bluuebunny/crossref_metadata_2025 huggingface dataset:
The University of Massachusetts Medical Center Office-based Continuity Experience: Are We Preparing Pediatrics Residents for Primary Care Practice?
Authors: Roberts Kenneth B. , Starr Susan , DeWitt Thomas G.
Published: August 2004

Objective. Surveys of residency graduates and employers have suggested that residency programs do not prepare residents well for practice. Since 1988, pediatric residents at the University of Massachusetts have been paired one-on-one with an office-based pediatrician for their 3-year continuity experience. This survey was conducted to determine if graduates of such a program are prepared to enter pediatric practice.

Methodology. Graduates of the program from 1991 through 1995 who entered primary care practice were surveyed about their preparedness for practice. The questionnaire was also sent to the residents' first employers. The 32 questions were directed to overall sense of preparedness, ability to manage the pace of practice, common illnesses, common behavior problems, anticipatory guidance, office management, and subspecialty problems.

Results. Data from all 25 residents who entered practice and the employers of 20 of the 25 residents were obtained and analyzed. Both groups rated overall resident preparedness to be “well-prepared” or “very well-prepared” and gave high scores on working at the pace of practice, diagnosing and treating common illnesses, diagnosing and treating common behavior problems, and providing anticipatory guidance. Areas in which residents were considered to be less well-prepared included anticipatory guidance about nutrition, managing problems by telephone, office management, gynecology, and orthopedics.

Conclusions. The results suggest that continuity experiences in office practices are associated with preparation for the pace and types of visits that occur commonly in primary care practice, abilities which previous surveys of residency alumni and employers have found lacking. Some areas may benefit from a formal curriculum which may be implemented in the office practice, at the medical center, or at both sites. Preceptors may benefit from faculty development and continuing medical education that is directed not only at teaching skills but also at content areas which were not addressed in their own residencies.
A Prospective Randomized Trial of Feeding Methods in Very Low Birth Weight Infants
Authors: Akintorin Subuola M. , Kamat Medha , Pildes Rosita S. , Kling Patricia , Andes Steven , Hill Joan , Pyati Suma
Published: August 2004

Objective. To test the hypothesis that very low birth weight infants fed by continuous nasogastric gavage (CNG) would achieve full enteral feedings (100 kcal/kg/d) at an earlier postnatal age and have less feeding intolerance (FI) than infants fed by intermittent bolus gavage (IBG).

Methods. Eighty infants were stratified by birth weight (700 to 1000 g and 1001 to 1250 g) and randomized into CNG or IBG feeding groups. CNG infants were comparable with IBG in birth weight, gestational age, sex, race, and day of onset of feeding (5.7 ± 2.1 days vs 5.6 ± 2.2 days, respectively). Feedings were given as undiluted Similac Special Care formula (Ross Laboratories, Columbus, OH) via a specific protocol designed for each 50 to 100 g birth weight category. Feedings were advanced isoenergetically by a maximum of 25 mL/kg/d until an endpoint of 100/kcal/kg/d for at least 48 hours was reached. An infant whose feedings were withheld for >12 hours based on predetermined criteria was considered to have an episode of FI.

Results. Infants in the CNG group reached full enteral feeding at 17.1 ± 8.9 days compared with 15.5 ± 5.5 days in the IBG group; these were not statistically different. Secondary outcome variables such as days to regain birth weight (CNG, 12.6 ± 5 days vs IBG, 12.5 ± 3.7 days), days to reach discharge weight of 2040 g (CNG, 60 ± 13.4 days vs IBG, 62 ± 13.6 days), and number of episodes of FI were not significantly different between feeding methods. FI was primarily associated with birth weight ≤1000 g (71%) vs 1001 to 1250 g (38%).

Conclusion. Feeding methods are associated with similar outcomes when feeding regimens are comparable.
Two Cases of Incontinentia Pigmenti Simulating Child Abuse
Authors: Ciarallo Lydia , Paller Amy S.
Published: August 2004

In the United States 1.4 million children were maltreated in 1988, resulting in an estimated 2000 to 5000 deaths.1Largely due to the rising awareness and sensitivity to the horrors of child abuse, the number of deaths declined to approximately 1500 in 1993.2 Guidelines have been published to aid in the identification and management of child maltreatment,3 and reporting of all suspicious cases is mandated by law. In our zealous efforts to protect children, some families are investigated because of misdiagnosed abnormalities, often cutaneous,4 leading to the unintentional injury of both patients and their families.5

In this report, we describe two patients with cutaneous and/or visceral manifestations of incontinentia pigmenti (IP) who were initially thought to be victims of child abuse.
Regulation of Growth of 7- to 36-Month-Old Children by Energy and Fat Intake in the Prospective, Randomized STRIP Baby Trial
Authors: Niinikoski Harri , Viikari Jorma , Rönnemaa Tapani , Helenius Hans , Jokinen Eero , Lapinleimu Helena , Routi Taina , Lagström Hanna , Seppänen Ritva , Välimäki Ilkka , Simell Olli
Published: August 2004

Objective. To study the fat and energy intakes of children between 7 and 36 months of age with different growth patterns.

