bluuebunny/crossref_metadata_2025 huggingface dataset:
Missed Insulin Meal Boluses and Elevated Hemoglobin A1c Levels in Children Receiving Insulin Pump Therapy
Authors: Burdick Jonathan , Chase H. Peter , Slover Robert H. , Knievel Kerry , Scrimgeour Laura , Maniatis Aristides K. , Klingensmith Georgeanna J.
Published: August 2004

Objective. To identify possible causes of suboptimal glycemic control (ascertained by hemoglobin A1c [HbA1c] level) in youths using insulin pump therapy.

Methods. Forty-eight youths who were receiving insulin pump therapy for ≥6 months, and who were using insulin pumps and blood glucose meters with data that could be downloaded at our facility, are included in this cross-sectional study. Possible causes of suboptimal glycemic control were evaluated by using 4 information sources: 1) insulin pump data downloads; 2) glucose meter data downloads; 3) patient/family questionnaire about insulin bolusing habits, eating habits, exercise, and blood glucose testing habits; and 4) a physician questionnaire. Physicians completed the questionnaire during the patient interview after reviewing the downloaded information and discussing these results with the patient/family.

Results. The mean (± standard deviation) age of participants was 15.3 (±3.0) years (range: 7–20 years), and the mean (± standard deviation) duration of type 1 diabetes and continuous subcutaneous insulin infusion was 8.2 (±4.0) and 1.9 (±1.0) years, respectively. Patients who missed <1 bolus per week had a mean (95% confidence interval) HbA1c level of 8.0% (7.7, 8.3), whereas those who missed ≥1 mealtime boluses per week had a mean HbA1c level (95% confidence interval) of 8.8% (8.6, 9.1). No significant relationships were found between HbA1c levels in males and females, the amount of exercise per week, or bolusing before insulin pump disconnection for exercise. Although not significant, a trend was found for those who missed <1 bolus per week to perform more blood glucose tests per day and for those who bolused before a meal rather than after to have lower HbA1c levels. Significant correlations were found between HbA1c levels and the number of missed mealtime boluses per week (r = .414) and mean blood glucose levels (r = .70).

Conclusion. Missed mealtime insulin boluses seem to be the major cause of suboptimal glycemic control in youths with diabetes receiving continuous subcutaneous insulin infusion therapy.
Comparison of Linear Growth Patterns in the First Three Years of Life Across Two Generations in Guatemala
Authors: Stein Aryeh D. , Barnhart Huiman X. , Wang Meng , Hoshen Moshe B. , Ologoudou Karen , Ramakrishnan Usha , Grajeda Ruben , Ramirez-Zea Manuel , Martorell Reynaldo
Published: August 2004

Objective. The secular increase in height is assumed to result from long-term improvements in nutritional intakes and reductions in infectious disease burdens. Nutritional supplementation in early life reduces stunting in chronically undernourished populations. It is not known whether these improvements have an impact on the growth of subsequent generations. Our objective was to estimate the intergenerational effect on offspring length of improved nutrition in the mother’s early childhood.

Methods. We studied 283 mother–child pairs (mothers born 1969–1977; children born 1996–1999). The mothers had received nutritional supplementation—either atole (enhanced protein-energy) or fresco (moderate energy, no protein), with both containing vitamins and minerals—prenatally and up to age 7 y as part of a community trial conducted in 4 villages in Guatemala. Length was measured on repeated occasions to 36 months of age in both mothers and children. Growth was modeled as a fractional polynomial.

Results. Children grew faster than their mothers. Children of mothers who received atole grew faster than children of women who received fresco. In both groups, lengths of individual children were positively correlated with lengths of their own mothers at the same ages. Correlations were generally stronger when the mothers had received atole in early life.

Conclusion. We have confirmed a secular trend in growth of children in a developing country setting. The rate of child growth reflects, in part, the growth pattern of the mother, including improvements to that pattern resulting from nutritional supplementation.
Epidemiology and Clinical Characteristics of Community-Acquired Pneumonia in Hospitalized Children
Authors: Michelow Ian C. , Olsen Kurt , Lozano Juanita , Rollins Nancy K. , Duffy Lynn B. , Ziegler Thedi , Kauppila Jaana , Leinonen Maija , McCracken George H.
Published: August 2004

Objectives. The precise epidemiology of childhood pneumonia remains poorly defined. Accurate and prompt etiologic diagnosis is limited by inadequate clinical, radiologic, and laboratory diagnostic methods. The objective of this study was to determine as precisely as possible the epidemiology and morbidity of community-acquired pneumonia in hospitalized children.

Methods. Consecutive immunocompetent children hospitalized with radiographically confirmed lower respiratory infections (LRIs) were evaluated prospectively from January 1999 through March 2000. Positive blood or pleural fluid cultures or pneumolysin-based polymerase chain reaction assays, viral direct fluorescent antibody tests, or viral, mycoplasmal, or chlamydial serologic tests were considered indicative of infection by those organisms. Methods for diagnosis of pneumococcal pneumonia among study subjects were published by us previously. Selected clinical characteristics, indices of inflammation (white blood cell and differential counts and procalcitonin values), and clinical outcome measures (time to defervescence and duration of oxygen supplementation and hospitalization) were compared among groups of children.

