bluuebunny/crossref_metadata_2025 huggingface dataset:
Resident and Family Continuity in Pediatric Continuity Clinic: Nine Years of Observation
Authors: Garfunkel Lynn C. , Byrd Robert S. , McConnochie Kenneth M. , Auinger Peggy
Published: August 2004

Objective. To assess resident, patient, and family continuity.

Background. Continuity clinic is the principal longitudinal primary care experience for pediatric residents. Although it has been a recommendation of the Residency Review Committee for pediatric training for more than 10 years and has been a requirement of the Accreditation Council of Graduate Medical Education since 1989, the extent to which continuity is achieved in this setting has not been reported.

Methods. Nine years (1984–1993) of residents' continuity clinic experience in a community hospital affiliate of a university training program were reviewed. Continuity was defined by recurring visits between the same patient/provider pair. The analysis from 57 different residents includes 48 intern (R1) years, 45 level two (R2) years, and 40 level three (R3) years; 32 of these residents completed all 3 years of training (3-year cohort) in the program during the study period. Observations included 89 952 visits by 11 009 patients in 7130 families. Continuity was determined for the resident, patient, and family.

Results. Residents saw an annual average of 93, 136, and 144 visits as R1s, R2s, and R3s. Residents saw 60% of their patients fewer than 3 times and nearly 40% only once. In the final year for those in the 3-year cohort, residents saw an average of 149 visits; 53% of the time these R3s had seen their patients once or twice over 3 years. Thirty percent of the patients never saw their primary care physician (PCP) and 72% of patients had fewer than 3 visits with their PCP. One quarter of the families never saw their continuity resident, and 62% saw their continuity resident fewer than 3 times.

Conclusions. These data demonstrate a remarkable lack of both resident and patient continuity in the principal clinical activity affording longitudinal primary care experiences during residency training. If more continuity is essential for both primary care of patients and education in general pediatrics, change in the structure of continuity experience is required.
Human Papillomavirus Screening in Pediatric Victims of Sexual Abuse
Authors: Siegfried Elaine , Rasnick-Conley Jane , Cook Sandra , Leonardi Craig , Monteleone James
Published: August 2004

Objective. To evaluate for the presence of subclinical human papillomavirus (HPV) in cases of suspected sexual abuse in children.

Design. Prospective data collection via interviews, physical examination, colposcopic examination, and tissue sampling by a surface swab technique.

Setting. A total of 40 pediatric patients ranging in age from 1 to 16 years who were referred to the Special Assessment and Management Clinic at Cardinal Glennon Children's Hospital, St Louis, MO, for probable or confirmed sexual abuse.

Interventions. In addition to colposcopic examination for physical signs of abuse, the patients were screened for evidence of sexually transmitted diseases, including syphilis, gonorrhea, andChlamydia. At that time, surveillance sampling of the throat, vaginal introitus, and/or rectum by a simple, rapid surface swab technique was performed to detect the presence of HPV.

Measurements. Template DNA was extracted from cotton swabs and analyzed using polymerase chain reaction analysis.

Results. Human β-globin sequences were detected in 58 (83%) of 70 specimens obtained from 40 patients, indicating successful processing had occurred. Using a consensus L1 primer-probe set capable of detecting multiple HPV genotypes, 2 (3%) of 58 samples from 2 (5%) of 40 patients were positive for HPV 16. None of the other 56 specimens yielded evidence of HPV. Appropriate positive and negative controls were included in each assay.

Conclusions. Our results suggest that subclinical HPV infection is possible, but not commonly associated with sexual abuse in children from St Louis, MO. In this group of children without condyloma, HPV 16 was the only type identified.
Sodium Space and Intravascular Volume: Dietary Sodium Effects in Cystic Fibrosis and Healthy Adolescent Subjects
Authors: Legris Gregory J. , Dearborn Dorr , Stern Robert C. , Geiss Cynthia L. , Hopfer Ulrich , Douglas Janice G. , Doershuk Carl F.
Published: August 2004

Objective. To assess the physiologic response to salt depletion in subjects with cystic fibrosis (CF) and control male adolescents for sodium balance, sodium space, and stimulation of the renin–angiotensin–aldosterone axis.

Design. Seven subjects with CF and six controls received a salt-replete (150 or 290 mmol NaCl per day) diet and then a salt-deplete (10 mmol NaCl per day) diet while in a clinical research center.

