bluuebunny/crossref_metadata_2025 huggingface dataset:
A Randomized Comparison of Surfactant Dosing via a Dual-lumen Endotracheal Tube in Respiratory Distress Syndrome
Authors: Valls-i-Soler Adolf , Fernández-Ruanova Begoña , y Goya Jon López-Heredia , Etxebarrı́a Lourdes Román , Rodriguez-Soriano Juan , Carretero (Caceres) Valentin ,   Spanish Surfactant Collaborative Group
Published: August 2004

Aim. To determine if 1-minute instillation of Curosurf via a dual-lumen endotracheal tube without interruption of mechanical ventilation could decrease the incidence of hypoxia (drop in oxygen saturation [Sao2] to <80%, or of transcutaneous partial pressure of oxygen [Ptco2] to <50 mm Hg [6.6 kPa]) and bradycardia (heart rate below 80 beats/minute) at dosing, without affecting the efficacy of the standard bolus delivery.

Design. Prospective, multicenter, randomized, nonblinded clinical trial.

Setting. Neonatal intensive care units of the Spanish Surfactant Collaborative Group.

Patients and Methods. One hundred ninety-eight infants (birth weight 600–2000 g) with respiratory distress syndrome needing mechanical ventilation with a fraction of inspired oxygen [Fio2] ≥0.40 were randomized before 24 hours to receive 200 mg/kg of Curosurf, either by bolus instillation (n = 99) or by a simplified dosing technique (n = 99), giving the full dose in 1 minute via a dual-lumen endotracheal tube without positioning, interruption of mechanical ventilation, or bagging. Two additional doses (100 mg/kg) were given within 12 and 24 hours of first dose, by the same method, if the infant still needed mechanical ventilation and had a Fio2 ≥0.30. The effects of both procedures on the incidence of acute adverse events at dosing, gas exchange, ventilator requirements, and outcome at 28 days were compared.

Results. Fewer episodes of hypoxia (18 vs 40% of doses), and a smaller decrease in heart rate and Sao2were observed in the dual-lumen group. Efficacy of surfactant, based on improvement of oxygenation, ventilator requirements, and number of doses required, was similar in both groups. Infants in the dual-lumen group had a lower total time exposure to supplemental oxygen (195 ± 199 vs 266 ± 221 hours). No differences in the incidence of air leaks, intraventricular hemorrhage, patent ductus arteriosus, bronchopulmonary dysplasia, or survival were observed.

Conclusion. A simplified 1-minute Curosurf dosing procedure via a dual-lumen endotracheal tube without fractional doses, ventilator disconnection, changes in the infant's position, or manual bagging was found to reduce the number of dosing-related adverse transient episodes of hypoxia. Although the simplified method appeared to be as effective as bolus delivery, this should be confirmed in a larger trial.
Pediatricians' Awareness of and Attitudes About Four Clinical Practice Guidelines
Authors: Christakis Dimitri A. , Rivara Frederick P.
Published: August 2004

Background. The increasing complexity of medical care and a desire to increase quality and control costs have led to growing use of clinical practice guidelines (CPGs). It is unclear how helpful these guidelines are to the practitioners expected to use them. We surveyed pediatricians about their knowledge and impressions of four well-publicized CPGs: the American Academy of Pediatrics' “Practice Parameter for Hyperbilirubinemia in Newborns” (hyperbilirubinemia), “A Guideline for the Management of Febrile Infants” (fever), the Agency for Health Care Policy and Research's “Guideline for Otitis Media With Effusion” (otitis), and the US Preventive Services Task Force Guide to Clinical Preventive Services (preventive care).

Objectives. 1) What percentage of practicing pediatricians are aware of these guidelines? 2) How helpful do they find them? 3) What are practitioners' perceived limitations of these guidelines? 4) Have these guidelines affected provider behavior? 5) Are there features of a provider's training or practice that are associated with changing practice as a result of guidelines?

Design. A national survey of 600 pediatricians selected at random from the American Medical Association master file.

Results. A total of 300 of 555 eligible participants (54%) returned surveys. Of the respondents, 66% were aware of the hyperbilirubinemia guideline, 64% of the fever guideline, 50% of the otitis guideline, but only 16% knew of the preventive care guidelines. Mean helpfulness scores (1 to 10 scale, where 1 = “not at all helpful” and 10 = “extremely helpful”) ranged from 3.67 to 6.67 for the different guidelines. In terms of limitations, 15% to 33% of respondents reported that CPGs were “too cookbook,” 6% to 19% reported that they were “too time-consuming,” and 4% to 16% reported that they were “too cumbersome.” Additional reported limitations were believing that a guideline left no room for personal experience and judgment, concern of increased liability risk, and poor parental acceptance of CPG recommendations. The proportions reporting change in management as a result of a CPG were 28% for the hyperbilirubinemia guideline, 36% for the fever guideline, 19% for the preventive care guidelines, and 28% for the otitis guideline. Mean helpfulness scores reported by nonuniversity-affiliated physicians were significantly higher than those reported by university-affiliated physicians. In a regression model of respondents aware of a particular guideline, more recent graduation from medical school and increased helpfulness scores were associated with guideline-related behavior change.

