bluuebunny/crossref_metadata_2025 huggingface dataset:
Survival in Early- and Late-Term Infants With Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation
Authors: Stevens Timothy P. , Chess Patricia R. , McConnochie Kenneth M. , Sinkin Robert A. , Guillet Ronnie , Maniscalco William M. , Fisher Susan G.
Published: August 2004

Background. Congenital diaphragmatic hernia (CDH) is a malformation of the diaphragm that allows bowel to enter the thoracic cavity, resulting in pulmonary hypoplasia and pulmonary hypertension. Approximately 50% of CDH patients are treated with extracorporeal membrane oxygenation (ECMO). The optimal gestational age for delivery of term infants with CDH at high risk for requiring ECMO is not known. The goal of this study was to compare survival of infants with CDH receiving ECMO born early term (38 0/7–39 6/7 weeks’ gestation) with those born late term (40 0/7–41 6/7 weeks’ gestation). Changes in survival rates of term infants and the factors associated with these changes were assessed over the 25 years that ECMO has been available.

Methods. Design. Retrospective cohort study of infants with CDH treated with ECMO.

Data Sources. The Extracorporeal Life Support Organization registry of patients treated at active Extracorporeal Life Support Organization centers from April 1976 through June 2001.

Analysis. Survival and clinical predictors of survival were compared between infants born early term (38 0/7–39 6/7 weeks’ gestation) and infants born late term (40 0/7–41 6/7 weeks’ gestation). Changes in survival rates over time and factors associated with survival were evaluated.

Results. Among full-term infants with CDH treated with ECMO, late-term compared with early-term delivery was associated with improved survival (63% vs 53%). Among full-term survivors of ECMO, late-term infants spent less time on ECMO (181 vs 197 hours) and less time in the hospital (60 vs 67 days). In multivariate analysis, greater birth weight, higher 5-minute Apgar score, higher arterial pH and Pco2 <50 torr before ECMO, and absence of a prenatal diagnosis of CDH were associated with survival.

Since the late 1980s, survival of infants with CDH requiring ECMO decreased from 63% to 52%. The decreased survival rate was associated with increased rates of prenatal diagnosis, early-term delivery, lower birth weight, longer ECMO runs, and more frequent complications on ECMO.

Conclusions. Among term infants with CDH receiving ECMO, late-term delivery compared with early-term delivery is associated with improved survival, shorter ECMO duration, shorter hospital length of stay, and fewer complications on ECMO. These data suggest that, at least for the ∼50% of CDH patients treated with ECMO, outcomes for infants with CDH may be improved by delay of elective delivery until 40 completed weeks of gestation.
Infant Feeding and Blood Cholesterol: A Study in Adolescents and a Systematic Review
Authors: Owen Christopher G. , Whincup Peter H. , Odoki Katherine , Gilg Julie A. , Cook Derek G.
Published: August 2004

Objective. To examine the influence of infant feeding method on serum total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol.

Methods. A cross-sectional study of 13- to 16-year-olds and a systematic review of studies (all observational) on the effects of infant feeding on cholesterol in infancy (<1 year), childhood or adolescence (1–16 years), and adulthood (≥17 years) were conducted using random effects models. Differences are presented as breastfed-bottle-fed. A total of 1532 individuals (92% white; 55% male; mean age: 15.1 years) in 10 British towns were studied, and 37 studies with 52 observations on TC (26 in infancy, 17 in childhood or adolescence, and 9 in adulthood; corresponding figures for LDL were 7, 4, and 6) were reviewed.

Results. Mean TC in childhood or adolescence (including the new study) was not related to infant feeding pattern (mean TC difference = 0.00; 95% confidence interval [CI]: −0.07 to 0.07 mmol/L). However, in infancy, mean TC was higher among those breastfed (mean TC difference = 0.64; 95% CI: 0.50–0.79 mmol/L), whereas in adults, mean TC was lower among those breastfed (mean TC difference = −0.18; 95% CI: −0.30 to −0.06 mmol/L). Patterns for LDL were similar to those for TC throughout.

Conclusions. Breastfeeding is associated with increased mean TC and LDL levels in infancy but lower levels in adulthood/adult life. These results suggest that breastfeeding may have long-term benefits for cardiovascular health and may have implications for the content of formula feed milks.
Clinical Profile of 30 Infants With Acute Pulmonary Hemorrhage in Cleveland
Authors: Dearborn Dorr G. , Smith Paul G. , Dahms Beverly B. , Allan Terrence M. , Sorenson W.G. , Montana Eduardo , Etzel Ruth A.
Published: August 2004

Between 1993 and 2000, 30 infants were hospitalized with acute pulmonary hemorrhage at Rainbow Babies and Children’s Hospital in Cleveland. Most infants presented with severe pulmonary symptoms requiring intensive support, but a few infants had less severe hemorrhage. Three quarters of the patients required ventilator support and blood transfusions. Eleven patients had transitory hemoglobinuria. Five patients died, but infants who survived did well. There are currently no specific treatment modalities, although we have advised moving to a different home and avoiding environmental tobacco smoke. Subsequently, rebleeding from the lower respiratory tract has decreased from 5 of 7 infants to 1 in 21. On the basis of decreased subsequent fatal hemorrhage, high dose glucocorticoids seem to be of some value. Several patients revealed continued low-grade alveolar hemorrhage for months after their initial bleed, even after removal from their original home environments.
When Inflicted Skin Injuries Constitute Child Abuse
Authors:   Committee on Child Abuse and Neglect
Published: August 2004

This Policy Statement was retired October 2006.

