bluuebunny/crossref_metadata_2025 huggingface dataset:
Chemical-Biological Terrorism and Its Impact on Children: A Subject Review
Authors:   Committee on Environmental Health and Committee on Infectious Diseases
Published: August 2004

There is an increasing threat that chemical and biological weapons will be used on a civilian population in an act of domestic terrorism. Casualties among adults and children could be significant in such an event. Federal, state, and local authorities have begun extensive planning to meet a chemical-biological incident by developing methods of rapid identification of potential agents and protocols for management of victims without injury to health care personnel. Because children would be disproportionately affected by a chemical or biological weapons release, pediatricians must assist in planning for a domestic chemical-biological incident. Government agencies should seek input from pediatricians and pediatric subspecialists to ensure that the situations created by multiple pediatric casualties after a chemical-biological incident are considered. This statement reviews key aspects of chemical-biological agents, the consequences of their use, the potential impact of a chemical-biological attack on children, and issues to consider in disaster planning and management for pediatric patients.
Type 2 Diabetes in Children and Adolescents
Authors: Association American Diabetes
Published: August 2004

This Statement of Endorsement was retired January 2014.
Sports Injuries: An Important Cause of Morbidity in Urban Youth
Authors: Cheng Tina L. , Fields Cheryl B. , Brenner Ruth A. , Wright Joseph L. , Lomax Tracie , Scheidt Peter C. ,   the District of Columbia Child/Adolescent Injury Research Network#
Published: August 2004

Introduction.

Sports injuries account for substantial morbidity and medical cost. To direct intervention, a population-based study of the causes and types of sports injuries was undertaken.

Method.

An injury surveillance system was established at all trauma center hospitals that treat residents 10 to 19 years old in the District of Columbia and the Chief Medical Examiner's Office. Medical record abstractions were completed for those seen in an emergency department, admitted to the hospital, or who died from injury June 1996 through June 1998.

Findings.

Seventeen percent (n = 2563) of all injuries occurred while participating in 1 of 6 sports (baseball/softball, basketball, biking, football, skating, and soccer) resulting in an event-based injury rate of 25.0 per 1000 adolescents or 25.0/1000 population year. Rates were higher in males for all sports. The most common mechanisms were falls (E880–888) and being struck by or against objects (E916–918). Hospitalization was required in 2% of visits and there were no deaths. Of those requiring hospitalization, 51% involved other persons, 12% were equipment-related, and 8% involved poor field/surface conditions. Of all baseball injuries, 55% involved ball or bat impact often of the head. Basketball injuries included several injuries from striking against the basketball pole or rim or being struck by a falling pole or backboard. Biking injuries requiring admission included 2 straddle injuries onto the bike center bar and collision with motor vehicles. Of all football injuries, 48 (7%) involved being struck by an opponent's helmet and 63 (9%) involved inappropriate field conditions including falls on or against concrete, glass, or fixed objects. In soccer there were 4 goal post injuries and a large proportion of intracranial injuries. There were 51 probable or clear assaults during sports and an additional 30 to 41 injuries from baseball bat assaults.

Conclusions.

Many sports including noncontact sports involved injuries of the head suggesting the need for improved head protection. Injuries involving collisions with others and assaults point to the need for supervision and enforcement of safety rules. The 16% of sports injury visits and 20% of hospitalizations related to equipment and environmental factors suggest that at least this proportion of injury may be amenable to preventive strategies. Design change may be warranted for prevention of equipment-related injuries. The many injuries involving inappropriate sports settings suggest the need for and use of available and safe locations for sports.
Effect of Infection Control Measures on the Frequency of Upper Respiratory Infection in Child Care: A Randomized, Controlled Trial
Authors: Roberts Leslee , PhD Epid, , Smith Wayne , Jorm Louisa , PhD BVSc, MSc(Epid), , Patel Mahomed , Douglas Robert M. , McGilchrist Charles
Published: August 2004

Background.

Acute upper respiratory infections are common in children who attend child care, and preventing transmission of disease in this setting depends on actions by child care staff. We set out to discover whether transmission of respiratory infections in child care could be reduced by improved infection control procedures.

Methods.

We performed a cluster, randomized, controlled trial of an infection control intervention conducted in child care centers in 1 city in Australia. The intervention was training of child care staff about transmission of infection, handwashing, and aseptic nosewiping technique. Implementation of the intervention was recorded by an observer. Illness was measured by parent report in telephone interviews every 2 weeks.

Results.

There were 311 child-years of surveillance for respiratory symptoms. By multivariable analysis, there was no significant reduction in colds in intervention center children across the full age range. However, a significant reduction in respiratory illness was present in children 24 months of age and younger. When compliance with infection control practices was high, colds in these children were reduced by 17%.

Conclusions.

This trial supports the role of direct transmission of colds in young children in child care. The ability of infection control techniques to reduce episodes of colds in children in child care was limited to children 24 months of age and under.
Hypothalamic-Pituitary-Adrenal Function and Glucocorticoid Sensitivity in Atopic Dermatitis
Authors: Ellison Julie A. , Patel Leena , Ray David W. , David PhD‡; Timothy J. , Clayton Peter E.
Published: August 2004

Objectives.

