively. Sixty-three patients were treated surgically and 27 were treated medically. Fifty-four patients were neonates, of whom 8 were treated medically and 46 were operated on (19 for a focal adenomatous hyperplasia and 27 for diffuse hyperinsulinism). Thirty-six patients had infancy-onset hyperinsulinism, of whom 19 were treated medically and 17 underwent pancreatectomy (10 patients for a focal adenomatous hyperplasia and 7 for diffuse hyperinsulinism).

Results.

Severe psychomotor retardation was found in 7 patients, 6 with neonatal-onset PHHI. Intermediate psychomotor disability existed in 12 patients; epilepsy existed in 16. Neonatal-onset was the main risk factor for severe retardation or epilepsy. Medically treated patients were less severely affected than those treated by surgery, and there was no difference between the diffuse and focal forms of hyperinsulinism.

Conclusion.

Neonatal hyperinsulinemic hypoglycemia is still a severe disease with an important risk to rapidly develop severe mental retardation and epilepsy.
Association of Plasma Cortisol and Chronic Lung Disease in Preterm Infants
Authors: Banks Beverly A. , Stouffer Nicole , Cnaan Avital , Ning Yue , Merrill Jeffrey D. , Ballard Roberta A. , Ballard Philip L. ,   the North American Thyrotropin-Releasing Hormone Trial Collaborators
Published: August 2004

Background.

It has been suggested that preterm infants may have developmental immaturity of the hypothalamic-pituitary-adrenal axis, and that decreased cortisol response to stress increases risk of chronic lung disease (CLD) secondary to inflammatory lung injury.

Methods.

To investigate the relationship between endogenous corticosteroid and CLD, we measured plasma cortisol during the first 28 days of life in a subset of neonates in the North American Thyrotropin-Releasing Hormone (TRH) Collaborative Trial. Analyses were performed on 314 infants, 24 to 32 weeks' gestation, whose mothers received 1 or 2 courses of antenatal corticosteroids plus TRH or placebo.

Results.

Mean cortisol was 3.1 μg/dL (range: 0.1–17.9) at birth, reached maximal levels at 24 hours (19.4 μg/dL, range: 0.8–124.6), and decreased to 5.9 μg/dL (range: 0.2–24.7) at 14 to 28 days of age; levels during the first week were not associated with gestational age. The Clinical Risk Index for Babies (CRIB), a neonatal assessment tool that is correlated with risk of mortality, was positively associated with cortisol level on days 1 and 3 through 7. TRH versus placebo treatment did not influence cortisol levels at any time point. To examine the relationship between cortisol and adverse outcome of death or CLD at 36 weeks' postmenstrual age (CLD36), logistic regression models adjusting for known contributing clinical factors (gestational age and CRIB score) were fit. There was a statistically borderline negative association between median cortisol level at 3 to 7 days and CLD36. After adjusting for gestational age and CRIB score, the predicted probability of CLD36 was only minimally influenced by the cortisol concentration.

Conclusion.

In preterm infants, basal plasma cortisol concentration during the first week is a weak predictor for CLD36. Possible benefits as well as risks of supplemental, low-dose cortisol treatment of high-risk preterm infants remain to be determined.
Excess Risk of Severe Acute Illness in Children With Chronic Health Conditions
Authors: Dosa Nienke P. , Boeing Nancy M. , MS NP, , Kanter Robert K.
Published: August 2004

We estimated the relative risk (RR) of an unscheduled pediatric intensive care unit (ICU) admission as a marker for severe acute illness in children with chronic health conditions, compared with previously healthy children. Potentially preventable events that lead to acute illness were identified to develop preventive strategies.

Methods. Children with chronic conditions were defined as those who have a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. RR was estimated from admissions and regional population data. Potentially preventable events that lead to ICU admission of chronically ill children were identified retrospectively from hospital records.