Methods. In the Special Turku coronary Risk factor Intervention Project for Babies, children were randomized to intervention (n = 540) and control groups (n = 522) at age 7 months. The intervention was aimed at replacing part of the saturated fat intake with monounsaturated and polyunsaturated fat to reduce children's exposure to high serum cholesterol values. The control children consumed a free diet. Children followed for >2 years (n = 848) were included in the analysis. Five groups of children representing different extreme growth patterns during the first 3 years of life were formed, and their energy and fat intakes were analyzed. Relative weight was defined as deviation of weight in percentages from the mean weight of healthy children of same height and sex, and relative height as deviation of height in SD units from the mean height of healthy children of same age and sex.

Results. Relative fat intakes (as percent of energy intake) were similar in children showing highly different height gain patterns. The thin (mean relative weight ≤ 5%) children consumed more fat (mean, 30% energy [ E%] [SD 7] at 13 months and 33 [4] E% at 24 months) than children with normal growth (27 [5] E% at 13 months and 31 [5] E% at 24 months). The energy intake of the tall (mean relative height ≥ 95%) and the obese (mean relative weight ≥ 95%) were highest, but weight-based energy intake of the tall (at 2 years, 82 [13] kcal/kg) and the obese (79 [17] kcal/kg) were lower than that of children with normal growth (89 [16] kcal/kg). The thin children consumed relatively more energy than the children with normal growth (at 2 years, 94 [13] kcal/kg and 89 [16] kcal/kg, respectively). Parental height and body mass index and the child's absolute and relative energy intakes predicted the best children's growth patterns. Children with consistently low fat intake grew equally to the children with higher fat intake.

Conclusions. Moderate supervised restriction of fat intake to values 25 to 30 E% is compatible with normal growth.
Infant Arousals During Mother-Infant Bed Sharing: Implications for Infant Sleep and Sudden Infant Death Syndrome Research
Authors: Mosko Sarah , Richard Christopher , McKenna James
Published: August 2004

Objective. Normative values for infant sleep architecture have been established exclusively in the solitary sleeping environment. However, most of the world's cultures practice some form of parent-infant cosleeping. In addition, no previous polysomnographic studies in infants examined the frequency of electroencephalogram (EEG) arousals. This is the first study to assess (a) EEG arousals in infants and their relationship to sleep stages; (b) the impact on arousals of mother-infant bed sharing; and (c) the temporal overlap of infant with maternal arousals during bed sharing.

Methodology. Three nights of polysomnography were performed in 35 breastfeeding mother-infant pairs when the infants were 11 to 15 weeks old. An adaptation night was followed by one bed sharing night and one solitary sleeping night. Twenty infants had been bed sharing since birth and 15 were routine solitary sleepers. Both epochal awakenings (EWs), based on 30-second epoch scoring of sleep-wake stages, and more transient arousals (TAs) ≥3 seconds were quantified.

Results. Stage 3–4 sleep was associated with a striking paucity of EWs and TAs compared with stages 1–2 or rapid eye movement sleep. Bed sharing facilitated EWs and TAs selectively during stage 3–4 sleep. EWs from stage 3–4 sleep were more frequent on the bed sharing night than on the solitary night in both infant groups. Routinely bed sharing infants also exhibited more frequent TAs in stage 3–4 than the routine solitary sleepers in both conditions. In both groups, the number of infant arousals (EWs + TAs) that overlapped the mother's was doubled during bed sharing, with infant arousals leading most often.

Conclusions. Mother-infant bed sharing promotes infant arousals. Together with a previous report that bed sharing reduces stage 3–4 sleep, this suggests that normative values for infant sleep must be interpreted within the context of the sleeping environment in which they were established. Given that arousability is diminished in stage 3–4, we speculate that, under otherwise safe conditions, the observed changes in stage 3–4 sleep and arousals associated with bed sharing might be protective to infants at risk for SIDS because of a hypothesized arousal deficit. The responsivity of the mother to infant arousals during bed sharing might also be protective.
War Experiences and Distress Symptoms of Bosnian Children
Authors: Goldstein Richard D. , Wampler Nina S. , Wise Paul H.
Published: August 2004

Objective. The war in Bosnia has had a tremendous impact on civilians. Little is known about the impact of modern warfare on children. This survey documents the nature and frequency of war-related experiences among Bosnian children and describes their manifestations of selected psychological sequelae.

Methods. A cross-sectional survey of 364 internally displaced 6- to 12-year-old children and their parents living in central Bosnian collectives was conducted during the war. Parents were surveyed for their children's war experiences; the children were surveyed for war-related distress symptoms.

Results. The children were exposed to virtually all of the surveyed war-related experiences. The majority had faced separations from family, bereavement, close contact with war and combat, and extreme deprivation. The prevalence and severity of experiences were not significantly related to a child's gender, wealth, or age, but were related to their region of residence, with children from the region of Sarajevo having the highest prevalence of experiences. Almost 94% of the children met Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria for posttraumatic stress disorder. Significant life activity affecting sadness and anxiety were reported by 90.6% and 95.5% of the children, respectively. High levels of other symptoms surveyed were also found. Children with greater symptoms had witnessed the death, injury, or torture of a member of their nuclear family, were older, and came from a large city.

