bluuebunny/crossref_metadata_2025 huggingface dataset:
Pneumatosis Intestinalis in Non-neonatal Pediatric Patients
Authors: Kurbegov Amethyst C. , Sondheimer Judith M.
Published: August 2004

Objectives.

To describe fully pneumatosis intestinalis (PI) in non-neonatal pediatric patients and to characterize those patients with higher risk of poor outcome, including need for surgery and death.

Methods.

A retrospective chart review was conducted of all patients 30 days of age and older with PI in a tertiary care children's hospital during an 8-year period. Underlying medical condition, presenting signs and symptoms, radiologic grade of pneumatosis, and events that immediately preceded the onset of PI were reviewed, and their correlation with outcome was assessed.

Results.

Thirty-seven episodes of PI occurred in 32 patients. Seventy-eight percent of patients were male, and the median age was 29 months. Major patient diagnostic groups identified with PI included healthy children (22%), patients with organ and bone marrow transplant (22%), patients with decompensated congenital heart disease (12.5%), motility disorders (12.5%), gastroschisis (9%), and short bowel syndrome (6%). The most common events that immediately preceded the onset of PI were noninfectious colitis (32%), acute enteric infection or toxin (27%), bowel ischemia (20%), and gastrointestinal dysmotility (17%). Resolution of PI with medical management occurred in 78% of episodes (good outcome). Twenty-two percent of episodes resulted in a poor outcome: patient death (8%) or surgery (14%). The presence of portal venous gas and low mean serum bicarbonate concentration were the only clinical factors that correlated significantly with poor outcome. Only 25% of patients with pneumoperitoneum required surgery. Poor outcome was seen most commonly in 2 patient diagnostic groups: transplant patients (43% of patients) and decompensated cardiac disease (50% of patients). The event that preceded PI also had an impact on outcome. PI preceded by ischemia or graft versus host disease colitis was associated with poor outcome in 50% and 75% of cases, respectively.

Conclusions.

PI is a radiologic sign that occurs in a variety of settings in non-neonates. PI preceded by bowel ischemia or graft versus host disease colitis has the worst prognosis, and the presence of portal venous gas and acidosis correlate with poor outcome. Not all patients with pneumoperitoneum require surgical intervention. Overall, outcome of PI in non-neonatal patients was better than that reported in neonates with necrotizing enterocolitis.pneumatosis intestinalis, necrotizing enterocolitis, non-neonatal.
Rescue Use of DNase in Critical Lung Atelectasis and Mucus Retention in Premature Neonates
Authors: Hassan Nahed O. El , Chess Patricia R. , Huysman Marianne W. A. , Merkus Peter J. F. M. , de Jongste Johan C.
Published: August 2004

Excessive or thick pulmonary secretions are a common clinical challenge in the neonatal population. Mucus accumulation can cause many life-threatening complications, including plugging of the endotracheal tube and increasing the risk of pulmonary infections. We report 3 premature neonates who had critical pulmonary collapse secondary to mucous plugging. Different conventional methods to liquefy mucus and facilitate removal of secretions were exhausted to no avail. The rescue use of DNase was effective in reestablishing airway patency. Thus, this drug could be a valuable tool in treating atelectasis and mucus-plugging in mechanically ventilated, premature neonates.
Case Report: Liver Glycogen Synthase Deficiency—A Cause of Ketotic Hypoglycemia
Authors: Rutledge S. Lane , Atchison Joycelyn , Bosshard Nils U. , Steinmann Beat
Published: August 2004

Glycogen synthase deficiency is a rare inborn error of metabolism, characterized by fasting hypoglycemia, hypoglycemic seizures, and ketonuria. Only 7 families with 14 affected children have been reported. Here, we report an additional patient with this deficiency. Findings in this patient were clinically and biochemically consistent with those reported in patients with ketotic hypoglycemia and may alert the clinician to consider glycogen synthase deficiency.
Sexuality Education for Children and Adolescents
Authors:   Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence
Published: August 2004

This Clinical Report was revised. See https://doi.org/10.1542/peds.2016-1348.

Children and adolescents need accurate and comprehensive education about sexuality to practice healthy sexual behavior as adults. Early, exploitative, or risky sexual activity may lead to health and social problems, such as unintended pregnancy and sexually transmitted diseases, including human immunodeficiency virus infection and acquired immunodeficiency syndrome. This statement reviews the role of the pediatrician in providing sexuality education to children, adolescents, and their families. Pediatricians should integrate sexuality education into the confidential and longitudinal relationship they develop with children, adolescents, and families to complement the education children obtain at school and at home. Pediatricians must be aware of their own attitudes, beliefs, and values so their effectiveness in discussing sexuality in the clinical setting is not limited.
Special Requirements for Electronic Medical Record Systems in Pediatrics
Authors:   Task Force on Medical Informatics
Published: August 2004

Electronic medical record (EMR) systems, which are usually designed for adult care, must perform certain functions to be useful in pediatric care. This statement outlines these functions (eg, immunization tracking and pediatric dosing calculations) to assist vendors and standards organizations with software design for pediatric systems. The description of these functions should also provide pediatricians with a set of requirements or desirable features to use when evaluating EMR systems. Particular attention is paid to special aspects of pediatric clinical care and privacy issues unique to pediatrics.
Cost-Effectiveness Analysis of an Intranasal Influenza Vaccine for the Prevention of Influenza in Healthy Children
Authors: Luce Bryan R. , Zangwill Kenneth M. , Palmer Cynthia S. , Mendelman Paul M. , Yan Lihan , Wolff Mark C. , Cho Iksung , Marcy S. Michael , Iacuzio Dominick , Belshe Robert B.
Published: August 2004

Objective.