Topical glucocorticoids (GCs) fail to produce a clinical response in some children with atopic dermatitis (AD), suggesting that GC resistance may be present. To determine whether such resistance is generalized or specific to diseased skin, hypothalamic-pituitary-adrenal (HPA) axis function has been assessed in children with moderate to severe AD, who showed a variable response to treatment with topical GC.

Study Design.

Thirty-five patients (.7–18.7 years old; median: 9.3 years) with AD requiring topical GCs from infancy underwent a low-dose adrenocorticotrophin hormone (ACTH; Synacthen) test (LDST) (500 ng/1.73 m2 ACTH). Groups 1 (7 patients), 2 (17 patients), and 3 (4 patients) used mild, moderate, or potent/very potent topical preparations, respectively. Group 4 (7 boys with severe, treatment-resistant disease) had received GC in at least 1 form (inhaled ± intranasal ± oral) in addition to varying potencies of topical GC. Fourteen healthy subjects (3.8–17.3 years old) served as control subjects. Group 4 patients had a daytime plasma cortisol profile and 08.00 hours measurement of plasma ACTH and its precursors.

Results.

The response to ACTH for groups 1 and 2 did not differ from that of control subjects. Group 3 had lower peak, increment, and area under curve cortisol responses than those in controls, whereas group 4 had lower baseline, peak, and area under curve cortisol responses. Eight patients failed the LDST (peak cortisol <500 nmol/L and increment <200 nmol/L): controls = 0/14, group 1 = 0/7, group 2 = 1/17, group 3 = 4/4, and group 4 = 3/7. Treatment score (based on GC potency, area treated, and duration) was the only factor to influence peak cortisol response on LDST (r2 = 24%). In group 4, only 1 of 7 patients had a cortisol profile within the normal range but he failed the LDST. In the 5 subjects with an 08.00 hours cortisol <300 nmol/L, the matched ACTH level was inappropriately low.

Conclusions.

HPA suppression was rarely found in children or adolescents with moderate to severe AD who used mild or moderately potent topical GCs over many years. However, HPA suppression was common in those receiving potent topical GC preparations or a combination of GC routes of administration. In those with severe AD, evidence of HPA suppression but lack of clinical response to GC treatment excluded significant generalized GC resistance. This would suggest that localized resistance to GCs within the diseased skin may be part of the aetiopathogenesis of severe AD.
Sibling Vesicoureteral Reflux in Multiple Gestation Births
Authors: Kaefer Martin , Curran Michael , Treves S. Ted , Bauer Stuart , Hendren W. Hardy , Peters Craig A. , Atala Anthony , Diamond David , Retik Alan
Published: August 2004

Background.

Vesicoureteral reflux (VUR) is the most commonly inherited disease of the genitourinary tract. Although the majority of evidence supports a genetic cause, the tendency for this condition to spontaneously improve over time has made it difficult to determine the actual mode of transmission. We report the incidence of VUR in siblings of multiple gestation births and for the first time compare the relative incidence of reflux between identical and fraternal twins.

Methods.

A database consisting of all radionuclide cystograms and voiding cystourethrograms performed between the years 1986 and 1996 was searched for multiple gestation births. The medical records of each patient were evaluated for age at presentation, zygosity, reflux grade, and time to resolution. Children with secondary causes of VUR (eg, posterior urethral valves) were excluded. Triplets were treated as 2 pairs of twins for statistical analysis.

Results.

Forty-six pairs met the inclusion criteria (31 dizygotic and 15 monozygotic). Overall, 23 (50%) of 46 siblings of index cases had demonstrable VUR. Comparison of VUR prevalence between identical and nonidentical twins was revealing with 80% (12/15) of identical twins and 35% (11/31) of fraternal twins having VUR. When only the youngest individuals in each group were considered, 100% (7/7) of the monozygotics and 50% (5/10) of the dizygotics demonstrated this trait.

Conclusions.

High concordance for VUR in identical twin siblings supports a genetic basis for the transmission of this disease. Results obtained from fraternal twin siblings provides convincing evidence that this trait is transmitted in an autosomal dominant fashion.
Patient Care Guidelines in Pediatrics
Authors: Yetman Robert J.
Published: August 2004

The increase in availability of patient care guidelines is consistent with the expansion of managed care health care systems and enhanced efforts of health care providers to deliver evidence-based patient care. When used effectively, guidelines support: 1) the reduction of unexplained variation in health care practice; 2) education of practitioners and health care delivery systems; and 3) the continuous improvement in processes that improve patient outcomes. It is with these goals in mind that Milliman and Robertson released its latest publication of Health Care Management Guidelines entitled Pediatric Health Status Improvement and Management (HSIM). This publication contains comprehensive information on many aspects of pediatric care, from the prenatal period through adolescence, from preventive medicine through chronic care.

