bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatric Care Recommendations for Freestanding Urgent Care Facilities
Authors:   Committee on Pediatric Emergency Medicine
Published: August 2004

Freestanding urgent care centers are increasing as a source of after-hours pediatric care. These facilities may be used as an alternative to hospital emergency departments for the care and stabilization of serious and critically ill and injured children. The purpose of this policy statement is to provide recommendations for assuring appropriate stabilization in pediatric emergency situations and timely transfer to a hospital for definitive care when necessary.
Fetal Therapy—Ethical Considerations
Authors:   Committee on Bioethics
Published: August 2004

This Policy Statement was retired October 2006.

Decisions to undertake fetal therapy involve a complex assessment of the best interests of the fetus and a pregnant woman's interest in her own health and freedom from unwanted invasion of her body. Pregnant women almost always accept a recommendation for fetal therapy that is approached collaboratively, especially if the therapy is of proven efficacy and has a low maternal risk. Fetal therapy of unproven efficacy should only be undertaken as part of an approved research protocol. In recommending fetal therapy of proven efficacy, physicians should respect maternal choice and assessment of risk. Under limited circumstances when fetal therapy would be effective in preventing irrevocable and substantial fetal harm with negligible risk to the health and well-being of the pregnant woman, should the pregnant woman be opposed to the intervention, physicians should engage in a process of communication and conflict resolution that may require consultation from an ethics committee and, in rare cases, require judicial review. A physician should never intervene without the woman's explicit consent before judicial review.
Combination Vaccines for Childhood Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP)
Authors:   Committee on Infectious Diseases, 1998–1999
Published: August 2004

This Policy Statement was retired January 2009.
Association Between Diabetes Control and Visits to a Multidisciplinary Pediatric Diabetes Clinic
Authors: Kaufman Francine Ratner , Halvorson Mary , Carpenter Sue
Published: August 2004

Objective.

To determine if there is a relationship between diabetes outcome as measured by HbA1C and the number of multidisciplinary clinic visits per year in children and youth with diabetes.

Research Design and Methods.

The number of clinic visits per year, the mean HbA1C (by DCA 2000, Miles, Tarrytown, NY), type of insurance, parental marital status, parental age, maximal parental grade level achieved, family income, self-identified race, and scores on adherence and knowledge tests were compared for 1995 in 360 patients with a mean age of 11.6 ± 4.8 years (1–2 visits, 85 patients; 3–4 visits, 275 patients), for 1996 in 412 patients with a mean age of 11.6 ± 4.7 years (1–2 visits, 115 patients; 3–4 visits, 297 patients), and for 1997 in 442 patients with a mean age of 11.8 ± 4.9 years (1–2 visits, 126 patients; 3–4 visits, 332 patients).

Results.

There was a significant difference in the mean HbA1C levels between subjects with 1 to 2 visits versus 3 to 4 visits during the 3 years of this study. In 1995, the mean HbA1C was 9.0 ± 2.0% for subjects with 1 to 2 visits and 8.3 ± 1.6% for subjects with 3 to 4 visits. In 1996, the mean HbA1C was 9.3 ± 2.0% for subjects with 1 to 2 visits and 8.4 ± 1.6% in those with 3 to 4 visits, whereas in 1997, the mean HbA1C was 9.1 ± 1.9% with 1 to 2 visits and 8.3 ± 1.5% with 3 to 4 visits. There was a significant difference in the number of visits by the age of the subject. The mean age of patients with 1 to 2 visits was 13.6 ± 4.5 years; it was 10.8 ± 4.6 years with 3 to 4 visits. However, for age groups <13 years versus ≥13 years, there was still a difference between HbA1C levels for subjects with 1 to 2 visits compared with 3 to 4 visits (8.9 ± 1.7% versus 8.1 ± 1.3%, respectively). The only patient/family characteristic that had an association with number of visits was the marital status of the parents. Children from single-parent households had fewer visits. There was no association between health insurance status and number of visits and there was no difference between the number of visits and the mean scores on tests of adherence or knowledge. Multivariate analysis showed that the number of visits was a significant predictor of HbA1C even after controlling for age, duration of diabetes, and scores on adherence and knowledge tests.

Conclusions.

The finding that subjects with more frequent visits to a multidisciplinary diabetes clinic had lower HbA1C levels during the 3 years of this study suggests that strategies should be developed to promote adherence with quarterly visits, particularly targeted to children from single-parent households and to teens.
Characterization of Lyme Meningitis and Comparison With Viral Meningitis in Children
Authors: Eppes Stephen C. , Nelson David K. , Lewis Linda L. , Klein Joel D.
Published: August 2004

Objectives.

The objectives of this study were to characterize Lyme meningitis (LM) in the pediatric population; to compare LM with viral meningitis (VM) with respect to epidemiology, history and physical examination, and laboratory data; and to provide means of early distinction of Lyme neuroborreliosis from other forms of aseptic meningitis.

Methods.