Results. Children with chronic health conditions had an RR of 3.3 for an unscheduled ICU admission related to their chronic condition, compared with previously healthy individuals (95% confidence interval [CI] = 2.5–4.2). The risk of severe acute illness in the small subgroup that received technology-assisted care was much greater (RR = 373; 95% CI = 330–422) than for the large group of chronically ill patients who did not require technology-assisted care (RR = 2.3; 95% CI = 1.7–3.0), each expressed relative to previously healthy children. Acute illness related to chronic health conditions accounted for 45% of 251 unscheduled ICU admissions during the 1-year study. Thirty-two percent of admissions that were related to chronic conditions were judged to have been potentially preventable. Preventable events were more common for those who did not require technology-assisted care, occurring in 38% of admissions, compared with those who received technology-assisted care, for whom 19% of admissions involved a preventable event. Fifty-six percent of potentially preventable events involved the physical or social environment and decisions made by the family, whereas 64% could be attributed to health care system factors.

Conclusions. Children with chronic health conditions account for a substantial share of severe acute illness in a region. Because their underlying conditions have already been identified, problems may be anticipated. The small number of children who receive technology-assisted care each have such a high risk of severe and unavoidable acute illness that individualized emergency care plans are justified. For the remainder of children with chronic conditions, investigation of health system strategies to improve families' ability to anticipate, minimize, or prevent related acute illness is warranted.
Relation of Two Different Subtypes of Croup Before Age Three to Wheezing, Atopy, and Pulmonary Function During Childhood: A Prospective Study
Authors: Castro-Rodrı́guez José A. , Holberg Catharine J. , Morgan Wayne J. , Wright Anne L. , Halonen Marilyn , Taussig Lynn M. , Martinez Fernando D.
Published: August 2004

Objective.

Some retrospective evidence suggests that children with a history of croup may be at increased risk of subsequently developing asthma, atopy, and diminished pulmonary function. The objective of this study was to determine the long-term outcome of croup (as diagnosed by a physician) in early life.

Methods.

Lower respiratory illnesses (LRIs) in the first 3 years of life were assessed in 884 children who were enrolled in a large longitudinal study of airway diseases at birth. Pulmonary function tests, markers of atopy, and wheezing episodes were studied at different ages between birth and 13 years.

Results.

Ten percent of children had croup with wheeze (Croup/Wheeze), 5% had croup without wheeze (Croup/No Wheeze), 36% had another LRI (Other LRI), and 48% had no LRI. Respiratory syncytial virus was more frequently isolated in children with Croup/Wheeze and Other LRI than in those with Croup/No Wheeze. There was no association between croup in early life and markers of atopy measured during the school years. Only children with Croup/Wheeze and with Other LRI had a significant risk of subsequent persistent wheeze later in life. Significantly lower levels of indices of intrapulmonary airway function were observed at ages <1 (before any LRI), 6, and 11 years in children with Croup/Wheeze and Other LRI compared with children with No LRI. Conversely, inspiratory resistance before any LRI episode was significantly higher in infants who later developed Croup/No Wheeze than in the other 3 groups.

Conclusions.

We distinguish 2 manifestations of croup with and without wheezing. Children who present with croup may or may not be at increased risk of subsequent recurrent lower airway obstruction, depending on the initial lower airway involvement, and preillness and postillness abnormalities in lung function associated with this condition.
Association of Lower Continuity of Care With Greater Risk of Emergency Department Use and Hospitalization in Children
Authors: Christakis Dimitri A. , Mell Loren , Koepsell Thomas D. , Zimmerman Frederick J. , Connell Frederick A.
Published: August 2004

Context.

The benefits of continuity of pediatric care remain controversial.

Objective.

To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization.

Design.

Retrospective cohort study.

Setting and Population.

We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics.

Main Exposure Variable.

A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider.

Main Outcome Measures.

ED utilization and hospitalization.

Results.

Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20–1.36]) and more likely to be hospitalized (HR: 1.22 [1.09–1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49–1.66]) and to be hospitalized (HR: 1.54 [1.33–1.75]). These risks were even greater for children on Medicaid and those with asthma.

Conclusions.

Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.
Back to Sleep: Good Advice for Parents but Not for Hospitals?
Authors: Hein Herman A. , Pettit Stephanie F.
Published: August 2004

Background.

In October 1998, when we surveyed nurses working in Iowa obstetric units about infant sleeping position in the hospital and recommendations for infant sleeping position at home, we learned that the side position was used frequently in the hospital and also was considered to be an acceptable alternative for sleeping position at home.

Objective.

The purpose of our present study was to determine why nurses continued to use and endorse the side sleeping position rather than the supine position.

Design.

We surveyed all Iowa hospitals that had an obstetric service as of July 1999 to learn why the side position was used.

Results.

All 94 hospitals with obstetric services responded to the survey and revealed that 2 major factors were considered when an infant was put to sleep on his/her side. The most frequent response was fear of aspiration (57 responses or 51.4%) and the second was adherence to a federal brochure that lists side sleeping as a reasonable alternative (38 responses or 34.2%).

Conclusion.

We conclude that the reasons reported for use of the side position in Iowa maternity hospitals do not justify its continuing use. We believe that information about the importance of placing an infant on his/her back to sleep and its superiority over placing an infant on his/her side to sleep is sufficient to warrant its availability in every maternity hospital. We speculate that if the infant sleeping position used in the hospital is not different from that taught to parents, there will be less parental confusion and greater adherence to infant positioning shown to reduce sudden infant death syndrome.
The Timing and Predictors of the Early Termination of Breastfeeding
Authors: Ertem Ilgi Ozturk , Votto Nancy , Leventhal John M.
Published: August 2004

Objective.

To determine the prevalence and correlates of the early discontinuation of breastfeeding by mothers eligible for the Women, Infants, and Children Program (WIC).

Methodology.

A longitudinal observational study in which we enrolled English-speaking mothers who initiated breastfeeding after delivering healthy-term infants at Yale-New Haven Hospital and planned to bring their infants to the hospital's primary care center. Data on mother's baseline knowledge, attitudes, beliefs, and problems regarding breastfeeding were collected by semistructured interviews within 48 hours after delivery, at 1 and 2 weeks' postpartum, and by chart reviews at 2 and 4 months. A nonparticipating control group was used to test the Hawthorne effect.

Results.

Of the 64 participating mothers, the majority were minority (56% black, 34% of Puerto Rican origin), single (75%), and already enrolled in WIC (91%). The rates of discontinuation of breastfeeding were 27%, 37%, 70%, and 89% by 1 week, 2 weeks, 2 months, and 4 months, respectively. The mother's knowledge and problems of lactation were not associated with the early discontinuation of breastfeeding. After using logistic regression to control for potential confounders, mothers who lacked confidence at baseline that they would still be breastfeeding at 2 months (risk ratio: 2.38, 95% confidence interval: 1.82–6.18), and those who believed that the baby prefers formula (risk ratio: 1.68, 95% confidence interval: 1.04–2.71) were more likely to stop breastfeeding within the first 2 weeks postpartum.

Conclusions.

The results of this study demonstrate that interventions aimed at prolonging the duration of breastfeeding in this population will need to shift focus from increasing knowledge and managing problems of lactation to enhancing the mother's confidence regarding breastfeeding, while also addressing beliefs regarding an infant's preferences.
A Randomized Trial of Alternative Two- and Three-Dose Hepatitis B Vaccination Regimens in Adolescents: Antibody Responses, Safety, and Immunologic Memory
Authors: Cassidy William M. , Watson Barbara , Ioli Virginia A. , Williams Karen , Bird Steven , West David J.
Published: August 2004

Objectives.

Hoping to increase hepatitis B (HB) vaccination of adolescents, we did the following: 1) studied if modified regimens of the recombinant HB vaccine, Recombivax HB (2 or 3 doses of 5 or 10 μg given over 4 or 6 months), induce protective anti-hepatitis B surface antibody [anti-HBsAb] levels (≥10 mIU/mL) comparable to the recommended regimen (5 μg at 0 and 1, and 6 months); 2) measured early antibody response after a single dose; and 3) assessed immunologic memory after 2- and 3-dose regimens.