Results. Space maintenance: CF subjects responded to salt depletion with a greater weight loss than did controls (1.9 vs 0.8 kg) and a decrease in 24Na+ space, whereas controls maintained 24Na+ space. Paired (Na-deplete/Na-replete) blood volumes decreased in subjects with CF, but not in controls. Renin–angiotensin–aldosterone axis stimulation: During salt repletion, subjects with CF had significantly higher aldosterone values than did controls in the afternoon, but not at 7:00 AM. During salt depletion, plasma renin activity and aldosterone increased significantly more in subjects with CF than in controls (renin, 35 vs 13 ng/mL/hour [9.7 vs 3.6 ng·L−1s−1]; aldosterone: 181 vs 101 ng/dL [5021 vs 2802 pmol/L]). Furthermore, the angiotensin antagonist saralasin increased renin much more in subjects with CF (154 vs 36 ng/mL per hour [43 vs 10 ng·L−1 s−1]). Vasomotor functions: Mean arterial pressure was decreased in subjects with CF on both diets and decreased significantly more with low salt only in subjects with CF. During salt depletion, subjects with CF showed enhanced orthostatic tolerance (less heart rate increase with standing) compared with controls, thus obscuring their volume loss. The blood pressure response to an acute infusion of saralasin suggested that in salt-replete subjects with CF, but not in controls, angiotensin receptors were functional in maintaining vascular tone. During salt depletion, angiotensin was more important for maintenance of blood pressure in subjects with CF than in controls, because the saralasin-induced drop in blood pressure was 20%, ie, close to shock levels, in subjects with CF, and only 6% in controls.

Conclusion. The data suggest that patients with CF are so successful in compensating for volume depletion by vigorous activation of the renin–angiotensin system that salt depletion/dehydration cannot be recognized easily by routine clinical measurements, eg, capillary refill, serum sodium levels, or tachycardia.
The Effects of a High-protein, Low-fat, Ketogenic Diet on Adolescents With Morbid Obesity: Body Composition, Blood Chemistries, and Sleep Abnormalities
Authors: Willi Steven M. , Oexmann Mary Joan , Wright Nancy M. , Collop Nancy A. , Key L. Lyndon
Published: August 2004

Objective. To evaluate the efficacy and metabolic impact of a high-protein, low-carbohydrate, low-fat ketogenic diet (K diet) in the treatment of morbidly obese adolescents with initial weights of >200% of ideal body weight.

Methods. Six adolescents, aged 12 to 15 years, weighing an average of 147.8 kg (range, 120.6–198.6 kg) and having an average body mass index of 50.9 kg/m2 (39.8–63.0 kg/m2), consumed the K diet for 8 weeks. Daily intake consisted of 650 to 725 calories, which was substantively in the form of protein (80–100 g). The diet was very low in carbohydrates (25 g) and fat (25 g). This was followed by 12 weeks of the K diet plus two carbohydrates (30 g) per meal (K+2 diet).

Main Outcome Measures. Anthropometric data and blood and urine were collected at enrollment, during week 1, and at 4-week intervals throughout the course of the study. Resting energy expenditure was measured by indirect calorimetry. Body composition was estimated using dual-energy x-ray absorptiometry, bioelectrical impedance analysis, and urinary creatinine excretion at enrollment and on completion of each phase of the diet. Nocturnal polysomnography and multiple sleep latency testing were conducted at baseline and repeated after an average weight loss of 18.7 kg to determine sleep architecture, frequency and duration of apneas, and daytime sleepiness.

Results. Subjects lost 15.4 ± 1.4 kg (mean ± SEM) during the K diet and an additional 2.3 ± 2.9 kg during the K+2 diet. Body mass index decreased 5.6 ± 0.6 kg/m2during the K diet and an additional 1.1 ± 1.1 kg/m2during the K+2 diet. Body composition studies indicated that weight was lost equally from all areas of the body and was predominantly fat. Dual-energy x-ray absorptiometry showed a decrease from 51.1% ± 2.1% body fat to 44.2% ± 2.9% during the K diet and then to 41.6% ± 4.5% during the K+2 diet. Lean body mass was not significantly affected. Weight loss was accompanied by a reduction in resting energy expenditure of 5.2 ± 1.8 kcal/kg of fat-free mass per day. Blood chemistries remained normal throughout the study and included a decrease in serum cholesterol from 162 ± 12 to 121 ± 8 mg/dL in the initial 4 weeks of the K diet. An increase in calcium excretion was accompanied by a decrease in total-body bone mineral content. A paucity of rapid eye movement sleep and excessive slow-wave sleep were seen in all subjects at enrollment. Weight loss led to an increase in rapid eye movement sleep (P < .02) and a decrease in slow-wave sleep (P < .01) to near normal levels.

Conclusions. The K diet can be used effectively for rapid weight loss in adolescents with morbid obesity. Loss in lean body mass is blunted, blood chemistries remain normal, and sleep abnormalities significantly decrease with weight loss.
Evaluation of a Diagnostic Approach to Pediatric Interstitial Lung Disease
Authors: Fan Leland L. , Kozinetz Claudia A. , Deterding Robin R. , Brugman Susan M.
Published: August 2004

Objective. To evaluate the value of a systematic approach to the diagnosis of pediatric interstitial lung disease (ILD).

Methods. In this descriptive, observational, prospective study, we evaluated 51 children presenting with ILD of unknown etiology during a 3-year period. Specific clinical information regarding history, physical examination, diagnostic evaluation, and final diagnosis was recorded on each patient.

