bluuebunny/crossref_metadata_2025 huggingface dataset:
Psychoeducational Outcome in Children With Early-Treated Congenital Hypothyroidism
Authors: Rovet Joanne F. , Ehrlich Robert
Published: August 2004

Objectives.

To describe the psychoeducational characteristics of children with congenital hypothyroidism (CH) identified through newborn screening and to study changes over time.

Method.

Examined were 83 children with early-treated CH, who were long-time participants in a prospective study of outcome after newborn screening, and 120 control children who were classmates (n = 80) or siblings (n = 42). Children were tested during the third (53 children with CH and 46 control children) or the sixth (51 children with CH and 76 control children) grades at school with 21 children with CH being seen in both grades. Test instruments included multiple measures of achievement and cognitive abilities as well as behavior rating scales completed by parents and teachers.

Results.

CH was associated with a slightly increased risk of learning disabilities in grade 3 but not grade 6. Third grade CH children scored lower than control children on tests of reading comprehension and arithmetic but did not differ on word recognition, writing, or spelling. Sixth grade CH children performed similar to controls on basic achievement tests but were reported to be doing poorer in several subject areas. For children with CH in grade 3, delayed skeletal maturity at diagnosis was associated with poorer word recognition ability and a longer period for normalizing thyroid hormone in infancy was correlated with weaker skill in learning sound–symbol correspondences.

Conclusion.

Early-treated CH is associated with mild delays in several basic achievement areas (reading comprehension and arithmetic) at the third grade level, with catch up by the sixth grade. However, as other findings indicate cognitive problems do persist into adolescence in memory, attention, and visuospatial processing areas, the implications of these deficits for other educational accomplishments needs additional follow-up. congenital hypothyroidism, thyroid hormone, newborn screening, achievement, behavior, attention.
Predischarge Bilirubin Screening in Glucose-6-Phosphate Dehydrogenase-Deficient Neonates
Authors: Kaplan Michael , Hammerman Cathy , Feldman Roselyn , Brisk Rachel
Published: August 2004

Objective.

To assess the validity of predischarge serum bilirubin values in determining or predicting hyperbilirubinemia in glucose-6-phosphate dehydrogenase (G-6-PD)-deficient neonates, and to facilitate appropriate discharge planning.

Methods.

Serum total bilirubin values were determined between 44 and 72 hours of life in a cohort of term, healthy neonates at high-risk for G-6-PD deficiency but with no other risk factors for hyperbilirubinemia. Percentile-based bilirubin nomograms were constructed for G-6-PD-deficient infants and normal infants according to age at sampling. The incidence of hyperbilirubinemia (serum bilirubin value ≥256 μmol/L [15 mg/dL]) for each group was determined according to the percentiles for that group.

Results.

In both G-6-PD-deficient neonates (n = 108) and control neonates (n = 215) with serum bilirubin values <50th percentile for age, the incidence of hyperbilirubinemia was low in the G-6-PD-deficient neonates, with no measurable incidence in the controls. The incidence of hyperbilirubinemia became clinically consequential, and significantly higher in the G-6-PD-deficient groups, when the percentiles were ≥50: for those in the 50% to 74% range the incidence was moderate (23%) for the G-6-PD-deficient and small (7%) for the control infants (relative risk, 3.29; 95% confidence interval, 1.01–10.67). Among those infants ≥75th percentile, 82% of the G-6-PD-deficient infants, compared with 25% of the control infants, were either already hyperbilirubinemic at the time of screening or subsequently developed hyperbilirubinemia (relative risk, 3.23; 95% confidence interval, 1.99–5.24).

Conclusions.

Timed, predischarge serum bilirubin screening can be used to identify G-6-PD-deficient neonates at low, intermediate, or high-risk of developing severe neonatal hyperbilirubinemia, and thus offer a selective approach to the discharge and follow-up surveillance of these infants.
Early Dexamethasone—Attempting To Prevent Chronic Lung Disease
Authors: Sinkin Robert A. , Dweck Harry S. , Horgan Michael J. , Gallaher Keith J. , Cox Christopher , Maniscalco William M. , Chess Patricia R. , D'Angio Carl T. , Guillet Ronnie , Kendig James W. , Ryan Rita M. , Phelps Dale L.
Published: August 2004

Background.

We previously demonstrated improved survival and early outcomes in a pilot trial of 2 doses of intravenous dexamethasone for infants with surfactant-treated respiratory distress syndrome.1 A multicenter, randomized, double-blind trial was undertaken to confirm these results.

Methods.

Infants <30 weeks' gestation were eligible if they had respiratory distress syndrome, required mechanical ventilation at 12 to 18 hours of age, and had received at least 1 dose of exogenous surfactant. Infants were excluded if sepsis or pneumonia was suspected or if congenital heart disease or chromosomal abnormalities were present. A total of 384 infants were enrolled—189 randomized to dexamethasone (.5mg/kg birth weight at 12–18 hours of age and a second dose 12 hours later) and 195 to an equal volume of saline placebo.

Results.