Conclusion. In their present form, CPGs are not perceived as very helpful by most practitioners. More recent medical school graduates and nonuniversity-affiliated physicians are more likely to find them helpful and more likely to change their behavior because of them.
Impact of Education for Physicians on Patient Outcomes
Authors: Clark Noreen M. , Gong Molly , Schork M. Anthony , Evans David , Roloff Dietrich , Hurwitz Martin , Maiman Lois , Mellins Robert B.
Published: August 2004

Objectives. This study was conducted to assess the impact of an interactive seminar based on self-regulation theory on 1) the treatment practices and communications and education behavior of physicians, 2) the health status and medical care utilization of their pediatric patients with asthma, and 3) the satisfaction with care of the subjects' parents.

Methods. A total of 74 general practice pediatricians were assigned to either a program or a control group in a randomized controlled study. Data were collected from physicians at baseline, and 69 (93%) provided follow-up data 5 months after the program. Data were also collected from 637 of their patients at baseline, and in a 22-month window after the intervention, 472 (74%) of this number provided follow-up data.

Results. After the seminar, physicians in the program group were more likely than were control group physicians to address patients' fears about medicines, review written instructions, provide a sequence of educational messages, write down how to adjust the medicines at home when symptoms change, and report that they spent less time with their patients. Parents of the children treated by program physicians were significantly more likely than were control group parents to report that the physician had been reassuring, described as a goal that the child be fully active, and gave information to relieve specific worries. After a visit with the physician, these parents were also more likely to report that they knew how to make management decisions at home. After the intervention compared to controls, patients of physicians in the program group were more likely to have received a prescription for inhaled antiinflammatory medicine and to have been asked by the physician to demonstrate how to use a metered-dose inhaler. After the intervention, children seen by program physicians made significantly fewer nonemergency office visits and visits for follow-up of an episode of symptoms; however, there were no differences in emergency department visits and hospitalizations. Among children who were placed on inhaled corticosteroids during this study, however, children treated by physicians who had received education had significantly fewer symptoms and fewer follow-up office visits, nonemergency physician office visits, emergency department visits, and hospitalizations.

Conclusions. The interactive seminar based on theories of self-regulation led to patient–physician encounters that were of shorter duration, had significant impact on the prescribing and communications behavior of physicians, led to more favorable patient responses to physicians' actions, and led to reductions in health care utilization.
Health and Developmental Outcomes at 18 Months in Very Preterm Infants With Bronchopulmonary Dysplasia
Authors: Grégoire Marie-Claude , Lefebvre Francine , Glorieux Jacqueline
Published: August 2004

Objective. To determine whether very preterm infants who are oxygen-dependent at 28 days of life but not at 36 weeks' gestational age are at high risk of morbidities at 18 months.

Population. A total of 217 infants born in a tertiary care center at 24 to 28 weeks' gestation in 1987 to 1992, classified into three groups: neonatal comparison group, O2 <28 days of life (n = 76); bronchopulmonary dysplasia (BPD)-1, O2 ≥28 days but not at 36 weeks' gestational age (n = 48); and BPD-2, O2 ≥36 weeks (n = 93).

Outcome Measures. Growth, persistent respiratory problems (asthma, tracheostomy, home oxygen therapy), surgery, hospitalizations, and neurodevelopmental impairments.

Results. Among the three groups, no differences were found in weight, height, head circumference, or total number of days of rehospitalizations for any causes, or in rate of rehospitalizations to the intensive care unit, persistent respiratory problems, cerebral palsy, or sensory impairment. Children with BPD-2 needed more hernia repairs compared with the other two groups (comparison group: 12% vs BPD-1: 10% vs BPD-2: 30%), had more days of readmissions for respiratory problems (comparison group: 2.0 vs BPD-1: 2.0 vs BPD-2 6.3 [BPD-1 vs BPD-2]), had a lower mean developmental quotient (comparison group: 97.4 ± 15.0 vs BPD-1: 97.9 ± 11.6 vs BPD-2: 90.7 ± 19.3). Intraparenchymal cerebral lesions, high family adversity, and prolonged ventilation were the most important factors influencing the developmental outcome.

Conclusion. Children with BPD-1 are similar in all respect at 18 months to children in the comparison group. Children with BPD-2 are similar to the other groups at 18 months in growth, general health, and neurologic outcome but differ in having a higher number of days of rehospitalizations for respiratory causes, more hernia repairs, and more developmental delays.
Cystatin C—A New Marker of Glomerular Filtration Rate in Children Independent of Age and Height
Authors: Bökenkamp Arend , Domanetzki Michael , Zinck Raymund , Schumann Gerhard , Byrd Dennis , Brodehl Johannes
Published: August 2004

Objectives. Serum creatinine is the most common endogenous marker of renal function. The proportionality between creatinine production and muscle mass requires adjustment for height and body composition. The low molecular weight protein cystatin C is produced by all nucleated cells and eliminated by glomerular filtration. Therefore, cystatin C was studied as an alternative marker of glomerular filtration rate (GFR) in children.