This retrospective analysis involved children admitted to Alfred I. duPont Hospital for Children between 1990 and 1996 whose discharge diagnoses indicated viral or aseptic meningitis or Lyme disease. LM was defined as the presence of cerebrospinal fluid (CSF) pleocytosis with positive Lyme serology and/or erythema migrans. Patients were considered to have VM if they exhibited CSF pleocytosis and had a positive viral culture. Demographic, clinical, and laboratory data were collected for each patient, and patients with LM were compared with age-matched patients with VM.

Results.

Of 179 patient records, 12 patients with LM and 10 patients with VM (all, >2 years old) were identified by using the above criteria. In comparing LM patients with VM patients, we noted no differences among demographic variables. Children with LM had significantly lower temperatures at the time of presentation. The presence of headache, neck pain, and malaise was similar for the two groups, but the duration of these symptoms was significantly longer among LM patients. Five children with LM had cranial neuropathies. All but 1 LM patient exhibited either papilledema, erythema migrans, or cranial neuropathy. These three findings were absent in the VM group. On CSF analysis, LM patients had fewer white blood cells (mean, 80/mm3 versus 301/mm3) and a significantly greater percentage of mononuclear cells than the VM patients.

Conclusions.

In this study, in a Lyme-endemic area, LM was about as common as VM in older children who were hospitalized with aseptic meningitis. Attention to pertinent epidemiologic and historical data, along with physical and CSF findings, allows early differentiation of LM from VM.
Genetic and Environmental Influences on Human Cord Blood Leptin Concentration
Authors: Tarquini Brunetto , Tarquini Roberto , Perfetto Federico , Cornélissen Germaine , Halberg Franz
Published: August 2004

Objective.

To examine in a population sample of cord blood the time structure (chronome) of leptin, an adipocyte-derived hormone, and to assess any effect of a familial history of noninsulin-dependent diabetes mellitus and obesity, separately, on both the maternal and the paternal side.

Subjects and Methods.

Leptin concentration was determined in cord blood from 93 infants. Effects of gender, gestational age, birth weight, maternal weight, familial antecedents of obesity and noninsulin-dependent diabetes mellitus, and circadian and about-yearly stage were assessed by linear regression and ANOVA.

Results.

Cord blood leptin concentration is elevated in the presence of a family history of obesity on the paternal side, but not on the maternal side. Leptin concentrations are higher in spring and summer than in fall and are higher in infants born before noon. In keeping with earlier work, leptin concentration in cord blood correlates positively with birth weight and height and is higher in infants who are appropriate for or large for gestational age than in infants who are small for gestational age or born prematurely.

Discussion.

Changes along the scales of the day and the seasons point to synchronizing environmental as well as genetic influence. An association of cord blood leptin concentration with obesity on the paternal side may help clarify the role of leptin in parental contributions to human obesity and may prompt focus on cholesterol metabolism.
Spread of Varicella-Zoster Virus DNA to Family Members and Environments From Siblings With Varicella in a Household
Authors: Asano Yoshizo , Yoshikawa Tetsushi , Ihira Masaru , Furukawa Hiroshi , Suzuki Kyoko , Suga Sadao
Published: August 2004

Objective.

To elucidate virus spread from siblings with varicella to other family members and environmental objects in a family setting before and after onset of the disease.

Materials and Methods.

Among a family consisting of five members, a boy developed varicella and the remaining two siblings developed the disease 17 and 18 days after onset of the index case. Swab samples from throats and hands of parents and three siblings and samples from several sources in the environment of the house were collected frequently before and/or after onset of the disease. Varicella-zoster virus (VZV) DNA in the samples was examined by a sensitive polymerase chain reaction amplification assay.

Results.

In total, 108 samples from the throats and hands of the three children with varicella, 72 such samples from parents, and 72 samples from the surfaces of several sources in the house were collected. Eight days after onset of the index case (the older boy), VZV DNA was detected in both samples from the index case and on the surfaces of four sources (air conditioner filter, table, television channel push-buttons, and door handle), but not from the two other siblings or parents. Then, it was detected once on the mother's hand and the air conditioner filter and three times on the television channel push-buttons by January 30, 1998, when the girl developed varicella, 17 days after onset of the index case. The younger brother developed the disease on January 31. Viral DNA could not be detected in any samples obtained on January 30; however, it was detected on the hands of the older boy and the father and in samples from the hand and throat of the girl on January 31. Thereafter, virus DNA was detected three times intermittently by February 13 on the hand and three times persistently in the throat of the girl. The virus DNA was detected three times between February 1 and 3 on the hand and three times between February 1 and 4 in the throat of the younger boy. It was detected occasionally on the hands of the older boy and the parents, and occasionally or intermittently on surfaces of four environmental sources between February 2 and 13.

Conclusions.

The present study showed the rapid and broad contamination of the environment with the VZV DNA when the varicella patient appeared in a family, although it does not directly mean infectivity.
The Perceptions and Practices of Pediatricians: Tobacco Intervention
Authors: Zapka Jane G. , Fletcher Kenneth , Pbert Lori , Druker Susan K. , Ockene Judith K. , Chen Liping
Published: August 2004

Objectives.

To investigate pediatrician self-reported intervention practices related to tobacco use and cessation. We queried about practices with three groups 1) children/adolescents who do not smoke; 2) children/adolescents who smoke; and 3) parents, and the relationship of counseling practices with the personal and professional practice-related factors of pediatricians.