Like other Milliman and Robertson Health Care Management Guidelines publications, Pediatric HSIM offers both treatment guides and benchmarks that enable health care professionals to provide optimal levels of care and to measure their performance against peers. The primary focus of Pediatric HSIM is on wellness across a child's lifetime, an objective that fits well with our goal as providers of care to children of keeping patients healthy through preventive medicine.
Swimming Programs for Infants and Toddlers
Authors:   Committee on Sports Medicine and Fitness and Committee on Injury and Poison Prevention
Published: August 2004

Infant and toddler aquatic programs provide an opportunity to introduce young children to the joy and risks of being in or around water. Generally, children are not developmentally ready for swimming lessons until after their fourth birthday. Aquatic programs for infants and toddlers have not been shown to decrease the risk of drowning, and parents should not feel secure that their child is safe in water or safe from drowning after participating in such programs. Young children should receive constant, close supervision by an adult while in and around water.
Suicide and Suicide Attempts in Adolescents
Authors:   Committee on Adolescence
Published: August 2004

Suicide is the third leading cause of death for adolescents 15 to 19 years old.1 Pediatricians can help prevent adolescent suicide by knowing the symptoms of depression and other presuicidal behavior. This statement updates the previous statement2 by the American Academy of Pediatrics and assists the pediatrician in the identification and management of the adolescent at risk for suicide. The extent to which pediatricians provide appropriate care for suicidal adolescents depends on their knowledge, skill, comfort with the topic, and ready access to appropriate community resources. All teenagers with suicidal symptoms should know that their pleas for assistance are heard and that pediatricians are willing to serve as advocates to help resolve the crisis.
Do Not Resuscitate Orders in Schools
Authors:   Committee on School Health and Committee on Bioethics
Published: August 2004

Increased medical knowledge and technology have led to the survival of many children who previously would have died of a variety of conditions. As these children with continuing life-threatening problems reach school age, families, professionals, and paraprofessionals have to deal with the challenges involved in their care. Some children may be at high risk of dying while in school. When families have chosen to limit resuscitative efforts, school officials should understand the medical, emotional, and legal issues involved.
Firearm-Related Injuries Affecting the Pediatric Population
Authors:   Committee on Injury and Poison Prevention
Published: August 2004

This statement reaffirms the 1992 position of the American Academy of Pediatrics that the absence of guns from children's homes and communities is the most reliable and effective measure to prevent firearm-related injuries in children and adolescents. A number of specific measures are supported to reduce the destructive effects of guns in the lives of children and adolescents, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban on handguns and semiautomatic assault weapons; and expanded regulations of handguns for civilian use. In addition, this statement reviews recent data, trends, prevention, and intervention strategies of the past 5 years.
Soothing Pain-Elicited Distress in Chinese Neonates
Authors: Bo Luk Kar , MN BN, , Callaghan Patrick
Published: August 2004

Objective.

To test the effect of nonnutritive sucking (NNS), music therapy (MT), and combined NNS and MT (NNS + MT), versus no intervention, on heart rate, transcutaneous oxygen (TcPao2) levels, and pain behavior of neonates in intensive care units having blood taken by a heel-stick procedure.

Methodology.

A within-subjects, counter-balancing, repeated-measures design conducted in a government-funded hospital in Hong Kong, comparing TcPao2 levels, heart rate, and pain behavior outcomes in 27 neonates.

Results.

Repeated-measures multivariate analysis of variance revealed statistically significant differences in outcomes across all interventions (Wilk's λ = .142; F[3,27] = 31.82; η2 = .47). One-way analysis of variance revealed that the 3 comfort interventions significantly reduced neonates' heart rate (Wilk's λ = .647; F[2,27] = 18.93; η2 = .35), improved their TcPao2 levels (Wilk's λ = .481;F [2,27] = 37.42; η2 = .51), and reduced their pain behavior (Wilk's λ = .312; F [2,27] = 76.42; η2 = .68). Posthoc scheffe tests revealed that NNS + MT had the strongest effect on neonates' TcPao2 levels and pain behavior; MT alone had the strongest effect on neonates' heart rate.

Conclusions.

Health professionals using NNS + MT when doing heel-sticks can improve the TcPao2 levels of neonates and reduce their pain. Using MT alone can improve the heart rate of neonates.
Activity, Dietary Intake, and Weight Changes in a Longitudinal Study of Preadolescent and Adolescent Boys and Girls
Authors: Berkey Catherine S. , Rockett Helaine R. H. , Field Alison E. , Gillman Matthew W. , Frazier A. Lindsay , Camargo Carlos A. , MD Jr, , Colditz Graham A.
Published: August 2004

Objective.

To examine the role of physical activity, inactivity, and dietary patterns on annual weight changes among preadolescents and adolescents, taking growth and development into account.

Study Design.

We studied a cohort of 6149 girls and 4620 boys from all over the United States who were 9 to 14 years old in 1996. All returned questionnaires in the fall of 1996 and a year later in 1997. Each child provided his or her current height and weight and a detailed assessment of typical past-year dietary intakes, physical activities, and recreational inactivities (TV, videos/VCR, and video/computer games).

Methods.

Our hypotheses were that physical activity and dietary fiber intake are negatively correlated with annual changes in adiposity and that recreational inactivity (TV/videos/games), caloric intake, and dietary fat intake are positively correlated with annual changes in adiposity. Separately for boys and girls, we performed regression analysis of 1-year change in body mass index (BMI; kg/m2). All hypothesized factors were in the model simultaneously with several adjustment factors.

Results.