Child abuse should be considered as the most likely explanation for inflicted skin injuries if they are nonaccidental and there is any injury beyond temporary reddening of the skin. Minor forms of abuse may lead to severe abuse unless abusive skin injuries are identified and labeled as such and interventions are made.
Distribution and Correlates of Non-High-Density Lipoprotein Cholesterol in Children: The Bogalusa Heart Study
Authors: Srinivasan Sathanur R. , Myers Leann , Berenson Gerald S.
Published: August 2004

Objective. Serum non–high-density lipoprotein (HDL) cholesterol (total cholesterol minus HDL cholesterol) is considered a better screening tool than low-density lipoprotein (LDL) cholesterol for the assessment of coronary artery disease (CAD) risk in adults because it includes all classes of atherogenic lipoproteins. Although population frequency distribution and clinically useful cutpoints for this variable in adults have been reported recently, such information is lacking in children. Therefore, this study sought to provide population-based data on the distribution and correlates of non-HDL cholesterol in biracial (black–white) children.

Methods. The study sample consisted of 2843 5- to 17-year-olds (57% white, 50% female) who participated in a cross-sectional screening of cardiovascular risk factors as part of the Bogalusa Heart Study.

Results. Non-HDL cholesterol levels were similar in black and white children, and higher in girls than in boys, especially among the younger (5–11 years) age group. Age was inversely related to both non-HDL cholesterol and LDL cholesterol. Body fatness as measured by body mass index and waist circumference was positively associated with non-HDL cholesterol. The magnitude of correlation with triglycerides was relatively higher for non-HDL cholesterol versus LDL cholesterol. Non-HDL cholesterol showed an inverse relation to HDL cholesterol. In a multivariate analysis, body mass index, age, gender, waist circumference, and cigarette smoking accounted for 7.7% of the variance in non-HDL cholesterol. Non-HDL cholesterol levels equivalent to currently recommended LDL cutpoints (110, 130, 160, and 190 mg/dL) for CAD risk assessment were 123, 144, 176, and 207 mg/dL.

Conclusion. Population-based data on non-HDL cholesterol are now available for children, which may help improve the CAD risk assessment and intervention.
Ambiguous Genitalia With Perineoscrotal Hypospadias in 46,XY Individuals: Long-Term Medical, Surgical, and Psychosexual Outcome
Authors: Migeon Claude J. , Wisniewski Amy B. , Gearhart John P. , Meyer-Bahlburg Heino F.L. , Rock John A. , Brown Terry R. , Casella Samuel J. , Maret Alexander , Ngai Ka Ming , Money John , Berkovitz Gary D.
Published: August 2004

Objectives. To identify and study adults (21 years or older) who have a 46,XY karyotype and presented as infants or children with genital ambiguity, including a small phallus and perineoscrotal hypospadias, reared male or female.

Methods. Participants were classified according to the cause underlying their intersex condition based on review of medical and surgical records. Long-term medical and surgical outcome was assessed with a written questionnaire and physical examination. Long-term psychosexual development was assessed with a written questionnaire and semistructured interview.

Results. Thirty-nine (72%) of 54 eligible patients participated. The cause underlying genital ambiguity of participants included partial androgen insensitivity syndrome (n = 14; 5 men and 9 women), partial gonadal dysgenesis (n = 11; 7 men and 4 women), and other intersex conditions. Men had significantly more genital surgeries (mean: 5.8) than women (mean: 2.1), and physician-rated cosmetic appearance of the genitalia was significantly worse for men than for women. The majority of participants were satisfied with their body image, and men and women did not differ on this measure. Most men (90%) and women (83%) had sexual experience with a partner. Men and women did not differ in their satisfaction with their sexual function. The majority of participants were exclusively heterosexual, and men considered themselves to be masculine and women considered themselves to be feminine. Finally, 23% of participants (5 men and 4 women) were dissatisfied with their sex of rearing determined by their parents and physicians.

Conclusions. Either male or female sex of rearing can lead to successful long-term outcome for the majority of cases of severe genital ambiguity in 46,XY individuals. We discuss factors that should be considered by parents and physicians when deciding on a sex of rearing for such infants.
46,XY Intersex Individuals: Phenotypic and Etiologic Classification, Knowledge of Condition, and Satisfaction With Knowledge in Adulthood
Authors: Migeon Claude J. , Wisniewski Amy B. , Brown Terry R. , Rock John A. , Meyer-Bahlburg Heino F. L. , Money John , Berkovitz Gary D.
Published: August 2004

Objectives. The objective of this study was to identify and study adults who have a 46,XY karyotype and presented as infants or children with variable degrees of undermasculinization of their genitalia (female genitalia, ambiguous genitalia, or micropenis). Participants’ knowledge of their condition, satisfaction with their knowledge, and desire for additional education about their intersex condition were assessed.

Methods. Participants were classified according to the cause underlying their intersex condition based on review of medical and surgical records. Knowledge of medical condition, satisfaction with that knowledge, and desire for additional education were assessed with a written questionnaire and a semistructured interview.

