bluuebunny/crossref_metadata_2025 huggingface dataset:
Accuracy of Analog Telephonic Stethoscopy for Pediatric Telecardiology
Authors: Belmont John M. , Mattioli Leone F.
Published: August 2004

Objective. Wide-bandwidth electronic stethoscopy is reliable and accurate for pediatric telecardiology. We tested a much less expensive and more convenient system for the same purpose, a narrow-bandwidth telephonic stethoscope (TS).

Methods. Seventy-six consecutive patients (mean age: 10.0; standard deviation: 6.5 years) in a pediatric cardiology outpatient clinic were studied. One pediatric cardiologist examined the patients with his acoustic stethoscope (AS); a second examined them within a few minutes using a remote TS. A nurse placed the TS chest piece as directed by the remote examiner via intercom, but neither video examination nor conversation with the parent/patient were permitted. Examiners independently recorded the stethoscope findings for all heart sounds, all murmurs, and heart disease (present/absent). TS accuracy was indexed using the κ statistic for TS/AS agreement and for TS agreement with auscultatory findings predicted from echocardiographic (echo) studies (N = 49).

Results. TS/AS agreement was satisfactory for presence/absence of heart disease (κ = 0.63) and for organic, functional, vibratory, diastolic aortic, and diastolic pulmonic murmurs (κ range: 0.65–0.75). For other specific murmurs and all heart sounds, TS/AS agreement was either unsatisfactory (κ ≤ 0.60) or indeterminate because prevalence was 0. TS-AS agreement improved when the TS was used by the more-experienced TS examiner and with patients at least 5 years of age. When the older children were examined by the more TS-experienced examiner, the TS-echo comparison yielded κ = 0.90, raw agreement = 0.96, sensitivity = 0.94, and specificity = 1.00.

Conclusions. In pediatric patients, a narrow-bandwidth telephonic stethoscope can accurately distinguish between functional and organic murmurs and thus can detect heart disease. Accuracy is greatest when the instrument is used by an experienced examiner with patients at least 5 years of age.
Pediatric Training and Job Market Trends: Results From the American Academy of Pediatrics Third-Year Resident Survey, 1997–2002
Authors: Cull William L. , Yudkowsky Beth K. , Shipman Scott A. , Pan Richard J.
Published: August 2004

Objectives. To examine trends in pediatric residents’ training and job search experiences from 1997–2002.

Methods. Annual national random samples of 500 graduating pediatric residents were surveyed, and responses were compared across survey years to identify trends. The overall response rate was 71%.

Results. From 1997–2002, there were more female residents and US underrepresented minorities and fewer international medical graduates. Each successive group of residents rated higher their preparation for fellowship training, for child advocacy, and for assessing community needs. These increases paralleled an increase in resident exposure to community sites as part of their residency education. Educational debt (in 2002 dollars) for residents increased substantially across survey years from an average of $64 070 in 1997 to $87 539 in 2002. Meanwhile, starting salaries (in 2002 dollars) for residents entering general pediatrics actually decreased. Interest in general pediatrics among residents decreased, whereas interest in subspecialty practice increased during this time period. Fewer residents with general pediatrics as a career goal had a job when surveyed, and fewer obtained their first-choice positions across years.

Conclusions. Experiences of graduating residents over the past 6 years provide insights into changes in pediatric residency education and the pediatric workforce. Efforts by pediatric educators and academic leaders to increase community experiences and child advocacy and to encourage greater interest in pediatric subspecialty careers seem to be succeeding. Unfortunately, demand for general pediatricians is weakening, and residents are experiencing increasing debt burdens.
Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved Outcome
Authors: Han Yong Y. , Carcillo Joseph A. , Dragotta Michelle A. , Bills Debra M. , Watson R. Scott , Westerman Mark E. , Orr Richard A.
Published: August 2004

Objective. Experimental and clinical studies of septic shock support the concept that early resuscitation with fluid and inotropic therapies improves survival in a time-dependent manner. The new American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) Guidelines for hemodynamic support of newborns and children in septic shock recommend this therapeutic approach. The objective of this study was to determine whether early septic shock reversal and use of resuscitation practice consistent with the new ACCM-PALS Guidelines by community physicians is associated with improved outcome.

Methods. A 9-year (January 1993–December 2001) retrospective cohort study was conducted of 91 infants and children who presented to local community hospitals with septic shock and required transport to Children’s Hospital of Pittsburgh. Shock reversal (defined by return of normal systolic blood pressure and capillary refill time), resuscitation practice concurrence with ACCM-PALS Guidelines, and hospital mortality were measured.

Results. Overall, 26 (29%) patients died. Community physicians successfully achieved shock reversal in 24 (26%) patients at a median time of 75 minutes (when the transport team arrived at the patient’s bedside), which was associated with 96% survival and >9-fold increased odds of survival (9.49 [1.07–83.89]). Each additional hour of persistent shock was associated with >2-fold increased odds of mortality (2.29 [1.19–4.44]). Nonsurvivors, compared with survivors, were treated with more inotropic therapies (dopamine/dobutamine [42% vs 20%] and epinephrine/norepinephrine [42% vs 6%]) but not increased fluid therapy (median volume; 32.9 mL/kg vs 20.0 mL/kg). Resuscitation practice was consistent with ACCM-PALS Guidelines in only 27 (30%) patients; however, when practice was in agreement with guideline recommendations, a lower mortality was observed (8% vs 38%).