Larger increases in BMI from 1996 to 1997 were among girls who reported higher caloric intakes (.0061 ± .0026 kg/m2 per 100 kcal/day; β ± standard error), less physical activity (−.0284 ± .0142 kg/m2/hour/day) and more time with TV/videos/games (.0372 ± .0106 kg/m2/hour/day) during the year between the 2 BMI assessments. Larger BMI increases were among boys who reported more time with TV/videos/games (.0384 ± .0101) during the year. For both boys and girls, a larger rise in caloric intake from 1996 to 1997 predicted larger BMI increases (girls: .0059 ± .0027 kg/m2 per increase of 100 kcal/day; boys: .0082 ± .0030). No significant associations were noted for energy-adjusted dietary fat or fiber.

Conclusions.

For both boys and girls, a 1-year increase in BMI was larger in those who reported more time with TV/videos/games during the year between the 2 BMI measurements, and in those who reported that their caloric intakes increased more from 1 year to the next. Larger year-to-year increases in BMI were also seen among girls who reported higher caloric intakes and less physical activity during the year between the 2 BMI measurements. Although the magnitudes of these estimated effects were small, their cumulative effects, year after year during adolescence, would produce substantial gains in body weight. Strategies to prevent excessive caloric intakes, to decrease time with TV/videos/games, and to increase physical activity would be promising as a means to prevent obesity.
Does Candidemia Predict Threshold Retinopathy of Prematurity in Extremely Low Birth Weight (≤1000 g) Neonates?
Authors: Karlowicz M. Gary , Giannone Peter J. , Pestian John , Morrow Ardythe L. , Shults Justine
Published: August 2004

Background.

Extreme prematurity is a risk factor for both candidemia and threshold retinopathy of prematurity (ROP) and may confound the reported association between these conditions.

Objective.

To determine if candidemia is an independent risk factor for threshold ROP.

Methods.

A cohort study was conducted of infants weighing ≤1000 g at birth using a prospectively maintained neonatal database. The study included infants admitted to the neonatal intensive care unit at ≤3 days of age between January 1, 1993 and December 31, 1997. We excluded infants not screened for ROP because they died, were discharged, or transferred. Threshold ROP (ie, requiring ablative therapy within 72 hours of diagnosis) was defined by the criteria of the American Academy of Pediatrics Section on Ophthalmology ROP subcommittee. Candidemia was defined as Candidaspecies growth from at least 1 blood culture. Cox proportional hazards regression was used to determine independent risk factors for threshold ROP.

Results.

Six hundred fourteen infants weighing ≤1000 g at birth, of which 165 were excluded: 120 died before ROP screening, 40 were admitted >3 days of age, and 5 were discharged or transferred before ROP screening. A total of 449 infants were included in the study; 58 (13%) developed threshold ROP. Candidemia occurred in 58 (13%) infants before developing the worst stage of ROP. Candidemia occurred in 27 of 73 (37%) at 23 to 24 weeks' gestational age (GA), 25 of 197 (13%) at 25 to 26 weeks' GA, and 6 of 129 (5%) at 27 to 28 weeks' GA, 0 of 50 >28 weeks' GA. Similarly, threshold ROP occurred in 25 of 73 (34%) at 23 to 24 weeks' GA, 26 of 197 (13%) at 25 to 26 weeks' GA, and 6 of 129 (5%) at 27 to 28 weeks' GA, and 1 of 50 (2%) >28 weeks' GA. Threshold ROP developed in 19 of 58 (33%) infants with a history of candidemia and 39 of 391 (10%) without candidemia. Proportional hazards analysis indicated that GA in weeks (hazard ratio = .75; 95% confidence interval [CI]: .61, .93) and non-black ethnicity (hazard ratio = 1.8; 95% CI: 1.05, 3.08) were significantly associated with threshold ROP. After controlling for GA and other factors, candidemia did not remain significantly associated with threshold ROP (hazard ratio = 1.6; 95% CI: .89, 2.89).

Conclusion.

Candidemia may not be an independent risk factor for threshold ROP in extremely low birth weight infants. The magnitude of the previously reported association between candidemia and threshold ROP (more than fivefold) is unlikely and much of the clinically observed association appears to be mediated by gestational age.
Systemic Candidiasis in Extremely Low Birth Weight Infants Receiving Topical Petrolatum Ointment for Skin Care: A Case–Control Study
Authors: Campbell Judith R. , Zaccaria Elena , Baker Carol J.
Published: August 2004

Background and Objective.

An increase in the incidence of systemic candidiasis (SC) followed a change in skin care for extremely low birth weight (ELBW) infants in our neonatal intensive care unit (NICU). We sought to determine whether the use of topical petrolatum ointment (TPO) for skin care of ELBW infants was associated with risk for SC.

Study Design.

Case–control study.

Setting.

A 48-bed NICU in a private hospital in Houston, Texas.

Patients.

Ten ELBW infants with and 30 without SC admitted to the NICU from December 1, 1997 through July 31, 1998.

Methods.

ELBW infants with SC were identified using hospital microbiology and infectious disease consultation databases. A case was defined as an infant weighing ≤1000 g at birth withCandida spp isolated from a normally sterile body site. Three infants without SC were matched to each case by birth weight, admission date, and survival to the age of SC onset for the case. Data were collected by retrospective medical record review. Molecular analysis of Candida isolates was performed by karyotyping and restriction fragment length polymorphism using pulsed-field gel electrophoresis.

Results.