Methods. Cystatin C and creatinine were measured in sera from inulin clearance (CIn) examinations performed in 184 children aged 0.24 to 17.96 years. CIn ranged from 7 to 209 mL/min/1.73 m2 (median, 77).

Results. The reciprocal of cystatin C correlated better with CIn (r = 0.88) than the reciprocal of creatinine (r = 0.72). Stepwise regression analysis identified no covariates for the correlation between cystatin C and CIn, whereas height was a covariate for creatinine. Using an estimate of GFR from serum creatinine and height, correlation with CIn was similar to cystatin C, but female gender and dystrophy were associated with an overestimation of GFR. Diagnostic accuracy in the identification of reduced GFR measured as area under the receiver-operating characteristic plot was 0.970 ± 0.135 (mean ± SE) for cystatin C and 0.894 ± 0.131 for creatinine (NS). A cutoff cystatin C concentration of 1.39 mg/L had 90% sensitivity and 86% specificity for detecting abnormal GFR.

Conclusion. Unlike creatinine, serum cystatin C reflects renal function in children independent of age, gender, height, and body composition.
Venipuncture Is More Effective and Less Painful Than Heel Lancing for Blood Tests in Neonates
Authors: Larsson Björn A. , Tannfeldt Gunnilla , Lagercrantz Hugo , Olsson Gunnar L.
Published: August 2004

Objective. Heel lancing has hitherto been the method of choice for screening tests of inborn errors of metabolism in neonates. Eutectic mixture of local anesthetic has little, if any, analgesic effect when applied to the heel of pre- and full-term infants. Today there seems to be no practical method that effectively alleviates the pain caused by heel lancing. The aim of this study was to investigate whether other methods, such as venipuncture of the dorsal side of the hand, are less painful and more efficient than heel lancing in neonates.

Methods. One hundred twenty healthy, full-term infants who underwent testing for phenylketonuria (PKU) were included in the study. They were randomized into three groups: a venipuncture group (VP) (n = 50), a heel-lance group with a small lancet (SL) (n = 50), or a large lancet (LL) (n = 20). Pain reactions were assessed by the Neonatal Facial Coding System (NFCS). The latency and duration of the first cry as well as the total screaming time was analyzed. The efficacy of the method was assessed by the time taken to complete the PKU test and number of times the skin had to be punctured.

Results. Nociceptive response. The NFCS scores after the first skin puncture were: VP, 247; SL, 333; and LL, 460. The NFCS scores were significantly lower in the VP than in the groups subjected to heel lancing. During the first 60 seconds after skin puncture, 44% of the infants cried in the VP group, compared with 72% and 85% in the SL and LL groups, respectively.

Efficacy. A successful PKU test with only one skin puncture was performed in 86% of the VP group, but in only 19% in the SL group and 40% in the LL group. The total time needed to obtain the PKU blood sample was 191 seconds (median) in the VP group, 419 seconds in the SL group, and 279 seconds in the LL group.

Conclusion. Venipuncture is more effective and less painful than heel lancing for blood tests in neonates.
Developmental Changes in Energy Expenditure and Physical Activity in Children: Evidence for a Decline in Physical Activity in Girls Before Puberty
Authors: Goran Michael I. , Gower Barbara A. , Nagy Tim R. , Johnson Rachel K.
Published: August 2004

Objective. To examine individual changes in energy expenditure and physical activity during prepubertal growth in boys and girls.

Methods. Total energy expenditure (TEE), resting energy expenditure, physical activity-related energy expenditure, reported physical activity, and fat and fat-free mass were measured three times over 5 years in 11 boys (5.3 ± 0.9 years at baseline) and 11 girls (5.5 ± 0.9 years at baseline).

Results. Four-year increases in fat (∼6 kg) and fat-free mass (∼10 kg) and resting energy expenditure (∼200 kcal/day) were similar in boys and girls. In boys, TEE increased at each measurement year, whereas in girls, there was an initial increase from age 5.5 (1365 ± 330 kcal/day) to age 6.5 (1815 ± 392 kcal/day); however, by age 9.5, TEE was reduced significantly (1608 ± 284 kcal/day) with no change in energy intake. The gender difference in TEE changes over time was explained by a 50% reduction in physical activity (kcal/day and hours/week) in girls between the ages of 6.5 and 9.5.

Conclusions. These data suggest a gender dimorphism in the developmental changes in energy expenditure before adolescence, with a conservation of energy use in girls achieved through a marked reduction in physical activity.
Low Serum Thyroxine on Initial Newborn Screening Is Associated With Intraventricular Hemorrhage and Death in Very Low Birth Weight Infants
Authors: Paul David A. , Leef Kathleen H. , Stefano John L. , Bartoshesky Louis
Published: August 2004

Transient hypothyroxinemia (TH) of prematurity has been correlated with poor neurodevelopmental outcome. However, the relationship between thyroid function and neonatal mortality and brain injury has not been described.

Objective. To investigate the relationship between thyroid function and neonatal outcome.

Methods. Review of infants weighing <1500 grams admitted to a single level III newborn intensive care unit (n = 342). Serum total T4 values of initial newborn screening of infants dying before hospital discharge were compared with those of surviving infants. Total T4values from infants with and without intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL) also were compared.