Results. One hundred fifty-four hospitalized children with LRIs were enrolled. Median age was 33 months (range: 2 months to 17 years). A pathogen was identified in 79% of children. Typical respiratory bacteria were identified in 60% (of which 73% were Streptococcus pneumoniae), viruses in 45%, Mycoplasma pneumoniae in 14%, Chlamydia pneumoniae in 9%, and mixed bacterial/viral infections in 23%. Preschool-aged children had as many episodes of atypical bacterial LRIs as older children. Children with typical bacterial or mixed bacterial/viral infections had the greatest inflammation and disease severity. Multivariate logistic-regression analyses revealed that high temperature (≥38.4°C) within 72 hours after admission (odds ratio: 2.2; 95% confidence interval: 1.4–3.5) and the presence of pleural effusion (odds ratio: 6.6; 95% confidence interval: 2.1–21.2) were significantly associated with bacterial pneumonia.

Conclusions. This study used an expanded diagnostic armamentarium to define the broad spectrum of pathogens that cause pneumonia in hospitalized children. The data confirm the importance of S pneumoniae and the frequent occurrence of bacterial and viral coinfections in children with pneumonia. These findings will facilitate age-appropriate antibiotic selection and future evaluation of the clinical effectiveness of the pneumococcal conjugate vaccine as well as other candidate vaccines.
Association Between Infant Continuity of Care and Pediatric Emergency Department Utilization
Authors: Brousseau David C. , Meurer John R. , Isenberg Mayme L. , Kuhn Evelyn M. , Gorelick Marc H.
Published: August 2004

Objective. The objective of this study was to examine the association between continuity of care (COC) and emergency department (ED) utilization during infancy, when the bonds between a provider and a family are first forming and health care utilization is at it highest levels.

Methods. A retrospective birth cohort was conducted of children who were born between December 1, 1999, and April 30, 2000; health care use during the first 25 months of life was analyzed. A COC score was calculated from well-child visits in the first 7 months of life. Subsequent ED utilization, for both a 12-month and an 18-month period, was evaluated through 2 measures: 1) ED reliance (the fraction of all visits that occurred in the ED) and 2) number of ED visits. Spearman rank correlation coefficients (rs) between COC and ED utilization were calculated. Partial rank correlations were calculated controlling for Medicaid status, income, gender, and the total number of health care visits.

Results. A total of 181 children were included in the study; 96 (53%) were male, and 48 (27%) were covered by Medicaid. COC scores ranged from 0 to 1, with a median of 1. COC scores were negatively correlated with both ED reliance (rs = −.214) and number of ED visits (rs = −.215) with 12 months of follow-up. The negative correlation was even stronger at 18 months of follow-up (ED reliance: rs = −.247; number of ED visits: rs = −.242), and this relationship remained significant with partial rank correlations.

Conclusions. Improved COC in infancy is associated with a decrease in subsequent ED utilization. Interventions aimed at increasing the continuity of early well-child visits may decrease ED utilization.
National Institute of Mental Health Multimodal Treatment Study of ADHD Follow-up: Changes in Effectiveness and Growth After the End of Treatment
Authors:   MTA Cooperative Group
Published: August 2004

Objective. Intent-to-treat analyses of the Multimodal Treatment Study of ADHD (MTA) revealed group differences on attention-deficit/hyperactivity disorder symptoms ratings, with better outcome in groups of participants who were assigned the medication algorithm—medication alone (MedMgt) and combined (Comb)—than in those who were not—behavior modification (Beh) alone and community comparison (CC). However, the effect size was reduced by 50% from the end of treatment to the first follow-up. The convergence of outcomes suggests differential changes by treatment group beween 14 and 24 months, which this report explores, both for benefits of treatment and for side effects on growth.

Methods. We documented reported medication use at 14- and 24-month assessments and formed 4 naturalistic subgroups (Med/Med, Med/NoMed, NoMed/Med, and NoMed/NoMed). Then we performed exploratory mediator analyses to evaluate effects of changes in medication use on 14- to 24-month change scores of effectiveness (symptom ratings) and growth (height and weight measures).

Results. The randomly assigned groups with the greatest improvement at the end of the treatment phase (Comb and MedMgt) deteriorated during the follow-up phase, but the other 2 groups (Beh and CC) did not. There were no significant differences in the 14- to 24-month growth rates among the randomly assigned groups, in contrast to significant growth suppression in the Comb and MedMgt at the end of the treatment phase. Changes in medication use mediated the 14- to 24-month change in attention-deficit/hyperactivity disorder symptom ratings: the subgroup that reported stopping medication (Med/NoMed) showed the largest deterioration, the subgroup that consistently reported (Med/Med) or never reported (NoMed/NoMed) medication use showed modest deterioration, and the subgroup that reported starting medication (NoMed/Med) showed improvement. Changes in medication use also mediated growth effects: the subgroup that consistently reported medication use (Med/Med) showed reduced height gain compared with the subgroup that never reported medication use (NoMed/NoMed), which actually grew faster than predicted by population norms.