Results. Patients were ineligible for recruitment because of death (9%), because of developmental delay (12%), or because they were not located (27%). Among the 96 eligible patients, 78% participated. Approximately half of the men (53%) and women (54%) exhibited a good understanding of their history. Fewer women who have a 46,XY chromosome complement and were born with female genitalia were informed about their intersex condition (36% with complete androgen insensitivity syndrome) than were women who were born with masculinized genitalia such as micropenis (80%) or ambiguous genitalia (72%). More women (66%) than men (38%) were satisfied with their knowledge of their medical and surgical history.

Conclusions. Almost half of the patients, reared male or female, were neither well informed about their medical and surgical history nor satisfied with their knowledge.
Maternal Adherence to the Zidovudine Regimen for HIV-Exposed Infants to Prevent HIV Infection: A Preliminary Study
Authors: Demas Penelope A. , Webber Mayris P. , Schoenbaum Ellie E. , Weedon Jeremy , McWayne Janis , Enriquez Elizabeth , Bamji Mahrukh , Lambert Genevieve , Thea Donald M.
Published: August 2004

Objective. To describe the extent of adherence to the recommended neonatal zidovudine (ZDV) regimen administered to infants who have been exposed to the human immunodeficiency virus (HIV) to prevent mother-to-child transmission of HIV and to determine which maternal factors are associated with compliance.

Methods. HIV-infected women (n = 87) who were participating in a larger study of perinatal transmission at 3 inner-city New York City hospitals were interviewed 2 to 6 weeks’ postpartum to assess adherence to neonatal prophylaxis, social support, social network factors, and depression. In addition, plasma samples of 45 of their infants were assayed for ZDV levels.

Results. A majority of women (71%) administered all of the prescribed 4 daily doses in the previous week, as measured by interview; self-reported adherence was not associated with any maternal characteristics. In contrast, poor adherence, as measured by lower infant ZDV plasma levels, was associated with asymptomatic HIV illness in the mother and having 2 or more other children; good adherence, as indicated by higher ZDV levels, was associated with the presence of a maternal social support network, disclosure of HIV infection, and mothers’ adherence to their own ZDV regimens during pregnancy. In multivariate regression analyses, maternal asymptomatic status (β = −0.40) was associated with lower infant ZDV levels, and maternal adherence during pregnancy (β = 0.37) was associated with higher levels.

Conclusions. Women who are HIV asymptomatic and lack a social support network are more likely not to comply with the recommended neonatal prophylactic regimen of antiretroviral therapy. Future studies should address the prenatal period and social network factors, such as disclosure of serostatus, and the custody of other children.
Factors Associated With HIV Testing Among HIV-Positive and HIV-Negative High-Risk Adolescents: The REACH Study
Authors: Murphy Debra A. , Mitchell Rick , Vermund Sten H. , Futterman Donna ,   for the Adolescent Medicine HIV/AIDS Research Network
Published: August 2004

Objective. To describe human immunodeficiency virus (HIV) testing patterns among high-risk, uninfected adolescents and HIV-infected adolescents, and factors associated with testing.

Methods. HIV-infected adolescents (N = 246) and high-risk, uninfected adolescents (N = 141) at 15 sites nationwide were asked about the number of times they were tested for HIV, the type of agency at which testing occurred, and reasons for testing.

Results. The majority of participants reported being influenced to obtain testing by health care providers (53.1% of the HIV-infected group and 66.1% of the HIV-uninfected group, respectively). Female participants were somewhat more likely to have used a confidential or anonymous site for the most recent test, compared with male participants (73.5% and 67.5%, respectively). Among the HIV-infected group, feeling sick was the only factor associated with number of tests. Among the HIV-uninfected group, having more male partners, marijuana use in the past 3 months, white race, and having had same-gender partners in their lifetime (males only) were associated with number of tests. Multivariate analyses identified 2 significant models. Modeling the probability of having been tested 3 or more times, black participants were less likely to be tested than white participants (odds ratio [OR] = 0.4), and participants who felt sick were more likely to be tested than those who did not (OR = 1.7). Modeling the probability that the last test would be positive, black participants were more likely than white participants to test positive (OR = 2.3); those who were tested because they thought they might have gotten HIV from sex (OR = 3.0) or they felt sick (OR = 3.9) were more likely to test positive; participants who were tested because a health care professional recommended it were actually less likely (OR = 0.5) to test positive.

Conclusions. Overall, these findings highlight the importance of making HIV testing more routinely available to sexually active adolescents. More work needs to be done to normalize HIV testing among adolescents, and more innovative approaches need to be implemented on a wide scale.
Outcomes of Primary Image-Guided Drainage of Parapneumonic Effusions in Children
Authors: Mitri Ragheed K. , Brown Stephen D. , Zurakowski David , Chung Kee Y. , Konez Orhan , Burrows Patricia E. , Colin Andrew A.
Published: August 2004

Objective. To assess the outcome of image-guided needle aspiration when compared with image-guided percutaneous catheter drainage in the management of parapneumonic effusions in children.

Methods. A retrospective chart review was conducted of the medical records, microbiology, and radiology reports of 67 children who presented with parapneumonic effusions and underwent primary image-guided drainage between April 1, 1995, and April 1, 2000.

