bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Inhaled Antiinflammatory Therapy on Hospitalization and Emergency Department Visits for Children With Asthma
Authors: Adams Robert J. , Fuhlbrigge Anne , Finkelstein Jonathan A. , Lozano Paula , Livingston James M. , Weiss Kevin B. , Weiss Scott T.
Published: August 2004

Objective.

Although the efficacy of inhaled antiinflammatory therapy in improving symptoms and lung function in childhood asthma has been shown in clinical trials, the effectiveness of these medications in real-world practice settings in reducing acute health care use has not been well-evaluated. This study examined the effect of inhaled antiinflammatory therapy on hospitalizations and emergency department (ED) visits by children for asthma.

Design.

Defined population cohort study over 1 year.

Setting.

Three managed care organizations (MCOs) in Seattle, Boston, and Chicago participating in the Pediatric Asthma Care–Patient Outcome Research and Treatment II trial.

Participants.

All 11 195 children, between 3 to 15 years old, with a diagnosis of asthma who were enrolled in the 3 MCOs between July 1996 and June 1997.

Outcome Measures.

We identified children with 1 or more asthma diagnoses using automated encounter data. Medication dispensings were identified from automated pharmacy data. Multivariate logistic regression analysis was used to calculate effects of inhaled antiinflammatory therapy on the adjusted relative risk (RR) for hospitalization and ED visits for asthma.

Results.

Over 12 months, 217 (1.9%) of children had an asthma hospitalization, and 757 (6.8%) had an ED visit. After adjustment for age, gender, MCO, and reliever dispensing, compared with children who did not receive controllers, the adjusted RRs for an ED visit were: children with any (≥1) dispensing of cromolyn, 0.4 (95% confidence interval [CI]: 0.3, 0.5); any inhaled corticosteroid (ICS), 0.5 (95% CI: 0.4, 0.6); any cromolyn or ICS combined (any controller), 0.4 (95% CI: 0.3, 0.5). For hospitalization, the adjusted RR for cromolyn was 0.6 (95% CI: 0.4, 0.9), for ICS 0.4 (95% CI: 0.3, 0.7), and for any controller 0.4 (95% CI: 0.3, 0.6). A significant protective effect for both events was seen among children with 1 to 5 and with >5 antiinflammatory dispensings. When the analysis was stratified by frequency of reliever dispensing, there was a significant protective effect for controllers on ED visits for children with 1 to 5 and with >5 reliever dispensings and on the risk of hospitalization for children with >5 reliever dispensings.

Conclusions.

Inhaled antiinflammatory therapy is associated with a significant protective effect on the risk for hospitalization and ED visits in children with asthma. Cromolyn and ICSs were associated with similar effects on risks.asthma drug therapy, inhaled antiinflammatory agents, health maintenance organizations, hospitalization, emergency department.
Comparison of Findings on Cranial Ultrasound and Magnetic Resonance Imaging in Preterm Infants
Authors: Maalouf Elia F. , Duggan Philip J. , Counsell Serena J. , Rutherford Mary A. , Cowan Frances , Azzopardi Denis , Edwards A. David
Published: August 2004

Objective.

To compare findings on hard copies of cranial ultrasound (US) and magnetic resonance imaging (MRI) obtained between birth and term in a group of preterm infants.

Participants and Methods.

Infants born at or below a gestational age of 30 weeks who underwent cranial US scan and MRI on the same day were eligible for this study. Infants underwent, whenever possible, 3 scans between birth and term. We calculated the predictive probability (PP) of US findings as a predictor of findings on MRI.

Results.

Sixty-two paired MRI and US studies were performed between birth and term in 32 infants born at a median gestational age of 27 (range: 23–30) weeks and a median birth weight of 918 (530–1710) grams. US predicted some MRI findings accurately: germinal layer hemorrhage (GLH) on US had a PP of 0.8 with a 95% confidence interval of (0.70–0.90) for the presence of GLH on MRI, intraventricular hemorrhage (IVH) on US had a PP of 0.85 (0.76–0.94) for the presence of IVH on MRI, and severe white matter (WM) echogenicity on US had a PP of 0.96 (0.92–1.0) for the presence of WM hemorrhagic parenchymal infarction on MRI. Other MRI changes were less well-predicted: mild or no WM echogenicity on US had a PP of 0.54 (0.41–0.66) for the presence of normal WM signal intensity on MRI, and moderate or severe WM echogenicity on US had a PP of 0.54 (0.42–0.66) for the presence of small petechial WM hemorrhage and/or diffuse excessive high-signal intensity (DEHSI) in the WM on T2-weighted images on MRI. However, mild/moderate or severe WM echogenicity on US scans performed at ≥7 days after birth had a PP of 0.72 (0.58–0.87) for the presence of WM hemorrhage and/or DEHSI on MRI. There were no cases of cystic periventricular leukomalacia.

Conclusion.