Conclusion. In the MTA follow-up, exploratory naturalistic analyses suggest that consistent use of stimulant medication was associated with maintenance of effectiveness but continued mild growth suppression.
Center Differences and Outcomes of Extremely Low Birth Weight Infants
Authors: Vohr Betty R. , Wright Linda L. , Dusick Anna M. , Perritt Rebecca , Poole W. Kenneth , Tyson Jon E. , Steichen Jean J. , Bauer Charles R. , Wilson-Costello Deanne E. , Mayes Linda C. ,   for the Neonatal Research Network
Published: August 2004

Objective. Previous multicenter studies have shown significant center differences in neonatal characteristics and morbidities. This study evaluated center differences in outcome at 18 to 22 months among extremely low birth weight (ELBW; 401-1000 g) infants after adjusting for demographics and antenatal interventions, and it identified neonatal interventions associated with outcome differences.

Methods. We assessed the outcome of 2478 liveborn infants who were admitted in 1993 and 1994 to the 12 centers of the Neonatal Research Network of the National Institute of Child Health and Human Development; 1483 (60%) infants survived to 18 to 22 months, and 1151 (78%) had comprehensive evaluations. Logistic regression analyses were performed to identify center differences and the association of 4 neonatal interventions—active resuscitation, postnatal steroids, ventilator treatment for ≤27 days, and full enteral feedings ≤24 days—with adverse outcomes (cerebral palsy, low Bayley scores, and neurodevelopmental impairment [NDI]), after adjusting for demographics and antenatal interventions.

Results. Using bivariate analyses, significant center differences were identified for mortality, antenatal and postnatal interventions, social and environmental variables, neonatal morbidities, and neurodevelopmental outcomes for the 12 centers. After adjustment for maternal and infant demographics and antenatal interventions, the percentage of ELBW infants who had died or had NDI at 18 to 22 months ranged from 52% to 85%. Active resuscitation and postnatal steroids were associated with increases of NDI of 11.8% and 19.3%, whereas shorter ventilation support and shorter time to achieve full enteral feeds were associated with decreases in NDI of 20.7% and 17.3%, respectively.

Conclusion. There are large and disturbing differences among centers in outcomes at 18 to 22 months after adjusting for demographic and antenatal interventions. Center differences in postnatal interventions associated with differences in outcome can provide hypotheses for testing in clinical trials to improve outcome.
Congenital Myotonic Dystrophy: Assisted Ventilation Duration and Outcome
Authors: Campbell Craig , Sherlock Rebecca , Jacob Pierre , Blayney Marc
Published: August 2004

Objective. To clarify the relationship between initial assisted ventilation duration and outcome for patients with congenital myotonic dystrophy (CDM).

Methods. A retrospective chart review was conducted of cases of CDM that presented to the Children’s Hospital of Eastern Ontario (Ottawa, Ontario, Canada) between 1980 and 2000. Inclusion criteria were conclusive testing for CDM and clinical presentation in the first 30 days of life. Duration of assisted ventilation, morbidity, mortality, and developmental outcome were measured.

Results. A total of 23 children met the inclusion criteria. One child died at 5 days of age, and 2 others had withdrawal of ventilation. The remaining 20 children were divided into 2 groups on the basis of whether they needed > or <30 days of ventilation. In the first year of life, 25% mortality was noted in the children with prolonged ventilation, whereas no child in the short ventilation duration group died. After 1 year of age, 1 child in each group died with follow-up of 2 to 16 years. The children with prolonged ventilation needed more hospitalizations. Delays were noted in development in both groups of children at ages 1, 3, and 6 years; however, there was an improvement in motor and language scores over time in all children. Children who required ventilation for <30 days had better motor, language, and activities of daily living scores at all ages.

Conclusions. Children with CDM with prolonged ventilation experienced 25% mortality in the first year. The use of a specific time period of ventilation to decide on withdrawal of therapy must be reconsidered given these findings. Prolonged ventilation was followed by greater morbidity and developmental delay than children with shorter ventilation duration.
Recurrent Abdominal Pain, Anxiety, and Depression in Primary Care
Authors: Campo John V. , Bridge Jeff , Ehmann Mary , Altman Sarah , Lucas Amanda , Birmaher Boris , Lorenzo Carlo Di , Iyengar Satish , Brent David A.
Published: August 2004

Objective. The prevalence of psychiatric disorder in children and adolescents with functional recurrent abdominal pain (RAP) is unknown. Our aim was to determine whether RAP is associated with psychiatric symptoms and disorders, anxious temperament, and functional impairment in pediatric primary care.

Methods. Children and adolescents who were 8 to 15 years of age, inclusive, and presented with RAP (N = 42) or for routine care in the absence of recurrent pain (N = 38) were identified by a screening procedure in pediatric primary care office waiting rooms and recruited to participate in a case-control study. Outcome measures were psychiatric diagnoses generated by standardized psychiatric interview administered blind to subject status and self, parent, and clinician ratings of child psychiatric symptoms, temperamental traits, and functional status.