Conclusions. Early recognition and aggressive resuscitation of pediatric-neonatal septic shock by community physicians can save lives. Educational programs that promote ACCM-PALS recommended rapid, stepwise escalations in fluid as well as inotropic therapies may have value in improving outcomes in these children.
Is Interleukin-6 −174 Genotype Associated With the Development of Septicemia in Preterm Infants?
Authors: Harding David , Dhamrait Sukhbir , Millar Ann , Humphries Steve , Marlow Neil , Whitelaw Andrew , Montgomery Hugh
Published: August 2004

Objective. Systemic infection affects one quarter of preterm infants. Defense from infection is in part mediated by the cytokine interleukin-6 (IL-6). We tested the hypothesis that the IL-6 −174 GG genotype, associated with lower IL-6 response to inflammation, is also associated with the development of septicemia in preterm infants.

Methods. The study group comprised 157 infants who were born at ≤32 weeks. Genotype distribution (34% [54] GG, 46% [72] GC, 20% [31] CC) and C allele frequency (0.43; 95% confidence interval [CI]: 0.37–0.48) were similar to the UK adult population. Among the patients who developed bacterially confirmed septicemia (n = 51 [33%]), there was a significantly higher prevalence of the IL-6 −174 GG genotype than that observed in those who did not develop infection (47% vs 28% for GG: odds ratio [OR]: 2.3; 95% CI: 1.1–4.5). This association remained statistically significant (OR: 2.7; 95% CI: 1.2–6.3) after multiple binary logistic regression adjustment for other significant predictors of the development of septicemia. Late infection alone was similarly associated with GG genotype (septicemia 47% vs no septicemia 29% for GG: OR: 2.2; 95% CI: 1.1–4.3).

Conclusions. Variation in the IL-6 gene seems to influence the defense against bacterial pathogens in the very preterm infant.
Dating of Bruises in Children: An Assessment of Physician Accuracy
Authors: Bariciak Erika D. , Plint Amy C. , Gaboury Isabelle , Bennett Sue
Published: August 2004

Objective. To determine whether physicians can estimate accurately the age of an accidental bruise on direct physical examination.

Methods. Children who presented to the emergency department of a children’s hospital with accidental bruises of known age and origin had demographic data and information about their injury recorded. History-blinded emergency pediatricians, other physicians, and trainees (fellows, residents, and medical students) independently examined the bruised area and recorded injury characteristics and age estimation and ranked characteristics that influenced their estimation.

Results. Fifty children with accidental bruises were enrolled. Emergency pediatricians’ accuracy of age estimation within 24 hours of actual age was 47.6%. Individual emergency pediatrician’s accuracy ranged from 0% to 100%, and the interobserver reliability was poor (κ = −0.03). Accuracy within 24 hours of actual age was 29.4% for other physicians and 36.8% for trainees, which was similar to the emergency pediatricians. Observers reported using color primarily to estimate age, followed by tenderness and then swelling; however, none of these factors was significantly correlated with accuracy.

Conclusions. Physician estimates of bruise age are highly inaccurate within 24 hours of the actual age of the injury. Large individual variability and poor interrater reliability also suggest that caution must be used when interpreting these estimates. This study supports earlier studies, urging extreme caution in estimating bruise age, even when such estimates are based on direct examination of the injured area.
Risk of Anaphylaxis After Vaccination of Children and Adolescents
Authors: Bohlke Kari , Davis Robert L. , Marcy S. M. , Braun M. M. , DeStefano Frank , Black Steven B. , Mullooly John P. , Thompson Robert S. ,   for the Vaccine Safety Datalink Team
Published: August 2004

Objective. To quantify the risk of anaphylaxis after vaccination of children and adolescents.

Methods. The study population consisted of children and adolescents who were enrolled at 4 health maintenance organizations that participated in the Vaccine Safety Datalink Project. For the period 1991–1997, we identified potential cases by searching for occurrences of International Classification of Diseases, Ninth Revision (ICD-9) code 995.0 (anaphylactic shock), E948.0 through E948.9 (adverse reaction from bacterial vaccines), and E949.0 through E949.9 (adverse reaction from other vaccines and biological substances). At 1 study site, we also included a range of other allergy codes. We restricted to diagnoses on days 0 to 2 after vaccination (ICD-9 995.0) or day 0 (all other ICD-9 codes). We then reviewed the medical record to confirm the diagnosis.

Results. We identified 5 cases of potentially vaccine-associated anaphylaxis after administration of 7 644 049 vaccine doses, for a risk of 0.65 cases/million doses (95% confidence interval: 0.21–1.53). None of the episodes resulted in death. Vaccines that were administered before the anaphylactic episodes were generally given in combination and included measles-mumps-rubella, hepatitis B, diphtheria-tetanus, diphtheria-tetanus-pertussis, Haemophilus influenzae type b, and oral polio vaccine. One case of anaphylaxis followed measles-mumps-rubella vaccine alone. At the site at which we reviewed additional allergy codes, we identified 1 case after 653 990 vaccine doses, for a risk of 1.53 cases/million doses (95% confidence interval: 0.04–8.52).

Conclusions. Patients and health care providers can be reassured that vaccine-associated anaphylaxis is a rare event. Nevertheless, providers should be prepared to provide immediate medical treatment should it occur.
Healing Patterns in Anogenital Injuries: A Longitudinal Study of Injuries Associated With Sexual Abuse, Accidental Injuries, or Genital Surgery in the Preadolescent Child
Authors: Heppenstall-Heger Astrid , McConnell Gina , Ticson Lynne , Guerra Lisa , Lister Julie , Zaragoza Toni
Published: August 2004

Objective. To study healing patterns of anogenital trauma in prepubescent children.

