bluuebunny/crossref_metadata_2025 huggingface dataset:
Orthostatic Intolerance in Adolescent Chronic Fatigue Syndrome
Authors: Stewart Julian M. , Gewitz Michael H. , Weldon Amy , Arlievsky Nina , Li Karl , Munoz Jose
Published: August 2004

Objectives.

To demonstrate the association between orthostatic intolerance and the chronic fatigue syndrome (CFS) in adolescents and to delineate the form that orthostatic intolerance takes in these children.

Study Design.

We investigated the heart rate and blood pressure (BP) responses to head-up tilt (HUT) in 26 adolescents aged 11 to 19 years with CFS compared with responses in adolescents referred for the evaluation of simple faint and to responses in 13 normal healthy control children of similar age.

Results.

A total of 4/13 of the controls and 18/26 simple faint patients experienced typical faints with an abrupt decrease in BP and heart rate associated with loss of consciousness. One CFS patient had a normal HUT. A total of 25/26 CFS patients experienced severe orthostatic symptoms associated with syncope in 7/25, orthostatic tachycardia with hypotension in 15/25, and orthostatic tachycardia without significant hypotension in 3/25. Acrocyanosis, cool extremities, and edema indicated venous pooling in 18/25. None of the control or simple faint patients experienced comparable acral or tachycardic findings.

Conclusions.

We conclude that chronic fatigue syndrome is highly related to orthostatic intolerance in adolescents. The orthostatic intolerance of CFS often has heart rate and BP responses similar to responses in the syndrome of orthostatic tachycardia suggesting that a partial autonomic defect may contribute to symptomatology in these patients.
Home-based Management Can Achieve Intensification Cost-effectively in Type I Diabetes
Authors: Dougherty Geoffrey , Schiffrin Alicia , White Donna , Soderstrom Lee , Sufrategui Maria
Published: August 2004

Background.

Newly diagnosed insulin-dependent diabetic children are most often admitted to hospital for education and insulin management and subsequently followed in outpatient clinics or office settings. However, most could be managed at home, given adequate family and health care team support and subsequent follow-up facilitated by home-based nursing intervention. We conducted a randomized trial of clinical, psychosocial, and cost effects of home-based management in a 2-year follow-up study of newly diagnosed diabetic children.

Methods. 

Sixty three patients were randomly assigned to traditional hospitalization and outpatient follow-up (hospital-based group) or home management (home-based group). Treatment differences between the two groups consisted of duration of initial hospital stay, site and timing of initial teaching, and nature and extent of subsequent nursing follow-up. Metabolic control was assessed by means of quarterly glycosylated hemoglobin measurements for 24 months and then at 36 months. Diabetes-related adverse events, knowledge of diabetes, adherence to the diabetes regimen, psychosocial impact, and social (total) costs incurred were assessed for 24 months.

Findings. 

Glycosylated hemoglobin concentrations were significantly lower in the home-based group at 12 to 24 months and at 36 months. Both groups had comparable numbers of diabetes-related adverse events. There were no significant group differences in psychosocial impact. Parents in the home-based group spent significantly fewer hours on diabetes care and incurred significantly lower out-of-pocket expenses during the 1st month. Health care sector costs were significantly higher. Hospital costs were $889 higher, and government costs $890 higher per child. Social (total) costs were only $48 higher per case (NS) with home care when parents' time was valued at $11.88 per hour.

Interpretation. 

Home-based management for newly diagnosed diabetic children can result in better metabolic control and similar psychosocial outcomes compared with traditional hospital- and clinic-based care without notable effects on social (total) costs.
The Role of the Pediatrician in Youth Violence Prevention in Clinical Practice and at the Community Level
Authors:   Task Force on Violence
Published: August 2004

Violence and violent injuries are a serious threat to the health of children and youth in the United States. It is crucial that pediatricians define their role and develop the appropriate skills to address this threat effectively. From a clinical perspective, pediatricians should incorporate into their practices preventive education, screening for risk, and linkages to necessary intervention and follow-up services. As advocates, pediatricians should become involved at the local and national levels to address key risk factors and assure adequacy of preventive and treatment programs. There are also educational and research needs central to the development of effective clinical strategies. This policy statement defines the emerging role of pediatricians in youth violence prevention and management. It reflects the importance of this issue in the strategic agenda of the American Academy of Pediatrics for promoting optimal child health and development.
Early Prognostic Indicators of Outcome in Infants With Neonatal Cerebral Infarction: A Clinical, Electroencephalogram, and Magnetic Resonance Imaging Study
Authors: Mercuri Eugenio , Rutherford Mary , Cowan Frances , Pennock Jackie , Counsell Serena , Papadimitriou Maria , Azzopardi Denis , Bydder Graeme , Dubowitz Lilly
Published: August 2004

Objective.

The aim of this study was to identify prognostic factors in newborns with cerebral infarction.

Design.

Antenatal and perinatal factors and early clinical, electroencephalogram (EEG), and magnetic resonance imaging (MRI) findings were compared with neurodevelopmental outcome in 24 children with evidence of cerebral infarction on neonatal MRI.

Results.