Conclusions. The war-related experiences of the children studied were both varied and severe, and were associated with a variety of psychological sequelae. This experience underscores the vulnerability of civilians in areas of conflict and the need to address the effects of war on the mental health of children.
The Effect of Recombinant Human Growth Hormone in Children With X-Linked Hypophosphatemia
Authors: Seikaly Mouin G. , Brown Richard , Baum Michael
Published: August 2004

Background. X-linked hypophosphatemia (XLH) is characterized clinically by rickets and growth retardation. Conventional treatment of XLH with oral phosphate and vitamin D fails to normalize linear growth.

Objective. To determine the benefit and the potential side effects of recombinant human growth hormone (rhGH) therapy in patients with XLH.

Design and Methods. A randomized, double-blind, crossover study was performed throughout a 24-month period in five children with XLH, each patient serving as his own control. The effect of 12 months of rhGH therapy on height, mineral metabolism, glucose and lipid metabolism, hemoglobin, thyroid and parathyroid function, serum 1,25-(OH)2 vitamin D, osteocalcin, growth hormone, urinary calcium, phosphate, nephrocalcinosis, renal function, and bone density was compared with the effects of 12 months of placebo administration on the same parameters.

Results. The average age (mean ± SEM) of the patients at the start of the study was 5.6 ± 1.4 years. Growth hormone therapy improved the height standard deviation score (z-score) from a baseline of −2.66 ± 0.21 to −2.02 ± 0.25 and to −1.46 ± 0.28, after 3 and 12 months, respectively. At the start of the control period the heightz-score was −2.27 ± 0.30 compared with −2.22 ± 0.16 after 12 months of placebo administration. The growth velocity standard deviation score was −1.90 ± 0.40 during the 12 months of placebo administration and +4.04 ± 1.50 during the 12 months of rhGH therapy. An increase in serum phosphate from 0.88 ± 0.07 mmol/L to 1.17 ± 0.14 mmol/L and tubular maximum for phosphate reabsorption (TmP/GFR) from 2.12 ± 0.15 to 3.41 ± 0.25 mg/dL, was observed after 3 months of rhGH therapy. However, both serum phosphate and TmP/GFR were unchanged from baseline after 6, 9, and 12 months of rhGH therapy. Neither serum phosphate nor TmP/GFR changed from baseline during the placebo administration. Insulin-like growth factor 1 (IGF-1) increased from 114 ± 25 to 354 ± 51 ng/mL after 12 months of rhGH therapy. Despite the increase in IGF-1 after rhGH therapy, the value did not exceed normal serum concentration. IGF-1 did not change from baseline after 12 months of placebo administration. Neither therapy with rhGH nor with placebo had an effect on glucose and lipid metabolism, hemoglobin, thyroid and parathyroid function, serum 1,25-(OH)2 vitamin D, alkaline phosphatase, osteocalcin, urinary calcium excretion, the grade of nephrocalcinosis, glomerular filtration rate, or urinary albumin excretion. Twelve months of rhGH therapy increased bone mass and width but not density. Twelve months of placebo administration had no effect on bone mass, width, or density.

Conclusion. Patients with XLH have an improvement in linear growth and a transient increase in serum phosphate attributable to a transient decrease in urinary phosphate excretion when treated with rhGH.
Oral Rehydration Therapy for Diarrhea: An Example of Reverse Transfer of Technology
Authors: Santosham Mathuram , Keenan Edward Maurice , Tulloch Jim , Broun Denis , Glass Roger
Published: August 2004

On November 13 and 14, 1996, a scientific symposium on oral rehydration therapy (ORT) was held at the Johns Hopkins University School of Hygiene and Public Health in Baltimore, MD. The purpose of the meeting was to review the current treatment practices for the treatment of this disease in the United States. The group noted that diarrhea resulted in 300 to 400 deaths per year among children, ∼︀200 000 hospitalizations, 1.5 million outpatient visits, and costs >$1 billion in direct medical costs.

ORT is well established therapy for the treatment and prevention of dehydration due to diarrhea. The principles of ORT treatment include early adequate rehydration therapy using an appropriate oral rehydration solution (ORS), replacement of ongoing fluid losses from vomiting and diarrhea with ORS, and frequent feeding of appropriate foods as soon as dehydration is corrected.

The effective use of ORT has saved millions of lives around the world. However, in the United States, ORT is grossly underused. Contrary to the recommendations of the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC), health care providers overuse intravenous hydration, prolong rehydration, delay reintroduction of feeding, and inappropriately withhold ORT, especially with children who are vomiting.

The expert panel noted that the majority of deaths, hospitalization, and visits to emergency departments could be prevented by the appropriate use of ORT. They generated guidelines for the treatment and prevention of dehydration secondary to diarrhea. These measures, together with training providers, could substantially reduce diarrhea mortality and decrease hospitalizations of children by 100 000 per year in the next 5 years.
Acquisition ofPseudomonas aeruginosain Children With Cystic Fibrosis
Authors: Farrell Philip M. , Shen Guanghong , Splaingard Mark , Colby Christopher E. , Laxova Anita , Kosorok Michael R. , Rock Michael J. , Mischler Elaine H.
Published: August 2004

Objective. This study was pursued as an extension of a randomized clinical investigation of neonatal screening for cystic fibrosis (CF). The project included assessment of respiratory secretion cultures for pathogens associated with CF. The objective was to determine whether patients diagnosed through neonatal screening and treated in early infancy were more likely to become colonized with Pseudomonas aeruginosa compared with those identified by standard diagnostic methods.