Results. A specific diagnosis was established by history and physical examination alone in 1 patient, noninvasive tests alone in 8 others, and invasive tests, including lung biopsy, in another 26. Of the remaining patients, 8 had a suggestivediagnosis, and 8 had no specific diagnosis.

Conclusions. A systematic approach to the diagnosis of pediatric ILD is useful, and not all patients need lung biopsy for diagnosis.
α1-Proteinase Inhibitor Therapy for the Prevention of Chronic Lung Disease of Prematurity: A Randomized, Controlled Trial
Authors: Stiskal Joseph A. , Dunn Michael S. , Shennan Andrew T. , O'Brien Karel K. E. , Kelly Edmond N. , Koppel Robert I. , Cox Diane W. , Ito Shinya , Chappel S. Lesley , Rabinovitch Marlene
Published: August 2004

Background. An imbalance between increased neutrophil elastase and a decreased antiprotease shield has been suggested as a factor contributing to the development of chronic lung disease (CLD). We hypothesized that administration of α1-proteinase inhibitor (A1PI), also known as α1-antitrypsin, to premature neonates would prevent CLD.

Design. A randomized, placebo-controlled, prospective study of A1PI supplementation was performed. Neonates <24 hours of age with birth weights 600–1000 g on respiratory support, and 1001–1250 g with respiratory distress syndrome (RDS) were eligible. Intravenous A1PI (60 mg/kg) or placebo was infused on days 0, 4, 7, and 14. Primary outcome was CLD in survivors, defined as the need for supplemental oxygen on day 28.

Results.  A total of 106 patients were recruited. There were no significant differences between groups in birth weight or incidence of RDS. The incidence of CLD in survivors was lower in the treated group, but the difference did not reach statistical significance (relative risk [RR], 0.79; confidence interval [CI], 0.60–1.02). This beneficial trend persisted at 36 weeks corrected gestational age (RR, 0.48; CI, 0.23–1.00). The incidence of pulmonary hemorrhage was lower in the treated group (RR, 0.22; CI, 0.05–0.98). Other complications were not significantly different between groups.

Conclusions. In this, the first trial of a protease inhibitor for the prevention of CLD in premature infants, the infusions were well-tolerated. A1PI therapy may impede the development of CLD and appears to reduce the incidence of pulmonary hemorrhage in some neonates born prematurely.
Drugs for Pediatric Emergencies
Authors:   Committee on Drugs
Published: August 2004

This statement provides current recommendations about the use of emergency drugs for acute pediatric problems that require pharmacologic intervention. At each clinical setting, physicians and other providers should evaluate drug, equipment, and training needs. The information provided here is not all-inclusive and is not intended to be appropriate to every health care setting. When possible, dosage recommendations are consistent with those in standard references, such as the Advanced Pediatric Life Support (APLS) andPediatric Advanced Life Support (PALS) textbooks.1 Additional guidance is available in the manual Emergency Medical Services for Children: The Role of the Primary Care Provider, published by the American Academy of Pediatrics, as well as in the PALS and APLS textbooks.
Hunger in Children in the United States: Potential Behavioral and Emotional Correlates
Authors: Kleinman Ronald E. , Murphy J. Michael , Little Michelle , Pagano Maria , Wehler Cheryl A. , Regal Kenneth , Jellinek Michael S.
Published: August 2004

Objective. Results from a recent series of surveys from 9 states and the District of Columbia by the Community Childhood Hunger Identification Project (CCHIP) provide an estimate that 4 million American children experience prolonged periodic food insufficiency and hunger each year, 8% of the children under the age of 12 in this country. The same studies show that an additional 10 million children are at risk for hunger. The current study examined the relationship between hunger as defined by the CCHIP measure (food insufficiency attributable to constrained resources) and variables reflecting the psychosocial functioning of low-income, school-aged children.

Methods. The study group included 328 parents and children from a CCHIP study of families with at least 1 child under the age of 12 years living in the city of Pittsburgh and the surrounding Allegheny County. A two-stage area probability sampling design with standard cluster techniques was used. All parents whose child was between the ages of 6 and 12 years at the time of interview were asked to complete a Pediatric Symptom Checklist, a brief parent-report questionnaire that assesses children's emotional and behavioral symptoms. Hunger status was defined by parent responses to the standard 8 food-insufficiency questions from the CCHIP survey that are used to classify households and children as “hungry,” “at-risk for hunger,” or “not hungry.”

Results. In an area probability sample of low-income families, those defined as hungry on the CCHIP measure were significantly more likely to have clinical levels of psychosocial dysfunction on the Pediatric Symptom Checklist than children defined as at-risk for hunger or not hungry. Analysis of individual items and factor scores on the Pediatric Symptom Checklist showed that virtually all behavioral, emotional, and academic problems were more prevalent in hungry children, but that aggression and anxiety had the strongest degree of association with experiences of hunger.