Methods. A prospective 10-year study was conducted of 94 children who had anogenital trauma and were followed to healing and documented using a colposcope with 35-mm camera attachment.

Results. The 13 boys and 81 girls were referred with injuries as a result of sexual assault or anogenital trauma. Hymenal injuries occurred in 37 cases; 2 transections healed after surgery, and 15 persisted unchanged. Partial tears, hymenal abrasions, or hematomas healed completely or with minor nonspecific changes. Of the 47 injuries to the posterior fourchette, 22 abrasions, hematomas, or tears healed completely; 12 tears healed with vascular changes; 2 developed labial fusions; 10 lacerations required surgery; and 6 scarred and 4 healed with vascular changes. Only 2 of 39 cases of perihymenal trauma healed with vascular changes. All 17 cases of labial trauma healed completely. Anal trauma healed completely in 29 of 31 with scarring occurring in only 2 cases that required surgery.

Conclusions. Anogenital trauma heals quickly, often without residua. Of the 94 cases, there were diagnostic anatomic changes in the 15 cases of hymenal transections (2 other cases healed completely with surgical reconstruction), 6 cases after surgical repair of posterior fourchette, and 2 cases of anal scarring after surgery.
Hemodynamic Changes in Anemic Premature Infants: Are We Allowing the Hematocrits to Fall Too Low?
Authors: Alkalay Arie L. , Galvis Sharon , Ferry David A. , Simmons Charles F. , Krueger Richard C.
Published: August 2004

Objective. Currently, many nurseries allow hematocrits to fall to <21% in apparently “stable” premature infants before considering a blood transfusion. We evaluated clinical changes and hemodynamic changes by echocardiogram in “stable” anemic premature infants before, during, and after transfusion.

Methods. “Stable” premature infants (≤32 weeks’ gestation) who were to receive transfusions (2 aliquots of 10 mL/kg packed red blood cells, 12 hours apart) were eligible for prospective enrollment. Cardiac function by echocardiography and vital signs were measured 4 times: 1 to 3 hours before and 2 to 4 hours after the initial aliquot and 4 to 7 hours and 27 to 34 hours after the second aliquot. Infants were grouped prospectively according to pretransfusion hematocrit ranges for analysis: ≤21% (low), 22% to 26% (mid), and ≥27% (high).

Results. Thirty-two infants were enrolled. No differences were observed between the groups in sex, birth weight, postconceptional age, or postnatal weight at enrollment. Before transfusion, low- and mid-range groups had higher left ventricular end systolic and diastolic diameters, in comparison with high range. Low range had increased stroke volume in comparison with the high-range group. These changes persisted after transfusion. Mean diastolic blood pressure rose and peak velocity in the aorta fell in the low-range group after transfusion. Pretransfusion hematocrit was correlated with but poorly predictive of echocardiographic measurements. Infants with inappropriate weight gain had increased ventricular end diastolic diameters, consistent with congestive heart failure.

Conclusions. Apparently “stable” anemic premature infants may be in a clinically unrecognized high cardiac output state, and some echocardiographic measurements do not improve within 48 hours after transfusion. The benefits of transfusion practices guided by measures of cardiac function should be evaluated.
Cerebral Function Monitoring: A New Scoring System for the Evaluation of Brain Maturation in Neonates
Authors: Burdjalov Vladimir F. , Baumgart Stephen , Spitzer Alan R.
Published: August 2004

Objective. Cerebral function monitoring (CFM), using compressed single-channel amplitude-integrated electroencephalogram recorded from 2 biparietal electrodes, has been shown previously to be a simple bedside tool for monitoring neonatal central nervous system (CNS) status. As the pattern of the CFM changes with gestational age, the technique can be used to assess brain maturation in premature infants. We have developed a new scoring system for the interpretation of neonatal CFM recordings. The objective of this study was to evaluate CFM tracings at increasing gestational and postnatal ages to develop a scoring system to quantify CFM pattern changes.

Methods. Term and preterm neonates were studied with CFM at 12 to 24 hours of life, 48 to 72 hours of life, and then weekly or biweekly until hospital discharge. Each study comprised 8 to 24 hours of continuous CFM recording. CFM recordings were evaluated using the scoring system for record continuity, presence of cyclic changes in electrical activity, degree of voltage amplitude depression, and bandwidth. Each variable was scored for each recording. All variables were summed to yield a total score (minimum 0, maximum 13). Total scores were correlated with gestational and postconceptional ages.

Results. Thirty infants were studied with gestational ages at birth that ranged from 24 to 39 weeks and birth weights that varied between 450 and 3850 g. A total of 146 CFM tracings were analyzed. With advancing gestational and postconceptional age, scores for each variable as well as total scores progressively increased with CNS maturation. The highest scores were attained at 35 to 36 weeks’ postconceptional age, which corresponded to previously reported subjective observations performed by visual description of CFM patterns. Of the 4 component variables that we analyzed, the most sensitive indicators of CNS maturity were 1) the presence of a cycling pattern, 2) the continuity of the record pattern, and 3) the CFM recording bandwidth.