Methodology. The design involved prospective cultures of respiratory secretions obtained generally by oropharyngeal swabs at least every 6 months and more often if clinically indicated. Patients were managed with a standardized evaluation and treatment protocol at the two Wisconsin certified CF centers; however, there were community and environmental variations associated with the follow-up period as described below.

Results. Overall, there were no differences in acquisition of respiratory pathogens between the screened and the control (standard diagnosis) groups. Evaluation of the data between and within the two centers, however, revealed significant differences with earlier acquisition of P aeruginosa in the center with the following distinguishing characteristics: urban location; following patients with the standard US approach in which newly diagnosed, young children were interspersed with older CF patients; and where there were more opportunities for social interactions with other CF patients. The differences were confined to the screened group followed in the urban center in which the median pseudomonas-free survival period was 52 weeks contrasted with 289 weeks in the other center. In addition, assessment of data for the entire CF populations followed at the two centers revealed that the urban center showed a significantly higher prevalence of P aeruginosa colonization in patients between the ages of 3 and 9 years.

Conclusions. These results present questions and generate hypotheses on risk factors for acquisition of P aeruginosain CF and suggest that clinic exposures and/or social interactions may predispose such patients to pseudomonas infections.
Vitamin–Mineral Supplement Use Among Preschool Children in the United States
Authors: Yu Stella M. , Kogan Michael D. , Gergen Peter
Published: August 2004

Objective. To estimate the prevalence of recent supplement use in a national sample of preschool children and to examine the relationship of maternal and child characteristics, past maternal supplement use practices, familial, health services, and child health factors associated with supplement use.

Methods. We used data on 8285 preschool children whose mothers were interviewed for the 1991 Longitudinal Follow-up to the 1988 National Maternal and Infant Health Survey. Data collection was conducted either by telephone or personal interview. The sample is representative of the estimated 3.8 million US born children in 1988 and alive in 1991. The outcome measures are whether the child was given any vitamin and mineral supplements at least 3 days a week in the 30 days before the interview and the type of supplement received. Statistical techniques included bivariate and weighted multiple logistic regression analysis.

Results. More than half of all US 3-year-olds (54.4%) were given some vitamin and mineral supplement. The most common supplements consumed were multivitamin–mineral with iron (59% of supplement users) and multivitamin–mineral without iron (26.4%). Children who received any supplements tended to have mothers who are non-Hispanic White, older, more educated, married, insured, receiving care from a private health care provider, have greater household income, and took supplements during pregnancy. Child health characteristics associated with supplement use included first birth order and having eating problems or poor appetites.

Conclusions. More than half of US preschool children used vitamin and mineral supplements. The sociodemographic and health predictors identified for supplement use suggest that groups at risk for nonuse are likely the same groups whose circumstances may predispose a need for supplementation.
Time for a New Growth Reference
Authors: de Onis Mercedes , Garza Cutberto , Habicht Jean-Pierre
Published: August 2004

The National Center for Health Statistics growth reference, recommended by the World Health Organization for international use since the late 1970s, has served many useful purposes. Among the most important are the provision of a single set of growth references for the assessment of the general nutritional status of populations of children in diverse settings, as an ancillary tool to screen children for health and nutrition disorders, and as a basis for educational materials that promote improved child care by families. However, because of serious drawbacks due to the origin and type of data used for their construction and the analytical methods applied in their derivation, the suitability of these curves for international purposes has been challenged recently.
Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through Age 21 Years
Authors:   Committee on Child Health Financing
Published: August 2004

The optimal health of children can best be achieved by providing access to comprehensive health care benefits. This policy statement replaces the 1993 statement, “Scope of Health Care Benefits for Infants, Children, and Adolescents Through Age 21 Years.” Changes involve services and procedures specific to the delivery of comprehensive preventive, prenatal, postnatal, and mental health care. These services should be delivered by appropriately trained and board-eligible/certified pediatric providers, including primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists.
Screening Dipstick Urinalysis: A Time to Change
Authors: Kaplan Robert E. , Springate James E. , Feld Leonard G.
Published: August 2004

Objective. This study attempted to determine the minimal cost of screening dipstick urinalyses in a hypothetical cohort of 2000 asymptomatic pediatric patients in a primary care setting.

Methodology. The minimal cost utilizing a private practitioner in an urban or suburban group pediatric setting was calculated. Costs were determined by using current charges for supplies ordered to perform tests in the office, charges for tests performed by a commercial laboratory, and the cost of an initial evaluation by a pediatric nephrologist. Data from published studies were also utilized.