Out of 24 infants, 19 had an infarction in the territory of a major cerebral vessel and 5 in the borderzone between cerebral arteries. Neuromotor outcome was normal in 17 and abnormal in 7 infants. Of these 7 infants, 5 infants showed a definite hemiplegia, whereas the other 2 showed some asymmetry of tone or function but no definite hemiplegia.

None of the adverse antenatal or perinatal factors was significantly associated with abnormal outcome. Neonatal clinical examination was also not always predictive of the outcome. The extent of the lesion on MRI was a better predictor. In particular, it was the concomitant involvement of hemisphere, internal capsule and basal ganglia that was always associated with an abnormal outcome whereas the involvement of only one or two of the three tended to be associated with a normal outcome.

EEG was also very helpful. Abnormal background activity either unilateral or bilateral was found in 6 infants and 5 out of 6 developed hemiplegia. In contrast, the presence of seizure activity in presence of a normal background was not related to abnormal outcome.

Conclusions.

Early MRI and EEG can help to identify the infants with cerebral infarction who are likely to develop hemiplegia.
Once-Daily Therapy for Streptococcal Pharyngitis With Amoxicillin
Authors: Feder Henry M. , Gerber Michael A. , Randolph Martin F. , Stelmach Paulette S. , Kaplan Edward L.
Published: August 2004

Objective.

An orally administered antimicrobial regimen for the treatment of group A β-hemolytic streptococcal (GABHS) pharyngitis given once rather than multiple times each day would be more convenient and might result in improved patient compliance. The purpose of this study was to evaluate the effectiveness of once-daily amoxicillin in the treatment of GABHS pharyngitis.

Patients.

Children presenting to a private pediatric office with GABHS pharyngitis.

Design.

Patients were randomly assigned to receive orally either amoxicillin (750 mg once daily) or penicillin V (250 mg three times a day) for 10 days. Compliance was monitored by urine antimicrobial activity.

Outcomes.

Outcomes were measured by impact on the clinical course, eradication of GABHS within 18 to 24 hours, and bacteriologic treatment failure rate as determined by follow-up throat cultures 4 to 6 and 14 to 21 days after completing therapy. GABHS isolates were serotyped to distinguish bacteriologic treatment failures (same serotype as initial throat culture) from new acquisitions (different serotypes).

Results.

During the 16 months of this study, 152 children between 4 and 18 years of age (mean, 9.9 years) were enrolled; 79 children were randomly assigned to receive once-daily amoxicillin and 73 were assigned to receive penicillin V three times a day. The children in the two treatment groups were comparable with respect to age, duration of illness before initiation of therapy, compliance, and signs and symptoms at presentation. There was no significant difference in the clinical or bacteriologic responses of the patients in the two treatment groups at the 18- to 24-hour follow-up visit. Bacteriologic treatment failures occurred in 4 (5%) of the 79 patients in the amoxicillin group and in 8 (11%) of the 73 patients in the penicillin V group.

Conclusions.

These data demonstrate that once-daily amoxicillin therapy is as effective as penicillin V therapy given three times a day for the treatment of GABHS pharyngitis, and if confirmed by additional investigations, once-daily amoxicillin therapy could become an alternative regimen for the treatment of this disease.
Clinical and Genetic Risk Factors for Cystic Fibrosis-related Liver Disease
Authors: Wilschanski Michael , Rivlin Joseph , Cohen Solomon , Augarten Arieh , Blau Hannah , Aviram Micha , Bentur Lea , Springer Chaim , Vila Yael , Branski David , Kerem Batsheva , Kerem Eitan
Published: August 2004

Objective.

The aim of this study was to define the role of possible risk factors for the development of cystic fibrosis (CF)-related liver disease and to analyze the association between liver disease and the different genotypes present in the Israeli CF patient population.

Patients and Methods.

All patients followed at the seven CF centers in Israel were included in this study. Liver disease was determined by persistently elevated serum liver enzymes and/or bilirubin, and/or significant ultrasonographic changes suggestive of chronic liver disease. The following clinical parameters were evaluated: ethnic origin, age at assessment of liver function, sex, history of meconium ileus, pancreatic function, history of distal intestinal obstruction syndrome, pulmonary function, and cystic fibrosis transmembrane conductance regulator mutation analysis.

Results.

Of the 288 patients screened, 80 (28%) had liver disease. Of the 256 patients with pancreatic insufficiency, 80 (31%) had liver disease compared with none of the 32 patients with pancreatic sufficiency. Genotype-phenotype correlation was performed on 207 patients carrying identified mutations that were previously classified according to phenotype severity. Liver disease was found in 56 (32%) of 173 patients carrying mutations associated with a severe phenotype and in 6 (38%) of 16 patients carrying at least one mutation associated with a variable genotype (G85E and/or 5T allele). None of the 18 patients carrying the 3849+10kb C->T mutation had liver disease. Prevalence of liver disease increased with age. No correlation was found between liver disease and severity of lung disease, nutritional status, history of meconium ileus, or distal intestinal obstruction syndrome.

Conclusion.

CF patients who have pancreatic insufficiency and carry mutations associated with a severe or a variable genotype are at increased risk to develop liver disease.
Developmental Dysplasia of the Hip: A New Approach to Incidence
Authors: Bialik Viktor , Bialik Gadi M. , Blazer Shraga , Sujov Polo , Wiener Fred , Berant Moshe
Published: August 2004

Objective.