Conclusion. Children from families that report multiple experiences of food insufficiency and hunger are more likely to show behavioral, emotional, and academic problems on a standardized measure of psychosocial dysfunction than children from the same low-income communities whose families do not report experiences of hunger. Although causality cannot be determined from a cross-sectional design, the strength of these findings suggests the importance of greater awareness on the part of health care providers and public health officials of the role of food insufficiency and hunger in the lives of poor children.
Variations in Transfusion Practice in Neonatal Intensive Care
Authors: Ringer Steven A. , Richardson Douglas K. , Sacher Ronald A. , Keszler Martin , Churchill W. Hallowell
Published: August 2004

Objective. To compare the transfusion practices between two neonatal intensive care units (NICUs) to assess the impact of local practice styles on the timing, number, and total volume of packed red cell transfusions in very low birth weight infants. To derive multivariate models to describe practice and to identify potential areas for improvement in the future.

Methodology. We reviewed phlebotomy losses and transfusion rates between two NICUs (A and B) for 270 consecutive admissions of birth weight <1500 g. We stratified for birth weight and for illness severity by the Score for Neonatal Acute Physiology (SNAP). Measures of short-term outcome were compared. We derived multivariate models to describe and compare the practices in the two NICUs.

Results. Patients in NICU A had smaller phlebotomy losses than those in NICU B. A lower percentage of the patients in NICU A (65% vs 87%) received transfusions, but they tended to receive a greater total volume per kg per patient (67 mL/kg vs 54.8 mL/kg). Transfusion timing differed between the NICUs; in NICU A only approximately one-half of their transfusions occurred in the first 2 weeks, whereas in NICU B almost 70% of the transfusions were given in this time period. Multivariate models showed that phlebotomy losses were significantly related to lower gestational age (GA) and higher SNAP. Hospitalization in NICU B resulted in 10.7 cc of additional losses relative to NICU A for a comparable GA and illness severity score. The volume of blood transfused per kilogram of body weight was a function of GA, SNAP, and hospital. Care practices in NICU A added an additional 19 cc of transfused volume in the first 14 days of life, and an additional 26 cc thereafter when adjusted for GA and SNAP. These differences in phlebotomy and transfusion were not associated with differences in the days of oxygen therapy or mechanical ventilation, the oxygen requirement at 28 days, the incidence of chronic lung disease, or the rate of growth by day 28.

Conclusions. We identified significant differences in phlebotomy and transfusion practices between two NICUs. We found no differences in short-term outcome, suggesting that the additional use of blood in one of the NICUs was discretionary rather than necessary. Our multivariate models can be used to characterize and quantify transfusion and phlebotomy practices. By predicting which patients are likely to require multiple transfusions, clinicians can target patients for erythropoietin therapy and identify those patients for whom donor exposure can be reduced by a unit of blood for multiple use. The models may help in monitoring changes in practice as they occur.
Relationship Between Reason for Placement and Medical Findings Among Children in Foster Care
Authors: Takayama John I. , Wolfe Ellen , Coulter Kevin P.
Published: August 2004

Objective. To determine the reasons for placement of children in foster care, the prevalence of medical findings during initial placement, and the relationship between reason for placement and medical findings. The association between placement reasons and parental substance abuse also was explored.

Methods. Population-based analysis of medical records of 749 children examined at the Child Protection Center in San Francisco from October 1, 1991, to December 31, 1992. Health evaluations consisted of a clearance examination of children during entry into foster care and a comprehensive examination 3 weeks later. Reasons for foster placement included abandonment, neglect, no available caretaker, physical abuse, sexual abuse, and failed placement.

Results. Nearly 50% of children in our study were <6 years of age. Neglect (30%), physical abuse (25%), and no available caretaker (24%) were the most frequent placement reasons, followed by abandonment (9%), failed placement (7%), and sexual abuse (5%). Substance abuse was documented in 30% of parents, 51% when the placement reason was neglect. Medical findings were identified in 60% of children. Among 0 to 6-year-olds, 27% had upper respiratory illnesses, 23% had developmental delay, and 21% had skin conditions; for children 7 to 12 years of age, 32% failed vision screening, 12% had dental caries, and 11% had upper respiratory illnesses; and among 13- to 18-year-olds, 31% failed vision screening and 12% had positive tuberculin skin tests. For younger children, skin conditions were associated with neglect, no available care taker, and failed placement, and developmental delay with neglect and abandonment. For adolescents, history of psychiatric illness was associated with neglect and failed placement. Marks of abuse for all age groups were limited to children who had been physically abused. Three or more diagnoses were identified for ∼20% of children who had been neglected or abandoned or had failed placement, compared with 10% of children who had been either physically or sexually abused.