Results. T4 values strongly correlated with gestational age (r = .56). Overall, 289 (85%) of 342 infants had TH. None of the infants had true congenital hypothyroidism. T4 values of infants with cystic PVL (n = 15) were not statistically different from those for infants who did not develop cystic PVL. Infants with IVH (n = 58) had a lower T4 value than did infants who did not develop IVH (5.4 ± 3.4 μg/dL vs 7.8 ± 3.6 μg/dL). Infants who died before hospital discharge (n = 24) had a lower T4 value than did infants discharged to home (3.4 ± 2.2 vs 7.9 ± 3.7 μg/dL). After controlling for potential confounding variables, T4 value remained associated with an increased odds of IVH (odds ratio: 1.2; 95% confidence interval: 1.05 to 1.4) and mortality (odds ratio: 2.3; 95% confidence interval 1.6 to 3.4).

Conclusions. In our population of very low birth weight infants, TH has an incidence of 85%. Very low T4 values on initial newborn screening are associated with increased odds of death and IVH. Additional investigation is needed to determine whether low serum thyroxine level contributes to IVH and neonatal death or whether it is simply an associated factor.
School-age Follow-up of Prophylactic Versus Rescue Surfactant Trial: Pulmonary, Neurodevelopmental, and Educational Outcomes
Authors: Sinkin Robert A. , Kramer Bonnie M. , Merzbach Joan L. , Myers Gary J. , Brooks John G. , Palumbo Donna R. , Cox Christopher , Kendig James W. , Mercier Charles E. , Phelps Dale L.
Published: August 2004

Background. Exogenous surfactant replacement has improved survival and reduced pulmonary complications of prematurity. Improved early outcomes for infants of <30 weeks' gestation treated with a strategy of prophylactic versus rescue surfactant, if needed, were demonstrated in a multicenter, randomized trial conducted between 1985 and 1988. We reevaluated a subset of survivors from this trial to determine the pulmonary and neurodevelopmental outcomes at school age.

Methods. At 4.5 to 8 years of age, all survivors from one of the three centers were located, and 96% were evaluated. The original randomization included stratification by center and followed an intention-to-treat methodology in assessing the efficacy of prophylactic versus rescue treatment with surfactant. The follow-up test battery included a health-assessment questionnaire, spirometry, 88% saturation test, neurologic examination, and the McCarthy Scales of Children's Abilities (MSCA) and the Conners' Parent Rating Scale–48. Educational achievement was determined by school class placement and teachers' reports of achievement.

Results. Of the 192 children originally enrolled, 154 survived. Evaluations were performed on 148 of these infants. An abnormal pulmonary history was found in 45 (30%) of the children: 16 (22%) in the prophylactic group and 29 (39%) in the rescue group. Formal pulmonary function was evaluated in 81 children; 29 (78%) in the prophylactic group and 33 (75%) in the rescue group were considered abnormal. No significant differences were found between the two groups on either cognitive or motor subscales of the MSCA, the Conners' Parent Rating Scale–48, the neurologic examination, the education services received in school, or the teacher ratings of below-average academic performance. Intelligence scores measured on the MSCA were low–normal for both groups. Some level of educational assistance was being provided to 72 (49%) of the cohort studied, and both groups had below average educational performance and increased needs for educational assistance.

Conclusions. Prophylactic surfactant administration to infants of <30 weeks' gestation was associated with fewer long-term clinical pulmonary complications than assignment to rescue administration. Formal pulmonary testing at school age did not reveal significant differences between treatment groups in those infants who could be tested. There also were no group differences found on neurologic, cognitive, behavioral, or educational assessments at school age.
Cat Scratch Disease Presenting With Peripheral Facial Nerve Paralysis
Authors: Walter Robert S. , Eppes Stephen C.
Published: August 2004

Acquired peripheral facial nerve paralysis is a relatively common disorder that affects both children and adults. The most frequent nontrauma-related etiologies in otherwise neurologically intact patients are idiopathic (Bell's palsy) and infectious, which includes otitis media, herpes zoster, Lyme disease, herpes simplex virus, Epstein–Barr virus, and Mycoplasma pneumoniae.1

Cat scratch disease (CSD) is typically a subacute, regional lymphadenitis caused by Bartonella henselae that is seen in children and young adults. CSD most often has a benign, self-limited course. However, 11% of CSD patients may present atypically, most commonly with Perinaud's oculoglandular syndrome or acute encephalopathy.6

We present a child with the first reported case of acute facial nerve paralysis in serologically proven CSD with typical lymphadenitis.
Pitfalls in the Diagnosis of Ventricular Shunt Dysfunction: Radiology Reports and Ventricular Size
Authors: Iskandar Bermans J. , McLaughlin Colleen , Mapstone Timothy B. , Grabb Paul A. , Oakes W. Jerry
Published: August 2004

Introduction. The diagnosis of shunt malfunction can be difficult even for the experienced clinician and may lead to disastrous circumstances when misinterpreted. Less experienced physicians may rely more on radiographic reports as a primary diagnostic modality. In this study, we evaluated the reliability of using these reports without accurate clinical assessment.