Intranasal influenza vaccine has proven clinical efficacy and may be better tolerated by young children and their families than an injectable vaccine. This study determined the potential cost-effectiveness (CE) of an intranasal influenza vaccine among healthy children.

Methods.

We conducted a CE analysis of data collected between 1996 and 1998 during a prospective 2-year efficacy trial of intranasal influenza vaccine, supplemented with data from the literature. The CE analysis included both direct and indirect costs. We enrolled 1602 healthy children aged 15 to 71 months in year 1, 1358 of whom were enrolled in year 2. One or 2 doses of intranasal influenza vaccine or placebo were administered to measure the cost per febrile influenza-like illness (ILI) day avoided.

Results.

During the 2-year study period, vaccinated children had an average of 1.2 fewer ILI fever days/child than unvaccinated children. In an individual-based vaccine delivery scenario with vaccine given twice in the first year and once each year thereafter at an assumed base case total cost of $20 for the vaccine and its administration (ie, per dose), CE was approximately $30/febrile ILI day avoided. CE ranged from $10 to $69/febrile ILI day avoided at $10 to $40/dose, respectively. In a group-based delivery scenario, vaccination was cost saving compared with placebo and remained so if vaccine cost was <$28 (the break-even price per dose). In the individual-based scenario, vaccination was cost saving if vaccine cost was <$5. In this scenario, nearly half of lost productivity in the vaccine group was attributable to vaccine visits, which overshadowed the relatively modest savings in ILI-associated costs averted.

Conclusions.

Routine use of intranasal influenza vaccine among healthy children may be cost-effective and may be maximized by using group-based vaccination approaches. cost-effectiveness, influenza, vaccine, children.
A Statewide Assessment of Lead Screening Histories of Preschool Children Enrolled in a Medicaid Managed Care Program
Authors: Vivier Patrick M. , Hogan Joseph W. , Simon Peter , Leddy Tricia , Dansereau Lynne M. , Alario Anthony J.
Published: August 2004

Objectives.

Despite the prominence of lead poisoning as a public health problem, recent Government Accounting Office reports indicate that only one fifth of children who are covered by Medicaid have been screened for lead poisoning. The purpose of this study was to examine the lead screening histories of children who were enrolled in a statewide, Medicaid managed care plan to determine the relative impact of the type of primary care provider site and family sociodemographic characteristics on the likelihood of being screened. The study also examined the prevalence of and risk factors for lead poisoning of children who had been screened.

Methods.

A random sample of 2000 preschool-age children was chosen from those who were enrolled continuously in the statewide, expanded, Medicaid managed care program for a 1-year period and between the ages of 19 and 35 months at the end of that year. Sociodemographic characteristics and lists of primary care providers were obtained from administrative data sets. Medical record audits at primary care provider sites were performed to obtain the lead screening histories of the children, including test dates and results.

Results.

Data on 1988 children were used for study analyses, and 80% of these children had at least 1 documented blood lead level. Children whose primary care provider was an office-based physician were less likely to be screened as compared with patients of health centers, hospital-based clinics, and staff model health maintenance organizations (68%, 86%, 89%, and 91% respectively). Variation in screening rates persisted in a multivariate analysis controlling for family sociodemographic characteristics and practice level variation. Of the 1587 children who had a documented blood lead test, 467 children (29%) had a blood lead level of ≥10 mg/dL on at least 1 test.

Conclusions.

Blood lead screening rates in Rhode Island's Medicaid managed care program are dramatically higher than national estimates for children who are enrolled in Medicaid. Potential explanations for this finding are 1) a high sensitization to the problem of lead poisoning in Rhode Island, 2) the primary care focus of the Medicaid program in Rhode Island facilitates the delivery of preventive services, and 3) the medical record audit approach used in this study was more comprehensive in identifying blood lead screens than techniques used in national studies. The high prevalence of elevated blood lead levels found in this study emphasizes the importance of screening among children who are enrolled in Medicaid.
Adolescents' Perceptions of Social Status: Development and Evaluation of a New Indicator
Authors: Goodman Elizabeth , Adler Nancy E. , Kawachi Ichiro , Frazier A. Lindsay , Huang Bin , Colditz Graham A.
Published: August 2004

Objective.

Eliminating health disparities, including those that are a result of socioeconomic status (SES), is one of the overarching goals of Healthy People 2010. This article reports on the development of a new, adolescent-specific measure of subjective social status (SSS) and on initial exploratory analyses of the relationship of SSS to adolescents' physical and psychological health.

Methods.