Results. Nine percent (179/2000) of patients were calculated to have an initial abnormal urinalysis. Upon retesting only 1.5% (29/2000) of patients were calculated to have a persistent abnormality. The calculated rate of a false positive/transient abnormality for all patients in the hypothetical cohort of 2000 asymptomatic pediatric patients was 84% (150/179). The calculated minimal cost for the outpatient evaluation of 2000 asymptomatic pediatric patients by dipstick urinalyses ranged between $5022 to $6475. The range depends on whether 50% versus 100% of patients with a repeat abnormal dipstick urinalysis were referred to a pediatric nephrologist for further evaluation. The calculated cost was $1290 to initially screen all 2000 patients with a dipstick urinalysis or 65 cents per patient. The calculated cost to evaluate the 29 patients with any persistent abnormality on repeat dipstick urinalysis was $3732 to $5185 or $129 to $179 per patient. This is the calculated cost for a single screening of 2000 asymptomatic pediatric patients. The calculated cost for four multiple screening urinalyses as currently recommended is $20 088 to $25 900. Additionally, these are only minimal initial calculated costs. Costs of any renal imagining or function studies ordered by the pediatric nephrologist or the pediatrician pursuing a further evaluation on his/her own were not included.

Conclusion. Multiple screening dipstick urinalyses in asymptomatic pediatric patients are costly and should be discontinued. In their place, we propose that a single screening dipstick urinalysis be obtained at school entry age, between 5 and 6 years old, in all asymptomatic children. The sample should be a first morning void.
Factors Affecting the Decision to Seek Health Care: The Voice of Adolescents
Authors: Ginsburg Kenneth R. , Menapace Adrian S. , Slap Gail B.
Published: August 2004

Objective. To learn from teenagers why they do, or do not, seek preventive health care.

Methods. A teen-centered methodology utilized focus groups, nominal group technique sessions, and surveys to allow adolescents to generate, prioritize, and explain their own responses. This article reports the qualitative explanations offered by youths in focus groups. In 21 groups, teenagers commented on the 15 factors that ninth graders in the School District of Philadelphia had determined most influenced their decision to seek care. Transcriptions were reviewed for consistent themes. Direct quotations are presented here to be representative of those themes.

Results. Two key points emerged. First, adolescents are more concerned about provider characteristics than site or system characteristics. Second, they worry deeply about disease transmission in the health care setting. Teenagers suggest some simple steps that may produce significant inroads toward developing an effective working relationship with them. A few examples include: to alleviate anxiety of disease transmission, providers should wash hands and remove instruments from sterile packaging in front of patients; to reassure teenagers of competence, providers should keep diplomas and certificates displayed; and to alleviate perceptions of racism, sites should post signs that clearly explain why patients are sometimes seen out of order.

Conclusions. Adolescents know what draws them to services and what offends them. This study documents, in the words of youths, the factors contributing to their decisions to seek care. The results allow health professionals who care for adolescents to consider what they do well and where change may be needed.
Knowledge and Attitudes About Otitis Media Risk: Implications for Prevention
Authors: Daly Kathleen A. , Selvius Ruth E. , Lindgren Bruce
Published: August 2004

Objectives. To investigate maternal knowledge and attitudes about otitis media (OM) risk, to estimate the prevalence of risk factors in the first year of life, and to identify barriers to the reduction of risk factors (eg, formula feeding, day care attendance, and exposure to passive smoke).

Methods. Questionnaires mailed to a systematic sample of 504 Minnesota women ≥18 years old identified through 1994 birth certificates.

Results. Eighty percent returned a completed survey. According to maternal report, 29% of infants (age 8 to 13 months) had recurrent OM (≥3 episodes) and 2% had tympanostomy tubes. Forty-six percent attended day care, 29% had ≥1 smoking parent, and 49% breastfed for ≤2 months. Women were more knowledgeable about OM signs and symptoms than about risk factors. Mean OM knowledge score (the sum of correct true-false responses) was 7.0 (standard deviation = 1.6). Using multiple linear regression, knowledge score was significantly related to marital status, education, age, area of residence, breastfeeding (months), and number of cigarettes smoked per day by the mother, but not to infant or sibling OM history or day care attendance (R2 = .23). Infant history of OM (odds ratio, 1.9; 95% confidence interval, 1.1 to 3.2) and white race (odds ratio, 0.3; 95% confidence interval, 0.1 to 0.8), but not the presence of risk factors, were significantly related to having received clinicians' advice about OM prevention advice.

Conclusion. OM education and prevention programs should target pregnant women and new mothers with OM risk factors, and those who are young, single, and less educated.
A Longitudinal Study of Developmental Outcome of Infants With Bronchopulmonary Dysplasia and Very Low Birth Weight
Authors: Singer Lynn , Yamashita Toyoko , Lilien Lawrence , Collin Marc , Baley Jill
Published: August 2004

Objective. Bronchopulmonary dysplasia (BPD) is now the leading cause of lung disease in US infants. In a large regional cohort, we tested the hypothesis that despite innovations in neonatal care, very low birth weight (VLBW) infants (<1500 g) with BPD had poorer developmental outcomes than nonaffected infants during the first 3 years of life, and that BPD predicted poorer outcome beyond the effects of other risk factors.