Results. RAP patients were significantly more likely to receive a diagnosis of a psychiatric disorder, with a categorical anxiety disorder in 33 (79%) and a depressive disorder in 18 patients (43%), and higher levels of anxiety and depressive symptoms, temperamental harm avoidance, and functional impairment than control subjects. Anxiety disorders (mean age of onset: 6.25 [standard deviation: 2.17] years) were significantly more likely to precede RAP (mean age of onset: 9.17 [standard deviation: 2.75] years) in patients with associated anxiety.

Conclusions. Youths who present with RAP in primary care deserve careful assessment for anxiety and depressive disorders. Future studies should examine treatments that are proved to be efficacious for pediatric anxiety and/or depressive disorders as potential interventions for RAP. Longitudinal, family, and psychobiological studies are needed to illuminate the nature of observed associations among RAP, anxiety, and depression.
The Effect of Skin-to-Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioral Responses of the Term Newborn: A Randomized, Controlled Trial
Authors: Ferber Sari Goldstein , Makhoul Imad R.
Published: August 2004

Background. The method of skin-to-skin contact (kangaroo care [KC]) has shown physiologic, cognitive, and emotional gains for preterm infants; however, KC has not been studied adequately in term newborns.

Aims. To evaluate the effect of KC, used shortly after delivery, on the neurobehavioral responses of the healthy newborn.

Study Design. A randomized, controlled trial using a table of random numbers. After consent, the mothers were assigned to 1 of 2 groups: KC shortly after delivery or a no-treatment standard care (control group).

Subjects. Included were 47 healthy mother-infant pairs. KC began at 15 to 20 minutes after delivery and lasted for 1 hour. Control infants and KC infants were brought to the nursery 15 to 20 and 75 to 80 minutes after birth, respectively.

Results. During a 1-hour-long observation, starting at 4 hours postnatally, the KC infants slept longer, were mostly in a quiet sleep state, exhibited more flexor movements and postures, and showed less extensor movements.

Conclusions. KC seems to influence state organization and motor system modulation of the newborn infant shortly after delivery. The significance of our findings for supportive transition from the womb to the extrauterine environment is discussed. Medical and nursing staff may be well advised to provide this kind of care shortly after birth.
Access to Care for Children of Migratory Agricultural Workers: Factors Associated With Unmet Need for Medical Care
Authors: Weathers Andrea , Minkovitz Cynthia , O’Campo Patricia , Diener-West Marie
Published: August 2004

Objective. To assess the correlates of unmet need for medical care among migrant children.

Design and Setting. A cross-sectional household survey used multistage sampling to identify migrant families in eastern North Carolina.

Participants. Three hundred adult caretakers of 1 (per household) randomly selected child <13 years old.

Results. Fifty-three percent of the children had an unmet medical need. The most common reasons for unmet medical need were lack of transportation (80%) and lack of knowledge of where to go for care (20%). Unmet medical need was associated inversely with less than very good health (odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.16–0.61) and less than high school caretaker education (OR: 0.62; 95% CI: 0.39–0.98) and was associated directly with 1) having bed-days due to illness (OR: 2.46; 95% CI: 1.42–4.26), 2) lacking an annual well examination (OR:1.89; 95% CI: 1.12–3.20), 3) transportation dependence (OR:1.97; 95% CI: 1.24–3.13), 4) female gender (OR: 1.69; 95% CI: 1.07–2.67), 5) preschool age (OR: 2.24; 95% CI: 1.28–3.92), and 6) very high caretaker work pressure (OR: 5.01; 95% CI: 2.98–8.42). Adjustment using multiple logistic regression reveals unmet medical need to be independently associated with preschool age (OR: 2.08; 95% CI: 1.05–4.13) and very high caretaker pressure to work (OR: 5.93; 95% CI: 3.24–10.85). Of sampled children, 27% were preschool aged, and 40% had caretakers categorized with high work pressure.

Conclusions. Medical-access barriers among migrant children are largely nonfinancial. Preschool-aged migrant children disproportionately experience unmet medical need. Decreasing forgone care among migrant children will likely require a combination of individual, health-system, and labor-policy modifications.
Randomized, Controlled Trial of Oral Creatine Supplementation (Not Effective) for Apnea of Prematurity
Authors: Bohnhorst Bettina , Geuting Tiana , Peter Corinna S. , Dördelmann Michael , Wilken Bernd , Poets Christian F.
Published: August 2004

Background. Hypoxic ventilatory depression in mice and muscle fatigue in adult humans are improved by creatine supplementation (CS). Because these issues may be operative in apnea of prematurity (AOP), we hypothesized that CS reduces episodes of hypoxemia and bradycardia in infants with AOP.

Methods. Infants were eligible for this double-blind, controlled trial if gestational age was <32 weeks and AOP was severe enough to require treatment with caffeine. If they had ≥1 desaturation (pulse oximeter saturation [SpO2] ≤ 80%) or bradycardia (heart rate ≤ two thirds of baseline) per hour in an initial 6-hour recording, they were randomized to a 2-week course of oral CS (200 mg/kg per day) or placebo (P). Infants then underwent 2 additional 6-hour recordings of breathing movements, nasal airflow, heart rate, pulse oximeter saturation (SpO2) and pulse waveforms after 7 and 14 days of treatment. Urinary creatine excretion was measured also. Recordings were analyzed for the frequency of bradycardia and desaturation, the primary outcome parameter, as well as for apnea (≥10 seconds), baseline heart and respiratory rate, and SpO2.