US accurately predicted the presence of GLH, IVH, and hemorrhagic parenchymal infarction on MRI. However, its ability to predict the presence of DEHSI and small petechial hemorrhages in the WM on T2 weighted images is not as good, but improves on scans performed at ≥7 days after birth. In addition, normal WM echogenicity on US is not a good predictor of normal WM signal intensity on MRI.
Type and Timing of Mothers' Victimization: Effects on Mothers and Children
Authors: Dubowitz Howard , Black Maureen M. , Kerr Mia A. , Hussey Jon M. , Morrel Tanya M. , Everson Mark D. , Starr Raymond H.
Published: August 2004

Objectives.

There is mounting concern about how mothers' own victimization experiences affect their children. This study examines the effects of mothers' victimization on their own mental health and parenting and on their children's behavior, development, and health. The effects of both timing and type of victimization are assessed. A related objective was to determine if there was a cumulative risk effect produced by victimization during both childhood and adulthood, or both physical and sexual.

Setting.

Urban families in an eastern state and urban and rural families in a southern state.

Participants.

A total of 419 mothers and their children 6 to 7 years old were identified from 2 sites. The eastern sample was recruited in the first 2 years of life from 3 pediatric clinics: 1 for children at high risk for human immunodeficiency virus disease, 1 for children with failure to thrive, and a third providing pediatric primary care. The southern sample was derived from a cohort of children at risk for adverse health or developmental outcomes, plus a systematic sampling of controls, recruited from area hospitals. At age 4, a random sample of children from the original cohort who had been maltreated along with a matched comparison group of nonmaltreated children were selected.

Results.

In general, mothers victimized during both childhood and adulthood had poorer outcomes than mothers victimized during either childhood/adolescence or adulthood who in turn had worse outcomes than mothers with no history of victimization. This manifested as more maternal depressive symptoms, harsher parenting, and more externalizing and internalizing behavior problems in their children. There were no significant differences in maternal functioning or child outcomes between those abused in childhood and those abused in adulthood. These findings were similar for type of victimization. Mothers' depression and harsh parenting were directly associated with their children's internalizing and externalizing behavior problems.

Conclusions.

Maternal victimization appears to be a highly prevalent problem in high-risk samples and is associated with harmful implications for mental health and parenting, as well as for the offspring. Pediatricians need to consider past and current victimization of mothers. Routine screening for these problems, followed by appropriate evaluation and intervention may reduce maternal depression, improve parenting, and reduce the incidence of behavior problems in children.
Impact of the Oregon Health Plan on Children With Special Health Care Needs
Authors: Mitchell Janet B. , Khatutsky Galina , Swigonski Nancy L.
Published: August 2004

Objective.

Although an increasing number of Medicaid children are enrolled in Medicaid managed care plans, little is known about how children with special health care needs fare under such programs. Of particular concern is the ability of such children to navigate a managed care system and gain access to specialty and other services. This study compares the managed care experiences of children with and without special care needs in the Oregon Health Plan.

Methodology.

Telephone surveys were conducted with a sample of parents of children enrolled in the Oregon Health Plan. Three groups of children were sampled: Supplemental Security Income (SSI) children with disabilities, children with asthma, and children without special health care needs. Descriptive and multivariate analyses were conducted to determine the impact of Medicaid managed care on access and satisfaction.

Results.

Children with disabilities in managed care plans did not experience any more difficulty accessing needed specialty care than did those without special health care needs. Children with asthma, however, reported higher levels of unmet need. There were no differences in access between children with disabilities enrolled in managed care and those children with disabilities remaining in fee-for-service.

Conclusions.

Unlike SSI children with disabilities, children who were not SSI-eligible but had asthma seemed to have difficulty obtaining some services. These children were not eligible for the same consumer protections afforded SSI children by Oregon. If states want to enroll all children with special health care needs into managed care programs, they must develop mechanisms for identifying such children and ensuring that they receive medically necessary services.
Care of Children in the Emergency Department: Guidelines for Preparedness
Authors:   American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and American College of Emergency Physicians, Pediatric Committee
Published: August 2004

Children requiring emergency care have unique and special needs. This is especially so for those with serious and life-threatening emergencies. There are a variety of components of the emergency care system that provide emergency care to children that are not limited to children. With regard to hospitals, most children are brought to community hospital emergency departments (EDs) by virtue of their availability rather than to facilities designed and operated solely for children. Emergency medical services (EMS) agencies, similarly, provide the bulk of out-of-hospital emergency care to children. It is imperative that all hospital EDs and EMS agencies have the appropriate equipment, staff, and policies to provide high quality care for children. This statement provides guidelines for necessary resources to ensure that children receive quality emergency care and to facilitate, after stabilization, timely transfer to a facility with specialized pediatric services when appropriate. It is important to realize that some hospitals and local EMS systems will have difficulty in meeting these guidelines, and others will develop more comprehensive guidelines based on local resources. It is hoped, however, that hospital ED staff and administrators and local EMS systems administrators will seek to meet these guidelines to best ensure that their facilities or systems provide the resources necessary for the care of children. This statement has been reviewed by and is supported in concept by the Ambulatory Pediatric Association, American Association of Poison Control Centers, American College of Surgeons, American Hospital Association, American Medical Association, American Pediatric Surgical Association, American Trauma Society, Brain Injury Association Inc, Emergency Nurses Association, Joint Commission on Accreditation of Healthcare Organizations, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of EMTs, National Association of School Nurses, National Association of State EMS Directors, National Committee for Quality Assurance, and Society for Academic Emergency Medicine.
Risk of Injury From Baseball and Softball in Children
Authors:   Committee on Sports Medicine and Fitness
Published: August 2004