Conclusions. Our proposed scoring system may be a valuable tool to quantify changes during CFM more objectively, reflecting variations in CNS activity in newborn infants and allowing for better statistical comparisons between amplitude-integrated electroencephalogram tracings from different patients as well as from the same patient at different points of time.
Symptoms of Sleep-Disordered Breathing in 5-Year-Old Children Are Associated With Sleepiness and Problem Behaviors
Authors: Gottlieb Daniel J. , Vezina Richard M. , Chase Cynthia , Lesko Samuel M. , Heeren Timothy C. , Weese-Mayer Debra E. , Auerbach Sanford H. , Corwin Michael J.
Published: August 2004

Objective. Sleep-disordered breathing (SDB) in children is reportedly associated with problem behaviors suggestive of attention-deficit/hyperactivity disorder; however, there are few data on the relation of SDB to problem behaviors in the general pediatric population. The goal of this study was to assess the prevalence of SDB symptoms in 5-year-old children and their relation to sleepiness and problem behaviors.

Methods. A population-based, cross-sectional survey was conducted of a birth cohort of children who were born in eastern Massachusetts. Subjects were 3019 5-year-old children (1551 boys, 1468 girls) who were enrolled in the Infant Care Practices Study and whose mothers were contacted within 3 months of their child’s fifth birthday. A parent-completed questionnaire was used to ascertain the presence and intensity of snoring and other SDB symptoms and the presence of daytime sleepiness and problem behaviors. Parent-reported hyperactivity, inattention, and aggressiveness were each assessed by a single question that was validated against the Conners’ Parent Rating Scale. SDB was defined as frequent or loud snoring; trouble breathing or loud, noisy breathing during sleep; or witnessed sleep apnea.

Results. Parent-reported hyperactivity (19%) and inattention (18%) were common, with aggressiveness (12%) and daytime sleepiness (10%) reported somewhat less often. SDB symptoms were present in 744 (25%) children. Compared with children without snoring or other symptoms of SDB, children with SDB symptoms were significantly more likely to have parent-reported daytime sleepiness (odds ratio [OR]: 2.2; 95% confidence interval [CI]: 1.7–2.8) and problem behaviors, including hyperactivity (OR: 2.5; CI: 2.0–3.0), inattention (OR: 2.1; 95% CI: 1.7–2.6), and aggressiveness (OR: 2.1; 95% CI: 1.6–2.6). These associations remained significant after adjustment for sex, race/ethnicity, maternal education level, maternal marital status, household income, and respiratory health history.

Conclusions. SDB symptoms are common in 5-year-old children and are associated with an increased risk of daytime sleepiness and with problem behaviors suggestive of attention-deficit/hyperactivity disorder.
Back to Sleep: Can We Influence Child Care Providers?
Authors: Moon Rachel Y. , Oden Rosalind P.
Published: August 2004

Objective. Despite the fact that 20% of sudden infant death syndrome (SIDS) deaths occur in child care settings, many child care providers continue to be unaware of the association of SIDS and infant sleep position and/or are misinformed as to the risks and benefits of the various sleep positions. The objective of this study was to determine whether an educational program for child care providers regarding SIDS and safe sleep environment is effective in 1) providing basic information and understanding regarding SIDS risk reduction practices, 2) changing child care provider behavior, and 3) promoting development of written sleep position policies.

Methods. We designed a 60-minute educational in-service for child care providers, to be led by a trained health educator. All providers who attended the in-service were asked to complete surveys before and after the in-service. Surveys assessed provider knowledge, beliefs, and practices. A 6-month follow-up interview was conducted with child care centers that had providers participating in the in-service.

Results. A total of 96 child care providers attended the educational in-service. Providers who were using the supine position exclusively increased from 44.8% to 78.1%. This change in behavior was sustained, with 85% of centers placing infants exclusively supine 6 months after the intervention. Awareness of the American Academy of Pediatrics recommendation of supine as the preferred position for infants increased from 47.9% to 78.1%, and 67.7% of centers continued to recognize supine as the recommended position 6 months later. The percentage of centers that reported written sleep position policies increased from 18.8% to 44.4%.

Conclusions. A targeted educational in-service for child care providers is effective in increasing awareness and knowledge, changing child care provider behavior, and promoting development of written sleep position policies. This change is sustained over at least a 6-month period.
Plasma Concentrations of Aminoterminal Pro Atrial Natriuretic Peptide and Aminoterminal Pro Brain Natriuretic Peptide in Healthy Neonates: Marked and Rapid Increase After Birth
Authors: Mir Thomas S. , Laux Reinhard , Hellwege Hans Henning , Liedke Bozena , Heinze Cornelius , von Buelow Helmut , Läer Stephanie , Weil Jochen
Published: August 2004

Objective. The purpose of the study was to examine the possible age dependency of plasma N-terminal pro atrial natriuretic peptide (N-ANP) and N-terminal pro brain natriuretic peptide (N-BNP) levels in healthy term neonates to establish normal ranges for the neonatal period.

Methods. N-ANP and N-BNP plasma concentrations were measured in peripheral venous (n = 116) and umbilical cord blood (n = 37) in 153 healthy term neonates (mean: 5.1; range: 0–30 days) using an enzyme immunoassay. The neonates were classified into 8 groups according to their age (day of delivery and 1, 2, 3, 4, 5–7, 8–14, and 14–30 days of age).