Results. Of 38 infants enrolled, 34 completed the study (17 in each group). Median (range) gestational age at birth was 27 (25–30) vs 27 (25–30) weeks, and at study 29 (26–36) vs 29 (27–33) weeks. Oral CS was well tolerated; no side effects were noted. Urinary creatine excretion was low in the P group (median: 27 mmol/mol of creatinine; range: 18–102) and increased in the CS group (6949 mmol/mol of creatinine; range: 1427–11807). CS, however, had no effect on the combined rate of bradycardia and desaturation (P: 2.7 per hour [range: 0.2–10.3]; CS: 4.1 per hour [range: 0.6–12.1]), nor was there any decrease in apnea rate (P: 1.7 per hour [range: 0–4.5]; CS: 2.2 per hour [range: 0.2–5.1]).

Conclusion. Despite a significant increase in creatine excretion, suggesting good enteral absorption, CS did not, in the dose and for the duration given in this study, improve symptoms of AOP in these infants.
The Bedding Environment, Sleep Position, and Frequent Wheeze in Childhood
Authors: Ponsonby Anne-Louise , Dwyer Terence , Trevillian Leigh , Kemp Andrew , Cochrane Jennifer , Couper David , Carmichael Allan
Published: August 2004

Objective. Synthetic quilt use has been associated with increased childhood wheeze in previous studies. Our aim was to examine whether the adverse effect of synthetic quilt use on frequent wheeze differed by usual sleep position.

Design, Setting, and Participants. A population-based cross-sectional study of 6378 (92% of those eligible) 7-year-olds in Tasmania, Australia, was conducted in 1995. Exercise-challenge lung function was obtained on a subset of 414 children from randomly selected schools.

Exposure Measures. Child bedding including pillow and overbedding composition and usual sleep position by parental questionnaire.

Outcome Measures. Frequent wheeze (>12 wheeze episodes over the past year), using the International Study of Asthma and Allergies in Childhood parental questionnaire, and baseline and postexercise forced expiratory volume in 1 second lung-function measures.

Results. Frequent wheeze (n = 117) was positively associated with synthetic quilts, synthetic pillows, electric blankets, and sleeping in a bottom bunk bed but did not vary by sleep position. In a nested case-control analysis, the association between synthetic quilt use and frequent wheeze differed by sleep position. Among children who slept supine, synthetic (versus feather) quilt use was associated with frequent wheeze (adjusted odds ratio: 2.37 [1.08, 5.23]). However, among nonsupine sleepers, overlying synthetic quilt use was not associated with frequent wheeze (adjusted odds ratio: 1.06 [0.60, 1.88]). This difference in quilt effect by sleep position was highly significant. Similarly, synthetic quilt use was associated with lower postexercise forced expiratory volume in 1 second measures among supine but not nonsupine sleeping children.

Conclusion. An increasing focus on the bedding environment immediately adjacent to the nose and mouth is required for respiratory disorders provoked by bedding, such as child asthma characterized by frequent wheeze.
Changes in Mortality for Extremely Low Birth Weight Infants in the 1990s: Implications for Treatment Decisions and Resource Use
Authors: Meadow William , Lee Grace , Lin Kathy , Lantos John
Published: August 2004

Objective. Much has changed in neonatal intensive care unit (NICU) care over the past decade. High-frequency oscillation, inhaled nitric oxide, and antenatal corticosteroids are now widely available. We wondered how these medical advances had affected both the epidemiology and ethics of life and death for extremely low birth weight (ELBW) infants in the NICU.

Methods. We identified 1142 ELBW infants (birth weight [BW] < 1000 g) consecutively admitted to our NICU between 1991 and 2001. We abstracted BW, gestational age, survival or death, and length of stay in the NICU. Statistical analyses were performed by using linear regression and 2-way analysis of variance.

Results. Both increasing BW and later year were significantly associated with improved survival. However, for larger ELBW infants, survival was ∼90% for the entire decade, and large-scale improvement was hardly possible. For smaller infants, greater improvements were both possible and observed, at least early in the decade. From 1991 to 1997, overall ELBW survival increased steadily (∼4% per year). However, from 1997 to 2001, there was no significant improvement in survival for ELBW infants. There was no change in the distribution of deaths accounted for by BW subgroups within the ELBW population from 1991 to 2001. Median length of stay for infants who eventually expired before discharge rose from 2 days in 1991 to 10 days in 2001. As a consequence, during the past decade, the percentage of infants whose outcome was “undeclared” by day of life 4 rose from 10% to 20% for ELBW infants overall and to 33% for infants with BWs of 450 to 700 g. The percentage of ELBW NICU bed-days occupied by nonsurvivors remained very low (∼7%) from 1991 to 2001.