Case infants had a mean (± standard deviation) age of onset of 21.5 ± 24 days. Infants with SC and controls did not differ in birth weight, gestational age, or duration of therapy with steroids, antibiotics, insulin, or total parenteral nutrition. Although cases were more likely to be born vaginally and had a longer duration endotracheal intubation than controls, these differences were not significant. The odds ratio for skin care with TPO in case infants versus control infants was 11 (95% confidence interval: 1.9–63). Skin care with TPO was discontinued and the incidence of SC decreased to baseline. Several Candida spp and genetic profiles were identified, suggesting that there was not a common source outbreak.

Conclusions.

We conclude that the use of TPO promoted an increase in the incidence of SC in ELBW infants. Additional investigation of potential infectious risks for ELBW infants receiving TPO skin care is warranted.
Factors Associated With Age at Operation for Children With Congenital Heart Disease
Authors: Chang Ruey-Kang R. , Chen Alex Y. , Klitzner Thomas S.
Published: August 2004

Objective.

Previous studies have shown that children with congenital heart disease (CHD) who live in nonurban areas or who do not have private insurance are at risk for delayed referral to a pediatric cardiologist. However, the effect of these factors on the age at which cardiac surgery is performed has not been evaluated. This study is designed to evaluate the factors that influence the age at which definitive surgical repair is performed.

Methods.

Data on hospital discharges for 1995 and 1996 in California were obtained from the Office of Statewide Health Planning and Development database. Children <18 years who underwent surgical repair for atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), or atrioventricular canal (AVC) were included in the study. Age at surgery was evaluated using type of CHD, gender, race, type of insurance, surgical centers, urban or rural home location, and distance between home and surgical center as independent variables.

Results.

In 1995–1996, 666 children underwent ASD closure (mean age: 5.1 years; median: 4.0 years), 582 VSD closure (mean age: 2.8; median: 1.1 years), 394 TOF repair (mean age: 1.7; median: .9 years), and 177 AVC repair (mean age: 1.1; median: .6 years). Comparing median and mean age at surgery, we found: AVC<TOF<VSD<ASD (< indicates younger than). A consistent trend for all 4 types of CHD was seen indicating that for median age at operation: private insurance<managed care<Medicaid. Gender or race had no effect on age at operation, although Asians tended to be older at surgery for all 4 types of CHD. There is a significant negative correlation between the case volume of surgical centers and median age at operation for ASD (r = −.37), VSD (r = −.49), TOF (r = −.63), and AVC (r = −.17). In addition, significant positive correlation was found between degree of urbanization of home locations (measured by population density) and median age at operation for ASD (r = .50), VSD (r = .77), and TOF (r = .18). No significant correlation was found between distance to surgical center and age at operation.

Conclusions.

Many medical and nonmedical variables play important roles in determining age for definitive repair of CHD in children. Type of insurance, a recognized surrogate for access to care, may play an important role. In addition, centers with higher surgical case volume were more likely to operate at a younger age. Finally, children in urban areas tend to be older at the time of surgery for ASD, VSD, and TOF.
Structural and Functional Brain Integrity of Fetal Alcohol Syndrome in Nonretarded Cases
Authors: Clark Campbell M. , Li David , Conry Julianne , Conry Robert , Loock Christine
Published: August 2004

Purpose.

To determine the structural and functional integrity of the brain in a sample of nonretarded individuals diagnosed with fetal alcohol syndrome.

Subjects.

The sample consisted of nineteen individuals who met the diagnostic criteria for fetal alcohol syndrome.

Methods.

Intellectual function was assessed using the Wechsler Adult Intelligence Scale-Revised. Structural integrity of the brain was assessed using magnetic resonance imaging whereas functional integrity was assessed using positron emission tomography and 18F-fluorodeoxyglucose.

Results.

The mean Full Scale IQ was 80.2 (range: 66–92). Only 1 magnetic resonance imaging was found to be abnormal. This abnormality was found for the subject with the lowest IQ. Decreases in relative regional cerebral metabolic rates were found in 5 brain regions comprising the thalamus and basal ganglia.

Conclusion.

These results when coupled with previous findings suggest a continuum of neuropathology in fetal alcohol syndrome. For cases with relatively mild intellectual deficits, the cause of the deficit is at a micro-level rather than a macro-level.
Echocardiographic Predictors of Outcome in Newborns With Congenital Diaphragmatic Hernia
Authors: Suda Kenji , Bigras Jean-Luc , Bohn Desmond , Hornberger Lisa K. , McCrindle Brian W.
Published: August 2004

Objective.

Despite new treatments, congenital diaphragmatic hernia (CDH) still has high mortality. The aim of this study was to identify echocardiographic predictors of outcome in newborns with an isolated CDH.

Methods.

We reviewed medical charts and echocardiograms of 40 newborns who presented with CDH in the first 24 hours of life, from 1992 to 1996. We compared the cardiac valves and great arteries diameters, left-ventricular volume and mass, Apgar scores, and modified McGoon index (the combined diameter of hilar pulmonary arteries, indexed to the descending aorta) of survivors and nonsurvivors. We performed Student's t test and multiple logistic regression analysis between the 2 groups.

Results.