The controversy over the incidence of developmental dysplasia of the hip (DDH) stems mainly from an ambiguity of criteria for defining a genuinely pathologic neonatal hip. In this study, we evaluate an algorithm we devised for the treatment of DDH, for its ability to identify those neonatal hips which, if left untreated, would develop any kind of dysplasia and, therefore, are to be included in the determination of DDH incidence.

Methods.

Clinical and ultrasonographic examinations for DDH were performed on 18 060 consecutive neonatal hips at 1 to 3 days of life. Newborns with skeletal deformities, neurologic/muscular disorders, and neural tube defects were excluded. Hips that featured any type of sonographic pathology were reexamined at 2 or 6 weeks, depending on the severity of the findings. Only hips in which the initial pathology was not improved or had deteriorated were treated; all others were examined periodically until the age of 12 months.

Results.

Sonographic screening of 18 060 hips detected 1001 instances of deviation from normal, indicating a sonographic DDH incidence of 55.1 per 1000. However, only 90 hips remained abnormal and required treatment, indicating a true DDH incidence of 5 per 1000 hips. All the others evolved into normal hips, and no additional instances of DDH were found on follow-up throughout the 12 months.

Conclusions.

The implementation of our protocol enables us to distinguish two categories of neonatal hip pathology: one that eventually develops into a normal hip (essentially sonographic DDH); and another that will deteriorate into a hip with some kind of dysplasia, including full dislocation (true DDH). This approach seems to allow for a better-founded definition of DDH, for an appropriate determination of its incidence, for decision-making regarding treatment, and for assessment of the cost-effectiveness of screening programs for the early detection of DDH. developmental dysplasia of the hip, incidence, neonatal screening, sonography.
Perinatal Risk Factors for Infant Hospitalization With Viral Gastroenteritis
Authors: Newman Robert D. , Grupp-Phelan Jacqueline , Shay David K. , Davis Robert L.
Published: August 2004

Context. 

A tetravalent vaccine against rotavirus, the most commonly identified etiologic agent of viral gastroenteritis (GE), has recently been licensed for use in the United States.

Objective. 

To evaluate whether specific groups of infants might be at sufficiently high risk to warrant a focused rotavirus vaccine policy, we investigated perinatal risk factors for hospitalization with viral GE and rotavirus in the first year of life.

Design. 

Population-based, case–control study.

Setting. 

Washington State linked birth certificate and hospital discharge abstracts from 1987 through 1995.

Patients. 

Infants, 1 through 11 months of age, hospitalized for viral GE (N = 1606) were patients in this study. Control subjects were 8084 nonhospitalized infants, frequency-matched to patients on year of birth.

Primary Outcome Measure. 

Maternal and infant characteristics associated with infant hospitalization for viral GE.

Results. 

We found a significant association between birth weight and the risk for hospitalization. Very low birth weight infants (<1500 g) were at the highest risk (odds ratio [OR] 2.6; 95% confidence interval [CI]: 1.6,4.1);, low birth weight infants (1500–2499 g), at intermediate risk (OR 1.6; 95% CI: 1.3,2.1); and large infants (>4000 g), at reduced risk (OR 0.8; 95% CI: 0.6,0.9). Other characteristics associated with GE hospitalization were male gender (OR 1.4; 95% CI: 1.3,1.6); maternal smoking (OR 1.2; 95% CI: 1.1,1.4); unmarried mother (OR 1.2; 95% CI: 1.1,1.4); Medicaid insurance (OR 1.4; 95% CI: 1.3,1.7); and maternal age <20 years (OR 1.2; 95% CI: 1.0,1.5). Infants born October through December were at decreased risk for hospitalization (OR 0.8; 95% CI: 0.7,0.9), as were infants born to Asian mothers (OR 0.5; 95% CI: 0.3,0.7), and infants born to mothers >34 years of age (OR 0.7; 95% CI: 0.6,0.9). Using these factors, the area under a receiver operating characteristic curve was 0.63. Therefore, to achieve a sensitivity of 90% in identifying high-risk infants, specificity would fall to 10%. Subanalyses of children admitted for viral GE during the peak of the Northwest rotavirus season (January to March) and children with confirmed rotavirus infection demonstrated similar risk factors and receiver operating characteristic curves.

Conclusion. 

We conclude that a focused rotavirus vaccination policy using readily identifiable potential high-risk groups would be unlikely to prevent most infant hospitalizations associated with rotavirus infection. However, the safety of rotavirus vaccine in low birth weight and premature infants must be established, because these children appear to be at greater risk for hospitalization with viral GE and rotavirus.
Congenital Hypothyroidism and Nonimmune Hydrops Fetalis: Associated?
Authors: Kessel Irene , Makhoul Imad R. , Sujov Polo
Published: August 2004