Design.

Mailed anonymous survey regarding their self-reported tobacco use prevention and cessation intervention practices.

Population.

Random sample of 350 pediatricians in one state.

Results.

A response rate of 75% was achieved. Pediatricians reported the greatest counseling practice in encouraging children/adolescents to not start smoking, followed by counseling adolescents who smoke. The lowest practice score was for intervening with parents who smoke. The age, gender, site of practice (eg, HMO, solo practice), and subspecialty status of the pediatricians were not related to practice. Pediatricians who reported at least some community involvement in local tobacco control efforts reported significantly higher levels of smoking cessation counseling with both children and adolescents and with parents who smoke. Pediatricians who reported previous training in counseling about tobacco issues also reported significantly higher levels of counseling of both adolescent smokers and parents who smoke but not of children and adolescents who do not smoke. Higher role perception, believing that smoking cessation counseling provided by pediatricians can be effective, and self-efficacy, were predictive of intervention with all three groups. The perceived barriers scale was not related to intervention with any group.

Conclusions.

Pediatricians are missing opportunities to help their patients to stop smoking and to prevent smoking initiation. Pediatricians are intervening least frequently with parents who smoke. Practices should be tailored to the specific target group.
Familial Mediterranean Fever: Clinical and Genetic Characterization in a Mixed Pediatric Population of Jewish and Arab Patients
Authors: Brik Riva , Shinawi Marwan , Kepten Ilana , Berant Moshe , Gershoni-Baruch Ruth
Published: August 2004

Objective.

Familial Mediterranean fever (FMF) is an autosomal recessive hereditary disease which primarily affects non-Ashkenazi Jews, Armenians, Arabs, and Turks. The gene responsible for the disease (MEFV/FMF) has been recently identified. Four common mutations in exon 10 of theMEFV gene seem to account for 86% of the DNA variations identified in patients with FMF. We conducted a phenotype/genotype correlation study in a mixed population of Jewish and Arab children with FMF.

Study Design.

Seventy patients clinically diagnosed as having FMF underwent molecular genetic studies using polymerase chain reaction and restriction endonuclease digestion methods to detect the presence of the four mutations (M694V, M680I, V726A, M694I). We then correlated the presence of each mutation with ethnic origin, age of onset, clinical manifestations, disease severity, and occurrence of amyloidosis.

Results.

The M694V mutation, which is predominant in non-Ashkenazi Jews, was found in 92% of our Jewish patients and in only 30% of the Arab patients. All four mutations were identified among 94% of the Arab patients, but with no particular prevalence for any one of them. The presence of a homozygous M694V mutation was significantly associated with a more severe form of the disease: the clinical onset of the disease manifested at an earlier age; the number of attacks per month was higher; the global assessment by the treating physician and the severity of pain scored higher; and arthritis was more frequent. Only patients with the M694V mutation had a family history of amyloidosis. No association was found between the type of mutation and the predominance of fever, abdominal pain, pleuritis, skin eruption, or response to colchicine in the clinical picture.

Conclusions.

Homozygosity for the M694V mutation, predominant among North African Jews, is associated with a severe course and prognosis for FMF. This mutation is less common among Arabs and, when present, occurs almost only in heterozygous form. In Arab patients, the disease tends to run a milder course and seems to bear a better prognosis. The phenotype/genotype patterns that are evident from our study of a mixed series of Jewish and Arab children with FMF might provide a rational basis for counseling about the natural history of the disease and for clinical treatment of FMF patients and their families.
The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart Study
Authors: Freedman David S. , Dietz William H. , Srinivasan Sathanur R. , Berenson Gerald S.
Published: August 2004

Background.

Although overweight and obesity in childhood are related to dyslipidemia, hyperinsulinemia, and hypertension, most studies have examined levels of these risk factors individually or have used internal cutpoints (eg, quintiles) to classify overweight and risk factors.

Objective.

We used cutpoints derived from several national studies to examine the relation of overweight (Quetelet index, >95th percentile) to adverse risk factor levels and risk factor clustering.

Design.

The sample consisted of 9167 5- to 17-year-olds examined in seven cross-sectional studies conducted by the Bogalusa Heart Study between 1973 and 1994.

Results.

About 11% of examined schoolchildren were considered overweight. Although adverse lipid, insulin, and blood pressure levels did not vary substantially with the Quetelet index at levels <85th percentile, risk factor prevalences increased greatly at higher levels of the Quetelet index. Overweight schoolchildren were 2.4 times as likely as children with a Quetelet index <85th percentile to have an elevated level of total cholesterol. Odds ratios for other associations were 2.4 (diastolic blood pressure), 3.0 (low-density lipoprotein cholesterol), 3.4 (high-density lipoprotein cholesterol), 4.5 (systolic blood pressure), 7.1 (triglycerides), and 12.6 (fasting insulin). Several of these associations differed between whites and blacks, and by age. Of the 813 overweight schoolchildren, 475 (58%) were found to have at least one risk factor. Furthermore, the use of overweight as a screening tool could identify 50% of schoolchildren who had two or more risk factors.

Conclusions.