A cross-sectional study of 10 843 adolescents and a subsample of 166 paired adolescent/mother dyads who participated in the Growing Up Today Study was conducted. The newly developed MacArthur Scale of Subjective Social Status (10-point scale) was used to measure SSS. Paternal education was the measure of SES. Indicators of psychological and physical health included depressive symptoms and obesity, respectively. Linear regression analyses determined the association of SSS to depressive symptoms, and logistic regression determined the association of SSS to overweight and obesity, controlling for sociodemographic factors and SES.

Results.

Mean society ladder ranking, a subjective measure of SES, was 7.2 ± 1.3. Mean community ladder ranking, a measure of perceived placement in the school community, was 7.6 ± 1.7. Reliability of the instrument was excellent: the intraclass correlation coefficient was 0.73 for the society ladder and 0.79 for the community ladder. Adolescents had higher society ladder rankings than their mothers (μteen = 7.2 ± 1.3 vs μmom = 6.8 ± 1.2; P = .002). Older adolescents' perceptions of familial placement in society were more closely correlated with maternal subjective perceptions of placement than those of younger adolescents (Spearman's rhoteens <15 years = 0.31 vs Spearman's rhoteens ≥15 years = 0.45; P < .001 for both). SSS explained 9.9% of the variance in depressive symptoms and was independently associated with obesity (odds ratiosociety = 0.89, 95% confidence interval = 0.83, 0.95; odds ratiocommunity = 0.91, 95% confidence interval = 0.87, 0.97). For both depressive symptoms and obesity, community ladder rankings were more strongly associated with health than were society ladder rankings in models that controlled for both domains of SSS.

Conclusions.

This new instrument can reliably measure SSS among adolescents. Social stratification as reflected by SSS is associated with adolescents' health. The findings suggest that as adolescents mature, SSS may undergo a developmental shift. Determining how these changes in SSS relate to health and how SSS functions prospectively with regard to health outcomes requires additional research.
Intussusception, Infection, and Immunization: Summary of a Workshop on Rotavirus
Authors: Kombo Lena A. , Gerber Michael A. , Pickering Larry K. , Atreya C. D. , Breiman Robert F.
Published: August 2004

This article summarizes the proceedings of a workshop sponsored by the National Institutes of Health and the National Vaccine Program Office, and held in Bethesda, Maryland, on January 21, 2000. The objective of the meeting was to focus research toward an understanding of the basis for the possible association between intussusception and the reassortant rhesus-human rotavirus vaccine tetravalent (RRV-TV). After numerous reports of intussusception after administration of RRV-TV, the manufacturers of this vaccine voluntarily withdrew it from the United States market. The American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians also withdrew their original recommendations for administration of RRV-TV to children at 2, 4, and 6 months of age. These actions will have global implications for the prevention of morbidity and mortality attributable to rotavirus infection. Benefit-cost ratios for the use of RRV-TV will be substantially different in developing countries compared with developed countries. Therefore, extensive research is needed in both of these settings, to further our understanding of the epidemiology, pathogenesis, and pathology of both rotavirus disease and intussusception to enable optimal prevention. The workshop reviewed the current understanding of the possible association between RRV-TV and intussusception, as well as the possible association between a variety of viral infections and intussusception. The workshop also identified critical areas of research regarding this possible association. This research will be essential not only for the development of safe and effective rotavirus vaccines, but for the development of other oral vaccines as well.
Use of Telehealth Technology to Extend Child Protection Team Services
Authors: Pammer William , Haney Michael , LMHC NCC, , Wood Betsy M. , Brooks Robert G. , Morse Karen , Hicks Patricia , Handler Eric G. , Rogers Howard , Jennett Penny
Published: August 2004

Objective.

In response to increased referrals to Florida's Child Protection Teams and concern regarding statewide availability of medical expertise in the area of child abuse and neglect, Children's Medical Services of the Florida Department of Health established a telemedicine project to facilitate immediate expert medical evaluations of alleged child abuse or neglect. This article describes a baseline examination of the project, including the technique of concept mapping, to examine how larger systematic factors influence the adaptation of telemedicine technology in child abuse examination settings.

Methods.

This study included interviews of key staff plus the incorporation of concept mapping, which takes qualitative data (individual statements and opinions) and quantifies them (sorts and ranks them by order of group importance).

Results.

Findings from interviews revealed that the frequency of use of telehealth services varies across the state as a result of several factors, including space limitations and staff training. Patients, however, seem to be comfortable with the use of the new technology. The concept mapping exercise displayed a progression of issues that are perceived to have an impact on the use of this technology.

Conclusions.

Technology use is affected by unforeseen variables, such as physical space limitations and examination room availability. Family concerns about patient privacy issues were rare and were resolved quickly by the health care practitioner. Although using this equipment is not difficult, the search for user-friendliness should be continued. Staff engagement early in the process likely will result in a greater likelihood of use of the technology.telehealth, telemedicine, child protection, child abuse and neglect, concept mapping.
Childhood Outcome After Early High-Frequency Oscillatory Ventilation for Neonatal Respiratory Distress Syndrome
Authors: Gerstmann Dale R. , Wood Kari , Miller Annie , Steffen Mike , Ogden Bob , Stoddard Ronald A. , Minton Stephen D.
Published: August 2004

Objective.