This statement updates the 1994 American Academy of Pediatrics policy statement on baseball and softball injuries in children. Current studies on acute, overuse, and catastrophic injuries are reviewed with emphasis on the causes and mechanisms of injury. This information serves as a basis for recommending safe training practices and the appropriate use of protective equipment.
COMMENTARY: Commercialism in Classrooms
Authors: Johnston Carden
Published: August 2004

Opinions expressed in commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. Commentaries are not peer-reviewed.
COMMENTARY: Nutritional Rickets in Georgia
Authors: Tomashek Kay M. , Nesby Shanna , Scanlon Kelley S. , Cogswell Mary E. , Powell Kenneth E. , Parashar Umesh D. , Mellinger-Birdsong Anne , Grummer-Strawn Laurence M. , Dietz William H.
Published: August 2004

Opinions expressed in commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. Commentaries are not peer-reviewed.
Recurrent Mycobacterium avium Osteomyelitis Associated With a Novel Dominant Interferon Gamma Receptor Mutation
Authors: Villella Anthony , Picard Capucine , Jouanguy Emmanuelle , Dupuis Stéphanie , Popko Stacey , Abughali Nazha , Meyerson Howard , Casanova Jean-Laurent , Hostoffer Robert W.
Published: August 2004

Mycobacterium avium causes infections in immunocompromised individuals. Recurrent infection with this organism has been associated with a deletion at the 818 residue of the interferon-γ receptor (IFN-γR). This mutation produces a truncated receptor without an intracytoplasmic tail, resulting in diminished signaling. We describe a substitution at the 832 residue of the IFN-γR causing a similar truncated receptor in a 7-year-old girl with recurrent M avium osteomyelitis.
Development and Evaluation of a Method for Evaluating Pediatric Residents' Knowledge and Skill in Performing Physical Examinations of the Ankle and Knee
Authors: Hergenroeder Albert C. , Laufman Larry , Chorley Joseph N. , Fetterhoff Amy C.
Published: August 2004

Background.

Pediatric residents need the knowledge and physical examination skills to evaluate common musculoskeletal injuries. The ankle and the knee are the 2 most common sites of musculoskeletal injury in young athletes. Methods for evaluating pediatric residents' knowledge and skills in examining the ankle and knee are needed.

Objectives.

1) To describe the development of a method for evaluating pediatric residents' knowledge and skill in performing physical examinations of the ankle and knee, and 2) to report the reliability of this method.

Methods.

A written test and a Clinical Skills Assessment Examination (CSAE) with a rating index were developed by the investigators to evaluate pediatric residents' knowledge and skills in examining the ankle and knee. Fifty-eight pediatric residents completed the written test and examined the ankle and knee of one standardized patient at the beginning of a required 1-month adolescent medicine rotation. Forty-eight residents repeated the evaluation at the end of the month. The investigators rated the residents' performance of the CSAE and then assessed interrater reliability using Cronbach's α. Test–retest correlation was calculated to assess the reliability of the written test.

Results.

Test–retest correlation for the written test was 0.72, establishing its reliability. Interrater reliability for rating the CSAE of the ankle and knee was 0.98 and 0.90, respectively.

Conclusion.

Pediatric residents' knowledge and skills in examining the ankle and knee can be reliably evaluated using the written test and CSAE described in this article. These could be used to assess the effectiveness of current curricula in improving pediatric residents' knowledge and skill in evaluating ankle and knee complaints and to assist in the design of future curricula. musculoskeletal, evaluation methods, resident curriculum.
Pediatric Residents' Performance of Ankle and Knee Examinations After an Educational Intervention
Authors: Hergenroeder Albert C. , Chorley Joseph N. , Laufman Larry , Fetterhoff Amy C.
Published: August 2004

Background.

Pediatric residents have the need for additional training in the care of common musculoskeletal injuries.

Objectives.

To implement and evaluate the effects of a teaching intervention on pediatric residents' knowledge and skills in performing the physical examination of the ankle and knee.

Study Design.

Prospective, intervention, single-sample study design.

Methods.

Pediatric residents (n = 58) on a 1-month adolescent medicine rotation received a teaching intervention after a baseline evaluation of their knowledge and skills. The teaching intervention was designed to improve their knowledge about and skills in performing physical examinations of the ankle and knee. The intervention included watching a videotape, followed by observation of the attending physician demonstrating the techniques on a standardized patient, followed by correct demonstration of the techniques by the resident. The residents' knowledge and skills were assessed at the end of the rotation and 9 months later. Knowledge was assessed using a written examination. Skills assessment was performed using a Clinical Skills Assessment Examination.

Results.

At baseline, the residents performed 37% of the ankle and 18% of the knee physical examination techniques correctly. At 1 and 9 months, the residents' knowledge of ankle and knee examinations was greater than at baseline. The residents performed 77% of the techniques correctly at 1 month and 67% at 9 months. The residents performed 55% of the knee examination techniques correctly at 1 month and 47% at 9 months. The teaching intervention was rated highly by the residents.