Because overweight is associated with various risk factors even among young children, it is possible that the successful prevention and treatment of obesity in childhood could reduce the adult incidence of cardiovascular disease.overweight, lipids, blood pressure, insulin, children, adolescents.
Sociodemographic Factors Identify US Infants at High Risk of Injury Mortality
Authors: Scholer Seth J. , Hickson Gerald B. , Ray Wayne A.
Published: August 2004

Objectives.

To identify sociodemographic predictors of infant injury mortality and to compare trends in injury mortality rates for high- and low-risk US infants from 1985 to 1991.

Design.

Historical cohort.

Setting/Study Participants.

The National Center for Health Statistics linked US infants (<1 year) born from 1985 to 1991 with death certificates.

Main Outcome Measures.

Multivariate regression was used to identify sociodemographic factors associated with injury mortality. The adjusted relative risks (RRs) of maternal age, education, marital status, number of other children, and infant birth weight were used to categorize infants into risk groups. We compared trends in injury rates for the highest and lowest risk groups.

Results.

There were 5963 injury deaths and 18.6 million infant years or 32.1 injury deaths per 100 000 infant years. Highest risk infants were born to mothers who were younger than 20 years compared with older than 30 years (RR, 3.25; 95% CI, 2.92–3.63), had less than a high school education compared with a college education (RR, 2.22; 95% CI, 1.95–2.53), had more than 2 other children compared with no other children (RR, 3.15; 95% CI, 2.88–3.45), were unmarried (RR, 1.67; 95% CI, 1.57–1.78), or had birth weights ≤1500 g compared with >2500 g (RR, 3.36; 95% CI, 2.94–3.84). Infants in the highest risk group (21.0% of the population) had a >10-fold increased risk of injury mortality compared with the lowest risk group (18.1% of the population) and there was no evidence that this disparity was narrowing.

Conclusions.

Sociodemographic predictors of infant injury mortality include maternal age, education, number of other children, marital status, and infant birth weight. Based on these factors, 1 in 5 infants in the United States can be identified at birth as having a >10-fold increased risk of injury mortality compared with infants in lowest risk group. Programs to reduce injuries in these high-risk groups are urgently needed.
Hepatitis B Vaccine Administered to Children and Adolescents at Yearly Intervals
Authors: Halsey Neal A. , Moulton Lawrence H. , O'Donovan J. Crossan , Walcher J. Ronald , Thoms Mary Lou , Margolis Harold S. , Krause David S.
Published: August 2004

Objective.

Hepatitis B vaccines are usually administered on a schedule of 0, 1 to 2, and 6 months. Longer intervals between the second and third doses have been studied, but the effectiveness of hepatitis B vaccine administered at intervals of >2 months between the first and second doses have not been studied. Our objective was to compare the antibody response in recipients of Engerix-B hepatitis B vaccine administered at 12-month intervals to the response to vaccine administered at 0-, 1-, and 6-month intervals.

Methods.

A total of 389 children, 5 through 16 years of age, were randomized to receive Engerix-B (10 mg) at a schedule of either 0-, 1-, and 6-month intervals or 0-, 12-, and 24-month intervals. Blood was drawn before and 1 month after the third dose.

Results.

Immediately before the third dose of vaccine, 92.3% of children who received vaccine on the 0-, 1-, and 6-month schedule and 88.8% of children who received the 0-, 12-, and 24-month schedule had antibody to hepatitis B surface (anti-HBs) antigen concentrations ≥10 mIU/mL. Of the children in the 0-, 1-, and 6-month schedule, 95% received the third dose according to protocol versus 90% of those in the 0-, 12-, 24-month schedule. The geometric mean anti-HBs concentration just before the third dose for recipients of the 0-, 1-, and 6-month schedule (117.9 mIU/mL) was somewhat lower than that for the children who had received vaccine on the 0-, 12-, and 24-month schedule (162.1 mIU/mL). One month after the third dose, >98% of all children had anti-HBs concentrations ≥10 mIU/mL and high geometric mean antibody concentrations were observed in both groups: 5687 mIU/mL for children on the 0-, 1-, and 6-month schedule and 3159 mIU/mL for children on the 0-, 12-, and 24-month schedule. Body mass index was correlated inversely with final antibody concentration, but age was not a factor after adjustment for body mass index.

Discussion.

Engerix-B administered on a 0-, 12-, and 24-month schedule is highly immunogenic. Providers should consider this alternate immunization schedule for children who are at low risk of immediate exposure to hepatitis B infections. vaccine, hepatitis B, hepatitis B vaccine, antigen, dose, schedule, immunization, adolescent.
Prevalence of IgA-Antiendomysium and IgA-Antigliadin Autoantibodies at Diagnosis of Insulin-Dependent Diabetes Mellitus in Swedish Children and Adolescents
Authors: Carlsson Anneli K. , Axelsson Irene E. M. , Borulf Stefan K. , Bredberg Anders C. A. , Lindberg Bengt A. , Sjöberg Klas G. , Ivarsson Sten-A.
Published: August 2004

Objective.

This study was conducted to investigate the prevalence of celiac disease (CD) in children and adolescents at diagnosis of insulin-dependent diabetes mellitus (IDDM) before insulin treatment was started.