Fourteen patients died 1 to 33 days after birth (median: 3 days), including 8 from progressive hypoxemia without operation; 26 have survived up to 5 years (median: 2 years) after successful operations. Nonsurvivors had significantly smaller diameters of right and left hilar pulmonary arteries, more frequent right-sided CDH, and lower mean Apgar scores at 1 and 5 minutes. The most significant prognostic factor was the modified McGoon index. A modified McGoon index ≤1.3 predicted mortality with a sensitivity of 85% and specificity of 100%.

Conclusion.

Echocardiographic measurement of hilar pulmonary arteries, which may represent the adequacy of the pulmonary vascular bed, is a strong prognostic factor for newborns with congenital CDH.
Factors Associated With Early Adiposity Rebound
Authors: Dorosty Ahmad R. , Emmett Pauline M. , Cowin SRD‡; Imogen S. , Reilly John J. ,   the ALSPAC Study Team
Published: August 2004

Objective.

The age at which body mass index (BMI) increases after its nadir in childhood, adiposity rebound (AR), is a critical period for the development of obesity. Children with early AR are at substantially increased risk of adult obesity. Few studies have examined the factors that influence the timing of the AR. The aims of this study were to test for influences on the timing of the AR, and to test the hypothesis that early AR is promoted by high-protein intake.

Design and Participants.

Longitudinal cohort study of 889 children representative of the United Kingdom, followed from birth to 5 years.

Main Outcome Measures.

We tested for differences in dietary intake, parental BMI, socioeconomic status, and childhood BMI between 3 groups of children characterized by the following: very early AR (at or before 43 months), early AR (from 49 but before 61 months), and later AR (after 61 months).

Results.

There was no evidence of associations between dietary protein intake, or any other dietary variable, and timing of the AR. Children with very early AR and early AR had parents with significantly higher BMI, and were significantly more likely to have at least 1 obese parent.

Conclusion.

This study does not support the hypothesis that early AR is promoted by high-protein intake. None of the dietary variables tested were significantly associated with timing of the AR, and timing of AR was not associated with socioeconomic status. Parental obesity was associated with an earlier AR.
Controversies Regarding Definition of Neonatal Hypoglycemia: Suggested Operational Thresholds
Authors: Cornblath Marvin , Hawdon Jane M. , Williams Anthony F. , Aynsley-Green Albert , Ward-Platt Martin P. , Schwartz Robert , Kalhan Satish C.
Published: August 2004

The definition of clinically significant hypoglycemia remains one of the most confused and contentious issues in contemporary neonatology. In this article, some of the reasons for these contentions are discussed. Pragmatic recommendations for operational thresholds, ie, blood glucose levels at which clinical interventions should be considered, are offered in light of current knowledge to aid health care providers in neonatal medicine. Future areas of research to resolve some of these issues are also presented.
Physical Fitness and Activity in Schools
Authors:   Committee on Sports Medicine and Fitness and Committee on School Health
Published: August 2004

Schools are in a uniquely favorable position to increase physical activity and fitness among their students. This policy statement reaffirms the American Academy of Pediatrics' support for the efforts of schools to include increased physical activity in the curriculum, suggests ways in which schools can meet their goals in physical fitness, and encourages pediatricians to offer their assistance. The recommendations in this statement are consistent with those published in 1997 by the Centers for Disease Control and Prevention.1
Invasive Group A Streptococcal Disease in Children and Association With Varicella-Zoster Virus Infection
Authors: Laupland Kevin B. , Davies H. Dele , Low Donald E. , Schwartz Benjamin , Green Karen ,   the Ontario Group A Streptococcal Study Group, McGeer Allison
Published: August 2004

Objectives.

To describe the incidence and clinical features of invasive group A streptococcal (GAS) disease in children in Ontario and determine the risk of invasive GAS infection following chickenpox.

Methods.

During 1992–1996, we conducted prospective, active, population-based surveillance for pediatric invasive GAS disease in Ontario, Canada (population: 11 million; 2.5 million children) and reviewed clinical and laboratory records.

Results.

There were 1.9 cases of invasive GAS disease per 100 000 children per year. Streptococcal toxic shock syndrome (STSS) occurred in 7% of cases and necrotizing fasciitis (NF) in 4% for incidences of .08 and .13 per 100 000 per year, respectively. Case-fatality rates were 56% for STSS, 10% for NF, and 4% overall. The presence of chronic underlying illness other than asthma was associated with death (relative risk [RR]: 11; 95% confidence interval [CI]: 2.4–45). Fifteen percent of children identified had preceding chickenpox infection, which significantly increased the risk for acquisition of invasive GAS disease (RR: 58; 95% CI: 40–85). Children with invasive GAS and recent chickenpox were more likely to have NF (RR: 6.3; 95% CI: 1.8–22.3).

Conclusions.

Childhood invasive GAS disease occurs at an incidence similar to the adult population but has a lower rate of STSS and case-fatality. Chickenpox dramatically increases the risk for acquiring invasive GAS disease, and universal chickenpox vaccination could potentially prevent up to 15% of all pediatric invasive GAS disease.
A Prospective Search for Urinary Tract Abnormalities in Infants With Isolated Preauricular Tags
Authors: Kohelet David , Arbel Eliana
Published: August 2004

Objective.

To determine whether isolated preauricular tags are associated with urinary tract abnormalities.

Methodology.