Hydrops fetalis (HF) consists of an abnormal accumulation of fluid in two or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema. Almost all observed cases of HF are of the nonimmune type, the causes of which remain undetermined in 15% of patients. We report a newborn infant with nonimmune hydrops fetalis (NIHF) and congenital hypothyroidism. The infant's mother was healthy and there were no malformations of the placenta or umbilical cord. The infant did not show any structural abnormalities of his central nervous, cardiovascular, gastrointestinal, or urinary tract systems, and there was no evidence of anemia, infectious disease, or inborn error of metabolism. An immune-based process was unlikely, because the blood group of the mother and infant was A-positive and results of an indirect Coombs test in the mother and a direct Coombs test in the infant were negative. The patient's condition gradually improved with mechanical ventilation, repeated thoracocentesis, and total parenteral nutrition. By day 5 of age the skin edema, pericardial effusion, and ascites disappeared, but accumulation of significant amounts of chylous pleural fluid persisted. Because of lethargy, FT4 and thyroid-stimulating hormone levels were obtained and showed hypothyroidism. Thyroid hormone supplementation was then started, and within 4 days the infant became more vigorous and was weaned from mechanical ventilation. After 7 days, the chylothorax resolved completely as the serum thyroxine level normalized. No reaccumulation of pleural effusion was noticed. The infant started to gain weight and was discharged from the hospital at 35 days of age. A possible pathophysiologic association between congenital hypothyroidism and NIHF is discussed. NIHF may be caused by lymphatic congestion attributable to an impairment of lymphatic flow and a delayed return of lymph to the vascular compartment. There could be a possibility that because of thyroid hormone deficiency in this patient, there was reduced adrenergic stimulation of the lymphatic system. This could result in a sluggish flow of the lymph with engorgement of the lymphatic system, leakage of lymph into the pleura and the interstitial spaces, and the production of chylothorax with NIHF. Animal studies demonstrate a direct relationship between lymph flow rate or lung liquid clearance and adrenergic receptor activity in the lymphatic system. These observations support our hypothesis that deficient adrenergic activity in congenital hypothyroidism might lead to chylothorax with NIHF in the fetus. We speculate that thyroid hormone may play a role in the regulation of adrenergic receptors in the lymphatic system and lungs, thus modulating both the lymphatic flow rate and lung liquid clearance, and facilitating the resolution of chylothorax. Examination of thyroid functions should be included in the investigation of fetuses and neonates with NIHF of an obscure origin.
Feeding Strategies for Premature Infants: Randomized Trial of Gastrointestinal Priming and Tube-feeding Method
Authors: Schanler Richard J. , Shulman Robert J. , Lau Chantal , Smith E. O'Brian , Heitkemper Margaret M.
Published: August 2004

Background

Data on enteral feeding management of premature infants are limited and often not the subject of randomized clinical trials. Several small studies suggest benefits from the early initiation of feeding, but do not assess the combined effects of time of initiation of feeding, tube-feeding method, and type of milk used. Either singly or in combination, these treatments may affect growth, bone mineralization, biochemical measures of nutritional status, and feeding tolerance, and, ultimately, the duration of hospitalization.

Methods.

A total of 171 premature infants, stratified by gestational age (26 to 30 weeks) and diet (human milk or preterm formula) were assigned randomly among four treatment combinations in a balanced two-way design comparing the presence or absence of gastrointestinal (GI) priming for 10 days and continuous infusion versus intermittent bolus tube-feeding.

Results.

The major outcome, time required for infants to attain full oral feeding, was similar among treatments. GI priming was not associated with any measured adverse effect and was associated with better calcium and phosphorus retention, higher serum calcium and alkaline phosphatase activity, and shorter intestinal transit times. The bolus tube-feeding method was associated with significantly less feeding intolerance and greater rate of weight gain than the continuous method. In addition, the greater the quantity of human milk fed, the lower the morbidity.

Conclusions.

Early GI priming with human milk, using the bolus tube-feeding method, may provide the best advantage for the premature infant.
Causes of Death in the Extremely Low Birth Weight Infant
Authors: Barton Lorayne , Hodgman Joan E. , Pavlova Zdena
Published: August 2004

Objective.

To present primary and secondary causes of death confirmed by autopsy for the extremely low birth weight infant.

Methods.

A total of 111 infants weighing between 300 and 1000 g at birth who died and were autopsied at our hospital during the 4-year period 1990–1993 were retrospectively reviewed. Clinical, pathologic, and laboratory data were retrieved including results of placental examinations and autopsy cultures. Primary and secondary causes of death were assigned by the authors.

Results.

Infection was the most common primary cause (56/111) followed by respiratory distress syndrome/bronchopulmonary dysplasia (24/111) and congenital defect (15/111). Immaturity as an only cause appeared almost exclusively in infants weighing <500 g at birth. Infection was significantly underdiagnosed clinically with most of these deaths attributed to immaturity or respiratory distress syndrome. In only 1 case was intraventricular hemorrhage considered the primary cause of death although it was present as a secondary cause in 19/111. Infections were divided into congenital (30/56) and acquired (26/56) by time of death. The congenital infections (≤48 hours) consisted of pneumonia and chorioamnionitis/funisitis attributable to maternal enteric organisms. Causative bacteria were obtained in pure culture in a number of these cases. The acquired infections were mainly caused by yeasts and nosocomial bacteria. Sixty-seven percent of the deaths occurred in the first 2 days and 12% were beyond the neonatal period at 29 to 104 days. Care was not initiated or was withdrawn in 50% of the infants, usually within the first 4 hours.