Results. The plasma N-ANP and N-BNP concentration were the highest at the first day of age (96 700; 6912–436 000 and 641; 254-1272 fmol/mL) and were found significantly higher compared with the day of delivery (5680; 1005–16 900 and 221; 58–478 fmol/mL; P < 0,0001). After this marked increase, N-ANP and N-BNP levels decreased steadily and became stable at the fifth (5232; 2691–7353 fmol/mL) and third (246; 110–430 fmol/mL) day of life, respectively.

Conclusions. The N-ANP and N-BNP plasma concentrations in healthy neonates showed a marked increase during the first days of age, suggesting that ANP and BNP have physiologic roles in the perinatal circulatory change from fetus to neonate.
Relation Between Dieting and Weight Change Among Preadolescents and Adolescents
Authors: Field Alison E. , Austin S. B. , Taylor C. B. , Malspeis Susan , Rosner Bernard , Rockett Helaine R. , Gillman Matthew W. , Colditz Graham A.
Published: August 2004

Objective. To assess whether dieting to control weight was associated with weight change among children and adolescents.

Methods. A prospective study was conducted of 8203 girls and 6769 boys who were 9 to 14 years of age in 1996, were in an ongoing cohort study, and completed at least 2 annual questionnaires between 1996 and 1999. Dieting to control weight, binge eating, and dietary intake were assessed annually from 1996 through 1998 with instruments designed specifically for children and adolescents. The outcome measure was age- and sex-specific z score of body mass index (BMI).

Results. In 1996, 25.0% of the girls and 13.8% of the boys were infrequent dieters and 4.5% of the girls and 2.2% of the boys were frequent dieters. Among the girls, the percentage of dieters increased over the following 2 years. Binge eating was more common among the girls, but in both sexes, it was associated with dieting to control weight (girls: infrequent dieters, odds ratio [OR]: 5.10; frequent dieters, OR: 12.4; boys: infrequent dieters, OR: 3.49; frequent dieters, OR: 7.30). During 3 years of follow-up, dieters gained more weight than nondieters. Among the girls, frequency of dieting was positively associated with increases in age- and sex-specific z scores of BMI (β = 0.05 and β = 0.04 for frequent and infrequent dieters vs nondieters). Among the boys, both frequent and infrequent dieters gained 0.07 z scores of BMI more than nondieters. In addition, boys who engaged in binge eating gained significantly more weight than nondieters.

Conclusions. Although medically supervised weight control may be beneficial for overweight youths, our data suggest that for many adolescents, dieting to control weight is not only ineffective, it may actually promote weight gain.
Simple Car Seat Insert to Prevent Upper Airway Narrowing in Preterm Infants: A Pilot Study
Authors: Tonkin Shirley L. , McIntosh Christine G. , Hadden Wendy , Dakin Caroline , Rowley Simon , Gunn Alistair J.
Published: August 2004

Objectives. To test prospectively the hypothesis that an infant car seat modification to allow the infant’s head to rest in a neutral position on the trunk would prevent narrowing of the upper airway and thus reduce oxygen desaturation in preterm infants who are restrained in car seats.

Methods. Seventeen preterm infants who were approved for discharge were evaluated in a car seat for newborns, with and without a foam insert that provided a slot for the back of the infants’ head. Respiration timed inspiratory radiographs for assessment of upper airway dimensions were taken during quiet sleep in each position. Infants were monitored in each position for 30 minutes with continuous polygraphic recording of respiratory, cardiac, and nasal airflow activity and pulse oximetry.

Results. Placement of the insert in the car seat was associated with a larger upper airway space (mean ± standard deviation, 5.2 ± 1.3 vs 3.6 ± 1.4 mm). This radiologic improvement was associated with a significant reduction in the frequency of episodes of oxygen desaturation to <85% (1.5 ± 2.1 vs 3.5 ± 3.5 episodes/infant), of bradycardia <90 bpm (0.1 ± 0.3 vs 1 ± 1.7), and of arousal (median [25th, 75th], 2.5 [1.3, 4.0] vs 5.0 [4.0, 7.0]).

Conclusions. The cause of oxygen desaturation in preterm infants who are restrained in car seats is multifactorial. The present data strongly support the hypothesis that flexion of the head on the body is a significant contributor to these episodes and that the mechanism is posterocephalic displacement of the mandible, leading to narrowing of the upper airway. Critically, this pilot study demonstrates that the frequency of episodes of desaturation in a standard newborn car seat can be substantially reduced by placement of a simple foam insert that allows the infant to maintain the head in a neutral position on the trunk during sleep.
Reducing Acute Adverse Outcomes in Youths With Type 1 Diabetes: A Randomized, Controlled Trial
Authors: Svoren Britta M. , Butler Deborah , Levine Bat-Sheva , Anderson Barbara J. , Laffel Lori M. B.
Published: August 2004

Objective. Both acute and chronic complications of diabetes account for a disproportionate percentage of US health care expenditures. Despite improvements in diabetes care, the incidence of adverse events in children with type 1 diabetes remains high, particularly for youths with poor glycemic control. Cost-effective intervention programs designed to reduce complications are needed. This study evaluated a low-intensity, nonmedical intervention using a case manager (called a “Care Ambassador”), with and without the supplementation of psychoeducational modules, designed to monitor and encourage routine diabetes care visits to reduce short-term adverse outcomes and improve glycemic control in youths with type 1 diabetes.