Seventy consecutive infants with isolated preauricular tags were examined by ultrasonography for urinary tract abnormalities on day 3 or 4 of life between January 1993 and August 1999, after parental consent and ethics approval. Karyotype analysis was conducted in all infants with urinary tract abnormalities. The study group was compared with a control group of 69 infants without preauricular tags hospitalized during the same period. The control group consisted of infants who underwent urinary tract ultrasonography as part of an investigation for persistent regurgitation and/or vomiting associated with cyanotic spells.

Results.

Urinary tract abnormalities were detected in 6 infants with isolated preauricular tags (6/70; 8.6%). Types of anomalies were as follows: hydronephrosis in 5 cases and horseshoe kidney in 1 case. The causes of hydronephrosis were ureteropelvic junction obstruction in 3 cases and vescicoureteric reflux in 2 cases. None of the infants in the control group had such abnormalities. All infants with urinary tract abnormalities had normal chromosomes. No statistically significant differences existed between groups concerning birth weight, gestational age, intrauterine growth, and male-to-female ratio.

Conclusions.

This study suggests a significant prevalence of urinary tract abnormalities in infants with preauricular tags. We recommend, therefore, that urinary tract ultrasonography be conducted in the routine assessment of infants with isolated preauricular tags.
False-Positive Tricyclic Antidepressant Drug Screen Results Leading to the Diagnosis of Carbamazepine Intoxication
Authors: Matos Michael E. , Burns Michele M. , Shannon Michael W.
Published: August 2004

Ingestion of toxic substances is a common problem in pediatrics. When presented with the limited history of an unknown ingestion in a patient with altered mental status, a clinician depends on the physical examination and a toxic screen to determine the ingested substance(s). Some toxic screens yield false-positive or false-negative results that confound identification of ingested toxins. Three cases are presented in which carbamazepine ingestions were identified because of the false-positive tricyclic antidepressant serum toxic screen result in each case.

Carbamazepine ingestion is one of the most common pediatric overdoses. Side effects include altered mental status, tachycardia, mydriasis, seizures, coma, and death. Several other substances also cause false-positive tricyclic antidepressant toxic screen results, including certain antipsychotic medications, antihistamines, and the muscle relaxant cyclobenzaprine. Specific tests and drugs causing false-positive results are presented in table form. More modern methods, specifically gas chromatographic-mass spectrometric, are more reliable in distinguishing these drugs. Knowledge of which substances commonly cause false-positive results on a given toxic screen can still lead the clinician to the correct diagnosis. tricyclic, carbamazepine, ingestion, intoxication, drug screen.
Coccygeal Pits
Authors: Weprin Bradley E. , Oakes W. Jerry
Published: August 2004

Background.

Congenital dermal sinuses represent cutaneous depressions or tracts that are lined by stratified squamous epithelium. They communicate between the surface of the skin and deeper structures and may occur anywhere along the craniospinal axis. These sinuses are thought to result from abnormal separation of the cutaneous and neural ectoderm between the third and fifth week of intrauterine life. They may be often accompanied by other cutaneous stigmata, various dysraphic abnormalities, or intraspinal tumors.

In the sacrococcygeal area, cutaneous congenital abnormalities are relatively common. It is estimated that 2% to 4% of children harbor intergluteal dorsal dermal sinuses. These intergluteal sinuses in the perianal region are frequently referred to as pits or dimples. Their cause is considered similar to other congenital dermal sinuses and appears unrelated to acquired pilonidal conditions observed in adults. They may become susceptible to local recurrent infection from trauma or hirsutism.

Controversy regarding the evaluation and management of cutaneous defects in the coccygeal region exists.

Methods.

Both a literature review and a career review of clinical material were performed. Databases for articles published in English were surveyed for key words relating to coccygeal sinuses using standard computerized search techniques. The medical records of children presenting to our neurosurgical clinic for evaluation of dorsal dermal sinuses were reviewed to identify those with intergluteal sinuses.

Results.

In the evaluation of reported cases and of our own, we were unable to identify any children with coccygeal sinuses without other cutaneous markers other than hair with findings suggestive of intraspinal communication.

Conclusions.

Intergluteal dorsal dermal sinuses are relatively common lesions that frequently come to neurosurgical attention. They do not seem to be associated with significant risk of spinal cord and intraspinal anomalies. Simple intergluteal dorsal dermal sinuses without other cutaneous findings do not require radiographic or surgical evaluation and treatment. If other markers or neurologic symptoms are present, however, radiographic evaluation may be indicated.
Imaging After Urinary Tract Infection in Male Neonates
Authors: Goldman Michael , Lahat Eli , Strauss Simon , Reisler Gad , Livne Amir , Gordin Lital , Aladjem Mordechay
Published: August 2004

Objective.

To assess the frequency of urinary tract anomalies in male neonates <8 weeks old who presented with urinary tract infection (UTI), and to evaluate a suitable imaging approach after the initial infection.

Design.

During a period of 4.5 years, from July 1994 through December 1998, 45 male neonates <8 weeks old (range: 5–56 days; mean: 23.77 days) with UTI were hospitalized. All patients had an ultrasound (US) and a voiding cystourethrogram (VCUG), except 1 neonate in whom VCUG was unsuccessful because of technical problems.

A dimercaptosuccinic acid (DMSA) scan was recommended to all patients but was performed only in 30 of 45, most of them with an abnormal VCUG. The renal scan was performed at least 4 months after the UTI.