Conclusions.

The residents' performance of ankle and knee examinations was suboptimal at baseline and improved significantly after the teaching intervention. Observed improvements persisted for a mean of 35 weeks. The teaching intervention described in this study could meet the need for improved ankle and knee examination skills, the 2 most common sites of skeletal injury in young athletes. The teaching model is novel in that it couples videotape and skills-based teaching methods with reliable evaluation methods. This model teaching method could be adapted for use in other pediatric residency training programs and other content areas. musculoskeletal, physical examination, resident curriculum.
Methemoglobinemia and Consumption of Vegetables in Infants
Authors: Sanchez-Echaniz Jesus , Benito-Fernández Javier , Mintegui-Raso Santiago
Published: August 2004

Objective.

To assess clinical and epidemiologic data of 7 infants diagnosed with acquired methemoglobinemia at the pediatric emergency department between 1993 and 1998. All cases were attributed to the consumption of mixed vegetables.

Methods.

Medical records were reviewed to collect anamnestic data; history of food ingestion; and results of physical examination, pulse oximetry, gasometry, cooximetry, urinalysis, and outcome. Local health authorities provided information on nitrate concentration in running water and in vegetables of common consumption in the area.

Results.

The mean age of the patients was 8.14 months (range: 7–13). None of the infants was undernourished, had diarrhea, or was given any drug. Drinking water showed a nitrate concentration of 3 to 6 ppm. All were fed homemade purée of mixed vegetables, prepared in advance and kept in the refrigerator for 12 to 27 hours. Silver beets were a common ingredient. No case showed metabolic acidosis. Methemoglobin level ranged between 10% and 58%. Three cases had nitrituria. Silver beets in our area were the vegetables with the highest nitrate concentration (mean: 3200 mg/kg).

Conclusions.

Consumption of silver beets and incorrect storage of homemade purées of mixed vegetables were potential causes of methemoglobinemia in this series. The disease may occur in children older than 6 months of age. Nitrituria in a cyanotic infant may suggest the diagnosis of methemoglobinemia. methemoglobinemia, nitrates, nitrites, food analysis, infant food, food preservation.
Examination of State Regulations Regarding Infants and Sleep in Licensed Child Care Centers and Family Child Care Settings
Authors: Moon Rachel Y. , Biliter Wendy M. , Croskell Sarah E.
Published: August 2004

Background.

Twenty percent of sudden infant death syndrome (SIDS) occurs in child care settings. Although the incidence of SIDS in the United States has decreased with increased awareness of the risks of prone infant sleeping, smoke exposure, soft bedding, and unsafe sleep environments, avoidance of these risk factors is not universally practiced in child care settings. Advocacy through state child care regulatory agencies and legislative bodies may be effective in more widespread awareness and avoidance of risk factors.

Objective.

To determine what individual state regulations for licensed child care centers and family child care settings exist regarding: 1) sleep positions for infants under 6 months old, 2) crib safety, 3) bedding safety, and 4) smoking in the facilities.

Design.

A descriptive survey of regulations for licensed child care centers and family child care settings in the 50 states and the District of Columbia.

Results.

Fifteen states use regulations adopted before publication of the first policy statement of the American Academy of Pediatrics on infant sleep position and SIDS in 1992. Six states require child care centers to place infants nonprone. Sixty-three percent of states require cribs in child care centers to meet at least 1 safety standard, and 45.1% require this in family child care homes. Six states have provisions limiting the use of soft bedding in child care centers, and 4 have such bans for family child care homes. Seventy-one percent of states prohibit smoking in child care centers during hours of operation; 17% of states have similar requirements for family child care homes.

Conclusions.

Many states use child care regulations that were written before the initial policy statements of the American Academy of Pediatrics regarding safe sleep environments for infants. Even those more recently adopted regulations do not adequately address sleep safety for infants. Pediatricians need to become more proactive in promoting safety regulations in child care. Adoption of new regulations can aid in education of child care providers and, thus, improve the safety for infants in child care.
Early Childhood Otitis Media in Relation to Children's Attention-Related Behavior in the First Six Years of Life
Authors: Minter Karin R. , Roberts Joanne E. , Hooper Stephen R. , Burchinal Margaret R. , Zeisel Susan A.
Published: August 2004

Objective.

This study examined whether otitis media with effusion (OME) and associated hearing loss during the first 4 years of life were related to the ratings of parents, teachers, and clinicians of children's attention and behavior in the first 6 years of life.

Methods.

In a prospective study, 85 black children were recruited from community-based child care programs when they were between 6 and 12 months old. OME and hearing status were monitored repeatedly from 6 months to 4 years old. Measures of attention and behavior were collected from parents, teachers, and clinicians when the children were infants, preschoolers, and first graders.

Results.

On average, children experienced either bilateral or unilateral OME 30% of the time and hearing loss 19.9% of the time between 6 months and 4 years old. Descriptive and inferential analyses revealed no significant associations between OME or hearing loss and the measures of attention or behavior completed by parents, teachers, and clinicians.

Conclusions.