Conclusions. Specific medical findings associated with reasons for placement provide health professionals with additional information to assess more accurately the health care needs of children entering foster care. As important, screening tests revealed high rates of vision problems and exposures to tuberculosis, warranting earlier and more comprehensive screening. Finally, children who have endured variations of neglect or failed placement may have more health problems than anticipated previously.
Trends in Pediatric Asthma Hospitalization Rates: Regional and Socioeconomic Differences
Authors: Goodman David C. , Stukel Therese A. , Chang Chiang-hua
Published: August 2004

Objective. Asthma hospitalization rates continue to increase nationally for children despite efforts by the National Institutes of Health and specialty organizations to improve outcomes through the dissemination of practice guidelines. To understand the generalizability of national trends to regional populations, we studied childhood hospitalizations over a 10-year period in four northeastern states.

Design. Longitudinal analysis of hospitalization rates by patient residence and patient characteristics using state hospital discharge datasets.

Population. Age <18 years residing in Maine, New Hampshire, Vermont, or New York state during the period 1985 to 1994.

Results. In multivariate analyses (controlling for age, sex, race/ethnicity, median household income, metropolitan status), we found that New York asthma hospitalization rates increased 3.8% per annum (95% confidence interval: 3.3,4.2), whereas in New Hampshire, rates decreased 5.8% (95% confidence interval: 7.6,4.1). Maine and Vermont rates did not change significantly during the study period. Increased asthma hospitalization rates were noted in black and Hispanic populations, in children residing in zip codes with lower median household incomes, and in those living in metropolitan areas. Hospitalization rates for nonasthma causes fell substantially. As a result, the proportion of hospital days attributed to childhood asthma increased in all population groups.

Conclusions. Asthma discharge rates measured by the state of residence or socioeconomic characteristic do not necessarily parallel national trends. None of the current hypotheses offered to explain national trends in asthma hospitalization rates (changes in disease severity, diagnostic substitution, or differences in the supply and character of medical care) can be the sole explanation of these regional trends. Efforts intended to improve asthma outcomes may benefit a greater number of children by redirecting resources toward specific populations identified through state hospital discharge datasets.
Universal Infant Hearing Screening by Automated Auditory Brainstem Response Measurement
Authors: Mason Judith A. , Herrmann Kenneth R.
Published: August 2004

Background. Our purpose was to identify infants with a bilateral, permanent, handicapping hearing loss and to provide them with amplification before age 6 months.

Methodology. The study population consisted of 10 372 infants born during a 5-year period. Universal hearing screening by automated auditory brainstem response was done in the nursery. Infants who failed the screening test were followed up diagnostically. Infants who were not tested in the nursery were followed up as outpatients. Hearing aids were recommended for those infants who had bilateral hearing loss.

Results. Successful screening in the nursery was achieved for 96% of infants. The failure rate was 4%. The incidence of bilateral loss requiring amplification was 1.4/1000. The false-positive rate was 3.5% after the initial screening and .2% when a two-stage screening procedure was used. The incidence of congenital bilateral hearing loss in the well population was 1/1000, and in the neonatal intensive care unit population, 5/1000. The cost of screening was $17 per infant, and the cost to identify each true bilateral hearing loss was $17 750. Amplification was recommended for 15 infants; well infants who used hearing aids before age 6 months achieved age-appropriate speech and language development.

Conclusions. Mild, moderate, and severe bilateral, persistent hearing loss can be identified in the nursery by automated auditory brainstem response measurement to provide amplification before age 6 months and thus optimize speech and language development.
Birth Outcome From a Prospective, Matched Study of Prenatal Crack/Cocaine Use: II. Interactive and Dose Effects on Neurobehavioral Assessment
Authors: Eyler Fonda Davis , Behnke Marylou , Conlon Michael , Woods Nanci Stewart , Wobie Kathleen
Published: August 2004

Objective. This prospective, longitudinal project was designed to determine the effects of prenatal cocaine use on the neurodevelopmental outcomes of infants from a historically understudied rural public health population.

Methodology. We interviewed >2500 women prenatally, identified 154 cocaine users, and matched 154 controls on race, parity, socioeconomic status, and location of prenatal care (that related to level of pregnancy risk). Drug testing was required at enrollment and at delivery; detailed demographic, psychosocial, and drug histories were taken at each available trimester and follow-up visit. After birth, certified evaluators, blinded to maternal history of drug use, administered the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) under controlled conditions. Evaluation time for preterm infants was adjusted for gestational age.

Results. After controlling for the effects of marijuana (users of other illicit drugs were excluded), alcohol, and tobacco use, the following results remained. There were significant drug group interactions on the BNBAS Qualifier Score of Alert Responsiveness that demonstrated lower scores among infants who were exposed to both cocaine and tobacco and among those exposed to both marijuana and tobacco. There were also significant correlations between the amount of cigarette, alcohol, marijuana, and cocaine exposure and several BNBAS scores. The reported amount of cocaine use in the third trimester was negatively related to scores of Orientation, Cost of Attention, and Alert Responsiveness (that was also related to amount of cocaine used over the entire pregnancy). When the effects of marijuana, alcohol, and tobacco were partialled out, the amount of cocaine use in the third trimester was negatively related to Regulation of State, a precursor of alertness, and the infant's ability to orient to the environment.