Results. Thirty-four patients had aspiration only, and 33 patients had pigtail catheters placed. The 2 drainage methods had similar median length of stay and complication rates. The reintervention rate in this study was 27% (18 patients). Children who underwent primary aspiration without catheter placement had significantly higher rates of reintervention. Method of drainage, pH lower than 7.2, and loculation of the fluid collection were independent predictors of reintervention. A low glucose level was an additive predictor of reintervention when the pH was low.

Conclusions. Aspiration and catheter drainage of parapneumonic effusions had similar complication rates and lengths of stay, but children who underwent primary aspiration had significantly higher reintervention rates, particularly when pH and glucose levels were low. Therefore, primary catheter placement for parapneumonic effusions should be considered in children who undergo diagnostic thoracentesis. The decision regarding tube placement could be facilitated by the on-site availability of a pH meter and a glucometer.
Nebulized Morphine as a Treatment for Dyspnea in a Child With Cystic Fibrosis
Authors: Cohen Steven P. , Dawson Timothy C.
Published: August 2004

Objective. To shed light on nebulized morphine, a new treatment for dyspnea in children with terminal lung disease.

Methods. A clinical case study was conducted on a patient in a tertiary care medical center.

Results. Nebulized morphine was administered in incremental doses ranging from 2.5 mg to 12.5 mg in a 10-year-old, 20-kg boy with end-stage cystic fibrosis. Before the nebulized morphine treatments were started, a dose of nebulized lidocaine failed to provide the patient with any relief. After each dose of morphine, the following parameters were recorded: visual analog “dyspnea” scores, vital signs, venous blood gases, and blood levels of morphine. The nebulized morphine was found to have a modest effect on the patient’s dyspnea, with no significant differences found between the varying doses. Venous carbon dioxide tension levels increased <4 mm Hg for all doses except 12.5 mg, for which there was a 9-mm Hg increase. Systemic blood levels of morphine were <10 ng/mL at all doses. The nebulized morphine did not cause any significant changes in blood pressure or heart rate for doses <12.5 mg.

Conclusions. Inhaled morphine was associated with a mild, beneficial effect on dyspnea, with minimal differences found between the lowest and highest doses. This “ceiling” effect may be the result of saturation of opioid receptors in the lung, the variable bioavailability of inhaled morphine, or a placebo response. More studies are needed to determine what, if any, the optimum dose of nebulized morphine is for children.
Kimura’s Disease: A Diagnostic Challenge
Authors: Shetty Avinash K. , Beaty Michael W. , McGuirt William F. , Woods Charles R. , Givner Laurence B.
Published: August 2004

Kimura’s disease is a rare inflammatory disorder of unknown cause, primarily seen in young Asian males. The disease is characterized by a triad of painless subcutaneous masses in the head or neck region, blood and tissue eosinophilia, and markedly elevated serum immunoglobulin E levels. We describe an 11-year-old Asian boy with Kimura’s disease who presented with a chronic left neck mass. The diagnosis was based on the characteristic histopathologic findings after surgical excision in conjunction with peripheral eosinophilia and elevated serum immunoglobulin E levels. Pediatricians in western countries should be aware of the clinical presentation of Kimura’s disease.
Impact of UniversalHaemophilus influenzaeType b Vaccination Starting at 2 Months of Age in the United States: An Economic Analysis
Authors: Zhou Fangjun , Bisgard Kristine M. , Yusuf Hussain R. , Deuson Robert R. , Bath Sue K. , Murphy Trudy V.
Published: August 2004

Objective. To evaluate the economic impact of universal Haemophilus influenzae type b (Hib) vaccination starting at 2 months of age.

Methods. Decision-tree-based analysis was conducted of a hypothetical US birth cohort of 3 815 469 infants using population-based vaccination coverage and disease incidence data. All costs were estimated from both the direct cost (medical and nonmedical) and societal perspectives. Net present value, cost-effectiveness ratios, and benefit-cost ratios of the US Hib vaccination program were evaluated.

Results. The results of these analyses showed that the universal vaccination program using the Hib conjugate vaccines in the United States in 2000 was cost-saving from both the direct and societal perspectives, with the benefit of the Hib vaccination program (net present value) from the direct cost and societal perspectives of $0.95 billion and $2.09 billion, respectively. Without a Hib vaccination program, the direct and societal costs of Hib invasive cases would be $1.35 billion and $2.58 billion, respectively. The direct and societal costs of the Hib vaccination program were estimated at $0.39 billion and $0.48 billion, respectively. The direct and societal benefit-cost ratios for the Hib vaccination program were 3.4 and 5.4, respectively. Varying the proportion of vaccines purchased and administered in the public versus the private sector and the proportion of combination vaccine versus monovalent vaccine administered did not have much effect on the results.

Conclusions. Regardless of the perspective (direct cost or societal) and the assumptions used, the benefit-cost ratios of the US vaccination program are >1.0. Potential changes in the program, including use of more or less Hib combination vaccines, would not significantly alter the benefit-cost ratio. The national Hib vaccination program is highly cost beneficial and results in substantial cost savings.
Safety of the Trivalent, Cold-Adapted Influenza Vaccine in Preschool-Aged Children
Authors: Piedra Pedro A. , Yan Lihan , Kotloff Karen , Zangwill Ken , Bernstein David I. , King James , Treanor John , Munoz Flor , Wolff Mark , Cho Iksung , Mendelman Paul M. , Cordova Julie , Belshe Robert B.
Published: August 2004

Objective. To provide additional information on the safety of trivalent, cold-adapted influenza vaccine (CAIV-T) in children.