In this sample of children, there was no relationship between amount of early childhood OME or hearing loss and measures of attention or behavior in the first 6 years of life as reported by parents, teachers, and clinicians. otitis media, hearing, attention, behavior.
Effects of Contingent Television on Physical Activity and Television Viewing in Obese Children
Authors: Faith Myles S. , Berman Nathaniel , Heo Moonseong , Pietrobelli Angelo , Gallagher Dympna , Epstein Leonard H. , Eiden Mark T. , Allison David B.
Published: August 2004

Objective.

Elevated television (TV) viewing and physical inactivity promote obesity in children. Thus, changes in physical activity and sedentary behavior seem critical to treating childhood obesity.

Present Study.

Using a randomized, 2-arm design, this pilot study tested the effects of contingent TV on physical activity and TV viewing in 10 obese children. TV viewing was contingent on pedaling a stationary cycle ergometer for experimental participants but was not contingent on pedaling for control participants. The study was conducted over 12 weeks, including a 2-week baseline period.

Results.

Multivariate analyses indicated that the intervention significantly increased pedaling and reduced TV-viewing time. During the treatment phase, the experimental group pedaled 64.4 minutes per week on average, compared with 8.3 minutes by controls. The experimental group watched 1.6 hours of TV per week on average, compared with 21.0 hours per week on average by controls during this phase. Secondary analyses indicated that the experimental group showed significantly greater reductions in total body fat and percent leg fat. Total pedaling time during intervention correlated with greater reductions in percent body fat (r = −0.68).

Conclusions.

Contingencies in the home environment can be arranged to modify physical activity and TV viewing and may have a role in treating childhood obesity. Contingent TV may be one method to help achieve this goal.
The Association Between Childhood Depression and Adulthood Body Mass Index
Authors: Pine Daniel S. , Goldstein Rise B. , Wolk Susan , Weissman Myrna M.
Published: August 2004

Objective.

Stress in childhood relates to both childhood depression and elevated adult body mass index (BMI), a measure of relative overweight. However, there are limited data on the association between major depression in childhood and BMI in adulthood. The current study examines this association.

Method.

Children 6 to 17 years old with major depression (n = 90) or no psychiatric disorder (n = 87) were identified at Columbia Presbyterian Medical Center and followed up 10 to 15 years later. Psychiatric status at intake and follow-up was assessed via standardized psychiatric interviews. BMI during adulthood was recorded so that the association between depression and BMI could be considered over time.

Results.

Participants with childhood major depression had a BMI of 26.1 ± 5.2 as adults, compared with a BMI of 24.2 ± 4.1 in healthy comparisons (t175 = 2.7). This association could not be explained by a number of potentially confounding factors, including age, gender, cigarette or alcohol use, social class, and pregnancy or medication history. Although poverty during adulthood also predicted adult BMI, both the association between poverty and adult BMI (t152 = 2.9), as well as between childhood depression and adult BMI (t152 = 2.2) were significant in a multivariate model. Finally, duration of depression between childhood and adulthood also emerged as a predictor of adult BMI.

Conclusions.

Depression during childhood is positively associated with BMI during adulthood. This association cannot be explained by various potential confounding variables and may develop over time as children pass into their adult years. body mass index, depression, children, adolescents.
Cardiovascular Effects of Hydrocortisone in Preterm Infants With Pressor-Resistant Hypotension
Authors: Seri Istvan , Tan Rosemarie , Evans Jaquelyn
Published: August 2004

Objective.

To study the cardiovascular effects of hydrocortisone in preterm infants with hypotension unresponsive to volume and pressor administration.

Study Design.

Retrospective review of the cardiovascular response to 23 courses of hydrocortisone administration during the first day of treatment in 21 preterm infants (gestational age: 26.9 ± 3.9 weeks; postnatal age: 11.3 ± 13.1 days). Hydrocortisone (2 mg/kg/d in 16 patients and 3–6 mg/kg/d in 5 patients) was administered when dopamine (22.2 ± 11 μg/kg/min, range: 8–60) alone (n = 16) or in combination with dobutamine (8.4 ± 4.9 μg/kg/min, range: 5–20,n = 7) and/or epinephrine (0.38 ± 0.56 μg/kg/min, range: 0.01–1.2, n = 4) failed to normalize blood pressure.

Results.

Mean blood pressure increased from 29.3 ± 4.1 to 34.1 ± 5.2, 38.0 ± 8.0, and 41.8 ± 6.6 mm Hg by 2, 4, and 6 hours of hydrocortisone administration, respectively, and remained stable thereafter. Urine output increased despite a decrease in fluid administration during the first day of hydrocortisone treatment. The dose of dopamine and the number of patients receiving dobutamine and/or epinephrine also decreased during the same period. Eighteen of the 21 patients survived.

Conclusions.

Preterm infants with volume- and pressor-resistant hypotension respond to hydrocortisone with rapid normalization of the cardiovascular status and sustained decreases in volume and pressor requirement.
Developmental Follow-Up of Breastfed Term and Near-Term Infants With Marked Hyperbilirubinemia
Authors: Harris Mary Catherine , Bernbaum Judy C. , Polin Jessica R. , Zimmerman Robert , Polin Richard A.
Published: August 2004

Objective.