Results.

Urinary tract abnormalities were observed in 22 of 45 male neonates. Nineteen had vesicoureteral reflux (VUR), 1 had VUR and a double collecting system, 1 had VUR and a posterior urethral valve, and 1 had an ureteropelvic junction stricture. Renal atrophy or scars, as demonstrated by DMSA scan, were detected almost exclusively in neonates with VUR grade 3 and above. Only 1 neonate with VUR grade 1 had a pathologic DMSA, and the US of this male also demonstrated renal atrophy. Escherichia coli was the pathogen in 62% (28 of 45), and 9 boys had bacteremia.

Conclusion.

We suggest that US and VCUG should be performed routinely after the initial UTI in male neonates. Renal scan should be reserved for those cases in which the US suggests renal parenchymal damage or when VCUG detects VUR grade 3 and above.
Does Treatment of Vesicoureteric Reflux in Childhood Prevent End-Stage Renal Disease Attributable to Reflux Nephropathy?
Authors: Craig Jonathan C. , PhD Epi), , Irwig Les M. , PhD FFAPHM, , Knight John F. , Roy L. Paul
Published: August 2004

Objective.

It is believed that end-stage renal disease (ESRD) attributable to reflux nephropathy is preventable by the active treatment of vesicoureteric reflux in childhood with long-term antibiotics and ureteric reimplantation surgery. We aimed to test this belief.

Methodology.

The Australia and New Zealand Dialysis and Transplant Registry of new patients 5 to 44 years of age treated for ESRD between 1971 and 1998, categorized by age and primary renal disease, was used to analyze the age-specific incidences of ESRD attributable to reflux nephropathy using a before–after study design. The early 1960s were regarded as the introduction period for the active treatment of childhood vesicoureteric reflux. A time-delay in treatment effect was expected. Patients with ESRD attributable to other causes were used as a comparative group.

Results.

The incidence of ESRD attributable to reflux nephropathy and nonreflux nephropathy has increased. For reflux nephropathy, the rate of change was significantly associated with age, with a downward trend in incidence with decreasing age suggesting a minor treatment effect. This trend was no longer evident when adjustment was made for changing diagnostic practices. An opposite trend was observed for the nonreflux nephropathy group, who demonstrated an upward trend in incidence with decreasing age.

Conclusions.

Treatment of children with vesicoureteric reflux has not been accompanied by the hoped-for reduction in the incidence of ESRD attributable to reflux nephropathy. A randomized trial with a control (no-treatment) arm is required to appropriately assess the medical belief that long-term antibiotics and surgery improve the natural history of vesicoureteric reflux.
Meta-analysis of Dietary Essential Fatty Acids and Long-Chain Polyunsaturated Fatty Acids as They Relate to Visual Resolution Acuity in Healthy Preterm Infants
Authors: SanGiovanni John Paul , Parra-Cabrera Socorro , Colditz Graham A. , Berkey Catherine S. , Dwyer Johanna T.
Published: August 2004

Objective.

To derive combined estimates of visual resolution acuity differences between healthy preterm infants consuming different compositions and ratios of essential fatty acids (EFAs) and docosahexaenoic acid (DHA), an omega-3 (n-3) long-chain polyunsaturated fatty acid (LCPUFA).

Data Sources.

Electronic biomedical reference database (Medline and Health Star from 1965 to July 1999) searches with index terms omega-3, n-3, infant, vision, acuity, and human. Current review article, monograph, and book chapter bibliography/reference section hand searches.

Study Selection.

A total of 5 original articles and 4 review chapters were reviewed for details on study design, conduct, and outcome. Four prospective trials of EFA/LCPUFA supplementation were included in these analyses. For behaviorally based outcomes, there were 2 randomized comparisons each at ≤1, 2, 6, 9, and 12 months of corrected age and 4 randomized comparisons at 4 months of corrected age. For electrophysiologically based outcomes (visual-evoked potential), there were 2 randomized comparisons each at ≤1 and ∼4 months of corrected age.

Data Extraction.

Dietary composition and EFA/LCPUFA balance, study design, and analytic characteristics (duration of feeding, source of EFAs/LCPUFAs, number of subjects in study population, number of subjects analyzed, and basis for estimating age), and experiment-based characteristics (location, number or sites, design, vision tests employed, testing protocol, and ophthalmic examination) were recorded independently by 2 researchers with a standardized protocol.

Data Synthesis.

The relative difference in visual resolution acuity between groups of infants who received a source of dietary EFAs/LCPUFAs and groups who did not was computed and then analyzed with the DerSimonian and Laird random-effects method.

Results.

Analysis of the randomized comparisons (DHA-supplemented formula vs DHA-free formula) showed significant differences in visual resolution acuity at 2 and 4 months of age. Combined estimates of behaviorally based visual resolution acuity differences at these ages were .47 ± .14 octaves and .28 ± .08 octaves, respectively. A 1-octave difference is a reduction in the width of the stimulus elements by 50%.

Conclusion.

These results support efficacy of n-3 LCPUFA intake in early visual system development, although supplementation safety issues still must be addressed through larger randomized trials. Whether n-3 intake confers lasting advantage in visually based process development across the life-span is still to be determined.