Material and Methods.

At diagnosis of IDDM, and before treatment was started, 115 children and adolescents were screened for IgA- antiendomysium (EMA) and IgA-antigliadin antibodies (AGA). Those found to be EMA-positive and/or AGA-positive were investigated further with intestinal biopsy.

Results.

Of the 115 patients, 2 had known CD at diagnosis of IDDM; of the remainder of patients, 6% (7/113) were found to be EMA-positive and 9% (10/113) were found to have AGA levels above normal. Of the 6 patients who underwent biopsy, 5 manifested villous atrophy. In addition, 2 patients with high EMA and AGA antibody titers refused biopsy, and 4 patients with low EMA and/or AGA titers were found to have normal titers at control before biopsy decision.

Conclusion.

Because the prevalence of CD at diagnosis of IDDM would seem to be 6% to 8%, screening for CD seems to be justified among patients with newly diagnosed IDDM.
Language Barriers and Resource Utilization in a Pediatric Emergency Department
Authors: Hampers Louis C. , Cha Susie , Gutglass David J. , Binns Helen J. , Krug Steven E.
Published: August 2004

Background.

Although an inability to speak English is recognized as an obstacle to health care in the United States, it is unclear how clinicians alter their diagnostic approach when confronted with a language barrier (LB).

Objective.

To determine if a LB between families and their emergency department (ED) physician was associated with a difference in diagnostic testing and length of stay in the ED.

Design.

Prospective cohort study.

Methods.

This study prospectively assessed clinical status and care provided to patients who presented to a pediatric ED from September 1997 through December 1997. Patients included were 2 months to 10 years of age, not chronically ill, and had a presenting temperature ≥38.5°C or complained of vomiting, diarrhea, or decreased oral intake. Examining physicians determined study eligibility and recorded the Yale Observation Score if the patient was <3 years old, and whether there was a LB between the physician and the family. Standard hospital charges were applied for each visit to any of the 22 commonly ordered tests. Comparisons of total charges were made among groups using Mann-Whitney U tests. Analysis of covariance was used to evaluate predictors of total charges and length of ED stay.

Results.

Data were obtained about 2467 patients. A total of 286 families (12%) did not speak English, resulting in a LB for the physician in 209 cases (8.5%). LB patients were much more likely to be Hispanic (88% vs 49%), and less likely to be commercially insured (19% vs 30%). These patients were slightly younger (mean 31 months vs 36 months), but had similar acuity, triage vital signs, and Yale Observation Score (when applicable). In cases in which a LB existed, mean test charges were significantly higher: $145 versus $104, and ED stays were significantly longer: 165 minutes versus 137 minutes. In an analysis of covariance model including race/ethnicity, insurance status, physician training level, attending physician, urgent care setting, triage category, age, and vital signs, the presence of a LB accounted for a $38 increase in charges for testing and a 20 minute longer ED stay.

Conclusion.

Despite controlling for multiple factors, the presence of a physician–family LB was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times. Additional study is recommended to explore the reasons for these differences and ways to provide care more efficiently to non-English-speaking patients. language barriers, resource utilization, test ordering.
Assessment of Neonatal Encephalopathy by Amplitude-integrated Electroencephalography
Authors: al Naqeeb Niran , Edwards A. David , Cowan Frances M. , Azzopardi Denis
Published: August 2004

Objective.

To define normal and abnormal patterns, test interobserver variability, and the prognostic accuracy of amplitude-integrated electroencephalography (aEEG) soon after the onset of neonatal encephalopathy.

Methods.

Consecutive cases of neonatal encephalopathy (n = 56; gestation median, 40; range, 35–42 weeks) and healthy infants (n = 14; gestation median, 40; range, 39–40 weeks) were studied. aEEG was recorded using a cerebral function monitor, at median, 0, range, 0–21 days of age. Of the infants, 24 of the 56 with encephalopathy and all of the normal infants were studied within 12 hours of birth (median, 5; range, 3–12 hours). Forty infants were suspected of having suffered birth asphyxia. Criteria for normal and abnormal patterns were defined and the interobserver variability of these classifications determined. Results were compared with neurodevelopmental outcome assessed at 18 to 24 months of age. aEEG also was compared with a standard EEG and with magnetic resonance imaging.

Results.

The median upper margin of the widest band of aEEG activity in the control infants was 37.5 μV (range, 30–48 μV), and median lower margin was 8 μV (range, 6.5–11 μV). We classified the aEEG background activity as normal amplitude, the upper margin of band of aEEG activity >10 μV and the lower margin >5 μV; moderately abnormal amplitude, the upper margin of band of aEEG activity >10 μV and the lower margin ≤5 μV; and suppressed amplitude, the upper margin of the band of aEEG activity <10 μV and lower margin <5 μV. Recordings were analyzed further for the presence of seizures, defined as periods of sudden increase in voltage accompanied by a narrowing of the band of aEEG activity.