In a previous multicenter controlled clinical trial, we randomly assigned surfactant-treated premature newborns with moderate to severe respiratory distress syndrome to early treatment with high-frequency oscillatory ventilation (HFOV) or to conventional ventilation (CV). Compared with control infants who were treated with CV, neonates who were treated with HFOV using a strategy designed to recruit and maintain lung volume and minimize oxygen exposure had clinical evidence of improved pulmonary outcome and less lung injury. We report a follow-up study designed to determine whether clinical differences persisted between these study groups.

Methods.

Patients were recruited from 81 survivors at 1 center (Provo, Utah) and evaluated for sociodemographic and health history, growth, mental development, motor proficiency, and pulmonary function.

Results.

Eighty-seven percent of the cohort who originally were assigned to treatment with HFOV (n = 36) or CV (n = 33) were seen in follow-up at a mean age of 77 months (6.4 years). There were no differences in the frequency of hospitalization, pulmonary illness, asthma, or disabilities. Growth, verbal IQ, and motor development were appropriate for age and not different between groups. Patients who initially were randomized to treatment with CV showed pulmonary function evidence of decreased peak expiratory flow, increased residual lung volume, and maldistribution of ventilation.

Conclusion.

Neurodevelopmental childhood outcome after early intervention HFOV was normal and not different compared with patients who were treated with CV. Surfactant replacement combined with early HFOV using a lung recruitment strategy ameliorates the acute lung injury in respiratory distress syndrome that predisposes some preterm infants to develop chronic lung disease.
A Population-Based Assessment of Pediatric All-Terrain Vehicle Injuries
Authors: Cvijanovich Natalie Z. , Cook Lawrence J. , Mann N. Clay , Dean J. Michael
Published: August 2004

Objective.

To describe the types of injuries sustained by children who ride all-terrain vehicles (ATVs), to estimate the hospital charges associated with these injuries, and to determine adherence to existing rules and regulations governing ATV use.

Methods.

Analysis of statewide hospital admissions (1992–1996) and emergency department (ED) visits (1996) in Utah. All patients who were younger than 16 years and had an external cause of injury code for ATV use were included.

Results.

In 1996, 268 ED visits by children involved an ATV. Boys were twice as commonly injured as girls (male:female ratio: 2.1:1), and skin and orthopedic injuries were most frequent. The median ED charge was $368, and ED charges for these patients totaled $138 000. From 1992 to 1996, 130 children were hospitalized as a result of injuries sustained during ATV use, with median charges of $4240 per admission. Male to female ratio was 2.7:1, and the average age was 11.2 ± 3.6 years. Mean injury severity score was 8.0 ± 6.0, and median length of stay was 2 days (range: 0–43 days). Orthopedic injuries were most frequent, but 25% (n= 32) of children sustained head or spinal cord injury. Most children (94%) were discharged from the hospital, but 8 children died as a result of their injuries. Utah regulations prohibit children who are younger than 8 years from driving an ATV and advise against carrying passengers on ATVs. However, 25% (n = 15) of all injured children who were younger than 8 were driving the ATV when injured, and 15% (n = 60) of injured children were passengers on ATVs. Four of the 8 fatally injured children were younger than 8, and all were driving the ATV at the time of the crash. Finally, the estimated injury rate per 100 registered ATVs is significantly higher for children than for adults (3.41 vs 1.71).

Conclusions.

ATV use results in significant injuries to children. Efforts to educate parents regarding the risks of ATV use, proper supervision, and use of safety equipment are warranted. Manufacturers of ATVs should continue to improve the safety profile of these inherently unstable vehicles.
Prevalence and Predictors of Immunization Among Inner-City Infants: A Birth Cohort Study
Authors: Brenner Ruth A. , Simons-Morton Bruce G. , Bhaskar Brinda , Das Abhik , Clemens John D. ,   the NIH-D.C. Initiative Immunization Working Group
Published: August 2004

Context.

Although the proportion of US children who are appropriately immunized increased dramatically in the past decade, rates remain suboptimal among low-income, inner-city youth. Timely initiation of immunization is an important predictor of immunization status later in childhood; however, prospective studies identifying predictors of initiation are lacking.

Objectives.

The objectives of this study were to: 1) describe immunization patterns in a cohort of infants born to predominantly low-income, inner-city mothers; 2) identify determinants, as measured at birth, of immunization status at 3 and 7 months of age; and 3) identify determinants of continuation of immunization among those who initiate immunization by 3 months of age.

Design.

Prospective, birth cohort study.

Methods.

Maternal/infant dyads were systematically selected from 3 District of Columbia hospitals between August 1995 and September 1996. Three hundred sixty-nine mothers were interviewed shortly after delivery, at 3 to 7 months postpartum, and at 7 to 12 months postpartum. Medical records were reviewed at all reported sites of care for 324 (88%) infants. Vaccinations assessed included diphtheria, tetanus, and pertussis; polio; and Haemophilus influenzae type B. Multivariate logistic regression analyses were used to determine factors associated with immunization status of infants at 3 and 7 months of age.