Conclusions.

Infection of the amniotic fluid leading to pneumonia was the major cause of death in the extremely low birth weight infant. Accurate cause of death can not be reliably ascertained without an autopsy accompanied by examination of the placenta in the early deaths. Antibiotic treatment of the mother and infant may have reduced the deaths from infection. Early failure to respond to neonatal intensive care may well indicate presence of a congenital pneumonia.
Cisapride: A Survey of the Frequency of Use and Adverse Events in Premature Newborns
Authors: Ward Robert M. , Lemons James A. , Molteni Richard A.
Published: August 2004

Objective.

This survey estimated the frequency of use and adverse events associated with cisapride treatment of premature newborns in intensive care units. It was initiated in response to a warning issued in Canada cautioning against cisapride treatment of premature infants of <36 weeks' gestation and <3 months of age.

Methodology.

Surveys were mailed to 105 neonatology training program directors to obtain the total number of neonatal intensive care unit (NICU) admissions, the number of admissions of infants of <36 weeks' gestation, the number of years that cisapride had been used, the estimated percent/number of premature patients treated with cisapride per year, and the frequency and nature of arrhythmias or other adverse events associated with cisapride treatment. Of 105 programs, 46 responded to a single mailing of the first survey. A second survey mailed to the 45 respondents to the first survey sought to determine the indications, diagnostic tests, and dosages used with cisapride treatment of premature newborns. Of the 45 programs, 26 responded to the second survey.

Results.

More than 58 000 premature newborns of <36 weeks' gestation were admitted to the NICUs we surveyed, and ∼19% were treated with cisapride. No deaths attributable to cisapride were reported among >11 000 preterm newborns treated. Three nonfatal arrhythmias were reported; two associated with 10-fold dosing errors and one with co-treatment with erythromycin, a macrolide antibiotic that reduces the metabolism of cisapride. Diarrhea was reported in 12 patients, and reversible liver enzyme changes were noted in one patient. Typically, cisapride treatment was started in dosages of 0.1 to 0.2 mg/kg/dose, repeated every 6 to 8 hours. Treatment usually was begun empirically, without a preceding study to document gastroesophageal reflux. The most frequent indications for cisapride treatment were choking or gagging, with associated apnea, bradycardia, and desaturation. Approximately 50% of patients had discontinued cisapride treatment before discharge. Eighty-four percent of clinicians judged cisapride to be effective for the problems being treated.

Conclusions.

Cisapride treatment of premature infants of <36 weeks' gestation and <3 months of age in NICUs appears to be widespread in the United States. Complications and adverse events were seen when cisapride was administered in excessive dosages or in combination with a drug that inhibits its metabolism and leads to increased serum concentrations. Severe toxicities such as arrhythmias were reported with a frequency of <1/11 000 NICU admissions. However, in a retrospective survey, episodes of toxicity, including mortality, attributable to cisapride may not have been recognized or reported.
Guidelines for the Pediatric Perioperative Anesthesia Environment
Authors:   Section on Anesthesiology
Published: August 2004

The American Academy of Pediatrics proposes the following guidelines for the pediatric perioperative anesthesia environment. Essential components are identified that make the perioperative environment satisfactory for the anesthesia care of infants and children. Such an environment promotes the safety and wellbeing of infants and children by reducing the risk for adverse events.
Newborn and Infant Hearing Loss: Detection and Intervention
Authors:   Task Force on Newborn and Infant Hearing
Published: August 2004

This statement endorses the implementation of universal newborn hearing screening. In addition, the statement reviews the primary objectives, important components, and recommended screening parameters that characterize an effective universal newborn hearing screening program.
Chest Roentgenogram in the Evaluation of Heart Defects in Asymptomatic Infants and Children With a Cardiac Murmur: Reproducibility and Accuracy
Authors: Birkebæk Niels H. , Hansen Lars K. , Elle Bo , Andersen Poul E. , Friis Merete , Egeblad Mogens , Damgaard-Pedersen Karen , Nielsen Nina T. , Oxhøj Henrik
Published: August 2004

Objectives. 

To evaluate the reproducibility and the accuracy of pediatric radiologists' assessments of chest radiographs with respect to the presence or absence of heart defects in children with an asymptomatic heart murmur.

Design. 

Ninety-eight children, ages 1 month to 15 years (median, 30.1 months), referred for evaluation of a heart murmur were consecutively included. They all had a standard chest radiograph and a color Doppler echocardiograph (CDE) performed. Six specialists in pediatric radiology evaluated the chest radiographs independently on two occasions 6 months apart. The radiologists were asked to classify each set of films into one of two categories: heart disease or no heart disease. The outcome of the CDE was considered the definite diagnosis. κ statistics were used to analyze the reproducibility of the radiologic assessments. Sensitivity, specificity, and the predictive value of a positive and a negative test were used for evaluation of the accuracy of the radiologic assessments.

Results. 

Mean intra- and interobserver κ values were all <0.6, and the majority were <0.4. Mean sensitivity was 0.3 (range: 0.17–0.52), mean predictive value of a positive test was 0.4, implying that 60% of the positive assessments were falsely positive. Mean specificity was 0.86 (range: 0.75–0.93) and the mean predictive value of a negative test was 0.80 implying that 20% of the negative assessments were falsely negative.