Methods. Children 15 to 71 months of age were enrolled in a multicenter, prospective, randomized, double-blind, and placebo-controlled trial to receive by nasal spray CAIV-T or placebo. In year 1 (1996–1997), 1314 were enrolled in the 2-dose cohort and 288 were enrolled in the 1-dose cohort. In year 2 (1997–1998), 1358 of the original participants received 1 dose of vaccine or placebo according to their original treatment group assignment. In year 3 (1998–1999) and year 4, the trial continued as an open-label safety trial of CAIV-T. A total of 642 and 549 children enrolled in years 3 and 4, respectively, received their third and fourth sequential annual doses of CAIV-T. Measured were 1) the occurrence of specific respiratory, gastrointestinal and systemic symptoms, unexpected symptoms (not specified in the diary card), and use of medications within the first 10 days after vaccination; 2) the occurrence of an acute illness and use of medication within 11 to 42 days after vaccination; and 3) the occurrence of serious adverse events within 42 days after vaccination.

Results. The adjusted odd ratios of specific respiratory and gastrointestinal symptoms during the 10 days after vaccination were determined in years 1 and 2. Runny nose or nasal congestion, vomiting, muscle aches, and fever were significantly associated with the first dose of CAIV-T. With the second dose, runny nose was the only symptom that was associated with CAIV-T. In year 2, CAIV-T did not cause excess in any of the specific respiratory and gastrointestinal symptoms. In years 3 and 4, specific respiratory and gastrointestinal symptoms were comparable to that observed in year 2. A CAIV-T–associated symptom was most likely to occur on day 2 with the first dose of vaccine. The occurrence of unexpected symptoms was primarily of the gastrointestinal system. Approximately 6% of CAIV-T and 3.6% of placebo recipients had a gastrointestinal symptom. CAIV-T seemed to be associated with a mild excess in abdominal pain and vomiting only with the first vaccine dose. A statistically significant increase in the use of analgesics/antipyretics was detected only with the first dose in CAIV-T vaccinees compared with placebo recipients (23.5% vs 16.6%). Between days 11 and 42, CAIV-T use was not associated with an excess of illness, otitis media, or use of medication. None of the 6 serious adverse events in CAIV-T recipients in years 1 to 4 was attributed to the vaccine.

Conclusions. CAIV-T was safe in children. Mild respiratory, gastrointestinal, and systemic symptoms of short duration were observed in a minority of children and primarily with the first vaccine dose. Sequential annual doses of CAIV-T were well tolerated.
Otitis Media in Early Childhood in Relation to Children’s School-Age Language and Academic Skills
Authors: Roberts Joanne E. , Burchinal Margaret R. , Zeisel Susan A.
Published: August 2004

Objective. To examine whether otitis media with effusion (OME) and associated hearing loss during the first 4 years of life are related to the language development and academic achievement of children between 4 years of age and second grade.

Methods. In a prospective cohort study, 83 black children, primarily from low-income families and recruited from community-based child care programs, were examined repeatedly between the ages of 6 months and 4 years for the presence of OME and hearing loss, both when well and when ill with OME. Children’s child-rearing environments at home were assessed annually from infancy through second grade, whereas children’s language and academic skills were assessed repeatedly between 4 years of age and second grade.

Results. We did not find in our longitudinal analyses a relationship between OME and hearing loss during the first 4 years of life and later academic skills in early reading and recognition of words heard. We did find that children with greater incidence of OME and hearing loss during the first 4 years of life scored lower in verbal math problems between kindergarten and second grade, even after partialing out important background factors. Children with more OME tended to score lower in math at the younger ages but caught up once they entered school. Follow-up analyses indicated also that children with more OME during the first 2 years of life scored lower in expressive language during the preschool and early elementary school years but caught up by second grade. In contrast, children from homes that were rated as more stimulating and responsive scored higher on every measure of language and academic skills than did children from less responsive homes. The home environment was related more strongly to all of the outcomes examined than was OME or hearing loss.

Conclusions. There was no evidence of a significant relationship between a history of OME or hearing loss and children’s later academic skills in reading or word recognition during the early elementary school years. Children with greater incidence of OME and hearing loss scored lower in math and expressive language at the younger ages but caught up in math with their peers on entering school and in expressive language by second grade. Furthermore, a child’s home environment was more related to early math and expressive language skills than was OME or hearing loss, and the home environment continued to be predictive of all of the language and academic outcomes through second grade. These study results should be interpreted cautiously when generalizing to other populations.
The Effect of Antibiotic Rotation on Colonization With Antibiotic-Resistant Bacilli in a Neonatal Intensive Care Unit
Authors: Toltzis Philip , Dul Michael J. , Hoyen Claudia , Salvator Ann , Walsh Michele , Zetts Laura , Toltzis Hasida
Published: August 2004

Objective. This study was designed to test whether rotation of antibiotics can reduce colonization with resistant Gram-negative bacilli in a neonatal intensive care unit (NICU).