Results.

At 3 months of age, 75% of infants were up-to-date (UTD) versus only 41% at 7 months. In adjusted analyses, baseline factors associated with being UTD at 3 months included enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during pregnancy, intention to breastfeed, and presence of the infant's grandmother in the household. Infants were less likely to be UTD if their mothers perceived higher barriers to immunization. Baseline factors associated with being UTD at 7 months included lower birth order and maternal employment. Among the subset of infants who were UTD at 3 months, only 53% remained UTD at 7 months. Factors measured at the first follow-up interview that were associated with continuation of immunization at 7 months included maternal employment and lower perceived barriers.

Conclusions.

Immunization rates during the first 7 months of life were low in this inner-city population. Factors associated with immunization status that are potentially amenable to change included perceived barriers to immunization and enrollment in WIC during pregnancy.
Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in a US Hospital Setting
Authors: Philipp Barbara L. , Merewood Anne , Miller Lisa W. , Chawla Neetu , Murphy-Smith Melissa M. , Gomes Jenifer S. , Cimo Sabrina , Cook John T.
Published: August 2004

Objective.

Breastfeeding initiation rates were compared at Boston Medical Center before (1995), during (1998), and after (1999) Baby-Friendly policies were in place. Boston Medical Center, an inner-city teaching hospital that provides care primarily to poor, minority, and immigrant families, achieved Baby-Friendly status in 1999.

Methods.

Two hundred complete medical records, randomly selected by a computer, were reviewed from each of 3 years: 1995, 1998, and 1999. Infants were excluded for medical records missing feeding data, human immunodeficiency virus–positive parent, neonatal intensive care unit admission, maternal substance abuse, adoption, incarceration, or hepatitis C–positive mother. All infant feedings during the hospital postpartum stay were tallied, and each infant was categorized into 1 of 4 groups: exclusive breast milk, mostly breast milk, mostly formula , and exclusive formula.

Results.

Maternal and infant demographics for all 3 years were comparable. The breastfeeding initiation rate increased from 58% (1995) to 77.5% (1998) to 86.5% (1999). Infants exclusively breastfed increased from 5.5% (1995) to 28.5% (1998) to 33.5% (1999). Initiation rates increased among US-born black mothers in this population from 34% (1995) to 64% (1998) to 74% (1999).

Conclusions.

Full implementation of the Ten Steps to Successful Breastfeeding leading to Baby-Friendly designation is an effective strategy to increase breastfeeding initiation rates in the US hospital setting.
Work of Breathing During Constant- and Variable-Flow Nasal Continuous Positive Airway Pressure in Preterm Neonates
Authors: Pandit Paresh B. , Courtney Sherry E. , Pyon Kee H. , Saslow Judy G. , Habib Robert H.
Published: August 2004

Background.

Constant-flow nasal continuous positive airway pressure (NCPAP) often is used in preterm neonates to recruit and maintain lung volume. Physical model studies indicate that a variable-flow NCPAP device provides more stable volume recruitment with less imposed work of breathing (WOB). Although superior lung recruitment with variable-flow NCPAP has been demonstrated in preterm neonates, corroborating WOB data are lacking.

Objective.

To measure and compare WOB associated with the use of variable-flow versus constant-flow NCPAP in preterm neonates.

Methods.

Twenty-four preterm infants who were receiving constant-flow NCPAP (means, SD) and had birth weight of 1024 ± 253 g, gestational age of 28 ± 1.7 weeks, age of 14 ± 13 days, and Fio2 of 0.3 ± 0.1 were studied. Variable-flow and constant-flow NCPAP were applied in random order. We measured changes in lung volume and tidal ventilation (VT) by DC-coupled/calibrated respiratory inductance plethysmography as well as esophageal pressures at NCPAP of 8, 6, 4, and 0 cm H2O. Inspiratory WOB (WOBI) and lung compliance were calculated from the esophageal pressure and VT data using standard methods. WOB was divided by VT to standardize the results.

Results.

WOBI decreased at all CPAP levels with variable-flow NCPAP, with a maximal decrease at 4 cm H2O. WOBI increased at all CPAP levels with constant-flow CPAP. Lung compliance increased at all NCPAP levels with variable-flow, with a relative decrease at 8 cm H2O, whereas it increased only at 8 cm H2O with constant-flow NCPAP. Compared with constant-flow NCPAP, WOBI was 13% to 29% lower with variable-flow NCPAP.

Conclusion.

WOBI is decreased with variable-flow NCPAP compared with constant-flow NCPAP. The increase in WOBI with constant-flow NCPAP indicates the presence of appreciable imposed WOB with this device. Our study, performed in neonates with little lung disease, indicates the possibility of lung overdistention at CPAP of 6 to 8 cm H2O with the variable-flow device. Further study is necessary to determine the efficacy of variable-flow NCPAP in neonates with significant lung disease and its use over extended periods of time.continuous-flow and variable-flow NCPAP, work of breathing, premature neonates, lung compliance.
Matrix Metalloproteinases-2, -8, and -9 and TIMP-2 in Tracheal Aspirates From Preterm Infants With Respiratory Distress
Authors: Cederqvist Katariina , Sorsa Timo , Tervahartiala Taina , Maisi Päivi , Reunanen Karoliina , Lassus Patrik , Andersson Sture
Published: August 2004

Objectives.