Methods. All shunt revisions seen at Children's Hospital (Birmingham, AL) between January 1996 and August 1996 were reviewed, excluding patients with brain tumors, supratentorial extraaxial fluid collections, and infections. Sixty-eight patients underwent 100 operations for shunt malfunction. All patients had evidence of shunt blockage, disconnection, catheter malposition, or valve pressure incompatibility. The prospective radiographic interpretation of preoperative computed tomography and magnetic resonance imaging scans was reviewed in each case.

Results. Twenty-four percent of the reports made no mention of shunt malfunction. In this group, the ventricular system was described as “unchanged,” “stable,” “normal,” “unremarkable,” “small,” “smaller,” “slit,” “negative,” and “no hydrocephalus,” with no other comment to support a diagnosis of shunt malfunction. An additional 9% of reports contained the same terms, while also hinting at some other clinical or radiographic data that suggest the possibility of shunt failure (eg, a shunt disconnection seen on plain radiographs), despite the scan findings. In all patients in this group, symptoms improved after surgery.

Conclusion. We conclude that as many as one third of patients presenting with shunt malfunction will not have the diagnosis of shunt malfunction supported by a prospective radiologic interpretation of brain imaging. Although the neurosurgical community can assess the clinical situation to determine the need for surgery, other clinicians can be easily reassured by a radiographic report that does not mention or diagnose shunt malfunction. Today, more than ever, nonneurosurgeons are being called on to evaluate complex clinical situations and may rely on radiographic reports.
Screening for Elevated Blood Lead Levels
Authors:   Committee on Environmental Health
Published: August 2004

Although recent data continue to demonstrate a decline in the prevalence of elevated blood lead levels (BLLs) in children, lead remains a common, preventable, environmental health threat. Because recent epidemiologic data have shown that lead exposure is still common in certain communities in the United States, the Centers for Disease Control and Prevention recently issued new guidelines endorsing universal screening in areas with ≥27% of housing built before 1950 and in populations in which the percentage of 1- and 2-year-olds with elevated BLLs is ≥12%. For children living in other areas, the Centers for Disease Control and Prevention recommends targeted screening based on risk-assessment during specified pediatric visits. In this statement, The American Academy of Pediatrics supports these new guidelines and provides an update on screening for elevated BLLs. The American Academy of Pediatrics recommends that pediatricians continue to provide anticipatory guidance to parents in an effort to prevent lead exposure (primary prevention). Additionally, pediatricians should increase their efforts to screen children at risk for lead exposure to find those with elevated BLLs (secondary prevention).
Facilities and Equipment for the Care of Pediatric Patients in a Community Hospital
Authors:   Committee on Hospital Care
Published: August 2004

This Clinical Report was revised. See https://doi.org/10.1542/peds.2020-0204.

Most children requiring hospitalization are admitted to community hospitals that vary significantly in their pediatric resources. The intent of this statement is to provide guidelines for furnishing and equipping a pediatric area in a community hospital.
Pediatric Cardiac Surgery: The Effect of Hospital and Surgeon Volume on In-hospital Mortality
Authors: Hannan Edward L. , Racz Michael , Kavey Rae-Ellen , Quaegebeur Jan M. , Williams Roberta
Published: August 2004

Objective. To examine the relationship between annual provider (hospital and surgeon) volume of pediatric cardiac surgery and in-hospital mortality.

Design. Population-based retrospective cohort study using a clinical database.

Setting. The 16 acute care hospitals in New York with certificate of need approval to perform pediatric cardiac surgery.

Patients. All children undergoing congenital heart surgery in New York from 1992 to 1995.

Main Outcome Measures. Risk-adjusted mortality rates for various hospital and surgeon volume ranges. Adjustments were made for severity of illness using logistic regression.

Results. A total of 7169 cases were analyzed. After controlling for severity of preprocedural illness using clinical risk factors, hospitals with annual pediatric cardiac surgery volumes of fewer than 100 had significantly higher mortality rates (8.26%) than hospitals with volumes of 100 or more (5.95%), and surgeons with annual volumes of fewer than 75 had significantly higher mortality rates (8.77%) than surgeons with annual volumes of 75 or more (5.90%).

Conclusions. Both hospital volume and surgeon volume are significantly associated with in-hospital mortality, and these differences persist for both high-complexity and low-complexity pediatric cardiac procedures.
Actuarial Survival in the Premature Infant Less Than 30 Weeks' Gestation
Authors: Cooper Timothy R. , Berseth Carol L. , Adams James M. , Weisman Leonard E.
Published: August 2004

Objective. Because survival from admission to discharge does not provide parents and physicians information about future life expectancy in the premature neonate, we characterized the actuarial survival, defined as the future life expectancy from a given postnatal age, in a large inborn population of premature infants <30 weeks' gestation.

Study Design. We determined daily actuarial survival of 1925 inborn infants (23 to 29 weeks' gestation) admitted to the Baylor Affiliated Nurseries from July 1986 through December 1994, stratified by 100-g birth weight and by 1-week gestational-age intervals.