Methods. We performed a 2-year prospective, randomized clinical trial in 299 youths with type 1 diabetes, aged 7 to 16 years, comparing 3 treatment programs (Care Ambassador [CA], Care Ambassador plus psychoeducational modules [CA+], and standard multidisciplinary diabetes care [SC]). The study was conducted in a large metropolitan US city from April 1997 through April 2000. Number of medical visits, frequency of hypoglycemic events, hospital/emergency department (ED) utilization, and glycosylated hemoglobin A1c were assessed during follow-up.

Results. During the 2-year study period, both the CA and CA+ groups had significantly more routine visits (mean [standard deviation]: 7.3 [2.06] and 7.5 [2.02], respectively) compared with the SC group (5.4 [2.62]). The CA+ intervention group had significantly reduced rates of short-term adverse outcomes compared with the other 2 groups; 25% fewer total hypoglycemic events, 60% fewer severe hypoglycemic events, and 40% fewer hospitalizations and ED visits. “High-risk” youths in the CA+ group (baseline glycosylated hemoglobin A1c ≥8.7%) were 3.4-fold (1.57–7.41) more likely to improve their glycemic control compared with those at high risk in the other 2 groups.

Conclusions. For youths with type 1 diabetes, the CA and CA+ interventions increased visit frequency. Youths in the CA+ intervention had reduced rates of hypoglycemia and hospital/ED utilization with estimated annual cost savings of $80 000 to $90 000. The CA+ intervention compared with the other 2 groups improved glycemic control in “high-risk” youths. Nonmedical case management incorporating psychoeducational modules seems to be a cost-effective approach to improving outcomes in youths with diabetes.
Congenital Hypothyroidism: Influence of Disease Severity andl-Thyroxine Treatment on Intellectual, Motor, and School-Associated Outcomes in Young Adults
Authors: Oerbeck Beate , Sundet Kjetil , Kase Bengt F. , Heyerdahl Sonja
Published: August 2004

Objective. To describe intellectual, motor, and school-associated outcome in young adults with early treated congenital hypothyroidism (CH) and to study the association between long-term outcome and CH variables acting at different points in time during early development (CH severity and early l-thyroxine treatment levels [0–6 years]).

Methods. Neuropsychological tests were administered to all 49 subjects with CH identified during the first 3 years of the Norwegian neonatal screening program (1979–1981) at a mean age of 20 years and to 41 sibling control subjects (mean age: 21 years).

Results. The CH group attained significantly lower scores than control subjects on intellectual, motor, and school-associated tests (total IQ: 102.4 [standard deviation: 13] vs 111.4 [standard deviation: 13]). Twelve (24%) of the 49 CH subjects had not completed senior high school, in contrast to 6% of the control subjects. CH severity (pretreatment serum thyroxine [T4]) correlated primarily with motor tests, whereas early l-thyroxine treatment levels were related to verbal IQ and school-associated tests. In multiple regression analysis, initial l-thyroxine dose (β = 0.32) and mean serum T4 level during the second year (β = 0.48) predicted Verbal IQ, whereas mean serum T4 level during the second year (β = 0.44) predicted Arithmetic.

Conclusions. Long-term outcome revealed enduring cognitive and motor deficits in young adults with CH relative to control subjects. Verbal functions and Arithmetic were associated with l-thyroxine treatment variables, suggesting that more optimal treatment might be possible. Motor outcome was associated with CH severity, indicating a prenatal effect.
Adolescent Assault Injury: Risk and Protective Factors and Locations of Contact for Intervention
Authors: Cheng Tina L. , Schwarz Donald , Brenner Ruth A. , Wright Joseph L. , Fields Cheryl B. , O’Donnell Regina , Rhee Peter , Scheidt Peter C.
Published: August 2004

Background. Violence is a large contributor to morbidity and mortality among adolescents. Most studies assessing markers for violent injury are cross-sectional. To guide intervention, we conducted a case-control study to explore factors associated with assault injury and locations to reach at-risk adolescents.

Objective. 1) To assess risk and protective factors for adolescent assault injury compared with 2 control groups of youth with unintentional injuries and noninjury complaints presenting to the emergency department and 2) to assess locations of contact with assault-injured youth for prevention programs.

Methods. Face-to-face and phone interviews were conducted with systematic samples of youth aged 12 to 19 years presenting to the emergency department with assault injury, unintentional injury, and noninjury complaints. Youth with intentional injuries were matched to youth in the 2 control groups on age ±1 year, gender, race, and residency.

Results. One hundred forty-seven 147 assault-injured youth completed interviews. One hundred thirty-three assault-injured youth were matched to 133 unintentionally injured and 133 noninjured youth presenting to the emergency department. Compared with the 2 control groups, assault-injured youth were more likely to have had more fights in the past year (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 2.02, 7.58; OR: 4.00; 95% CI: 2.23, 7.18) and fights requiring medical treatment (OR: 35.49; 95% CI: 8.71, 144.68; OR: 80.00; 95% CI: 11.13, 574.80). Eighty percent of assault-injured youth had been in 1 or more fights in the last 12 months compared with 55% and 46% in unintentional and noninjured controls, respectively. Assault-injured youth were more likely to have had previous weapon injuries (OR: 9.50; 95% CI: 3.39, 26.6; OR: 8.50; 95% CI: 3.02, 23.95) and have seen someone shot (OR: 2.00; 95% CI 1.12, 3.58; OR: 2.00; 95% CI: 1.12, 3.58). Eighty-six percent of assault-injured youth had a regular health care provider with 82% reporting a visit within the last year. There were no differences between cases and controls with regard to physician contact, extracurricular activity involvement, school or church attendance, police contact, weapon access or weapon-carrying, or witnessing nonweapon-related violence.