Methods. Three groups of infants (122 with BPD, 84 VLBW without BPD, and 123 full-term) were followed longitudinally to 3 years of age with the Bayley Scales of Mental and Motor Development. Comparison groups of VLBW infants without BPD and full-term infants did not differ in sex, race, or socioeconomic status. Statistical analyses included hierarchical and stepwise multiple regression.

Results. Infants with BPD performed more poorly at all ages. By 3 years, cognitive and/or motor development was in the range of retardation (<70 standard score) for 21% to 22% of infants with BPD. In multiple regression analyses controlling for socioeconomic and neonatal risk conditions, BPD had an independent negative effect on motor outcome at 3 years. Neurologic risk, a summary measure of neurologic problems other than intraventricular hemorrhage, and the presence of BPD independently predicted motor delay. By 3 years, social class, race, and neurologic risk predicted mental outcome, suggesting that the specific effects of BPD are primarily on the motor domain.

Conclusions. In VLBW infants, BPD predicts poorer motor outcome at 3 years, after control for other risks. Cohorts of infants with BPD also had higher rates of mental retardation, associated with greater neurologic and social risk. These findings underscore the need for intensive prevention and habilitation efforts for this growing group of VLBW survivors, as well as investigation into the potential role of BPD in the higher rates of learning disabilities in VLBW cohorts at school age.
Clinical Findings in Bordetella pertussis Infections: Results of a Prospective Multicenter Surveillance Study
Authors: Heininger Ulrich , Klich Kerstin , Stehr Klemens , Cherry James D.
Published: August 2004

Objective. To study the clinical presentation of culture-confirmed pertussis in children and their contacts with cough illnesses in an outpatient setting.

Methodology. In conjunction with a large pertussis vaccine efficacy trial in Germany, a central laboratory to isolateBordetella species from nasopharyngeal specimens was established in Erlangen in October 1990. Pediatricians in private practices in southern Germany, the Saar region, and Berlin were encouraged to obtain nasopharyngeal specimens and clinical characteristics from patients with cough illnesses ≥7 days' duration.Bordetella species were isolated by use of calcium alginate swabs, Regan–Lowe agar, and modified Stainer–Scholte broth. Clinical characteristics were determined by initial and follow-up questionnaires.

Results. From October 1990 to September 1996, 20 972 specimens were submitted, and B pertussis was isolated in 2592 instances (12.4%). Of the culture-proven cases, 50.7% were female, and the age range was 6 days to 41 years, with a mean and median of 4.3 years and 4.1 years, respectively. The following characteristics were noted. Only 4% of the patients had received pertussis vaccine. Of unvaccinated patients, 90.2% had paroxysmal cough, 78.9% demonstrated whooping, and 53.3% presented with posttussive vomiting; 5.7% had fever ≥38°C. The duration of cough was ≤4 weeks in 37.9% and ≤3 weeks in 17.4%. Leukocytosis and lymphocytosis (values above the age-specific mean) were observed in 71.9% and 75.9% of unvaccinated patients, respectively. The overall complication rate was 5.8%, and pneumonia (29%) was the most frequent complication. In infants <6 months of age, the rate of complications was 23.8%. One death in a 7-month-old infant occurred.

Conclusions. Typical symptoms of pertussis were observed in the great majority of patients regardless of age group. However, the duration of cough was surprisingly short in one sixth of the patients. These short illness cases would not be classified as pertussis according to the World Health Organization clinical case definition, which requires ≥21 days of spasmodic cough.
Management of Neutralizing Antibody to Ceredase in a Patient With Type 3 Gaucher Disease
Authors: Brady Roscoe O. , Murray Gary J. , Oliver Katherine L. , Leitman Susan F. , Sneller Michael C. , Fleisher Thomas A. , Barton Norman W. ,   Collaborators
Published: August 2004

Objectives. The beneficial effects of macrophage-targeted glucocerebrosidase (Ceredase) in patients with Gaucher disease are well established. A minority of recipients develop transient nonneutralizing antibodies to the exogenous enzyme. A 7-year-old patient with type 3 Gaucher disease whose clinical course began to deteriorate while receiving Ceredase developed a progressively increasing titer of IgG antibody that blocked the catalytic activity of Ceredase. We sought to develop a strategy that would restore the benefit of enzyme replacement therapy in this patient.

Methods. The patient was treated with two courses of a combination of plasma exchange, cyclophosphamide, intravenous IgG, and large doses of Ceredase.

Results. After the second course of this regimen, the titer of the neutralizing antibody in the blood gradually declined to negligible levels. Clinical parameters that had been deteriorating (reduction of hemoglobin level, increased serum acid phosphates activity, repeated skeletal infarctions, progressive enlargement and infarction of the spleen) all improved. There has been no recurrence of the neutralizing antibody in this patient.