Methods. A monthly rotation of gentamicin, piperacillin-tazobactam, and ceftazidime was compared with unrestricted antibiotic use in side-by-side NICU populations (rotation team vs control team). Pharyngeal and rectal samples were obtained 3 times a week and tested for Gram-negative bacilli resistant to each of the rotation antibiotics. Pulsed-field gel electrophoresis analysis determined the numbers of genetically discordant resistant organisms on each team. The association between colonization with a resistant bacillus (the primary outcome) and team assignment was tested.

Results. A total of 1062 infants were studied during a 1-year period. A total of 10.7% infants on the rotation team versus 7.7% on the control team were colonized with a resistant bacillus. No interteam differences were distinguishable when the numbers of genetically discordant resistant organisms were normalized to the total number of team admissions. The incidence of nosocomial infection and mortality also were similar across teams.

Conclusion. These data indicate that rotation of parenteral antibiotics according to the applied protocol has no detectable effect in decreasing the reservoir of resistant Gram-negative bacilli in a tertiary-care NICU.
Development and Validation of a Multivariable Predictive Model to Distinguish Bacterial From Aseptic Meningitis in Children in the Post-Haemophilus influenzae Era
Authors: Nigrovic Lise E. , Kuppermann Nathan , Malley Richard
Published: August 2004

Context. Children with meningitis are routinely admitted to the hospital and administered broad-spectrum antibiotics pending culture results because distinguishing bacterial meningitis from aseptic meningitis is often difficult.

Objective. To develop and validate a simple multivariable model to distinguish bacterial meningitis from aseptic meningitis in children using objective parameters available at the time of patient presentation.

Design. Retrospective cohort study of all children with meningitis admitted to 1 urban children’s hospital from July 1992 through June 2000, randomly divided into derivation (66%) and validation sets (34%).

Patients. Six hundred ninety-six previously healthy children aged 29 days to 19 years, of whom 125 (18%) had bacterial meningitis and 571 (82%) had aseptic meningitis.

Intervention. Multivariable logistic regression and recursive partitioning analyses identified the following predictors of bacterial meningitis from the derivation set: Gram stain of cerebrospinal fluid (CSF) showing bacteria, CSF protein ≥80 mg/dL, peripheral absolute neutrophil count ≥10 000 cells/mm3, seizure before or at time of presentation, and CSF absolute neutrophil count ≥1000 cells/mm3. A Bacterial Meningitis Score (BMS) was developed on the derivation set by attributing 2 points for a positive Gram stain and 1 point for each of the other variables.

Main Outcome Measure. The accuracy of the BMS when applied to the validation set.

Results. A BMS of 0 accurately identified patients with aseptic meningitis without misclassifying any child with bacterial meningitis in the validation set. The negative predictive value of a score of 0 for bacterial meningitis was 100% (95% confidence interval: 97%–100%). A BMS ≥2 predicted bacterial meningitis with a sensitivity of 87% (95% confidence interval: 72%–96%).

Conclusions. The BMS accurately identifies children at low (BMS = 0) or high (BMS ≥2) risk of bacterial meningitis. Outpatient management may be considered for children in the low-risk group.
Impact of a Health Maintenance Organization Hospitalist System in Academic Pediatrics
Authors: Landrigan Christopher P. , Srivastava Rajendu , Muret-Wagstaff Sharon , Soumerai Stephen B. , Ross-Degnan Dennis , Graef John W. , Homer Charles J. , Goldmann Donald A.
Published: August 2004

Objective. Hospitalist systems decrease length of stay (LOS) and cost for hospitalized adults. Whether hospitalist systems decrease LOS and cost for hospitalized children has not been conclusively established. We wanted to determine whether a health maintenance organization’s (HMO’s) implementation of a pediatric hospitalist system affected LOS, costs, mortality, readmission rate, follow-up rate, and parents’ ratings of care.

Design. Interrupted time-series study of general pediatric patients admitted to a freestanding pediatric teaching hospital from 1993 to 1998. The intervention group consisted of all patients admitted to a staff model not-for-profit HMO that began using hospitalists in October 1996. Patients in other HMOs and traditional insurance groups were studied for comparison. The main outcomes were mean LOS and inflation-adjusted costs. Other outcomes included parents’ ratings of care and mortality, readmission, and follow-up rates.

Results. Immediately after the introduction of the hospitalist system, mean LOS for staff model not-for-profit HMO fell 12% (0.3 days), and mean cost of hospitalization decreased 16% ($217) compared with prehospitalist levels. Parental ratings of care, initially somewhat low, improved substantially. Seven-day follow-up rates, mortality, and readmission rates did not change. Comparison groups experienced no concurrent improvements in LOS, cost, parental ratings, mortality, or readmission rates.

Conclusions. A pediatric hospitalist system within a staff-model HMO significantly improved LOS, cost, and parental ratings of care without affecting rates of posthospitalization follow-up. Additional studies are needed both to measure broader aspects of quality and to assess the impact of such a program on patients being cared for through other types of delivery and insurance systems.
Self-Assessment of Pubertal Stage in Overweight Children
Authors: Bonat Sandra , Pathomvanich Annatura , Keil Margaret F. , Field Alison E. , Yanovski Jack A.
Published: August 2004

Objective. For those with normal body habitus, self-assessments have been reported to yield Tanner stage ratings similar to those found by actual examinations. Little is known about whether such self-assessments are accurate in obese children. We therefore determined the reliability of Tanner stage self-assessments in both nonobese and obese children.