Conclusions. Fighting was common among all groups. Assault-injured youth were more likely to have had previous weapon injuries and were high-risk for future injury. Past fights, past fight injuries, and seeing someone else shot were markers associated with assault injury. Health providers do have access to at-risk teens for clinical risk assessment and intervention.
Constipation With Acquired Megarectum in Children With Autism
Authors: Afzal Nadeem , Murch Simon , Thirrupathy Kumran , Berger Leslie , Fagbemi Andrew , Heuschkel Robert
Published: August 2004

Objective. Recent evidence suggests that autistic children may have significant gastrointestinal symptoms. Although constipation occurs in 2% to 5% of healthy children, its clinical diagnosis is often difficult in children with behavioral disorders. We thus aimed to assess the prevalence of fecal loading in autistic children with gastrointestinal symptoms and to identify possible predictors of constipation.

Methods. We studied abdominal radiographs of 103 autistic children (87 boys) who were referred for gastroenterological assessment, in comparison with 29 control radiographs from children who were referred to the emergency department, most with abdominal pain. Radiographs were scored independently, in blinded manner, by 4 pediatric gastroenterologists and a radiologist. The severity of constipation was determined using a validated index. Details of stool habit, abdominal pain, dietary history, and laxative use were obtained from case notes.

Results. The incidence of constipation in the control subjects with abdominal pain was higher than reported for normal children. Despite this, moderate or severe constipation was more frequent in the autistic group than in the control subjects (36% vs 10%). Analysis of rectosigmoid loading showed more striking differences (54.4% of autistic children had moderate/severe loading or acquired megarectum compared with 24.1% of control subjects). Multivariate regression analysis showed consumption of milk to be the strongest predictor of constipation in the autistic group, whereas stool frequency, gluten consumption, soiling, and abdominal pain were not predictive of constipation.

Conclusions. Constipation is a frequent finding in children with gastrointestinal symptoms and autism, particularly in the rectosigmoid colon, often with acquired megarectum. The absence of any correlation between the clinical history and the degree of fecal impaction in autistic children confirms the importance of an abdominal radiograph in the assessment of their degree of constipation.
School-Age Outcomes in Children Who Were Extremely Low Birth Weight From Four International Population-Based Cohorts
Authors: Saigal Saroj , Ouden Lya den , Wolke Dieter , Hoult Lorraine , Paneth Nigel , Streiner David L. , Whitaker Agnes , Pinto-Martin Jennifer
Published: August 2004

Objective. The aim of this study was to determine whether learning and school problems in extremely low birth weight (ELBW) and reference children differ between cohorts in different countries.

Methods. Participants were 4 international population-based cohorts of ELBW survivors who were 500 to 1000 g birth weight from New Jersey, central-west Ontario, Bavaria, and Holland (n = 532) and were followed longitudinally from birth. Psychometric data were collected independently and prospectively and included at least 1 measure of cognitive status and 1 measure of achievement administered to the children between the ages of 8 and 11 years. Adjustments were made for comparison of all measures based on reference norms within each country. Information on special educational assistance and grade repetition was obtained from the parents.

Results. The overall follow-up rate was 84% (range: 74%–90%; n = 436). The proportion of children who performed within the normal range (≥85) were as follows: IQ between 44% and 62%; reading between 46% and 81%; arithmetic between 31% and 76%; and spelling between 39% and 65%. Children from New Jersey had the lowest rates of cognitive and achievement deficits, and Bavarian children did less well in achievement scores relative to their peers and other cohorts. Despite these differences, more than half of all cohorts required special educational assistance and/or repeated a grade.

Conclusions. School difficulties were found to be a serious sequelae of ELBW in all 4 countries, an observation that has social and economic implications.
Computed Tomography and Radiation Risks: What Pediatric Health Care Providers Should Know
Authors: Frush Donald P. , Donnelly Lane F. , Rosen Nancy S.
Published: August 2004

Computed tomography (CT) is an extremely valuable diagnostic tool. Recent advances, particularly multidetector technology, have provided increased and more diverse applications. However, there is also the potential for inappropriate use and unnecessary radiation dose. Because some data indicate that low-dose radiation (such as that in CT) may have a significant risk of cancer, especially in young children, it is important to limit CT radiation by following the ALARA (as low as reasonably achievable) principle. There is a variety of strategies to limit radiation dose, including performing only necessary examinations, limiting the region of coverage, and adjusting individual CT settings based on indication, region imaged, and size of the child. The pediatric health care provider has a pivotal role in the performance of CT and may be the only individual who discusses these important CT radiation issues with the child and family. For this reason, this article will summarize the issues with CT patterns of use and radiation risk, and provide dose reduction strategies pertinent to pediatric health care providers.
Bullous Myringitis: A Case-Control Study
Authors: McCormick David P. , Saeed Kokab A. , Pittman Carmen , Baldwin Constance D. , Friedman Norman , Teichgraeber Davis C. , Chonmaitree Tasnee
Published: August 2004