Conclusions. Very few patients with Gaucher disease who are treated with Ceredase develop a neutralizing antibody to the exogenous enzyme. In the rare instances where this phenomenon occurs, it is likely that the strategy we have used (plasma exchange, cyclophosphamide, intravenous IgG, and large doses of enzyme) may provide benefit to such individuals. It is also likely that this technique may be helpful when enzyme replacement therapy is attempted in patients with other disorders in which the genetic mutation abrogates the production of the protein (CRIM-negative individuals).
Breastfeeding and the Risk of Life-threatening EnterotoxigenicEscherichia coli Diarrhea in Bangladeshi Infants and Children
Authors: Clemens John D. , Rao Malla R. , Chakraborty J. , Yunus Mohammed , Ali Mohammed , Kay Bradford , van Loon Frederick P. L. , Naficy Abdullah , Sack David A.
Published: August 2004

Objective. To assess the relationship between breastfeeding and the risk of life-threatening enterotoxigenicEscherichia coli (ETEC) diarrhea among Bangladeshi infants and young children <36 months of age.

Design. Case–control study.

Setting. A rural Bangladesh community.

Participants. A total of 168 cases with clinically severe ETEC diarrhea detected in a treatment center-based surveillance system during 1985 to 1986 and 3679 controls selected in three surveys of the same community during the same calendar interval.

Outcomes. Cases and controls were compared for the frequency of antecedent breastfeeding patterns.

Results. Compared with other feeding modes, exclusive breastfeeding of infants was associated with significant protection against severe ETEC diarrhea (relative risk [RR] = 0.51; 95% confidence interval [CI]: 0.28,0.96). However, during the second and third years of life, the risk of this outcome was similar in both breastfed and nonbreastfed children (RR = 0.98; 95% CI: 0.45,2.12), and no significant overall protective association between breastfeeding and severe ETEC diarrhea was evident during the first 3 years of life (RR = 0.86; 95% CI: 0.43,1.74).

Conclusions. Exclusive breastfeeding appeared to protect infants against severe ETEC diarrhea, but breastfeeding was not associated with protection after infancy, nor was it associated with a major overall reduction of severe ETEC disease during the first 3 years of life. Although not diminishing the importance of breastfeeding, our findings suggest that other interventions, such as immunization and education about proper food hygiene, may also be required in efforts to prevent this major pediatric disease.
Hyponatremic Seizures Secondary to Oral Water Intoxication in Infancy: Association With Commercial Bottled Drinking Water
Authors: Bruce Robert C. , Kliegman Robert M.
Published: August 2004

In recent years, hyponatremic seizures resulting from water intoxication have been reported in the United States with an increasing frequency that some have likened to an epidemic.1 Infants of parents living in poverty and uninformed of the risks of feeding fluids other than infant formula to their babies are particularly at risk.1 Young infants with vomiting and diarrhea are especially prone to developing hyponatremia if fed fluids lacking sufficient sodium, but even those who are otherwise well may develop symptomatic hyponatremia as a result of being fed excess solute-free water. Most often tap water, either in the form of supplemental feedings or overly dilute formula, has been given in excessive amounts over relatively short periods of time.113 Less frequently, water in other forms such as juice, soda, or tea has been implicated.1216 This report includes the cases of two infants treated at our institution for hyponatremic seizures and water intoxication after being fed with the same bottled drinking water product marketed for use in infants. The medical records of all infants ≤1 year of age admitted to our institution over 10 years with the diagnosis of hyponatremic seizures were also reviewed.
Adolescent Sexual Aggression: Risk and Protective Factors
Authors: Borowsky Iris Wagman , Hogan Marjorie , Ireland Marjorie
Published: August 2004

Objective. Little research addresses the correlates of sexual aggression in nonclinical populations of adolescents. The purpose of this study was to identify risk and protective factors associated with sexual violence among male and female adolescents.

Methods. We analyzed data on 71 594 students in the 9th and 12th grades responding to the 1992 Minnesota Student Survey, an anonymous, self-report survey examining an array of risk environments, health-compromising behaviors, and protective factors. The responses of students reporting a history of forcing someone into a sexual act were compared with those who reported that they had never forced someone into a sexual act. Separate analyses were conducted for males and females.

Results. A history of sexual violence perpetration was reported by 4.8% of male and 1.3% of female adolescents. Using a logistic regression model, sexual aggression was associated with experiencing intrafamilial or extrafamilial sexual abuse, witnessing family violence, frequent use of illegal drugs, anabolic steroid use, daily alcohol use, gang membership, high levels of suicide risk behavior, and excessive time spent “hanging out.” Emotional health and connectedness with friends and adults in the community were protective factors for male adolescents against sexually aggressive behavior, and academic achievement was a protective factor for female adolescents.

Conclusions. A history of forcing someone into a sexual act was associated with several risk and protective factors. Efforts to prevent adolescent sexual violence should target individuals at increased risk. Through their psychosocial assessment of young people, health care professionals can play a role in identifying, counseling, and making appropriate referrals for adolescents at risk for sexually aggressive behavior.
Rehospitalization With Respiratory Syncytial Virus After Neonatal Intensive Care Unit Discharge: A 3-Year Follow-up
Authors: Nachman Sharon A. , Navaie-Waliser Maryam , Qureshi Muhammad Z.
Published: August 2004

Objectives. This study sought to determine 1) the incidence of rehospitalization with respiratory syncytial virus (RSV) infection within a 3-year follow-up among infants discharged from the neonatal intensive care unit (NICU), and 2) to examine associations between age at readmission and medical and sociodemographic characteristics among infants rehospitalized with RSV.