Methods. We studied 244 children age 6 to 12 years, 135 girls and 109 boys, 41% of whom were obese (body mass index ≥95th percentile for age and gender). Girls rated both breast and pubic hair development and boys rated pubic hair development using a standardized series of drawings accompanied by explanatory text. After self-ratings were completed, a pediatric endocrinologist or trained nurse practitioner who was blinded to subjects’ self-ratings examined each subject.

Results. Self-ratings of breast Tanner stage were concordant with actual stage in 48%, overestimated in 25%, and underestimated in 27% of nonobese girls. By contrast, breast Tanner stage was overestimated by 38% of obese girls and was underestimated by only 12%. On average, obese girls overestimated actual Tanner breast stage by 0.47 ± 0.9 stages. Pubic hair ratings were largely concordant with actual pubic hair stage in both obese and nonobese girls. Both nonobese and obese boys significantly overestimated actual Tanner pubic hair stage, by 0.51 ± 1.1 stages and 0.31 ± 0.8 stages, respectively.

Conclusions. We conclude that, in children 6 to 12 years of age, self-assessment cannot be used to determine reliably the breast Tanner stage of obese girls or the pubic hair stage of boys.
Ultrasonography Is Unnecessary in Evaluating Boys With a Nonpalpable Testis
Authors: Elder Jack S.
Published: August 2004

Objective. An inguinal sonogram often is obtained in boys with a nonpalpable testis to “localize” the testis, ie, determine whether the testis is present. The results of ultrasonography in boys with a nonpalpable testis were analyzed.

Methods. The records of boys who were referred to a pediatric urology center with a diagnosis of nonpalpable testis and who had undergone inguinal sonography were reviewed. The results of sonography were compared with findings in the office as well as surgical findings.

Results. A total of 62 boys who were referred with a diagnosis of a nonpalpable testis and who had undergone a sonogram were reviewed. The sonogram was ordered by the primary care physician in 51 boys (82%) and by a general urologist in 11 cases (18%). The testis was identified by sonography in 12 (18%) of 66 cases, and all were localized to the inguinal canal. Physical examination by a pediatric urologist showed that 6 were in the scrotum and 6 were in the inguinal canal or perineum. Of the 54 testes that were not localized by the sonogram, 33 (61%) were palpable and 21 (39%) were nonpalpable. Of the truly nonpalpable testes, laparoscopy and abdominal/inguinal exploration identified the testis as abdominal in 10 cases and atrophic secondary to spermatic cord torsion in 11 cases.

Conclusion. Sonography is unnecessary in boys with a nonpalpable testis, because it rarely if ever localizes a true nonpalpable testis, and it does not alter the surgical approach in these patients.
Topical Anesthetics for Intravenous Insertion in Children: A Randomized Equivalency Study
Authors: Kleiber Charmaine , Sorenson Mark , Whiteside Kathy , Gronstal B. Ann , Tannous Raymond
Published: August 2004

Objectives. Children view needle sticks as the worst source of pain and fear in the hospital setting. In an effort to minimize the pain of needle sticks, the use of eutectic mixture of lidocaine and prilocaine (EMLA) has become standard practice in many children’s hospitals. Unfortunately, EMLA requires at least 60 minutes to be fully effective and reportedly may cause vasoconstriction, leading to difficult vein cannulation. A newly available local anesthetic (ELA-Max) may require less time and cause less vasoconstriction. The purpose of this randomized crossover study was to investigate the anesthetic equivalence of EMLA and ELA-Max.

Methods. Thirty well children (14 girls and 16 boys) who were between the ages of 7 and 13 years volunteered to have EMLA applied to the dorsal aspect of 1 hand for 60 minutes and ELA-Max applied to the other hand for 30 minutes. Right and left hands were randomized to treatment type and order of intravenous (IV) insertion. Clinical Research Center nurses, blind to the anesthetic randomization, attempted to insert a 22-gauge Teflon IV catheter into a vein in each hand. The children rated pain during IV insertion on the Oucher scale, and the nurse rated the difficulty of the insertion.

Results. There was no significant difference in pain ratings for hands that were treated with EMLA (mean: 20.5) or with ELA-Max (mean: 24), and there was no difference for the difficulty of vein cannulation. Children’s preprocedure state anxiety was positively associated with pain ratings.

Conclusions. ELA-Max, applied for 30 minutes before IV cannulation, has an anesthetic effectiveness similar to EMLA applied for 60 minutes. Some children rated IV insertion pain fairly high for both hands (eg, 60 on a 0- to 100-point scale) despite anesthetic treatment. Preprocedural anxiety may affect the perception and/or rating of pain. There were no differences between hands that were treated with EMLA or with ELA-Max for success of IV insertion.
Predictors of Hearing Loss in Children With Symptomatic Congenital Cytomegalovirus Infection
Authors: Rivera Lisa B. , Boppana Suresh B. , Fowler Karen B. , Britt William J. , Stagno Sergio , Pass Robert F.
Published: August 2004

Objective. Congenital cytomegalovirus (CMV) infection is a major cause of sensorineural hearing loss (SNHL) and neurologic impairment in children. Although the majority of children with symptomatic congenital CMV infection develop hearing loss, many symptomatic infants have normal hearing. The purpose of this study was to identify indicators present in the newborn period that have predictive value for the development of hearing loss in children with symptomatic congenital CMV infection.