Results. In the 501- to 600-g birth weight stratum, actuarial survival improved from 31% at birth, to 61% on day of life 7, and then to 75% on day of life 28; in the 901- to 1000-g birth weight stratum, actuarial survival improved from 88%, to 94%, and then to 98% throughout the same times, respectively. Similar trends were obtained when data were stratified by gestational age.

Conclusions. Survival in the smallest infants improves dramatically during the first few days of life, but there is a significant risk for late death in the smallest of these infants.
Childhood Drownings and Fencing of Outdoor Pools in the United States, 1994
Authors: Logan Pamela , Branche Christine M. , Sacks Jeffrey J. , Ryan George , Peddicord John
Published: August 2004

Objectives. To determine the prevalence of proper fencing around outdoor swimming pools among US households and to describe this fencing in relation to demographic and other household factors. To estimate the number of drownings among children <5 years of age that might be prevented by having proper fencing around all residential pools in the United States.

Methods. A 1994, randomly dialed national telephone survey contacted 5238 adults who reported demographic information and household characteristics including whether the household had an outdoor swimming pool and the fencing around the pool. Data were weighted to obtain national estimates and percentages. The number of preventable drownings was estimated with a population-attributable risk equation.

Results. Approximately 18.5 million American households owned or had access to an outdoor swimming pool in 1994, and 76% (13.9 million) of them appeared to have had adequate fencing. Adequate fencing was associated with household income and type of home. We estimate that 19% of pool-related drownings among children <5 years of age in 1994 (88 drownings) might have been prevented if all residential pools in the United States were properly fenced.

Conclusions. Adequate pool fencing prevents a child from having access to a swimming pool if a responsible adult is not present and has been promoted as a method to prevent drowning. Our research suggests that even if all residential pools in the United States were properly fenced, most drownings among children <5 years of age would not be prevented. Thus, additional strategies to prevent drowning will be needed.
Telephone Call Reminders and Attendance in an Adolescent Clinic
Authors: O'Brien Grael , Lazebnik Rina
Published: August 2004

Objective. To determine the effect of a single telephone call reminder on appointment compliance among adolescents in an inner city, hospital-based clinic.

Methods. A randomized clinical trial was conducted at the Adolescent Clinic, a part of the Ambulatory Pediatric Practice Clinic in Cleveland, Ohio, from December 1995 to November 1996. A total of 703 routine adolescent ambulatory appointments were randomized to receive either a single telephone call reminder 1 day before the appointment or to receive no reminder. A single telephone call attempt was directed primarily to the parent or guardian of the patient in the assignment group. If not available, the reminder message was left with the patient or other family member, or on the answering machine. The study variables selected included age, gender, appointment time, distance from clinic, and payment source, and for the intervention group, the recipient of the reminder telephone call. The outcome measure was the attendance rate.

Results. The intervention group (n= 347) and control group (n = 356) were well balanced for all study variables. The overall attendance rate was 49.8%. Only 204 (58.8%) of the 347 attempted intervention appointments were contacted successfully by telephone. In the attempted intervention analysis, the attendance rate of 55.6% in the intervention group (n = 347), regardless of whether subjects were successfully contacted by telephone, was 26.1% greater than the 44.1% attendance rate in the control group. In the completed intervention analysis, the attendance rate of 65.2% in the successfully contacted individuals within the intervention group (n = 204) was increased by 47.8% over that in the control group. In the univariate analysis, attendance for self-paying patients (25.4%) was worse than that for any group. In the logistic regression analysis, both the reminder telephone call intervention and the payment source were independent predictors of attendance. In the group that was called successfully (n = 204), there was no association between attendance and the recipient of the telephone call.

Conclusions. Telephone reminders are a very effective method of increasing attendance in a hospital-based adolescent clinic. The reminder is a consistently effective intervention whether the message is delivered to the patient, to the parent or other family member, or to a telephone answering machine. Adolescent patients whose visits are not covered by Medicaid or commercial insurance are least likely to attend their clinic appointments, and a telephone call reminder has no effect on this pattern.
Zinc Supplementation Reduces the Incidence of Acute Lower Respiratory Infections in Infants and Preschool Children: A Double-blind, Controlled Trial
Authors: Sazawal Sunil , Black Robert E. , Jalla Sanju , Mazumdar Sarmila , Sinha Anju , Bhan Maharaj K.
Published: August 2004

Background. Increased acute lower respiratory infection incidence, severity, and mortality are associated with malnutrition, and reduced immunological competence may be a mechanism for this association. Because zinc deficiency results in impaired immunocompetence and zinc supplementation improves immune status, we hypothesized that zinc deficiency is associated with increased incidence and severity of acute lower respiratory infection.

Methods. We evaluated the effect of daily supplementation with 10 mg of elemental zinc on the incidence and prevalence of acute lower respiratory infection in a double-blind, randomized, controlled trial in 609 children (zinc, n = 298; control, n = 311) 6 to 35 months of age. Supplementation and morbidity surveillance were done for 6 months.

Results. After 120 days of supplementation, the percentage of children with plasma zinc concentrations <60 μg/dL decreased from 35.6% to 11.6% in the zinc group, whereas in the control group it increased from 36.8% to 43.6%. Zinc-supplemented children had 0.19 acute lower respiratory infection episodes/child/year compared with 0.35 episodes/child/year in the control children. After correction for correlation of data using generalized estimating equation regression methods, there was a reduction of 45% (95% confidence interval, 10% to 67%) in the incidence of acute lower respiratory infections in zinc-supplemented children.