Conclusions. The observed decrement in state regulation, attention, and responsiveness among cocaine-exposed neonates raises concerns about later developmental abilities as well as the effect these infants may have on caregivers (who themselves may be compromised in their parenting abilities by their drug use). Follow-up of these infants will reveal if these disadvantages continue. These early results also emphasize the importance of considering amount and time of drug exposure as well as the interactive effects of drug exposure and other risk variables.
Prevalence of IgA-Antigliadin Antibodies and IgA-Antiendomysium Antibodies Related to Celiac Disease in Children With Down Syndrome
Authors: Carlsson Annelie , Axelsson Irené , Borulf Stefan , Bredberg Anders , Forslund Marianne , Lindberg Bengt , Sjöberg Klas , Ivarsson Sten-Anders
Published: August 2004

Objective. This study was undertaken to investigate the prevalence of celiac disease in children and adolescents with Down syndrome.

Material and Methods. Forty-three children and adolescents with Down syndrome were screened for IgA-antigliadin antibodies (AGA) and IgA-antiendomysium antibodies (EMA). Patients found to be either AGA- or EMA-positive were investigated further with intestinal biopsy.

Results. None of the 43 patients had known celiac disease at entry into the study; 37% (16/43) were found to have AGA levels above normal, and 16% (7/43) to be EMA-positive. Of the 15 patients who underwent biopsy, 8 manifested villous atrophy. Villous atrophy was present in all 7 of the EMA-positive patients, whereas the villi were normal in 7 of the 13 AGA-positive patients who underwent biopsy.

Conclusions. EMA is a good immunologic marker for use in screening for celiac disease, and screening is justified in patients with Down syndrome.
Screening for Retinopathy in the Pediatric Patient With Type 1 Diabetes Mellitus
Authors:   Sections on Endocrinology and Ophthalmology
Published: August 2004

This Clinical Report was revised. See https://doi.org/10.1542/peds.2005-0875.
Late Vascular Occlusion of Central Lines in Pediatric Malignancies
Authors: Wilimas Judith A. , Hudson Melissa , Rao Baskar , Luo Xiaolong , Lott Lennie , Kaste Sue C.
Published: August 2004

Objective.  To determine whether thrombi or vascular occlusion represent a late complication persisting several years after removal of central venous lines (CVLs) in children and adolescents treated for childhood cancer.

Methods. Children whose treatment for malignancy included placement of a CVL that had been removed at least 2 months previously were studied during scheduled follow-up that included contrast-enhanced computed tomography. Spiral volume acquisition was used to obtain 3-mm images from the chest apices through the right hilum, and three-dimensional reconstruction of angiograms was performed. Thrombosis/occlusion was defined as narrowing, obstruction, or filling defect of the deep venous system, with or without the formation of collateral veins. Charts were reviewed to document patient characteristics, previous CVL complications, administration of hyperalimentation, use of urokinase, and family history of venous thrombosis.

Results. Twenty-three patients treated for solid tumors and 2 treated for B-cell acute lymphocytic leukemia or lymphoma were studied. Lines had been in place from 0.2 to 36 months (median, 7.4) and were removed at 2.3 to 121.8 months (median, 32.5) before study. Nine patients received hyperalimentation for periods ranging from 2 to 38 weeks (median, 12). Four patients had required urokinase instillations, and one developed superior vena cava syndrome; 4 had a CVL-related infection (two superficial and two Candida line infections). Occlusion was seen on computed tomography angiograms in 3 of the 25 patients (12%; 95% confidence interval: 4.5–31%). One of the patients with occlusion had superior vena cava syndrome; none had a family history of thrombosis, use of a double lumen CVL, or multiple instillations of urokinase.

Conclusions. Persistent asymptomatic vascular occlusion does occur as a late complication of CVL placement for treatment of childhood malignancies, although the frequency appears low among patients treated primarily for solid tumors. Prospective studies of large numbers of patients with a broader spectrum of diagnoses are necessary to define the incidence of and risk factors for this complication and to assess the need for prevention with anticoagulation or other therapy. Pediatricians caring for patients with a history of cancer and CVLs should be aware that these patients may have persistent vascular occlusion that could predispose them to recurrent thrombosis or postphlebitic syndrome.
Inhaled Nitric Oxide for the Early Treatment of Persistent Pulmonary Hypertension of the Term Newborn: A Randomized, Double-Masked, Placebo-Controlled, Dose-Response, Multicenter Study
Authors: Davidson Dennis , Barefield Elaine S. , Kattwinkel John , Dudell Golde , Damask Michael , Straube Richard , Rhines Jared , Chang Cheng-Tao ,   the I-NO/PPHN Study Group
Published: August 2004

Objectives. To assess the dose-related effects of inhaled nitric oxide (I-NO) as a specific adjunct to early conventional therapy for term infants with persistent pulmonary hypertension (PPHN), with regard to neonatal outcome, oxygenation, and safety.