Conclusions. 1) Fewer infants in all ELBW subgroups are dying, compared with a decade ago, and the improvement has been most prominent for BWs of 450 to 700 g, at which mortality was and remains to be greatest. 2) This progress seems to have slowed, or even stopped, by the end of the decade. 3) Although most NICU nonsurvivors still expire early, doomed infants are lingering longer. 4) Nonsurvivors continue to occupy a constant (and extremely small) fraction of NICU bed-days.
Postnatal Depression and Faltering Growth: A Community Study
Authors: O’Brien Louise Margaret , Heycock Elizabeth Gardner , Hanna Mariam , Jones Peter Watts , Cox John Lee
Published: August 2004

Objective. To investigate the association between faltering growth in children and maternal postnatal depression.

Methods. Children aged ≤2 years were identified from community child health surveillance records if their weights fell across 2 centile channels on standardized growth charts or fell below the second centile. Mothers of these index children were invited to complete the Edinburgh Postnatal Depression Scale and the anxiety subscale of the Hospital Anxiety and Depression Scale. Those who scored above threshold values on either scale were interviewed with the revised Clinical Interview Schedule. Matched control children were obtained from health visitor records, and records of their weights were obtained. Mothers of control children completed the same questionnaires.

Results. A total of 196 index children and 567 control children were studied. Significantly more mothers in the index group scored above the threshold for both the Edinburgh Postnatal Depression Scale (33% vs 22%; odds ratio [OR]: 1.71; 95% confidence interval [CI]: 1.16-2.53) and the Hospital Anxiety and Depression Scale (24% vs 13%; OR: 2.08; 95% CI: 1.33-3.25) questionnaires. Furthermore, clinical interviews with these mothers demonstrated that 21% of the index group and 11% of the control group fulfilled criteria for depressive episode (OR: 1.88; 95% CI: 1.21-2.94).

Conclusions. Depression in mothers of children with faltering growth during the first 2 years of life is significantly greater than in mothers of children who are gaining weight appropriately. In view of the high rates of maternal depression in children with poor weight gain, clinical management at presentation of either problem should focus on both members of the mother–child dyad and on the interaction between mother and child. These findings have implications for all professionals who work in primary and secondary health care.
More Evidence for Reach Out and Read: A Home-Based Study
Authors: Weitzman Carol Cohen , Roy Lisa , Walls Theodore , Tomlin Ricarda
Published: August 2004

Objective. Reach Out and Read (ROR), a clinic-based literacy program, has been shown to improve literacy outcomes in impoverished children. No study has used direct observation to assess a child’s home literacy environment or to control for important confounders, such as the quality of the home environment. The objective of this study was to determine the relationship between the frequency of ROR encounters that a family receives during well-child visits and a child’s home literacy profile, while accounting for important confounders, such as the quality of the home environment.

Methods. A cross-sectional study was conducted of 137 children (aged 18-30 months) who received pediatric well-child care at the Yale-New Haven Hospital Primary Care Center. The number of ROR encounters that the family received was determined though parent interview, direct observation, and a review of the medical record. After a brief waiting room interview, a home visit was conducted. An assessment of the child’s home literacy environment was completed on the basis of 10 variables that were obtained from parent report and direct observation within the home. These variables were summed to form a Child Home Literacy Index. The Home Observation for Measurement of the Environment, a standardized measure of the nurturing quality of the home environment, was also administered. Hierarchical linear regression was conducted to determine the significance of ROR on a child’s home literacy environment.

Results. A total of 100 families completed both a waiting room interview and a home visit. Families received between 0 and 6 books in the ROR program. A total of 93% of families reported reading to their children, but only 35% of parents identified reading as a favorite activity of their child and 45% of parents reported that this was a favorite joint activity. Hierarchical linear regression demonstrated that increasing frequency of ROR encounters contributed a small but significant portion of the variance explaining a child’s home literacy profile (5%), with this model accounting for a total of 19% of the variance.

Conclusions. A modest literacy intervention, such as ROR, can have a significant impact on a child’s home literacy environment.
Spanking in Early Childhood and Later Behavior Problems: A Prospective Study of Infants and Young Toddlers
Authors: Slade Eric P. , Wissow Lawrence S.
Published: August 2004

Objective. To explore the relationship of spanking frequency before age 2 with behavior problems near time of entry into school.

Methods. Children who were younger than 2 years were followed up ∼4 years later, after they had entered school. The likelihood of significant behavior problems at follow-up was estimated in multivariate analyses that controlled for baseline spanking frequency and other characteristics. Participants were mothers from a large-scale national study and their children. Statistical analysis included an ethnically diverse sample of 1966 children aged 0 to 23 months at baseline. Two dichotomous indicators of behavior problems were used. The first indicated that maternal rating of child behavior problems exceeded a threshold. The second indicated that a mother met with a school administrator to discuss her child's behavior problems.

Results. White non-Hispanic children who were spanked more frequently before age 2 were substantially more likely to have behavior problems after entry into school, controlling for other factors. For Hispanic and black children, associations between spanking frequency and behavior problems were not statistically significant and were not consistent across outcome measures.