Conclusions. A dietary zinc supplement resulted in a significant reduction in respiratory morbidity in preschool children. These findings suggest that interventions to improve zinc intake will improve the health and survival of children in developing countries.
Family Burden and Adaptation During the Initial Year After Traumatic Brain Injury in Children
Authors: Wade Shari L. , Taylor H. Gerry , Drotar Dennis , Stancin Terry , Yeates Keith Owen
Published: August 2004

Objective. Traumatic brain injury (TBI) often leads to long-term behavioral and cognitive deficits in children. However, little is known about the burden and psychosocial morbidity of pediatric TBI for families. The purpose of this study was to test the hypothesis that moderate and severe TBI in children has more adverse consequences than orthopedic trauma.

Design. The sample was comprised of children between the ages of 6 and 12 recruited from hospital trauma and inpatient units including 53 with severe TBI, 56 with moderate TBI, and 80 with orthopedic injuries not involving central nervous system insult. Measures of injury-related burden, parental distress, and family functioning were administered to the child's primary caregiver at baseline assessment conducted soon after injury and at 6- and 12-month follow-ups. Multivariate repeated measures analysis of covariance was used to examine group differences in these outcomes over time.

Results. Caregivers in the severe TBI group reported significantly higher levels of family burden, injury-related stress, and parental psychological symptoms than caregivers in the orthopedic injury group (ORTHO). The groups did not differ with respect to marital distress. Caregivers in the severe TBI group were significantly more likely than caregivers in the ORTHO group to exceed the clinical cutoff on the Brief Symptom Inventory and to report clinically significant levels of family dysfunction at follow-up.

Conclusions. The findings suggest that severe TBI is a source of considerable caregiver morbidity, even when compared with other traumatic injuries. Caregivers in the severe TBI group had persistent stress associated with the child's injury, as well as the reactions of other family members, and a relative risk of clinically significant psychological symptoms nearly twice that of the ORTHO comparison group. These findings underscore the need for interventions that facilitate family adaptation after pediatric TBI.
Course of Tic Severity in Tourette Syndrome: The First Two Decades
Authors: Leckman James F. , Zhang Heping , Vitale Amy , Lahnin Fatima , Lynch Kimberly , Bondi Colin , Kim Young-Shin , Peterson Bradley S.
Published: August 2004

Objective. Prevalence studies indicate a 10-fold higher rate of Tourette syndrome (TS) among children compared with adults. The purpose of this investigation was to examine the course of tic severity during the first 2 decades of life.

Method. A birth-year cohort of 42 TS patients followed at the Yale Child Study Center was recontacted an average of 7.3 years after their initial clinical evaluation. Data concerning the onset and course of tic severity until 18 years of age were available on 36 TS patients. A variety of statistical techniques were used to model aspects of the temporal patterning of tic severity.

Results. Mean (SD) tic onset at 5.6 (2.3) years of age was followed by a progressive pattern of tic worsening. On average, the most severe period of tic severity occurred at 10.0 (2.4) years of age. In eight cases (22%), the frequency and forcefulness of the tics reached a severe level during the worst-ever period such that functioning in school was impossible or in serious jeopardy. In almost every case this period was followed by a steady decline in tic severity. By 18 years of age nearly half of the cohort was virtually tic-free. The onset of puberty was not associated with either the timing or severity of tics.

Conclusions. A majority of TS patients displayed a consistent time course of tic severity. This consistency can be accurately modeled mathematically and may reflect normal neurobiological processes. Determination of the model parameters that describe each patient's course of tic severity may be of prognostic value and assist in the identification of factors that differentially influence the course of tic severity.
Neonatal Circumcision: When Can Infants Reliably Be Expected to Void?
Authors: Narchi Hassib , Kulaylat Naji
Published: August 2004

Objective. Analysis of factors influencing voiding after neonatal circumcision.

Design. Prospective study of the following factors in 200 circumcised infants: birth weight, gestational and postnatal age, type and timing of feeding before the procedure, and timing of last voiding before circumcision.

Results. There was no significant difference in the age when circumcision was performed between breastfed infants (6 and 60 hours) and in those formula-fed (8 and 130 hours). All infants voided after circumcision, with 75% of breastfed infants and 100% of formula-fed infants voiding within 8 hours of the procedure. Breastfed infants voided up to 8 hours after the procedure, compared with up to 6 hours in formula-fed infants, but without a significant difference.

The interval between last feed before the procedure and the time of voiding after circumcision was significantly shorter in formula-fed infants (1 to 9 hours) than in breastfed infants (2 to 21 hours). The interval between precircumcision and postcircumcision voiding was also significantly shorter in formula-fed infants (3 to 12 hours) than in breastfed infants (1 to 23 hours). Ninety percent of formula-fed and 64% of breastfed infants voided within 10 hours of the last voiding before circumcision.

No infants aspirated during the procedure, regardless of the time of the last feed. No hemorrhagic, infectious, or surgical complications of circumcision were observed.