Methods. A 3-year retrospective review of NICU discharges at a tertiary care center identified 2506 infants. Using medical record numbers linked with International Classification of Diseases, 9th ed, diagnostic codes for RSV infection, bronchiolitis, or respiratory distress, 67 NICU graduates were identified as having been readmitted from November to April (RSV season). Bivariate analyses and logistic regression modeling were applied to determine the association between a series of predictor variables and age at readmission with RSV by 90 days, 125 days, and 180 days after discharge from the NICU.

Results. The 3-year incidence of readmission with RSV infection after NICU discharge was 2.7%. During the 3-year follow-up, 6.4% of very low birth weight infants, 2.8% of low birth weight infants, and 1.7% of normal weight infants were readmitted with RSV. Crude results revealed that the presence of bacteremia, intraventricular hemorrhage, and necrotizing enterocolitis, as well as ventilation use, were associated with younger age at readmission with RSV. Simultaneous consideration of the effects of all of these medical predictors and birth weight on age at readmission revealed that normal birth weight was the only significant factor associated with younger age at readmission with RSV.

Conclusions. This study found significantly lower rates of RSV readmission among NICU graduates than those reported previously in the literature. Based on these data, prophylactic treatment of all preterm infants may not be warranted.
Tobacco, Alcohol, and Other Drugs: The Role of the Pediatrician in Prevention and Management of Substance Abuse
Authors:   Committee on Substance Abuse
Published: August 2004

During the past three decades, the responsibility of pediatricians to their patients and their patients' families regarding the prevention of substance abuse and the diagnosis and management of problems related to substance abuse has increased. The American Academy of Pediatrics (AAP) has highlighted the importance of such issues in a variety of ways, including its guidelines for preventive services. Nonetheless, many pediatricians remain reluctant to address this issue. The harmful consequences of tobacco, alcohol, and other drug use are a concern of medical professionals who care for infants, children, adolescents, and young adults. Thus, pediatricians should include discussion of substance abuse as a part of routine health care, starting with the prenatal visit and as a part of ongoing anticipatory guidance. Knowledge of the extent and nature of the consequences of tobacco, alcohol, and other drug use as well as the physical, psychological, and social consequences is important for pediatricians. Pediatricians should incorporate substance abuse prevention into daily practice, acquire the skills necessary to identify young people at risk for substance abuse, and provide or obtain assessment, intervention, and treatment as necessary.
Age for Routine Administration of the Second Dose of Measles–Mumps–Rubella Vaccine
Authors:   Committee on Infectious Diseases
Published: August 2004

This Policy Statement was retired May 2009.

The purpose of this statement is to inform physicians of a modification in the recommendation of the appropriate age for routine administration of the second dose of measles–mumps–rubella (MMR) vaccine. The implementation of the two-dose measles vaccine schedule has improved the control of measles, but some outbreaks continue to occur in school children, although ≥95% of children in school have received one dose of vaccine. Because most measles vaccine failures are attributable to failure to respond to the first dose, that all children receive two doses of measles-containing vaccine is essential for the control of measles. Routine administration of the second dose of MMR vaccine at school entry (4 to 6 years of age) will help prevent school-based outbreaks. Physicians should continue to review the records of all children 11 to 12 years of age to be certain that they have received two doses of MMR vaccine after their first birthday. Documenting that all school children have received two doses of measles-containing vaccine by the year 2001 will help ensure the elimination of measles in the United States and contribute to the global effort to control and possibly eradicate measles.
Neonatal Hospital Lengths of Stay, Readmissions, and Charges
Authors: Marbella Anne M. , Chetty Veerappa K. , Layde Peter M.
Published: August 2004

Objective. To evaluate trends in length of hospital stay, hospital charges, and readmission rates of Wisconsin newborns from 1989 through 1994 in light of recent policies requiring earlier discharges after delivery of newborns.

Methodology. Two data sources were used: 1) 1989–1994 Hospital Inpatient Discharge Data from the Wisconsin Office of Health Care Information, and 2) 1994 birth certificate and matched infant mortality data from the Wisconsin Center for Health Statistics. Average lengths of stay and average hospital (delivery and readmission) charges were calculated, and readmission rates were estimated for full-term, premature, and sick newborns.

Results. There were 368 955 full-term and 26 668 premature newborns in Wisconsin from 1989 through 1994. The average length of stay decreased by 24% in full-term newborns from 1989 through 1994, while average hospital (delivery and readmission) charges rose over 40% during the same period. Average length of stay for premature infants increased by 24% while their hospital delivery charges increased 214% during the study period. Readmission rates halved, yet charges per readmission doubled for full-term infants. More than twice as many full-term newborns were classified as sick in 1994 (43%) compared with 1989 (19%).

Conclusions. Managed care efforts to control costs of neonatal care through earlier newborn discharge policies may have limited impact. Physicians or hospitals may be compensating for these policies by classifying more newborns as sick, thereby allowing for longer hospital stays to be reimbursed by the insurance carriers. Premature infants, <7% of the total births, account for half of all hospital delivery charges. Efforts to reduce premature births may have a greater impact on neonatal health care costs than efforts to discharge full-term newborns earlier.