Matrix metalloproteinases (MMPs) are a family endoproteinases that act in degradation of extracellular matrix and basement membranes. The development of bronchopulmonary dysplasia (BPD) is characterized by early pulmonary inflammation, increased microvascular permeability, and subsequently by disordered repair. The aims of our study were to characterize the presence and molecular weight forms of MMP-2, -8, and -9 and their specific inhibitor, tissue inhibitor of metalloproteinases (TIMP)-2, in lungs of preterm infants during the early postnatal period and to determine whether levels of these MMPs and TIMP-2 in tracheal aspirate fluid (TAF) are associated with acute or chronic lung morbidity of the preterm infant.

Methods.

TAF samples were collected from 16 intubated preterm infants (gestational age 27.0 ± 2.0 weeks; birth weight 875 ± 246 g) during their first 5 postnatal days. The presence and molecular weight forms of MMPs and TIMP-2 were identified by Western immunoblotting, and their levels were evaluated by densitometric scanning.

Results.

MMP-8 in TAF was higher in infants who needed treatment with surfactant (25.4 ± 6.3 vs 10.6 ± 1.5 arbitrary unit/secretory component of immunoglobulin A [AU/SC]) and in whom BPD developed (N = 6; 27.6 ± 5.2 vs 15.1 ± 5.0 AU/SC). TIMP-2 levels were lower in infants with initial arterial to alveolar oxygen tension ratios <0.22 (2.7 ± 1.1 vs 16.8 ± 7.4 AU/SC) and in infants needing mechanical ventilation for >1 week (5.2 ± 2.1 vs 22.8 ± 11.7 AU/SC).

Conclusions.

In preterm infants, an imbalance between pulmonary MMP-8 and TIMP-2 participates in the acute inflammatory process in respiratory distress syndrome and may contribute to the development of chronic lung injury.
Objective Sleepiness Measures in Pediatric Obstructive Sleep Apnea
Authors: Gozal David , Wang Mei , Pope Dennis W.
Published: August 2004

Objectives.

Excessive daytime sleepiness (EDS) occurs frequently in adult patients with obstructive sleep apnea (OSA). However, the incidence of EDS in children with OSA is unknown.

Methods.

To determine overall daytime sleepiness in pediatric OSA, 54 children with OSA, 14 children with primary snoring (PS), and 24 controls (C) underwent an overnight diagnostic polysomnogram followed the next day by a multiple sleep latency test.

Results.

The mean apnea index was 15.1 ± 9.5 standard deviation in OSA, 1.1 ± 0.5 in PS, and 0.1 ± 0.3 in C. Mean sleep latencies were 23.7 ± 3.0 minutes in C, 23.7 ± 3.1 minute in PS, and 20.0 ± 7.1 minute in OSA patients. However, only 7 children with OSA had mean sleep latencies <10 minutes. In addition, shorter sleep latencies were more likely to occur in more obese OSA patients and those with more severe apnea index, and oxyhemoglobin desaturation.

Conclusions.

Shortened sleep latencies occur in children with OSA, but EDS is infrequent and tends to develop among more severe and/or obese patients.
Breath-Holding Spells Associated With Significant Bradycardia: Successful Treatment With Permanent Pacemaker Implantation
Authors: Kelly Amy M. , Porter Co-burn J. , McGoon Michael D. , Espinosa Raul E. , Osborn Michael J. , Hayes David L.
Published: August 2004

Objective.

To determine whether children with pallid breath-holding spells associated with bradycardia can be treated safely and successfully with permanent pacemaker implantation.

Methods.

The records of pediatric patients who had apparent breath-holding spells and associated bradycardia and were treated with permanent pacemaker implantation were reviewed.

Results.

Ten pediatric patients with apparent breath-holding spells associated with bradycardia were treated with a permanent ventricular demand pacemaker at the Mayo Clinic between 1985 and 1995. Patients had onset of symptoms between ages 6 days and 12 months and presented for evaluation between ages 12 months and 5 years. Duration of spells was 15 seconds to 10 minutes. Medications to prevent spells were unsuccessful. Electrocardiograms documented asystolic pauses of 1.7 to 24 seconds (mean: 11.9 seconds). Permanent ventricular demand pacemakers were implanted at 10 months to 5 years of age (median: 14.5 months): 9 endocardial and 1 epicardial. Three patients required pacemaker revision. At follow-up of 38 to 170 months (median: 65.5), 5 patients had complete resolution of spells, 2 had only mild color change without loss of consciousness or seizure activity, and 3 continued to have minor brief spells.

Conclusions.

Permanent pacemaker therapy for children with pallid breath-holding spells associated with severe bradycardia is safe, efficacious, and warranted.
Randomized Trial of Nutrient-Enriched Formula Versus Standard Formula for Postdischarge Preterm Infants
Authors: Lucas Alan , Fewtrell Mary S. , Morley Ruth , Singhal Atul , Abbott Rebecca A. , Isaacs Elizabeth , Stephenson Terence , MacFadyen Una M. , Clements Helena
Published: August 2004

Objectives.