Conclusion 

We found a low reproducibility, as well as a low accuracy, of the radiologic assessments of the chest radiographs of children with an asymptomatic heart murmur with respect to the presence or absence of heart disease. A false-positive radiologic assessment of the chest radiograph with respect to heart defects causes unnecessary anxiety and further examinations, whereas a false-negative assessment might result in omission of relevant investigations and proper identification of the heart defect. We cannot recommend the use of chest radiographs in the initial evaluation of the asymptomatic child with a heart murmur. If a heart defect cannot be excluded by clinical examination a CDE must be performed.
Human Immunodeficiency Virus Status and Delayed-Type Hypersensitivity Skin Testing in Ugandan Children
Authors: Mandalakas Anna Maria , Guay Laura , Musoke Philippa , Carroll-Pankhurst Cindie , Olness Karen N.
Published: August 2004

Background. 

In previous studies, delayed-type hypersensitivity (DTH) skin testing has been shown to be affected by several factors including nutritional status, intercurrent infection, host immune status, and previous exposure to the antigen being used.

Objective. 

To determine the effect of human immunodeficiency virus type 1 (HIV-1) status on DTH skin testing in a cohort of HIV-1-infected and noninfected Ugandan children followed prospectively from birth.

Design. 

Nested case-control study.

Setting. 

Primary care clinic serving study participants at Mulago Hospital, Makerere University, Kampala, Uganda.

Participants. 

Thirty HIV-1-infected children and 30 age-matched, HIV-1-noninfected children.

Methods. 

After completion of history and physical, each child underwent Mantoux skin testing with both Candidaand purified protein derivative (PPD). Results of skin testing were read in 48 to 72 hours. Complete chart reviews were performed on all children. CD4 lymphocyte counts were obtained on all HIV-1-infected children at the time the skin testing was read.

Results. 

The average age of participants was 67 months (range, 51–92 months). HIV-1-infected children (mean CD4 lymphocyte count, 1069 mL−1; range, 86–3378 mL−1), compared with noninfected, age-matched peers, developed significantly smaller PPD reaction size (mean, 1.18 mm ± 4.3 vs 3.6 mm ± 7.6, respectively). Candida responses were not different between the two groups of children. Among HIV-1-infected children, there was a larger Candida reaction size in children who had recently received chloroquine treatment. There was no significant correlation between Candida reactivity and PPD reactivity, progressive HIV-1 disease, or CD4 lymphocyte count. The six children diagnosed clinically with active tuberculosis had lower absolute CD4 lymphocyte counts than children without tuberculosis. Lack of reaction to PPD was associated with lower CD4 lymphocyte counts and progressive HIV-1 disease.

Conclusions. 

In HIV-1-infected Ugandan children, DTH skin testing was influenced by the choice of antigen selected, HIV-1 infection, and recent treatment with chloroquine. Based on these findings, we believe that further prospective, longitudinal investigation into the role of chloroquine in HIV-1-infected children is needed. We emphasize the limitations of DTH skin testing in HIV-infected children as an adjunct in the diagnosis of active tuberculosis.
A Comparison of the Mogen and Gomco Clamps in Combination With Dorsal Penile Nerve Block in Minimizing the Pain of Neonatal Circumcision
Authors: Kurtis Peter S. , DeSilva Hema N. , Bernstein Bruce A. , Malakh Lillian , Schechter Neil L.
Published: August 2004

Objectives. 

1) To compare the Mogen and Gomco clamps with regard to pain experienced during neonatal circumcision, and 2) to assess neonatal circumcision pain with and without dorsal penile nerve block (DPNB).

Design/Methods. 

A randomized, controlled, nonblinded clinical trial; 48 healthy, full-term infants were randomized into one of the following four groups: Gomco vs Mogen with (+) or without (−) DPNB. DPNB+ infants were injected with 0.8 mL of 1% lidocaine before circumcision. DPNB− infants received no placebo injection. Heart rate, respiratory rate, and oxygen saturation (Sao2) during the procedure were monitored and data transferred to computer files by using the Datalab software system. Crying was recorded on videotape. Pre- and postcircumcision saliva samples for cortisol analysis were collected. Heart rate, respiratory rate, Sao2, cortisol changes, and duration of crying were evaluated statistically with two-way analyses of variance andt tests.

Results. 

The type of clamp but not the use of anesthesia was significantly associated with the length of the procedure (mean Mogen time, 81 seconds; mean Gomco time, 209 seconds) and percentage of respiratory rate change. The use of anesthesia but not the type of clamp was significantly associated with percentage of crying time and percentage of Sao2 change during the procedure. Heart rate changes and total crying time were significantly associated withboth the type of clamp and the use of anesthesia.Neither clamp type nor anesthesia status was significantly associated with salivary cortisol changes, although the mean increase for the DPNB− group was approximately twice that for the DPNB+ group. Fifty-six percent of infants circumcised with the Mogen clamp and DPNBdid not cry at all during the procedure.

Conclusions. 