In recent years, the increased prevalence of breastfeeding in conjunction with early discharge practices has increased the risk for marked hyperbilirubinemia in neonates. This has resulted in the potential for bilirubin brain injury in affected infants. The purpose of this study was to identify all infants ≥36 weeks' gestational age with bilirubin levels >25 mg/dL and evaluate them for early and late evidence of bilirubin brain injury.

Methods.

We reviewed the charts of all infants (from 1993–1996) ≥36 weeks' gestational age who were readmitted to the hospital during the first week of life with bilirubin levels >25 mg/dL. Readmission records were reviewed for early signs of bilirubin encephalopathy. Magnetic resonance imaging (MRIs) and Brainstem auditory-evoked responses (BAERs) were reviewed for evidence of bilirubin toxicity. At follow-up, study infants had a complete neurodevelopmental examination, repeat MRIs, and behavioral hearing evaluations.

Results.

From 1993 to 1996, we identified 6 term and near-term infants readmitted to the hospital within the first week of life with peak bilirubin values ranging from 26.4 mg/dL (451 μmol/L) to 36.9 mg/dL (631 μmol/L). Five of 6 infants had bilirubin values >30 mg/dL (513 μmol/L). All were exclusively breastfed or fed a combination of breast and bottle feedings. Five of 6 infants presented with abnormal neurologic signs. Four infants had initial MRIs, 3 of whom had increased signal intensity in the basal ganglia consistent with kernicterus. Two infants had abnormal BAERs; both also had abnormal MRIs. Five of 6 infants received exchange transfusions and all were treated with phototherapy and intravenous fluids. Follow-up examinations between 3 months and 2 years showed resolution of clinical signs in all but 1 infant. Four infants had a subsequent normal MRI and 1 had residual hearing impairment. One infant demonstrated severely abnormal developmental evaluations, as well as both an abnormal initial MRI and BAERs. Follow-up MRI showed evidence of encephalomalacia with changes not characteristic of kernicterus.

Conclusions.

We observed transient neurologic abnormalities in 5 of 6 infants readmitted to the hospital during the first week of life with marked hyperbilirubinemia. The abnormalities resolved following aggressive management using hydration, phototherapy, and exchange transfusion and may not correlate with long-term prognosis. Less aggressive therapy may be associated with residual neurologic abnormalities. We speculate that inadequate establishment of breastfeeding coupled with early discharge practices may play a role in the development of marked hyperbilirubinemia in these infants.
Improving the Delivery of Adolescent Clinical Preventive Services Through Skills-Based Training
Authors: Lustig Julie L. , Ozer Elizabeth M. , Adams Sally H. , Wibbelsman Charles J. , Fuster C. Daniel , Bonar Robert W. , Irwin Charles E.
Published: August 2004

Objective.

To examine the efficacy of skills-based training workshops on primary care providers' screening and counseling practices with adolescents during routine outpatient well visits.

Design.

Sixty-three primary care providers in outpatient pediatric departments within a managed health care organization participated in two 4-hour workshops on clinical preventive services for adolescents. The workshops focused on adolescent health, confidentiality, screening, and anticipatory guidance/brief counseling for 5 risk behaviors including: helmet and seatbelt use, tobacco use, alcohol use, and sexual behavior. A pre/posttest design was used to assess clinicians' screening and counseling practices during the pretraining and posttraining periods. Independent adolescent reports of clinicians' practices were obtained from 2 samples of 14- to 16-year-old adolescents immediately after their routine well visit in the outpatient clinics. One sample of adolescents reported during a pretraining period and a separate sample reported during a period after the training.

Results.

Adolescent reports indicated that after the training workshops, the average percentage of adolescents screened by their primary care providers increased significantly for seatbelt use (from mean 38% to 56%), helmet use (from mean 27% to 45%), tobacco use (from mean 64% to 76%), alcohol use (from mean 59% to 76%), and sexual behavior (from mean 61% to 75%). Additionally, the average percentage of adolescents offered brief counseling by their clinicians increased significantly after training in the areas of seatbelt use (from mean 36% to 51%), helmet use (from mean 25% to 43%), and sexual behavior (from mean 42% to 58%). Improvement after the training in brief counseling for tobacco use was marginally significant (from mean 60% to 69%) and for alcohol use was not significant, although there was an increase. Clinicians also significantly increased their discussion of the limits of confidentiality with their adolescent patients after the training workshops (from mean 32% to 45%).

Conclusions.

This study offers strong support for the efficacy of skills-based training for primary care providers as a method for increasing screening and counseling practices with adolescents. The present findings suggest that with appropriate skills-based training, practicing clinicians can implement several of the national guidelines that direct them to provide preventive services for multiple behaviors in a routine outpatient visit. Screening and counseling in these visits are important in the early identification, detection, and prevention of behaviors associated with the primary adolescent morbidities and mortalities. Thus, enhancing the delivery of clinical preventive services is an important step in the prevention of untoward health outcomes for youth.
Closed-Loop Controlled Inspired Oxygen Concentration for Mechanically Ventilated Very Low Birth Weight Infants With Frequent Episodes of Hypoxemia
Authors: Claure Nelson , Gerhardt Tilo , Everett Ruth , Musante Gabriel , Herrera Carmen , Bancalari Eduardo
Published: August 2004

Background.