Preterm infants are frequently discharged from the hospital growth retarded and show reduced growth throughout childhood. In a large efficacy and safety trial, we tested the hypothesis that nutritional intervention in the first 9 months postterm would reverse postdischarge growth deficits and improve neurodevelopment without adverse safety outcomes.

Participants and intervention.

Two hundred eighty-four infants (mean gestation: 30.9 weeks) were studied; 229 were randomly assigned a protein, energy, mineral, and micronutrient-enriched postdischarge formula (PDF; N = 113) or standard term formula (TF; N = 116) from discharge (mean 36.5 weeks' postmenstrual age). A reference group (N = 65) was breastfed until at least 6 weeks' postterm.

Outcome measures.

Anthropometry was performed at 6 weeks and 3, 6, 9, and 18 months. Development was measured at 9 months (Knobloch, Passamanick, and Sherrard's developmental screening inventory) and 18 months (Bayley Scales of Infant Development II; primary outcome) postterm.

Results.

At 9 months, compared with the TF group, those fed PDF were heavier (difference 370 g; 95% confidence interval [CI]: 84–660) and longer (difference 1.1 cm; 95% CI: 0.3–1.9); the difference in length persisted at 18 months (difference 0.82 cm; 95% CI: −0.04–1.7). There was no effect on head circumference. The effect of diet was greatest in males; at 9 months length deficit with TF was 1.5cm (95% CI: 0.3–2.7), and this remained at 18 months (1.5cm [95% CI: 0.3–2.7]). There was no significant difference in developmental scores at 9 or 18 months, although PDF infants had a 2.8 (−1.3–6.8) point advantage in Bayley motor score scales. At 6 weeks' postterm, exclusively breastfed infants were already 513 g (95% CI: 310–715) lighter and 1.6cm (95% CI: 0.8–2.3) shorter than the PDF group, and they remained smaller up to 9 months' postterm.

Conclusions.

1) Improving postdischarge nutrition in the first 9 months may “reset” subsequent growth—at least until 18 months for body length. We intend to follow-up the children at older ages. The observed efficacy of PDF was not associated with adverse safety outcomes. 2) We cannot reject the hypothesis that postdischarge nutrition benefits motor development and this requires additional study. 3) Our data raise the possibility that breastfed postdischarge preterm infants may require nutritional supplementation, currently under investigation.
Relationship of Childhood Obesity to Coronary Heart Disease Risk Factors in Adulthood: The Bogalusa Heart Study
Authors: Freedman David S. , Khan Laura Kettel , Dietz William H , Srinivasan Sathanur R. , Berenson Gerald S.
Published: August 2004

Background.

Childhood obesity is related to adult levels of lipids, lipoproteins, blood pressure, and insulin and to morbidity from coronary heart disease (CHD). However, the importance of the age at which obesity develops in these associations remains uncertain.

Objective and Design.

We assessed the longitudinal relationship of childhood body mass index (BMI, kg/m2) to adult levels of lipids, insulin, and blood pressure among 2617 participants. All participants were initially examined at ages 2 to 17 years and were reexamined at ages 18 to 37 years; the mean follow-up was 17 years.

Results.

Of the overweight children (BMI ≥95th percentile), 77% remained obese (≥30 kg/m2) as adults. Childhood overweight was related to adverse risk factor levels among adults, but associations were weak (r ∼ 0.1–0.3) and were attributable to the strong persistence of weight status between childhood and adulthood. Although obese adults had adverse levels of lipids, insulin, and blood pressure, levels of these risk factors did not vary with childhood weight status or with the age (≤8 years, 12–17 years, or ≥18 years) of obesity onset.

Conclusions.

Additional data are needed to assess the independent relationship of childhood weight status to CHD morbidity. Because normal-weight children who become obese adults have adverse risk factor levels and probably will be at increased risk for adult morbidity, our results emphasize the need for both primary and secondary prevention.
Increased Risk for Developmental Disabilities in Children Who Have Major Birth Defects: A Population-Based Study
Authors: Decouflé Pierre , Boyle Coleen A. , Paulozzi Leonard J. , Lary Joseph M.
Published: August 2004

Objective.

We sought to quantify the strength of associations between each of four specific developmental disabilities (DDs) and specific types of major birth defects.

Methods.

We linked data from 2 independent surveillance systems, the Metropolitan Atlanta Congenital Defects Program and the Metropolitan Atlanta Developmental Disabilities Surveillance Program. Children with major birth defects (n = 9142; born 1981–1991 in metro Atlanta) and 3- to 10-year-old children who were born between 1981 and 1991 in metro Atlanta and identified between 1991 and 1994 as having mental retardation, cerebral palsy, hearing impairment, or vision impairment (n = 3685) were studied. Prevalence ratio (PR), which is the prevalence of a DD in children with 1 or more major birth defects divided by the prevalence of the same DD in children without major birth defects, was measured.

Results.