Methods. Randomized, placebo-controlled, double-masked, dose-response, clinical trial at 25 tertiary centers from April 1994 to June 1996. The primary endpoint was the PPHN Major Sequelae Index ([MSI], including the incidence of death, extracorporeal membrane oxygenation (ECMO), neurologic injury, or bronchopulmonary dysplasia [BPD]). Patients required a fraction of inspired oxygen [Fio2] of 1.0, a mean airway pressure ≥10 cm H2O on a conventional ventilator, and echocardiographic evidence of PPHN. Exogenous surfactant, concomitant high-frequency ventilation, and lung hypoplasia were exclusion factors. Control (0 ppm) or nitric oxide (NO) (5, 20, or 80 ppm) treatments were administered until success or failure criteria were met. Due to slowing recruitment, the trial was stopped at N = 155 (320 planned).

Results. The baseline oxygenation index (OI) was 24 ± 9 at 25 ± 17 hours old (mean ± SD). Efficacy results were similar among NO doses. By 30 minutes (no ventilator changes) the Pao2 for only the NO groups increased significantly from 64 ± 39 to 109 ± 78 Torr (pooled) and systemic arterial pressure remained unchanged. The baseline adjusted time-weighted OI was also significantly reduced in the NO groups (-5 ± 8) for the first 24 hours of treatment. The MSI rate was 59% for the control and 50% for the NO doses (P = .36). The ECMO rate was 34% for control and 22% for the NO doses (P = .12). Elevated methemoglobin (>7%) and nitrogen dioxide (NO2) (>3 ppm) were observed only in the 80 ppm NO group, otherwise no adverse events could be attributed to I-NO, including BPD.

Conclusion. For term infants with PPHN, early I-NO as the sole adjunct to conventional management produced an acute and sustained improvement in oxygenation for 24 hours without short-term side effects (5 and 20 ppm doses), and the suggestion that ECMO use may be reduced.
A Phase I/II Study of the Protease Inhibitor Ritonavir in Children With Human Immunodeficiency Virus Infection
Authors: Mueller Brigitta U. , Nelson Robert P. , Sleasman John , Zuckerman Judy , Heath-Chiozzi Margo , Steinberg Seth M. , Balis Frank M. , Brouwers Pim , Hsu Ann , Saulis Rima , Sei Shizuko , Wood Lauren V. , Zeichner Steve , Katz T. Teresa K. , Higham Colleen , Aker Diane , Edgerly Maureen , Jarosinski Paul , Serchuck Leslie , Whitcup Scott M. , Pizzuti David , Pizzo Philip A.
Published: August 2004

Background. Ritonavir, a potent antiretroviral protease inhibitor, has been approved for the treatment of adults and children with human immunodeficiency virus (HIV) infection. In a phase I/II study, we assessed the safety, tolerability, and pharmacokinetic profile of the oral solution of ritonavir in HIV-infected children and studied the preliminary antiviral and clinical effects.

Methods. HIV-infected children between 6 months and 18 years of age were eligible. Four dose levels of ritonavir oral solution (250, 300, 350, and 400 mg/m2 given every 12 hours) were evaluated in two age groups (≤2 years, >2 years). Ritonavir was administered alone for the first 12 weeks and then in combination with zidovudine and/or didanosine. Clinical and laboratory parameters were monitored every 2 to 4 weeks.

Results. A total of 48 children (median age, 7.7 years; range, 0.5 to 14.4 years) were included in this analysis. Dose-related nausea, diarrhea, and abdominal pain were the most common toxicities and resulted in discontinuation of ritonavir in 7 children. Ritonavir was well absorbed at all dose levels, and plasma concentrations reached a peak 2 to 4 hours after a dose. CD4 cells counts increased by a median of 79 cells/mm3 after 4 weeks of monotherapy and were maintained throughout the study. Plasma HIV RNA decreased by 1 to 2 log10 copies/mL within 4 to 8 weeks of ritonavir monotherapy, and this level was sustained in patients enrolled at the highest dose level of 400 mg/m2 for the 24-week period.

Conclusions. The oral solution of ritonavir has potent antiretroviral activity as a single agent and is relatively well tolerated by children when administered alone or in combination with zidovudine or didanosine.
The Use of Albuterol in Hospitalized Infants With Bronchiolitis
Authors: Dobson Joseph V. , Stephens-Groff Susan M. , McMahon Shawn R. , Stemmler Margaret M. , Brallier Susan L. , Bay Curtis
Published: August 2004

Objectives. To determine whether the use of albuterol by nebulization enhances physiologic or clinical recovery in hospitalized infants with moderate bronchiolitis.