Conclusion. Postoperative voiding time is predictable. Healthy infants who undergo an uncomplicated circumcision can be discharged before voiding occurs.
Female Genital Mutilation
Authors:   Committee on Bioethics
Published: August 2004

The traditional custom of ritual cutting and alteration of the genitalia of female infants, girls, and adolescents, referred to as female genital mutilation (FGM), persists primarily in Africa and among certain communities in the Middle East and Asia. Immigrants in the United States from areas where FGM is endemic may have daughters who have undergone a ritual genital procedure or may request that such a procedure be performed by a physician. The American Academy of Pediatrics (AAP) believes that pediatricians and pediatric surgical specialists should be aware that this practice has serious, life-threatening health risks for children and women. The AAP opposes all forms of FGM, counsels its members not to perform such ritual procedures, and encourages the development of community educational programs for immigrant populations.
Should Fewer Premature Infants Be Screened for Retinopathy of Prematurity in the Managed Care Era?
Authors: Wright Kelly , Anderson Mark E. , Walker Esteban , Lorch Vichien
Published: August 2004

Objective. To determine appropriate upper limits for gestational age and birth weight when screening infants for retinopathy of prematurity (ROP).

Design. Retrospective survey.

Setting. Tertiary neonatal intensive care nursery.

Patients. Seven hundred seven infants born July 1, 1990 to June 30, 1996 and screened for ROP according to the 1988 to 1996 American Academy of Pediatrics guidelines.

Outcome Measures. Maximum stage of ROP with respect to birth weight and gestational age.

Results. No ROP more than Stage 1 was observed in infants with gestational ages ≥32 weeks or birth weights ≥1500 g. All cases of threshold and Stage 4 ROP were confined to infants with gestational ages ≤30 weeks or birth weights <1200 g.

Conclusions. The latest American Academy of Pediatrics screening guidelines for ROP are discretionary for infants with birth weights >1500 g or gestational ages >28 weeks. If ROP screening is limited to infants with birth weights of ≤1500 g, 34.2% fewer infants would require screening compared with the previous <1800 g recommendation, while missing no cases of ROP more than Stage 1. A gestational age cut-off of ≤28 weeks, however, is less desirable, and could potentially miss several infants with more advanced retinopathy (including Stage 4). If ROP screening criteria were instead modified to include infants of gestational ages <32 weeks, the number of patients requiring screening could be reduced 29.1% compared with the previous recommendation of <35 weeks, again without missing any cases of ROP more than Stage 1. Use of such a screening strategy (birth weight <1500 g or gestational age <32 weeks) is predicted to save in excess of 1.5 million dollars annually in the United States, while missing no cases of ROP more than Stage 1.
Occult Bacteremia With Group B Streptococci in an Outpatient Setting
Authors: Peña Barbara M. Garcia , Harper Marvin B. , Fleisher Gary R.
Published: August 2004

Objectives. We undertook this study to determine the relative frequency of occult bacteremia with group B streptococci (GBS) and to define the clinical features of infants with occult bacteremia attributable to GBS at the time of initial clinical contact.

Design. The logs of the microbiology laboratory were reviewed for blood and cerebrospinal fluid isolates of GBS from 1982 to 1996. Records of patients identified with GBS were abstracted. Patients were classified as having occult bacteremia if GBS were isolated from their blood and they seemed nontoxic and had no apparent clinical or laboratory evidence of focal infection. All other patients were diagnosed with sepsis, meningitis, or nonmeningeal foci.

Results. We reviewed the medical records of 147 children with GBS and identified 108 outpatients, including 47 (44%) with occult bacteremia, 42 (39%) with meningitis, 11 (10%) with nonmeningeal foci, and 8 (7%) with sepsis. Compared with patients with sepsis or focal infections, those with occult bacteremia were older (61.1 vs 39.1 days) and had slightly, although not significantly, higher white blood cell (WBC) counts (13 280 ± 6854 vs 10 688 ± 8574), but similar degrees of fever. Among the 47 patients with occult bacteremia, none died, as compared with 2 of 61 with serious infections, and fewer had neurologic sequelae (0/47 vs 11/61). Patients with occult bacteremia >90 days of age generally had temperatures >39°C (9/11, mean 39.3°C) and WBC counts >15 000/mm3 (7/10, mean 19 070/mm3), both of which differed significantly compared with those who were <90 days of age. Thirty of the 47 patients with occult bacteremia received intravenous antibiotics and recovered. One of 8 patients discharged without antibiotics and none of 8 with antibiotics developed a focal complication; 1 discharged patient was lost to follow-up.

Conclusions. Almost one-half of the children with GBS disease beyond the immediate neonatal period had occult bacteremia. Among 8 untreated patients with bacteremia, 1 developed a focal complication. Although the small proportion of children with GBS occult bacteremia who were >90 days of age usually had the risk factors of temperature >39°C and WBC >15 000/mm3, as seen with occult bacteremia attributable to other organisms, the majority of the patients who were younger did not have a characteristic clinical syndrome. Prevention of sequelae in these young infants will require a low threshold for diagnosis and treatment.