Prior studies have shown that bullous myringitis (BM) accounts for <10% of acute otitis media (AOM) cases, and that the distribution of viral and bacterial pathogens in BM is similar to that in AOM without BM, except for a relative increase in the proportion of Streptococcus pneumoniae in BM. We studied 518 cases of AOM in children aged 6 months to 12 years. Using tele-otoscopy to assist the diagnosis, we identified 41 cases (7.9%) with BM. Children who had AOM with BM were older than AOM patients without BM (median age: 4.3 years vs 18 months). We compared 41 cases of AOM with BM to 41 control cases of age-, race-, and gender-matched AOM patients without BM. When compared with this matched control group, children with BM had more severe symptoms at the time of diagnosis and were more likely to have bulging of the tympanic membrane in the quadrants that were not obscured by the bulla. Children with AOM and BM may require aggressive pain management. Although parents and clinicians may agree that a watchful waiting approach is appropriate for older children with mild AOM, children experiencing painful AOM with BM may not be successful candidates for a watchful-waiting approach, because parents may resist postponement of antibiotic therapy in children who are more symptomatic.
Longstanding Obliterative Panarteritis in Kawasaki Disease: Lack of Cyclosporin A Effect
Authors: Kuijpers Taco W. , Biezeveld Maarten , Achterhuis Annemiek , Kuipers Irene , Lam Jan , Hack C. E. , Becker Anton E. , van der Wal Allard C.
Published: August 2004

Kawasaki disease is a childhood vasculitis of medium-sized vessels, affecting the coronary arteries in particular. We have treated a therapy-resistant child who met all diagnostic criteria for Kawasaki disease. After the boy was given intravenous immunoglobulins and salicylates, as well as several courses of pulsed methylprednisolone, disease recurred and coronary artery lesions became progressively detectable. Cyclosporin A was started and seemed clinically effective. In contrast to the positive effect on inflammatory parameters, ie, C-reactive protein and white blood cell counts, a novel plasma marker for cytotoxicity (granzyme B) remained elevated. Coronary disease progressed to fatal obstruction and myocardial infarction. Echocardiography, electrocardiograms, and myocardial creatine phosphokinase did not predict impending death. At autopsy an obliterative panarteritis was observed resulting from massive fibrointimal proliferation, affecting the aorta and several large and medium-sized arteries. Immunophenotypic analysis of the inflammatory infiltrates in arteries revealed mainly granzyme-positive cytotoxic T cells and macrophages in the intima and media, as well as nodular aggregates of T cells, B cells, and plasma cells in the adventitia of affected arteries. These findings further endorse the role of specific cellular and humoral immunity in Kawasaki disease. Unremitting coronary arteritis and excessive smooth muscle hyperplasia resulted in coronary occlusion despite the use of cyclosporin A.
Increasing Immunization Coverage
Authors:   Committee on Community Health Services and Committee on Practice and Ambulatory Medicine
Published: August 2004

Despite many recent advances in vaccine delivery, the goal for universal immunization set in 1977 has not been reached. In 2001, only 77.2% of US toddlers 19 to 35 months of age had received their basic immunization series of 4 doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine, 3 doses of inactivated poliovirus vaccine, 1 dose of measles-mumps-rubella (MMR) vaccine, and 3 doses of Haemophilus influenzae type b (Hib) vaccine. Children who are members of a racial or ethnic minority, who are poor, or who live in inner-city or rural areas have lower immunization rates than do children in the general population. Additional challenges to vaccine delivery include the introduction of new childhood vaccines, ensuring a dependable supply of vaccines, bolstering public confidence in vaccine safety, and sufficient compensation for vaccine administration.

Recent research has demonstrated specific and practical changes physicians can make to improve their practices’ effectiveness in immunizing children, including the following: 1) sending parent reminders for upcoming visits and recall notices; 2) using prompts during all office visits to remind parents and staff about immunizations needed at that visit; 3) repeatedly measuring practice-wide immunization rates over time as part of a quality improvement effort; and 4) having in place standing orders for registered nurses, physician assistants, and medical assistants to identify opportunities to administer vaccines. Pediatricians should work individually and collectively at local and national levels to ensure that all children receive all childhood immunizations on time. Pediatricians also can proactively communicate with parents to ensure they understand the overall safety and efficacy of vaccines.
Principles of Child Health Care Financing
Authors:   Committee on Child Health Financing
Published: August 2004

Child health care financing must maximize access to quality, comprehensive pediatric and prenatal health care. This policy statement replaces the 1998 policy statement by the same title. Changes reflect recent state and federal legislation that affect child health care financing. The principles outlined in the statement will be used to evaluate the changing structure of child health care financing.
Infants Born to Mothers With Severe Acute Respiratory Syndrome
Authors: Shek Chi C. , Ng Pak C. , Fung Genevieve P. G. , Cheng Frankie W. T. , Chan Paul K. S. , Peiris Malik J. S. , Lee Kim H. , Wong Shell F. , Cheung Hon M. , Li Albert M. , Hon Ellis K. L. , Yeung Chung K. , Chow Chun B. , Tam John S. , Chiu Man C. , Fok Tai F.
Published: August 2004

Severe acute respiratory syndrome (SARS) is a newly discovered infectious disease caused by a novel coronavirus. During the community outbreak in Hong Kong, 5 liveborn infants were born to pregnant women with SARS. A systematic search for perinatal transmission of the SARS-associated coronavirus, including serial reverse transcriptase-polymerase chain reaction assays, viral cultures, and paired serologic titers, failed to detect the virus in any of the infants. In addition, none of the infants developed clinical, radiologic, hematologic, or biochemical evidence suggestive of SARS. One preterm infant developed jejunal perforation and another developed necrotizing enterocolitis with ileal perforation shortly after birth. This case series is the first report to describe the clinical course of the first cohort of liveborn infants born to pregnant women with SARS.