Methods. This prospective, double-blind, placebo-controlled, randomized clinical trial was performed from December 1995 to March 1996. A total of 52 patients <24 months of age with a diagnosis of moderately severe, acute viral bronchiolitis were enrolled and assigned to receive nebulized albuterol or normal saline placebo for 72 hours under a standardized protocol. Primary outcome measures included improvement in oxygen saturation (Sao2) during hospitalization and survival analysis to assess the time required to reach preestablished discharge criteria on three measures: Sao2, accessory muscle use, and wheezing. An additional secondary outcome measure was actual length of hospital stay. Adverse outcomes also were compared between treatment groups.

Results. There was no significant difference in mean Sao2 between albuterol and placebo at baseline, 24 hours, or maximum Sao2 achieved during hospitalization. Both groups showed significant improvement in oxygen saturation over time, but there was no significant difference in improvement between the two groups. The study had a power of 90% to detect a difference in mean percentage point improvement of 2% Sao2. There was no difference in time to reach discharge criteria as defined by Sao2, accessory muscle use, or wheezing. There was no difference in length of hospital stay or in the frequency of adverse outcomes.

Conclusions. Nebulized albuterol therapy does not appear to enhance recovery or attenuate severity of illness in infants hospitalized with acute, moderate bronchiolitis, as evidenced by improvement in oxygen saturation, time to meet standardized discharge criteria, or length of hospital stay.
The Role of Parents in End-of-Life Decisions in Neonatology: Physicians' Views and Practices
Authors: van der Heide Agnes , van der Maas Paul J. , van der Wal Gerrit , Kollée Louis A. A. , de Leeuw Richard , Holl Robert A.
Published: August 2004

Objective. End-of-life decisions for newborn infants are usually made with the consent of parents as well as physicians, but may occasionally involve disagreement about which decision is in the best interest of the child. Our study was aimed at providing an empirical background for the ethical discussion on the parent's versus the physician's role in decision-making.

Methods. We conducted face-to-face interviews with a stratified sample of pediatricians. The response rate was 99%. The most recent decisions in newborn infants to hasten death or not prolong life and the most recent cases in which such decisions were not made because either the parents or the physician objected were comprehensively discussed.

Results. Decisions to hasten death or not prolong life were usually made after discussing it with parents and did not occur while parents were known to disagree. Situations in which an end-of-life decision was not made because parents did not consent predominantly involved infants with complications of prematurity (24%) or perinatal asphyxia (40%), whereas situations in which parents requested an end-of-life decision that was not acceded to by the pediatrician involved Down syndrome as the main diagnosis in 43% and as a concurrent diagnosis in 21%. Pediatricians afterwards often expressed feelings of discontent about situations in which there had been disagreement with parents.

Conclusions. The opinion of parents about which medical decision is in the best interest of their child is for pediatricians only decisive in case it invokes the continuation of treatment. The principle of preserving life is abandoned only when the physician feels sufficiently sure that the parents agree that such a course of action is in the best interest of the child.
Neonatal Circumcision and Pain Relief: Current Training Practices
Authors: Howard Cynthia R. , Howard Fred M. , Garfunkel Lynn C. , de Blieck Elisabeth A. , Weitzman Michael
Published: August 2004

Objective. We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure.

Methods. Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%).

Results. Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02–0.08] or obstetrical (OR, 0.14; 95% CI, 0.08–0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3–110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4–306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7–7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7–4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties.

Conclusions. Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.
Plasma Leptin in Infants: Relations to Birth Weight and Weight Loss
Authors: Marchini Giovanna , Fried Gabriel , Östlund Eva , Hagenäs Lars
Published: August 2004

Background. The hormone leptin, produced in the adipose tissue, is involved in the regulation of body weight. The release of the hormone is increased in obese adults and decreased after fasting in human adults. This study investigated whether the plasma leptin level was related to the infant's birth weight and whether the level was reduced in connection with the physiological weight loss during the neonatal period.

Methods. We measured the plasma leptin level in cord blood from infants who were large for gestational age (LGA) (n = 15), small for gestational age (SGA) (n = 16), and appropriate for gestational age (AGA) (n = 38). AGA infants (n = 120), who were exclusively breastfed, were also studied during their first 4 postnatal days in a cross-sectional method. One blood sample was collected before breastfeeding from each infant. Plasma leptin concentrations were determined by radioimmunoassay.

Results. The median (range) concentration of leptin from cord blood was increased in LGA infants and decreased in SGA infants compared with the level in AGA infants. There was a positive correlation between the log of the plasma leptin level in cord blood and both the infant's birth weight (r = 0.76; n = 69) and the body mass index (r = 0.63; n = 69). The normal 3% to 6% weight reduction that occurs during the first 4 postnatal days was associated with a 26% decrease in the plasma leptin level in healthy breastfed infants.

Conclusions. The plasma leptin level is highly correlated to the size of adipose tissue mass and decreases in connection with the initial physiological weight loss in newborn infants. These data provide evidence that leptin is highly related to the nutritional status already during the fetal and neonatal periods.