Conclusion. Among white non-Hispanic children but not among black and Hispanic children, spanking frequency before age 2 is significantly and positively associated with child behavior problems at school age. These findings are consistent with those reported in studies of children older than 2 years but extend these findings to children who are spanked beginning at a relatively early age.
Placement Stability and Mental Health Costs for Children in Foster Care
Authors: Rubin David M. , Alessandrini Evaline A. , Feudtner Chris , Mandell David S. , Localio A. Russell , Hadley Trevor
Published: August 2004

Objective. Although prior population-based studies have found that children in foster care use more mental health services than their Medicaid peers, less is known about how different experiences in foster care impact the likelihood of mental health service use. The primary aim of this study is to test the hypothesis that instability of foster care placements is associated with higher costs for mental health care services. The secondary aim is to test the hypothesis that foster care children are also more likely to generate high costs for mental health services if they generate higher costs for non–mental health claims.

Methods. Using administrative child welfare data linked to Medicaid claims, we assembled a unique retrospective cohort of adjudicated dependent children >2 years old who entered foster care between July 1993 and June 1995, spent at least 9 months in care, and were Medicaid eligible during a 1-year follow-up period. The primary outcome was high mental health service use, defined as having costs in the top decile of the sample. The primary independent variables were the number of foster care placements during the year and whether placements were interrupted by a return home for at least 1 month during that year (episodic foster care). We used logistic regression to estimate the association between placements and service utilization, with adjustment for age and physical health care costs.

Results. Of the 1635 children in the study, 41% had ≥3 foster care placements, and 5% had episodic foster care during the year of observation. The top 10% of mental health service users accounted for 83% of the $2.4 million in mental health costs. Both multiple placements and episodic foster care increased the predicted probability of high mental health service use. Higher physical health care costs also increased the probability of high mental health use for all children, but this increased probability was most dramatic among children with episodic foster care (probability of high mental health use: 0.78; 95% confidence interval: 0.42–0.94).

Conclusions. Foster care placement instability was associated with increased mental health costs during the first year in foster care, particularly among children with increasing general health care costs. These findings highlight the importance of interventions that address the global health of children in foster care and may permit better targeting of health care resources to subgroups of children most likely to use services.
Recommendations for Influenza Immunization of Children
Authors:   Committee on Infectious Diseases
Published: August 2004

Epidemiologic studies indicate that children of all ages with certain chronic conditions and otherwise healthy children younger than 24 months of age are hospitalized for influenza infection and its complications at high rates similar to those experienced by the elderly. Annual influenza immunization is recommended for all children with high-risk conditions who are 6 months of age and older. Young, healthy children are at high risk of hospitalization for influenza infection; therefore, the American Academy of Pediatrics recommends influenza immunization for healthy children 6 through 24 months of age, for household contacts and out-of-home caregivers of all children younger than 24 months of age, and for health care professionals. To protect these children more fully against the complications of influenza, increased efforts are needed to identify all high-risk children and inform their parents when annual immunization is due. The purposes of this statement are to update recommendations for routine use of influenza vaccine in children and to review the indications for use of trivalent inactivated influenza vaccine and live-attenuated influenza vaccine.
Recent Trends in Child Restraint Practices in the United States
Authors: Winston Flaura K. , Chen Irene G. , Elliott Michael R. , Arbogast Kristy B. , Durbin Dennis R.
Published: August 2004

Objective. To assess the success of recent outreach activities to promote appropriate child restraint in motor vehicles by examining trends in restraint types used by children under age 9 in 3 large regions of the United States.

Methods. Cross-sectional study was conducted of children who were under age 9 and in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 8730 crashes involving 10 195 children, representing 128 291 crashes involving 149 820 children, was collected between December 1, 1998, and November 30, 2002. Parent report was used to determine restraint type used in the crash. Logistic regression models were used to analyze the secular trend of restraint type use.

Results. Overall, for children under age 9, seat belt use decreased significantly from 49% to 36% between 1998 and 2002; for 7- and 8-year-olds, from 97% to 92%; and for 3- to 6-year-olds, from 63% to 34%. Concurrently, gains were achieved in overall child restraint use from 49% to 63%, for 7- and 8-year-olds, from 2% to 5%; and for 3- to 6-year-olds, from 35% to 65%. Child restraint use remains stable for children from birth to 2 years of age (from 97% in 1998 to 98% in 2002). Both the use of child safety seat and belt positioning booster seat increased significantly, whereas shield booster seat use decreased significantly.

Conclusion. Although considerable achievements have been realized over a short period of time, substantial inappropriate restraint still remains: 62% of children aged 4 to 8 remain inappropriately restrained in adult seat belts. Parents hear safety messages when they are relevant to their children. As a result, sustained efforts about appropriate restraint must continue to maintain and improve the gains achieved in appropriate child restraint use. The additional benefits realized by recent changes in child restraint laws remain to be evaluated.
Educating Pediatricians on Children's Oral Health: Past, Present, and Future
Authors: Krol David M.
Published: August 2004

Objective. The American Academy of Pediatrics (AAP) policy Oral Health Risk Assessment Timing and Establishment of the Dental Home encourages pediatricians to play an important role in the oral health of children. The purpose of this study was to determine how well pediatricians are prepared to play the AAP suggested role in children's oral health by examining the oral health content of their educational process.