Design.

One thousand twenty-six adolescents were randomized to 1 of 5 treatment groups (10 μg at 0 and 4 or 0 and 6 months; 5 μg at 0 and 6 or 0, 2, and 4 or 0, 1, and 6 months) in an open trial. Anti-HBsAb was measured in all participants just before and 1 month after the last dose, and at several other times in a subset of vaccinees. Anti-HBsAb response to a booster dose 2 years later was examined to assess immunologic memory in participants vaccinated with 5 μg at 0 and 6 or 0, 1, and 6 months.

Results.

All regimens induced ≥10 mIU/mL of anti-HBs in ≥95% of vaccinees. Geometric mean titers ranged from 674.8 to 3049.4 mIU/mL. Geometric mean titers were higher with regimens using the following: 1) 10 versus 5 μg; 2) 3 versus 2 doses; and 3) vaccination intervals of 6 versus 4 months. After 6 months, 63.8% of vaccinees given one 10-μg dose had ≥10 mIU/mL of anti-HBsAb versus 41.6% after one 5-μg dose. Participants vaccinated with either two or three 5-μg doses retained robust immunologic memory.

Conclusions.

The results of this study show that a 2-dose regimen of Recombivax HB is as immunogenic and induces immunologic memory as effectively as the recommended 3-dose regimen. A regimen of two 10-μg doses may be of significant benefit for vaccinees who are poorly compliant or deviate from the intended vaccination schedule.
Randomized Trial of Nasal Synchronized Intermittent Mandatory Ventilation Compared With Continuous Positive Airway Pressure After Extubation of Very Low Birth Weight Infants
Authors: Barrington Keith J. , Bull Dale , Finer Neil N.
Published: August 2004

Objective.

To determine whether noninvasive, nasal synchronized intermittent mandatory ventilation (nSIMV) improves the likelihood that very low birth weight infants will be successfully extubated.

Methods.

Infants of <1251-g birth weight who were due to be extubated before 6 weeks of age were eligible once they were receiving <35% oxygen and were on a ventilator rate of <18 breaths per minute (bpm). Extubation was performed following intravenous loading with aminophylline, after a successful trial of 12 hours of endotracheal synchronized intermittent mandatory ventilation at a rate of 8. Infants were randomized to either nasal continuous positive airway pressure (nCPAP) at 6 cm H2O or nSIMV after extubation. nSIMV was commenced at a rate of 12 bpm with pressure on the ventilator set to achieve a delivered pressure of at least 12 cm H2O and a peak end expiratory pressure of 6 cm H2O. Continuous recording for diagnosis of apnea was performed for 72 hours after extubation. Objective criteria for failure of extubation were as follows: a Paco2 >70; Fio2 >0.7; or severe recurrent apnea (>2 apneas requiring intermittent positive-pressure ventilation in 24 hours or >6 apneas >20 seconds per day). The study ended after 72 hours postextubation or when infants satisfied failure criteria. A sample size of 54 was determined by power analysis.

Results.

Mean birth weight (831 standard deviation [SD]: 193 g) and gestation (26.3 SD: 1.8 weeks) did not differ between groups. Mean age at extubation was 7.6 (SD: 9.7) days, range 1 to 40 days. The nSIMV group had a lower incidence of failed extubation 4/27 compared with the continuous positive airway pressure group, 12/27. This was attributable to both a decreased incidence of apnea and a decreased incidence of hypercarbia. There was no increase in the incidence of abdominal distension or feeding intolerance.

Discussion.

nSIMV is effective in preventing extubation failure in very low birth weight infants in the first 72 hours after extubation. Noninvasive ventilation may have other roles in the care of the very low birth weight infant.
Screening Guidelines for Retinopathy of Prematurity: The Need for Revision in Extremely Low Birth Weight Infants
Authors: Subhani Muhammad , Combs Adriann , Weber Pamela , Gerontis Corina , DeCristofaro Joseph D.
Published: August 2004

Objective.