Mechanically ventilated very low birth weight infants often present with frequent episodes of hypoxemia, and maintaining arterial oxygen saturation by pulse oximetry (Spo2) within a normal range by manual fraction of inspired oxygen (Fio2) adjustments is difficult and time consuming.

Objectives.

An algorithm for closed-loop Fio2 control (cFio2) to maintain Spo2 within a target range was compared with continuous manual Fio2(mFio2) adjustments by a nurse in a group of ventilated infants who presented with frequent episodes of hypoxemia.

Results.

Fourteen infants (birth weight: 712 ± 142 g; gestational age: 25 ± 1.6 weeks; age: 26 ± 11 days; synchronized intermittent mandatory ventilation rate: 24 ± 10 b/m; peak inspiratory pressure: 17.5 ± 2.0 cmH2O; positive end-expiratory pressure: 4.3 ± 0.5 cmH2O) were studied for 2 hours on each mode in random sequence. Both modes aimed to maintain Spo2 between 88% and 96%.

There were 15 ± 7 and 16 ± 6 hypoxemic episodes/hour (Spo2 <88%, >5 s) during mFio2 and cFio2, respectively; episode duration was 41 ± 23 and 32 ± 15 s, totaling 19 ± 16% and 17 ± 12% of recording time. There were 13 ± 10 and 10 ± 8 hyperoxemic episodes/hour (Spo2>96%, >5 s) during mFio2 and cFio2,respectively; episode duration was 27 ± 15 and 24 ± 19 s, totaling 15 ± 14% and 10 ± 9% of recording time. Mean Spo2 and Fio2 levels were similar during both modes. The nurse made 29 ± 17 adjustments/hour during mFio2. There was a significant increase in the duration of normoxemia (Spo2 between 88%–96%) during cFio2 (75 ± 13 vs 66 ± 14% of recording time).

Conclusion.

In this group of infants, cFio2 was at least as effective as a fully dedicated nurse in maintaining Spo2 within the target range, and it may be more effective than a nurse working under routine conditions. We speculate that during long-term use, cFio2 may save nursing time and reduce the risks of morbidity associated with supplemental oxygen and episodes of hypo- and hyperoxemia.
Attitudes of New York City High School Students Regarding Firearm Violence
Authors: Kahn Doron J. , Kazimi Marwan M. , Mulvihill Michael N.
Published: August 2004

Objectives.

To assess prevalence of gun possession, attitudes regarding gun possession and gun violence, knowledge and influences of gun violence, and the potential role of physicians in gun violence prevention education among adolescents.

Methods.

An anonymous questionnaire was distributed to 9th through 12th grade high school students at 3 public high schools in New York City.

Results.

Three hundred forty-two surveys were distributed and returned. The prevalence of guns in the homes was 19.6%. Of respondents, 43.2% thought it was okay for anyone to have guns, and 57.3% had been injured or have had a relative injured by a gun. Although 11.6% of adolescents had felt the need to talk to an adult about guns, only 3.0% listed their physicians as one of these adults. However, if asked by their physician, 63.8% would discuss the issue with them. Only 5.7% of adolescents have had a physician speak to them about guns.

Conclusions.

The adolescent population surveyed is frequently exposed to gun violence. Although physicians rarely counsel adolescents regarding gun violence and firearm safety, many adolescents would be receptive to this mode of intervention.adolescence, attitude, firearm ownership, firearm violence, physician role.
Why Don't Low-Income Mothers Worry About Their Preschoolers Being Overweight?
Authors: Jain Anjali , Sherman Susan N. , Chamberlin DPA; Leigh A. , Carter Yvette , Powers Scott W. , Whitaker Robert C.
Published: August 2004

Context.

Mothers are in an important position to prevent obesity in their children by shaping early diet and activity patterns. However, many mothers of overweight preschool children are not worried about their child's weight.

Objective.

To explore mothers' perceptions about how they determine when a child is overweight, why children become overweight, and what barriers exist to preventing or managing childhood obesity.

Design.

Three focus groups with 6 participants in each. Participant comments were transcribed and analyzed. Themes were coded independently by the 6 authors who then agreed on common themes.

Setting.

A clinic of the Special Supplemental Nutrition Program for Women, Infants, and Children in Cincinnati, Ohio.

Participants.

Eighteen low-income mothers (13 black, 5 white) of preschool children (mean age of 44 months) who were at-risk for later obesity. All but 1 mother had a body mass index (BMI) ≥25 kg/m2, and 12 mothers had a BMI ≥30 kg/m2. All but 1 child had a BMI ≥85th percentile for age and sex, and 7 had a BMI ≥95th percentile.

Results.

Mothers did not define overweight or obese in their children according to how height and weight measurements were plotted on the standard growth charts used by health professionals. Instead, mothers were more likely to consider being teased about weight or developing limitations in physical activity as indicators of their child being overweight. Children were not believed to be overweight if they were active and had a healthy diet and/or a good appetite. Mothers described overweight children as thick or solid. Mothers believed that an inherited tendency to be overweight was likely to be expressed in the child regardless of environmental factors. In trying to shape their children's eating, mothers believed that their control over the child's diet was challenged by other family members. If a child was hungry, despite having just eaten, it was emotionally difficult for mothers to deny additional food.