Tests of interobserver variability showed excellent agreement both for assessment of amplitude (κ statistic = 0.85) and for identification of seizures (κ statistic = 0.76)

There was a close relationship between the aEEG and subsequent outcome: 19 of 21 infants with a normal aEEG finding were normal on follow-up at 18 to 24 months of age, whereas 27 of 35 infants with a moderately abnormal or suppressed aEEG and/or seizures died or developed neurologic abnormalities. Thus, aEEG predicted outcome with a sensitivity of 0.93, a specificity of 0.70, positive predictive value of 0.77, negative predictive value of 0.90, and the likelihood ratio of a positive result of 3.1 and a negative result of 0.06. For the 24 infants studied within 12 hours of birth, the corresponding results were sensitivity, 1.0; specificity, 0.82; positive predictive value, 0.85; negative predictive value, 1; likelihood ratio of a positive result, 5.5; and likelihood ratio of a negative result, 0.18.

Conclusion.

The aEEG is a simple but accurate and reproducible clinical tool that could be useful in the assessment of infants with encephalopathy.
The Pediatrician's Role in Community Pediatrics
Authors:   Committee on Community Health Services
Published: August 2004

This policy statement offers pediatricians a concise definition of community pediatrics and provides a set of specific recommendations that underscore the critical nature of this important dimension of the profession.
Risk Factors for Early-onset Group B Streptococcal Sepsis: Estimation of Odds Ratios by Critical Literature Review
Authors: Benitz William E. , Gould Jeffrey B. , Druzin Maurice L.
Published: August 2004

Objective.

To identify and to establish the prevalence of ORs for factors associated with increased risk for early-onset group B streptococcal (EOGBS) infection in neonates.

Study Design.

Literature review and reanalysis of published data.

Results.

Risk factors for EOGBS infection include group B streptococcal (GBS)-positive vaginal culture at delivery (OR: 204), GBS-positive rectovaginal culture at 28 (OR: 9.64) or 36 weeks gestation (OR: 26.7), vaginal Strep B OIA test positive at delivery (OR: 15.4), birth weight ≤ 2500 g (OR: 7.37), gestation <37 weeks (OR: 4.83), gestation <28 weeks (OR: 21.7), prolonged rupture of membranes (PROM) >18 hours (OR: 7.28), intrapartum fever >37.5°C (OR: 4.05), intrapartum fever, PROM, or prematurity (OR: 9.74), intrapartum fever or PROM at term (OR: 11.5), chorioamnionitis (OR: 6.43). Chorioamnionitis is reported in most (88%) cases in which neonatal infection occurred despite intrapartum maternal antibiotic therapy. ORs could not be estimated for maternal GBS bacteriuria during pregnancy, with preterm premature rupture of membranes, or with a sibling or twin with invasive GBS disease, but these findings seem to be associated with a very high risk. Multiple gestation is not an independent risk factor for GBS infection.

Conclusions.

Mothers with GBS bacteriuria during pregnancy, with another child with GBS disease, or with chorioamnionitis should receive empirical intrapartum antibiotic treatment. Their infants should have complete diagnostic evaluations and receive empirical treatment until infection is excluded by observation and negative cultures because of their particularly high risk for EOGBS infection. Either screening with cultures at 28 weeks gestation or identification of clinical risk factors, ie, PROM, intrapartum fever, or prematurity, may identify parturients whose infants include 65% of those with EOGBS infection. Intrapartum screening using the Strep B OIA rapid test identifies more at-risk infants (75%) than any other method. These risk identifiers may permit judicious selection of patients for prophylactic interventions.
Helicobacter pyloriInfection and Insulin Requirement Among Children With Type 1 Diabetes Mellitus
Authors: Begue Rodolfo E. , Mirza Ayesha , Compton Terry , Gomez Ricardo , Vargas Alfonso
Published: August 2004

Objective.

Helicobacter pylori induces gastric inflammation and the production of cytokines in infected individuals. Theoretically, this increased production of cytokines could be deleterious for the control of the glycemia of patients with diabetes. This study aimed to describe the insulin requirement among patients with type 1 diabetes and H pylori infection compared with uninfected counterparts.

Methods.

Cross-sectional design. Demographic information (age, gender, race, annual family income, and number of individuals per room in the household) and clinical information (age at diagnosis of diabetes, duration of illness, weight, height, compliance with clinical appointments, daily insulin units per kilogram of body weight [IU/kg/d], and glycosylated hemoglobin A level) was obtained from children and adolescents with diagnosis of type 1 diabetes mellitus who were seen at Children's Hospital in New Orleans. A total of 2 mL of blood was also collected and sera were tested forH pylori-specific immunoglobulin G antibodies using an enzyme immunoassay. The daily insulin requirement among infected and uninfected children was compared, and the effect of other variables was evaluated with multiple linear regression.

Results.

Of the 71 subjects who were evaluated (median age: 11 years), 11 (15.5%) were found to be infected. H pylori infection was more frequent among subjects who were older, who had a lower family income, and who were black. Infected children were found to require more insulin (1.2 vs 0.9 IU/Kg/d) and their glycosylated hemoglobin A level was higher (14.9 vs 11.8) than the level found in uninfected subjects. Multiple linear regression analysis identified H pylori infection duration of illness, race (black), body mass index, and gender (female), to be associated independently with increased daily insulin requirement (IU/kg/d).