Methods. This article reviews current medical education guidelines, programs, surveys, and pediatrician experiences in oral health training at the undergraduate, graduate, and continuing medical education levels.

Results. Although some medical schools, residency programs, and continuing medical education efforts do include oral health in their curricula, the practice is not widespread. Professional and oversight organizations such as the Association of American Medical Colleges, the Council on Medical Student Education in Pediatrics, Association of Pediatric Program Directors, AAP, and the pediatric Residency Review Committee do not include oral health in key guidelines and surveys of the medical education continuum. When surveyed, pediatricians state that the time spent on oral health education at each level of training is inadequate.

Conclusions. Overall, the level of oral health training for pediatricians at the undergraduate, graduate, and continuing medical education levels is inadequate to provide pediatricians with the competencies required for the provision of quality oral health care to children. Despite this inadequacy, educational efforts are under way and various tools and guidelines are available in a few locations. In addition, numerous opportunities exist for the organizations responsible for pediatrician education to ensure that curricula are designed and adopted to achieve these competencies, faculty are trained to teach these competencies, and program accreditation and certification are closely linked to acquisition of these competencies. Ensuring the success of such efforts will require cooperation between many organizations and disciplines and a genuine commitment to improve pediatric education and medical care for children.
Cognitive Function of Children With Cystic Fibrosis: Deleterious Effect of Early Malnutrition
Authors: Koscik Rebecca L. , Farrell Philip M. , Kosorok Michael R. , Zaremba Kathleen M. , Laxova Anita , Lai Hui-Chuan , Douglas Jeff A. , Rock Michael J. , Splaingard Mark L.
Published: August 2004

Objective. Patients who have cystic fibrosis (CF) and experience delayed diagnosis by traditional methods have greater nutritional insult compared with peers diagnosed via neonatal screening. The objective of this study was to evaluate cognitive function in children with CF and the influence of both early diagnosis through neonatal screening and the potential effect of early malnutrition.

Methods. Cognitive assessment data were obtained for 89 CF patients (aged 7.3-17 years) during routine clinic visits. Patients had been enrolled in either the screened (N = 42) or traditional diagnosis (control) group (N = 47) of the Wisconsin CF Neonatal Screening Project. The Test of Cognitive Skills, Second Edition was administered to generate the Cognitive Skills Index (CSI) and cognitive factor scores (Verbal, Nonverbal, and Memory).

Results. Cognitive scores in the overall study population were similar to normative data (CSI mean [standard deviation]: 102.5 [16.6]; 95% confidence interval: 99.1-105.9). The mean (standard deviation) CSI scores for the screened and control groups were 104.4 (14.4) and 99.8 (18.5), respectively. Significantly lower cognitive scores correlated with indicators of malnutrition and unfavorable family factors such as single parents, lower socioeconomic status, and less parental education. Our analyses revealed lower cognitive scores in patients with low plasma α-tocopherol (α-T) levels at diagnosis. In addition, patients in the control group who also had vitamin E deficiency at diagnosis (α-T < 300 μg/dl) showed significantly lower CSI scores in comparison with α-T–sufficient control subjects and both deficient and sufficient α-T subsets of screened patients.

Conclusion. Results suggest that prevention of prolonged malnutrition by early diagnosis and nutritional therapy, particularly minimizing the duration of vitamin E deficiency, is associated with better cognitive functioning in children with CF.
The Cost of Giving Childhood Vaccinations: Differences Among Provider Types
Authors: Glazner Judith E. , Beaty Brenda L. , Pearson Kellyn A. , Berman Stephen
Published: August 2004

Objective. To describe costs to providers of delivering childhood immunizations.

Methods. We collected variable costs—costs that vary with the amount of services rendered—including cost of practitioner and staff time and supplies, using a cost accounting method, from 12 practices (4 pediatric practices, 4 family practices, and 4 public health agencies) in rural and urban areas in Colorado. For private practices, we estimated fixed costs—costs that do not vary with the amount of services, eg, rent and insurance). We also collected reimbursement information for vaccinations for private practices.

Results. Variable costs per shot (excluding vaccine cost) were $8.15 for pediatric practices, $5.79 for family practices, and $5.41 for public health agencies. Total costs per shot, including fixed costs, were $10.67 for pediatric practices and $7.57 for family practices. Average reimbursement for pediatricians and private family practices was $8.27 and $6.68, respectively. For pediatric practices, average variable costs were barely exceeded by average reimbursement, and reimbursement was 22% less than average total costs. This contrasts with an earlier study of the rural practices investigated here, in which there was a comfortable margin between reimbursement and variable costs.

Conclusion. The decline in the ratio of reimbursement to cost for private practices, particularly for pediatric practices, suggests that referral to public agencies by private providers for vaccinations may increase and that if vaccinations are not as frequently provided in the child's medical home, then the currently high childhood immunization rates may be in jeopardy.