Conclusions.

Health professionals should not assume that defining overweight according to the growth charts has meaning for all mothers. Despite differing perceptions between mothers and health professionals about the definition of overweight, both groups agree that children should be physically active and have healthy diets. Health professionals may be more effective in preventing childhood obesity by focusing on these goals that they share with mothers, rather than on labeling children as overweight.
Falls From Heights: Windows, Roofs, and Balconies
Authors:   Committee on Injury and Poison Prevention
Published: August 2004

Falls of all kinds represent an important cause of child injury and death. In the United States, approximately 140 deaths from falls occur annually in children younger than 15 years. Three million children require emergency department care for fall-related injuries. This policy statement examines the epidemiology of falls from heights and recommends preventive strategies for pediatricians and other child health care professionals. Such strategies involve parent counseling, community programs, building code changes, legislation, and environmental modification, such as the installation of window guards and balcony railings.
The Use and Misuse of Fruit Juice in Pediatrics
Authors:   Committee on Nutrition
Published: August 2004

Historically, fruit juice was recommended by pediatricians as a source of vitamin C and an extra source of water for healthy infants and young children as their diets expanded to include solid foods with higher renal solute. Fruit juice is marketed as a healthy, natural source of vitamins and, in some instances, calcium. Because juice tastes good, children readily accept it. Although juice consumption has some benefits, it also has potential detrimental effects. Pediatricians need to be knowledgeable about juice to inform parents and patients on its appropriate uses.
Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines
Authors: Schutzman Sara A. , Barnes Patrick , Duhaime Anne-Christine , Greenes David , Homer Charles , Jaffe David , Lewis Roger J. , Luerssen Thomas G. , Schunk Jeff
Published: August 2004

Objective.

In children <2 years old, minor head trauma (HT) is a common injury that can result in skull fracture and intracranial injury (ICI). These injuries can be difficult to detect in this age group; therefore, many authors recommend a low threshold for radiographic imaging. Currently, no clear guidelines exist regarding the evaluation and management of head-injured infants. We sought to develop guidelines for management based on data and expert opinion that would enable clinicians to identify children with complications of HT and reduce unnecessary imaging procedures.

Methods.

Evidence: References addressing pediatric HT were generated from a computerized database (Medline). The articles were reviewed and evidence tables were compiled.

Expert Panel: The multidisciplinary panel was comprised of nine experts in pediatric HT.

Consensus Process: A modified Delphi technique was used to develop the guidelines. Before the one meeting, panel members reviewed the evidence and formulated answers to specific clinical questions regarding HT in young children. At the meeting, guidelines were formulated based on data and expert consensus.

Results.

A management strategy was developed that categorizes children into 4 subgroups, based on risk of ICI. Children in the high-risk group should undergo a computed tomography (CT) scan. Those in the intermediate risk group with symptoms of possible ICI should either undergo CT scan or observation. Those in the intermediate risk group with some risk for skull fracture or ICI should undergo CT and/or skull radiographs or observation. Those in the low-risk group require no radiographic imaging.

Conclusions.

We have developed a guideline for the evaluation of children <2 years old with minor HT. The effect of these guidelines on clinical outcomes and resource utilization should be evaluated.
A Syndrome of Transient Encephalopathy Associated With Adenovirus Infection
Authors: Straussberg Rachel , Harel Liora , Levy Yael , Amir Jacob
Published: August 2004

Background and Objective.

Adenovirus is a common pathogen in the pediatric population. Respiratory, gastrointestinal, or renal systems are often involved in adenovirus infections. Several neurologic syndromes have been attributed to adenovirus, such as adenovirus aseptic meningitis, myelitis, subacute focal encephalitis, and Reye-like syndrome. The purpose of this study was to describe the clinical features and encephalography findings in 7 infants treated in our center for a syndrome of transient encephalopathy associated with adenovirus infection.

Study Participants.

Three females and 4 males ages 7 to 34 months seen in our department between July 1983 and February 1984 and September 1998 and May 1999 presented with fever of at least 7 days' duration and a gradual decline in the state of alertness. Score on the Glasgow Coma Scale ranged from 9 to 12. Findings on lumbar puncture were normal. In all 7 patients, the encephalogram showed moderate to severe background slowing compatible with encephalopathy. All patients were catarrheal and had mild hepatomegaly with slight elevation of liver enzymes. Some had bronchopneumonia, diarrhea, and conjunctivitis either isolated or in combination.

Methods and Results.

Adenovirus was isolated by immunfluorescence technique in all patients—from the sputum in 3 patients, nasopharynx in 5, conjunctiva in 4, and rectal swab in 5. In 5 patients, serotyping was performed by an antibody neutralization method. Adenovirus type 3 was ascertained from a nasal swab in 1 patient, sputum specimens in 3, throat swab in 3, and rectal cultures in 5. The clinical course was characterized by a progressive recovery of alertness. After several days, there was a complete reversal of neurologic findings.

Conclusion.

We suggest that this syndrome of transient encephalopathy is a distinct entity and should be considered as another of the several neurologic syndromes known to be associated with adenovirus infection.