DPNB is effective in reducing neonatal circumcision pain with either the Mogen or the Gomco clamp. For a given anesthesia condition, the Mogen clamp is associated with a less painful procedure than the Gomco. The Mogen clamp with DPNB causes the least discomfort during neonatal circumcision.
Nasal Continuous Positive Airway Pressure and Early Surfactant Therapy for Respiratory Distress Syndrome in Newborns of Less Than 30 Weeks' Gestation
Authors: Verder Henrik , Albertsen Per , Ebbesen Finn , Greisen Gorm , Robertson Bengt , Bertelsen Aksel , Agertoft Lone , Djernes Birgitte , Nathan Erling , Reinholdt Jes
Published: August 2004

Objective.

To determine whether early versus late treatment with porcine surfactant (Curosurf) reduces the requirement of mechanical ventilation in very preterm infants primarily supported by nasal continuous positive airway pressure (nasal CPAP).

Design.

Multicenter randomized, controlled trial.

Patients.

The study population comprised 60 infants <30 weeks' gestation with respiratory distress syndrome (RDS) who had an arterial to alveolar oxygen tension ratio (a/APo2) of 0.35 to 0.22.

The cohort from which the study population was generated comprised 397 infants.

Results.

The need for mechanical ventilation or death within 7 days of age was reduced from 63% in the late-treated infants to 21% in early-treated infants. Increasing numbers of antenatal steroid doses also improved the outcome, especially in the early-treated infants. Six hours after randomization mean a/APo2 rose to 0.48 in the early-treated infants compared with 0.36 in the late-treated. The need of mechanical ventilation before discharge was reduced from 68% in the late-treated to 25% in the early-treated infants.

Conclusions.

Nasal CPAP in combination with early treatment with Curosurf significantly improves oxygenation and reduces the subsequent need for mechanical ventilation in infants <30 weeks' gestational age with RDS.
Multiple-birth Infants at Higher Risk for Development of Deformational Plagiocephaly
Authors: Littlefield Timothy R. , Kelly Kevin M. , Pomatto Jeanne K. , Beals Stephen P.
Published: August 2004

Objective. 

Deformational plagiocephaly refers to the development of an abnormal head shape in infants resulting from externally applied molding forces, which may occur either prenatally or postnatally. We have observed that an unexpectedly high number of multiple-birth infants have presented to our center with this condition. The purposes of this investigation were to: 1) determine the significance of this observation; and 2) examine the risk factors that may make this population more susceptible to the development of plagiocephaly.

Materials and Methods. 

A retrospective review of our database was performed to identify those infants who were of multiple-birth origin. The parents of these infants were contacted by phone to complete a survey regarding the prenatal and postnatal history of their child. Similar information was obtained for the state of Arizona from the Office of Vital Statistics. A χ2analysis was used to compare the incidence of multiple births in Arizona with the incidence of multiple births in our treatment population.

Results. 

Between 1993 and 1996, 69 (8.6%) of the 801 infants treated for deformational plagiocephaly at our Phoenix center were of multiple-birth origin. Four infants who had been treated postoperatively after surgery for craniosynostosis, as well as 5 patients who had been referred from out of state, were excluded from further study. The χ2 analysis of the remaining 60 patients confirmed that a statistically significant number of plural-birth infants had presented with deformational plagiocephaly. Four risk factors were identified as having occurred at high frequency in this population: in utero constraint, supine sleeping position, torticollis, and prematurity.

Conclusions. 

The current findings of this investigation confirm that a significant number of multiple-birth infants have presented to our clinic with deformational plagiocephaly. Compared with their singleton counterparts, plural infants seem to be at higher risk for the development of deformational plagiocephaly, because they are more likely to be exposed to multiple risk factors.deformational plagiocephaly, multiple birth, plurality.
The Scope of Unmet Maternal Health Needs in Pediatric Settings
Authors: Kahn Robert S. , Wise Paul H. , Finkelstein Jonathan A. , Bernstein Henry H. , Lowe Janice A. , Homer Charles J.
Published: August 2004

Objective. 

Previous work has focused attention on the prevalence of specific maternal health problems known to affect children, such as smoking or depression. However, the cumulative health burden experienced by mothers and the potential for a practical pediatric health services response have not been examined. The aims of this study were to characterize: 1) the prevalence and cumulative burden of maternal health behaviors and conditions, 2) maternal access to a source of comprehensive adult primary care, and 3) maternal perceptions of a pediatric role in screening and referral.

Methods. 

We surveyed 559 consecutive women bringing a child 18 months of age or less to one of four pediatric primary care sites between July 1996 and May 1997. The pediatric sites included one outpatient program in an academic hospital, one in a community health center, and two in-staff model practices of a managed care organization (these last two were combined for analysis). The self-administered questionnaire contained previously validated questions to assess health behaviors and conditions (smoking, alcohol abuse, depression, violence, risk for unintended pregnancy, serious illness, self-reported health) and access to care (regular source, regular provider, health insurance, care delayed or not received). Maternal attitudes toward a pediatric role in screening and referral were also elicited.

Results. 

In the three settings, response rates ranged from 75% to 84%. The average age of the women ranged from 25.1 to 32.1 years and the average age of the children ranged from 6.5 to 8.0 months. Across the settings, the percentage of women reporting at least one health condition (66%–74%) was similarly high, despite significant demographic differences among sites. Many women reported more than one condition (31%–37%); among all women who smoked, 33% also screened positive for alcohol abuse, 31% for emotional or physical abuse, and 48% for depression. Access to comprehensive adult primary care was variable with 23% to 58% of women reporting one or more barriers depending on the site. Across all sites, >85% of mothers reported they would “not mind” or “would welcome” a pediatric role in screening and referral.