Conclusion.

In our study population, children with type 1 diabetes and H pylori infection had an increased daily insulin requirement compared with the requirement of their uninfected peers. The reason for this association requires additional investigation.
Flexible Flat Feet in Children: A Real Problem?
Authors: Garcı́a-Rodrı́guez Antonio , Martı́n-Jiménez Felipe , Carnero-Varo Manuel , Gómez-Gracia Enrique , Gómez-Aracena Jorge , Fernández-Crehuet Joaquı́n
Published: August 2004

Objectives

To estimate the prevalence of flexible flat feet in the provincial population of 4- to 13-year-old schoolchildren and the incidence of treatments considered unnecessary.

Setting.

Province of Málaga, Spain.

Methods.

We examined and graded by severity a sample of 1181 pupils taken from a total population of 198 858 primary schoolchildren (CI: 95%; margin of error: 5%). The sample group was separated into three 2-year age groups: 4 and 5 years, 8 and 9 years, and 12 and 13 years. The plantar footprint was classified according to Denis1 into three grades of flat feet: grade 1 in which support of the lateral edge of the foot is half that of the metatarsal support; grade 2 in which the support of the central zone and forefoot are equal; and grade 3 in which the support in the central zone of the foot is greater than the width of the metatarsal support.

The statistical analysis for the evaluation of the differences between the groups was performed with Student's t and χ2 tests as appropriate.

Results.

The prevalence of flat feet was 2.7%. Of the 1181 children sampled, 168 children (14.2%) were receiving orthopedic treatment, but only 2.7% had diagnostic criteria of flat feet. When we inspected the sample, we found that a number of children were being treated for flat feet with boots and arch supports. Most of them did not have a flat plantar footprint according to the criteria that we used for this work. Furthermore, in the group of children that we diagnosed as having flat feet, only 28.1% were being treated. We found no significant differences between the number of children receiving orthopedic treatments and the presence or absence of a flat plantar footprint. Children who were overweight in the 4- and 5-year-old group showed an increased prevalence for flat feet as diagnosed by us.

Conclusion.

The data suggest that an excessive number of orthopedic treatments had been prescribed in the province. When extrapolated to the 1997 population of schoolchildren within the age groups studied the figures suggested that ∼28 167 children in Málaga province probably would have been receiving orthopedic treatments with boots and insoles at the time of our study. Consequently, the total expenditure on orthopedic boots and insoles that year could be estimated as 676 008 000 pesetas ($4 447 422 in US currency).
Randomized Placebo-controlled Trial of a 42-Day Tapering Course of Dexamethasone to Reduce the Duration of Ventilator Dependency in Very Low Birth Weight Infants
Authors: Kothadia Jamanadas M. , O'Shea T. Michael , Roberts Dia , Auringer Sam T. , Weaver R. Grey , Dillard III§; and Robert G.
Published: August 2004

Objective.

To assess the effect on duration of ventilator dependency of a 42-day tapering course of dexamethasone in very low birth weight neonates.

Methods.

Infants (N = 118) were assigned randomly, within birth weight/gender strata, to treatment with either a 42-day tapering course of dexamethasone or an equal volume of saline as placebo. Entry criteria were 1) birth weight <1501 g; 2) age between 15 and 25 days; 3) <10% decrease in ventilator settings for 24 hours and Fio2 ≥0.3; 4) absence of patent ductus arteriosus, sepsis, major congenital malformation, congenital heart disease; and 5) no evidence of maternal HIV or hepatitis B infection. The dosage schedule was 0.25 mg/kg bid for 3 days, then 0.15 mg/kg bid for 3 days, then a 10% reduction in the dose every 3 days until a dose of 0.1 mg/kg had been given for 3 days, from which time a dose of 0.1 mg/kg qod was continued until 42 days after entry. The primary endpoint was the number of days on assisted ventilation after study entry. Secondary outcomes of interest included days on supplemental oxygen, days of hospitalization, and potential adverse effects, such as infection, gastrointestinal bleeding, left ventricular hypertrophy, and severe retinopathy of prematurity.

Results.

Infants in the dexamethasone- and placebo-treated groups were similar in terms of baseline attributes, including birth weight, gestational age, gender, race, and ventilator settings at entry. Infants treated with dexamethasone were on assisted ventilation and supplemental oxygen for fewer days after study entry (median days on ventilator, 5th and 95th percentiles, 13 [1–64] vs 25 [6–104]; days on oxygen, 59 [6–247] vs 100 [11–346]). No differences were found in risk of death, infection, or severe retinopathy. In subgroup analyses, the association of dexamethasone with more rapid weaning from the ventilator was weaker among infants enrolled before the 16th day of life, infants with chest radiographs showing cystic changes and/or hyperinflation, and infants requiring an Fio2 ≥0.7 or a peak inspiratory pressure ≥19 at study entry.

Conclusions.

A 42-day tapering course of dexamethasone decreases the duration of ventilator and oxygen dependency in very low birth weight infants and is not associated with an increased risk of short-term adverse effects.
Physically Abused Adolescents: Behavior Problems, Functional Impairment, and Comparison of Informants' Reports
Authors: Kaplan Sandra J. , Labruna Victor , Pelcovitz David , Salzinger Suzanne , Mandel Francine , Weiner Merrill
Published: August 2004

Objective.