Among the 9142 children who were born with a major birth defect, 657 (7.2%) had a serious DD compared with 0.9% in children with no major birth defect, yielding a PR of 8.3 (95% confidence interval: 7.6–9.0). In general, the more severe the DD, the higher was the PR. Birth defects that originated in the nervous system and chromosomal defects resulted in the highest PRs for a subsequent DD. For all other categories of birth defects, PRs were lowest when all major birth defects present were confined to a single category (ie, isolated defects). PRs for any DD increased monotonically with the number of coded birth defects per child or the number of different birth defect categories per child, regardless of the severity of the defect or whether defects of the nervous system, chromosomal defects, or “other syndromes” were counted.

Conclusions.

These data highlight the possible early prenatal origins of some DDs and suggest that both the number of coded birth defects present and the number of anatomic systems involved are strongly related to functional outcomes.
Improving Management of Diabetic Ketoacidosis in Children
Authors: Felner Eric I. , White Perrin C.
Published: August 2004

Objective.

The optimal fluid management for diabetic ketoacidosis (DKA) is uncertain. In an effort to simplify DKA therapy, we revised the treatment protocol in our institution to use a simpler method of calculating fluid needs, use fluids with higher sodium concentration, and allow glucose concentration to be adjusted easily. We performed a retrospective study to determine the effects of these revisions.

Design.

We compared patients treated with traditional and revised protocols (∼220 and ∼300 patients, respectively, over consecutive 2.75-year intervals). Sixty patient records were randomly selected from the first group (30 treated with each of 2 protocol versions) and 30 from the second group. Biochemical and clinical parameters were analyzed.

Results.

Patients selected for detailed analysis were similar in demographics and initial laboratory measurements. Patients treated under the revised fluid protocol received less total fluid, needed fewer intravenous fluid changes, were treated at less cost, and resolved acidosis more rapidly than patients treated under the original protocols. The rate of cerebral edema (0.3%–0.5%) was unchanged.

Conclusion.

A DKA protocol that necessitates less fluid delivery and fewer calculations simplifies therapy and is associated with more rapid correction of acidosis.
Injuries Associated With Infant Walkers
Authors:   Committee on Injury and Poison Prevention
Published: August 2004

In 1999, an estimated 8800 children younger than 15 months were treated in hospital emergency departments in the United States for injuries associated with infant walkers. Thirty-four infant walker-related deaths were reported from 1973 through 1998. The vast majority of injuries occur from falls down stairs, and head injuries are common. Walkers do not help a child learn to walk; indeed, they can delay normal motor and mental development. The use of warning labels, public education, adult supervision during walker use, and stair gates have all been demonstrated to be insufficient strategies to prevent injuries associated with infant walkers. To comply with the revised voluntary standard (ASTM F977-96), walkers manufactured after June 30, 1997, must be wider than a 36-in doorway or must have a braking mechanism designed to stop the walker if 1 or more wheels drop off the riding surface, such as at the top of a stairway. Because data indicate a considerable risk of major and minor injury and even death from the use of infant walkers, and because there is no clear benefit from their use, the American Academy of Pediatrics recommends a ban on the manufacture and sale of mobile infant walkers. If a parent insists on using a mobile infant walker, it is vital that they choose a walker that meets the performance standards of ASTM F977-96 to prevent falls down stairs. Stationary activity centers should be promoted as a safer alternative to mobile infant walkers.
Improving Preventive Service Delivery Through Office Systems
Authors: Bordley W. Clayton , Margolis Peter A. , Stuart Jayne , Lannon Carole , Keyes Lynette
Published: August 2004

Objective.

Rates of childhood immunizations and other preventive services are lower in many practices than national goals and providers' own estimates. Office systems have been used in adult settings to improve the delivery of preventive care, but their effectiveness in pediatric practices is unknown. This study was designed to determine whether a group of primary care practices in 1 community could implement office-based quality improvement systems that would significantly improve their delivery of childhood preventive services. The study was part of a larger community-wide intervention study reported in a preceding study.

Methods.

All the major providers of primary care to children in 1 community were recruited and agreed to participate (N = 8 practices). Project staff worked onsite with improvement teams in each practice to develop tailored systems to assess and improve the delivery of immunizations and screening for anemia, tuberculosis, and lead exposure. Office-based quality improvement systems typically involved some combination of chart prescreening, risk assessment forms, Post-it prompts, flowsheets, reminder/recall systems, and patient education materials. Office systems also often involved redistributing responsibilities among office staff.

Results.

All 8 participating practices created improvement teams. Project staff met with the practices 10 to 15 times over 12 months. After the period of office assistance, the overall rates for all preventive services except tuberculosis screening increased by amounts that were both clinically and statistically significant. Absolute percent improvements included: complete immunizations at 12 months, 7%; complete immunizations at 24 months, 12%; anemia screening, 30%; lead screening, 36%. The amount of improvement achieved varied considerably between practices.

Conclusions.

Office systems and the principles of quality improvement that underlie them seem to be effective in improving the delivery of childhood preventive services. Important predisposing factors may exist within practices that affect the likelihood that an individual practice will make significant improvements. prevention, immunizations, improvement, office systems, primary care.