Conclusions. 

Two-thirds of women bringing their children for pediatric care had health problems regardless of the site of care. Many women also reported substantial barriers to comprehensive health care. Most women reported acceptance of a pediatric role in screening and referral. Given the range and depth of maternal health needs, strategies to connect or reconnect mothers to comprehensive adult primary care from a variety of pediatric settings should be explored.
Changes in Oxygenation With Inhaled Nitric Oxide in Severe Bronchopulmonary Dysplasia
Authors: Banks Beverly A. , Seri Istvan , Ischiropoulos Harry , Merrill Jeffrey , Rychik Jack , Ballard Roberta A.
Published: August 2004

Background.

Severe bronchopulmonary dysplasia (BPD), which is associated with high mortality and morbidity, is thought to be the result of mechanical, inflammatory, and oxidant injury to the immature lung, and includes the development of pulmonary hypertension with vascular remodeling.

Methods.

A phase II pilot study was conducted to determine the effect of inhaled nitric oxide (iNO) on oxygenation in severe BPD. This was an open-labeled, noncontrolled trial to evaluate safety and determine appropriate dosing for a future randomized controlled trial. Infants were eligible for enrollment if they were ≥4 weeks of age and ventilator dependent with a mean airway pressure of ≥10 cm H2O and an Fio2 of ≥0.45. Study infants received iNO (20 ppm) for 72 hours, and Fio2 was adjusted to maintain oxygen saturations of >92%. Infants who had a ≥15% reduction in Fio2 after 72 hours received prolonged treatment with low-dose iNO, weaning by 20% every 3 days as tolerated.

Findings.

Sixteen preterm infants (23–29 weeks of gestation), age 1 to 7 months, were enrolled. Eleven of 16 infants had a significant increase in Pao2 after 1 hour of iNO (median change, 24 mm Hg; range, −15 to 59 mm Hg;P < .01), but there was no significant change in Paco2. After 72 hours of iNO, 11 infants had ≥15% reduction in Fio2, and 7 of the 11 had ≥35% reduction (P < .01). Among the 11 infants who responded to iNO after 72 hours, 10 had a sustained improvement in oxygenation throughout their course of treatment (duration, 8–90 days), and ventilator support could also be decreased. No adverse effects from iNO (increased methemoglobin, bleeding, or increased plasma 3-nitrotyrosine) were observed. Four of the 11 infants (36%) who responded to iNO ultimately weaned off mechanical ventilation and 4 died, whereas all the infants who failed to respond to iNO either died or continue to require mechanical ventilation.

Interpretation.

We conclude that the use of low-dose iNO may improve oxygenation in some infants with severe BPD, allowing decreased Fio2 and ventilator support without evidence of adverse effects. Randomized clinical trials of low-dose iNO for BPD are warranted.
A Polymerase Chain Reaction-based Epidemiologic Investigation of the Incidence of Nonpolio Enteroviral Infections in Febrile and Afebrile Infants 90 Days and Younger
Authors: Byington Carrie L. , Taggart E. William , Carroll Karen C. , Hillyard David R.
Published: August 2004

Objective.

Enteroviruses are important pathogens in infants, but their true contribution to febrile illness in infants ≤90 days old is unknown. The purpose of this study was to use the polymerase chain reaction (PCR) for diagnosis of enteroviral (EV) infection in febrile and afebrile infants ≤90 days of age to improve the understanding of the epidemiology of EV infection in this population.

Methods.

Patients included all unimmunized, febrile infants ≤90 days of age admitted to Primary Children's Medical Center (Salt Lake City, UT) for sepsis evaluation from December 1996 to December 1997. Blood, urine, cerebrospinal fluid, and throat swabs were tested for enteroviruses using a PCR assay (Roche Molecular Systems, Branchburg, NJ). Alternate PCR assays separated polio and nonpolio enteroviruses. Results of bacterial cultures, outcome, and hospital charges were obtained. Blood from afebrile, control infants ≤90 days old was tested for enteroviruses.

Results.

A total of 345 febrile infants were enrolled; 89 (25.8%) were positive for enterovirus. The incidence of EV infection ranged from 3.2% in January to 50% in August and October. Five EV-positive, febrile infants (5.6%) had concomitant urinary tract infections, and 1 (1.1%) had concomitant bacteremia. Infants with confirmed EV infection were significantly less likely to have bacterial infection than those who were EV-negative. All infants infected with an enterovirus recovered. Average length of stay was 3 days, average charges were nearly $4500. Eighty-six afebrile, control infants were enrolled; 6 (6.9%) were positive for enterovirus; 3 had received oral polio vaccine.

Conclusions.

Nonpolio EV infections commonly cause fever in infants ≤90 days of age. Rates of EV positivity are low in afebrile, unimmunized infants. The use of PCR to identify febrile infants with nonpolio EV infections may decrease length of hospital stay, unnecessary antibiotic administration, and charges.