This study, like earlier studies that focused on younger abused children, ascertained whether physically abused adolescents exhibited increased internalizing and externalizing behaviors. Relevance to pediatric practice is discussed.

Design.

A cross-sectional design was used to compare the behavior of physically abused adolescents and comparison adolescents using self-reports, parent reports, and teacher reports. The level of agreement among raters was also examined.

Participants.

The subjects were 99 physically abused adolescents between the ages of 12 and 18 years, who were recruited from Child Protective Services. Comparison subjects were 99 community-recruited nonabused adolescents who were matched for age, gender, and income with the abused adolescents.

Measures.

The behavior of the adolescents was assessed using the Child Behavior Checklist, and the comparable Youth Self-Report and Teacher Report Form, which are widely used measures of behavioral and emotional problems. The Child Global Assessment Scale was also used as a measure of functional impairment and of the need for mental health services.

Results.

Parents and teachers rated the problems of abused adolescents as significantly greater than the problems of nonabused adolescents on all checklist subscales. Abused adolescents reported significantly greater problems only on externalizing behavior subscales. In addition, based on interviewer ratings, physically abused adolescents exhibited significantly greater functional impairment.

Conclusions.

Similar to previous research on abused children, physically abused adolescents exhibit externalizing and internalizing behavior problems and experience greater functional impairment. Parent, teacher, and adolescent reports of externalizing behaviors were similar, but physically abused adolescents reported fewer internalizing behaviors than did the other informants.
Symptomatic Congenital Cytomegalovirus Infection in Infants Born to Mothers With Preexisting Immunity to Cytomegalovirus
Authors: Boppana Suresh B. , Fowler Karen B. , Britt William J. , Stagno Sergio , Pass Robert F.
Published: August 2004

Objectives.

To determine the frequency of symptomatic congenital cytomegalovirus (CMV) infection in the offspring of women with a recurrent maternal CMV infection and to characterize the demographic and newborn findings.

Methods.

Study subjects consisted of infants with symptomatic congenital CMV infection identified by a newborn virologic screening program at the University of Alabama Hospital between 1991 and 1997 and were enrolled in a long-term follow-up study. Maternal infections were categorized by an analysis of archival serum specimens collected before pregnancy and at the time of delivery. Demographic data and clinical findings at birth were collected from maternal and newborn hospital records and from parents at the time of initial evaluation.

Results.

Of the 47 infants with symptomatic congenital CMV infection identified during the study period, 8 were born to mothers with a confirmed nonprimary or recurrent CMV infection. The type of maternal infection could be ascertained in only ∼43% (20/47) of the children with symptomatic congenital CMV infection born at the University of Alabama Hospital during the study period. There were no significant differences in demographic characteristics of the recurrent infection group and the infants who were born to mothers with either primary CMV infection during pregnancy or unclassified maternal infection. Similarly, the range of severity of clinical abnormalities during the newborn period did not differ in the two groups of children. Furthermore, there were no significant differences in the incidence of sequelae at long-term follow-up in the two groups of children.

Conclusions.

Symptomatic congenital CMV infection can occur after a nonprimary or recurrent maternal infection. However, the exact incidence of symptomatic congenital CMV infection among children born to women with preexisting immunity remains to be defined.
Cost of Chickenpox in Canada: Part II. Cost of Complicated Cases and Total Economic Impact
Authors: Law Barbara , Fitzsimon Catherine , Ford-Jones Lee , McCormick John , Rivière Marc ,   Members of the Immunization Monitoring Program—Active (IMPACT)
Published: August 2004

Objective.

Primarily, to determine the direct medical costs and productivity losses associated with complicated chickenpox (hospitalized cases) and, secondarily, to quantify the overall economic burden of chickenpox in Canada.

Methods.

Direct medical resource consumption patterns were determined by chart review of 160 otherwise healthy children and 40 children with leukemia hospitalized for chickenpox. Children were selected from the database of the Immunization Monitoring Program Active (IMPACT), a network of 11 tertiary-care hospitals in Canada that collected information at the time of hospitalization from January 1991 to March 1996. An additional 26 healthy children hospitalized were recruited prospectively by IMPACT. Productivity losses (time lost from work and daily activities) were assessed by caregiver interviews. Treatment costs were determined from the patient, Ministry of Health, and societal perspectives.

Results.

The average societal per case cost for complicated chickenpox in healthy children was $7060 and $8398, respectively, from the retrospective and prospective assessments. For children with leukemia, the direct medical cost was estimated at $7228. These costs were combined with a cost established previously for uncomplicated chickenpox. The estimated yearly overall economic impact of chickenpox in Canada was $122.4 million, with $24.0 million attributable to Ministry of Health costs, assuming an estimated yearly incidence of 346 527 cases and a 0.54% rate of hospitalization for healthy children.

Conclusions.

Direct medical costs are the major cost driver in the care of complicated chickenpox. However, in the context of the overall economic burden of the disease, uncomplicated chickenpox is the major cost driver, contributing 89% to the total cost.