Methods. Of the 190 children who had symptomatic congenital CMV infection and were born between 1966 and 1997 and enrolled in a follow-up study, hearing outcome was known for 180 children. Follow-up data were analyzed using univariate and multivariate logistic regression analyses to determine the specific demographic, newborn clinical, and laboratory findings predictive of hearing loss. The amount of infectious CMV in urine was quantified in a subset of 21 children who were born between 1994 and 1998.

Results. The presence of intrauterine growth retardation, petechiae, hepatosplenomegaly, hepatitis, thrombocytopenia, and intracerebral calcifications was associated with the development of hearing loss on univariate analysis. The presence of microcephaly and other neurologic abnormalities was not predictive of hearing loss. Logistic regression analysis revealed that only petechiae and intrauterine growth retardation independently predicted hearing loss. None of the demographic and other newborn findings predicted progressive hearing loss. The children who developed hearing loss had higher urine CMV titers during infancy than those with normal hearing.

Conclusion. In children with symptomatic congenital CMV infection, evidence of disseminated infection with or without the presence of neurologic involvement at birth was predictive of the development of hearing loss. However, it was not possible to identify factors that are independently predictive of the development of progressive hearing loss.
The Contribution of Prone Sleeping Position to the Racial Disparity in Sudden Infant Death Syndrome: The Chicago Infant Mortality Study
Authors: Hauck Fern R. , Moore Cathryn Merrick , Herman Stanislaw M. , Donovan Mark , Kalelkar Mitra , Christoffel Katherine Kaufer , Hoffman Howard J. , Rowley Diane
Published: August 2004

Background. Rates of sudden infant death syndrome (SIDS) are over twice as high among African Americans compared with Caucasians. Little is known, however, about the relationship between prone sleeping, other sleep environment factors, and the risk of SIDS in the United States and how differences in risk factors may account for disparities in mortality.

Objective. To assess the contribution of prone sleeping position and other potential risk factors to SIDS risk in a primarily high-risk, urban African American population.

Design, Setting, and Population. Case-control study consisting of 260 infants ages birth to 1 year who died of SIDS between November 1993 and April 1996. The control group consists of an equal number of infants matched on race, age, and birth weight. Prospectively collected data from the death scene investigation and a follow-up home interview for case infants were compared with equivalent questions for living control participants to identify risk factors for SIDS.

Main Outcome Measures. Risk of SIDS related to prone sleeping position adjusting for potential confounding variables and other risk factors for SIDS, and comparisons by race-ethnicity.

Results. Three quarters of the SIDS infants were African American. There was more than a twofold increased risk of SIDS associated with being placed prone for last sleep compared with the nonprone positions (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 1.6–3.7). This OR increased after adjusting for potential confounding variables and other sleep environment factors (OR: 4.0; 95% CI: 1.8–8.8). Differences were found for African Americans compared with others (OR: 1.8; 95% CI: 1.2–2.6 and OR: 10.3, 95% CI: 10.3 [3.2–33.8, respectively]). The population attributable risk was 31%. Fewer case mothers (46%) than control mothers (64%) reported being advised about sleep position in the hospital after delivery. Of those advised, a similar proportion of case mothers as control mothers were incorrectly told or recalled being told to use the prone position, but prone was recommended in a higher proportion of black mothers (cases and controls combined) compared with nonblack mothers.

Conclusions. Prone sleeping was found to be a significant risk factor for SIDS in this primarily African American urban sample, and approximately one third of the SIDS deaths could be attributed to this factor. Greater and more effective educational outreach must be extended to African American families and the health personnel serving them to reduce prone prevalence during sleep, which appears, in part, to contribute to the higher rates of SIDS among African American infants.
Do Children With Falling Blood Lead Levels Have Improved Cognition?
Authors: Liu Xianchen , Dietrich Kim N. , Radcliffe Jerilynn , Ragan N. Beth , Rhoads George G. , Rogan Walter J.
Published: August 2004

Objective. Exposure to lead at levels encountered by urban children impairs cognitive development. An observational study suggested improvement in IQ when blood lead level fell, but the only randomized trial of chelation showed no benefit in IQ.

Methods. We did a new analysis of the data from the clinical trial using change in blood lead level as the independent variable. The 741 children began with blood lead levels between 20 and 44 μg/dL, and were 13 to 33 months old at randomization to chelation or placebo. Blood lead levels were measured repeatedly, and cognitive tests were given at baseline, 6 months, and 36 months follow-up.

Results. By 6 months after randomization, blood lead levels had fallen by similar amounts in both chelated and placebo children, despite the immediate drops in the chelated group; there was no association between change in blood lead level and change in cognitive test score. Blood lead levels continued to fall. At 36 months follow-up, in the placebo group only, cognitive test scores had increased 4.0 points per 10 μg/dL fall in blood lead level from baseline to 36 months follow-up and 5.1 points from 6 to 36 months.

Conclusions. The improvement in scores in the placebo group only implies that factors other than declining blood lead levels per se are responsible for cognitive improvement; it is possible but less likely that succimer, the active drug, impairs cognition.