To determine whether significant retinopathy of prematurity (ROP) can be detected before 31 to 33 weeks' postmenstrual age (PMA) in extremely low birth weight (ELBW) infants.

Methods.

Medical records of all ELBW infants (<1000 g at birth) admitted to our regional perinatal center between April 1995 and January 1999 were reviewed retrospectively. Screening examinations for ROP were routinely performed at 4 to 6 weeks' chronological age (CA) from birth and followed at least every other week. Data were collected for infants who developed ROP. We determined the PMA at which the first screening eye examination demonstrated prethreshold disease and the subsequent examination that showed threshold disease (if it occurred). The percentages of infants who developed prethreshold ROP diagnosed at ≤31 weeks' PMA and of those who progressed to threshold ROP before 34 weeks' PMA were determined.

Results.

All 258 ELBW infants were screened for ROP. Seventy-eight infants (30%) were diagnosed with prethreshold ROP. Twenty-seven of these infants (35%) progressed to threshold ROP. Ten infants who progressed to threshold ROP were <34 weeks' PMA at the time of this diagnosis. Of these 10 infants, 3 were diagnosed at 31 weeks' PMA, 4 at 32 weeks', and 3 at 33 weeks'.

Conclusion.

More than 80% of ELBW infants who developed prethreshold disease in this cohort were ≤33 weeks' PMA. The joint statement screening option of independently using 31 to 33 weeks' PMA for the first eye examination would have led to a diagnosis of threshold ROP on first examination in as many as 13% (10/78) of our patients. Early identification of prethreshold ROP is important for providing timely intervention in this rapidly progressive disease. Therefore, ELBW infants should receive initial ROP screening using the CA guideline of 4 to 6 weeks rather than the 31- to 33-week postconceptional age guideline.
Impact of the Change in Polio Vaccination Schedule on Immunization Coverage Rates: A Study in Two Large Health Maintenance Organizations
Authors: Davis Robert L. , Lieu Tracy A. , Mell Loren K. , Capra Angela M. , Zavitkovsky Ann , Quesenberry Charles P. , Black Steven B. , Shinefield Henry R. , Thompson Robert S. , Rodewald Lance E.
Published: August 2004

Objective.

In January 1997, one of the most significant changes to United States vaccine policy occurred when polio immunization guidelines changed to recommend a schedule containing inactivated polio vaccine (IPV). There were concerns that parent or physician reluctance to accept IPV into the routine childhood immunization schedule would lead to lowered coverage. We determined whether adoption of an IPV schedule had a negative impact on immunization coverage.

Design.

A cohort study of 2 large health maintenance organizations (HMOs), Group Health Cooperative and Kaiser Permanente Northern California, was conducted. For analysis at 12 months of age, children who were born between October 1, 1996, and December 31, 1997, and were commercially insured and covered by Medicaid were continuously enrolled; for analysis at 24 months of age, children who were born between October 1, 1996, and June 30, 1997, and were commercially insured and covered by Medicaid were continuously enrolled. The 3 measures of immunization status at 12 and 24 months of age were up-to-date status, cumulative time spent up-to-date, and the number of missed opportunity visits.

Results.

At both HMOs, children who received IPV were as likely to be up to date at 12 months as were children who received oral poliovirus vaccine (OPV), whereas at Group Health, children who received IPV were slightly more likely to be up to date at 24 months (relative risk: 1.12; 95% confidence interval [CI]: 1.05, 1.19). These findings were consistent for children who were covered by Medicaid. At Kaiser Permanente, children who received IPV spent ∼3 fewer days up to date in the first year of life, but this difference did not persist at 2 years of age. At Group Health, children who received IPV were no different from those who received OPV in terms of days spent up to date by 1 or 2 years of age. At Group Health, children who received IPV were less likely to have a missed opportunity by 12 months old (odds ratio [OR] 0.46; 95% CI: 0.31, 0.70), but this finding did not persist at 24 months of age. At Kaiser Permanente, children who received IPV were more likely to have a missed opportunity by 12 months (OR 2.06; 95% CI: 1.84, 2.30), and 24 months of age (OR 1.50; 95% CI: 1.36, 1.67).

Conclusions.

The changeover from an all-OPV schedule to one containing IPV had little if any negative impact on vaccine coverage. Use of IPV was associated with a small increase in the likelihood of being up to date at 2 years of age at one of the HMOs and conversely was associated with a small increase in the likelihood of having a missed-opportunity visit in the other HMO.polio, poliomyelitis, vaccination, immunization coverage.
Financing Graduate Medical Education to Meet Pediatric Workforce Needs
Authors:   Committee on Pediatric Workforce
Published: August 2004

This statement reviews the current system of funding for graduate medical education (GME) in the United States and evaluates the potential of alternative GME funding mechanisms, including a portable authorization system, to meet future pediatric workforce needs. It addresses key issues relating to the financing of GME: Medicare direct medical education (DME) and indirect medical education adjustment (IMEA) payments, an all-payer GME trust fund, and a market mechanism to distribute GME funds for both core pediatric and pediatric subspecialty education. In a concluding series of recommendations, the statement calls for changes to the current system of GME funding to ensure the production of a pediatrician workforce that will be able to meet the future needs of infants, children, adolescents, and young adults.
Health Care for Children and Adolescents in the Juvenile Correctional Care System
Authors:   Committee on Adolescence
Published: August 2004

Over the past decade, there has been a dramatic increase in the population of juvenile offenders in the United States. Juveniles detained or confined in correctional care facilities have been shown to have numerous health problems. Such conditions may have existed before incarceration; may be closely associated with legal problems; may have resulted from parental neglect, mental health disorders, or physical, drug, or sexual abuse; or may develop within the institutional environment. Delinquent youths are often disenfranchised from traditional health care services in the community. For these adolescents, health care provided through correctional services may be their major source of health services. Pediatricians and correctional health care systems have an opportunity and responsibility to help improve the health of this underserved and vulnerable group of adolescents.
Hypovitaminosis D in Healthy Schoolchildren
Authors: Fuleihan Ghada El-Hajj , Nabulsi Mona , Choucair Mahmoud , Salamoun Mariana , Shahine Carmen Hajj , Kizirian Aline , Tannous Raja
Published: August 2004

Background.

Vitamin D is essential for skeletal growth, but there are currently no guidelines for vitamin D supplementation after infancy. This study investigates vitamin D insufficiency in healthy children.

Methods.

Children ages 10 to 16 years from 3 private schools in Beirut, Lebanon, with differing socioeconomic status (SES) were studied: 169 in the spring of 1999 and 177 in the following fall; 83 students participated in both study phases. They had a physical examination, answered a dietary questionnaire, and blood was drawn for calciotropic hormones and indices of bone turnover.

Results.

Overall, 52% of the students were vitamin D-insufficient; the proportion of insufficiency was 65% in the winter and 40% at the end of the summer. During both seasons, girls had lower vitamin D levels than did boys; those who followed the dress code of covered head, arms, and legs had the lowest levels. Students in the mid-SES school had lower 25-hydroxyvitamin D (25-OHD) levels than did the ones from the high-SES school. After adjusting for confounders, gender, SES, and body mass index remained the significant predictors of vitamin D levels in both seasons (R2 = 0.53, for spring and 0.28 for fall). There was a significant inverse correlation between 25-OHD levels and parathyroid hormone levels that was best fitted by a curvilinear model (R2 = 0.19).

Conclusion.

Even in a sunny country, hypovitaminosis D is common in schoolchildren, more so in the winter. Girls, especially those with a lower SES, are at particular risk. The inverse changes in parathyroid hormone suggest that insufficient vitamin D levels may deleteriously affect skeletal metabolism in healthy adolescents. Vitamin D insufficiency may be prevalent in many other countries where supplementation of milk with vitamin D is not mandatory. Our results call to a reconsideration of vitamin D supplementation in high-risk adolescents to further optimize skeletal health. vitamin D insufficiency, bone metabolism, nutrition, gender, socioeconomic status.