No differences were found in the dexamethasone versus placebo groups, respectively, regarding the primary outcomes of survival (79% vs 83%), survival without oxygen at 36 weeks' corrected gestational age (CGA; both 59%), and survival without oxygen at 36 weeks' CGA and without late glucocorticoid therapy (46% vs 44%). No significant differences between the groups in estimates from Kaplan-Meier survival analyses were found for median days on oxygen (50 vs 56 days), ventilation (20 vs 27 days), days to regain birth weight (15.5 vs 14 days), or length of stay (LOS; 88 vs 89 days). Infants given early dexamethasone were less likely to receive later glucocorticoid therapy for bronchopulmonary dysplasia during their hospitalization (27% vs 35%). No clinically significant side effects were noted in the dexamethasone group, although there were transient elevations in blood glucose and blood pressure followed by a return to baseline by study day 10. Among infants who died (40 vs 33), there were no differences in the median days on oxygen, ventilation, nor LOS. However, in survivors (149 vs 162), the following were observed: median days on oxygen 37 versus 45 days, ventilation 14 versus 19 days, and LOS 79 versus 81 days, for the dexamethasone versus placebo groups, respectively.

Conclusions.

This dose of early intravenous dexamethasone did not reduce the requirement for oxygen at 36 weeks' CGA and survival was not improved. However, early dexamethasone reduced the use of later prolonged dexamethasone therapy, and among survivors, reduced the median days on oxygen and ventilation. We conclude that this course of early dexamethasone probably represents a near minimum dose for instituting a prophylactic regimen against bronchopulmonary dys- plasia.
Evaluation of Infants With Subdural Hematoma Who Lack External Evidence of Abuse
Authors: Morris Mark W. , Smith Sally , Cressman Joanne , Ancheta Joey
Published: August 2004

Objective.

Advances in radiologic technique have increased the recognition of subdural hematoma. No study to date has addressed the role of child protective investigation into the cause and management of subdural hematoma in children who lack other indicators of abuse.

Methods.

Medical records, radiology studies, and social service notes for all infants and children referred for child abuse investigation who had any form of intracranial hemorrhage were reviewed. The study covered the 12 months of 1997. All referrals were to the Suncoast Child Protection Team (St Petersburg, FL).

Results.

There were 19 investigations because of subdural hematoma. Eight children had retinal hemorrhage as well as other major findings of trauma, such as bruises and/or fractures; all 8 were victims of child abuse. Two infants had tiny subdurals adjacent to accidental linear skull fractures. Nine infants were investigated for the possibility of abuse that had no findings of trauma apart from the subdural hematoma. These 9 cases form the basis for this study. The age range was 11 days to 15 months. Inflicted cerebral trauma was the medical diagnosis in 8 of the 9 cases; 1 case had a final diagnosis of possible inflicted injury in a high-risk setting.

Conclusions.

Infants with subdural hematoma but no other findings of abuse present a difficult challenge to child protection workers. Investigation by a medically oriented team can uncover the circumstances of the trauma in most instances and can usefully direct protective efforts. The high incidence of severe sequelae in infants with inflicted cerebral trauma warrants a vigorous approach.
Parental Perspectives of the Health Status and Health-Related Quality of Life of Teen-Aged Children Who Were Extremely Low Birth Weight and Term Controls
Authors: Saigal Saroj , Rosenbaum Peter L. , Feeny David , Burrows Elizabeth , Furlong William , Stoskopf Barbara L. , Hoult Lorraine
Published: August 2004

Objectives.

To compare the health status and health-related quality of life of teen-aged children who were extremely low birth weight (ELBW) with matched controls from the perspective of their parents.

Study Design.

Geographically defined cohort; longitudinal follow-up; cross-sectional interviews. Participants: parents of 149/169 (88%) ELBW children between 12 and 16 years of age (including 41 children with neurosensory impairments) and 126/145 (87%) parents of term controls. Health status of the teenagers was classified according to the 6 attributes of the Health Utilities Index Mark 2, based on information obtained during parent interviews. Parents were asked to imagine themselves living in their own child's health state and 4 preselected hypothetical health states when providing directly measured standard gamble utility scores.

Results.

Parents of ELBW children reported a higher frequency and more complex functional limitations than parents of controls for their own children's health status. Also, the mean utilities were lower (ELBW = .91 vs controls = .97) and the variability in their scores was greater. There were no differences in the valuation of the hypothetical health states provided by parents of ELBW and control children.

Conclusions.

ELBW children were reported to have a greater burden of disability than were control children based on parental descriptions. Nonetheless, parents of ELBW children, on average, rated the health-related quality of life of their children fairly high. Thus, differences in reported functional status are not necessarily associated with lower utility scores.
Medical Education About End-of-Life Care in the Pediatric Setting: Principles, Challenges, and Opportunities
Authors: Sahler Olle Jane Z. , Frager Gerri , Levetown Marcia , Cohn Felicia G. , Lipson Michael A.
Published: August 2004

Objective.

To identify the opportunities for and barriers to medical education about end-of-life (EOL) care in the pediatric setting.

Methods.

A working group of pediatric specialists and ethicists was convened at the National Consensus Conference on Medical Education for Care Near the End-of-Life sponsored by the Open Society Institute's Project Death in America and the Robert Wood Johnson Foundation. The charge to the working group was to consider the unique aspects of death in childhood, identify critical educational issues and effective instructional strategies, and recommend institutional changes needed to facilitate teaching about EOL care for children.

Conclusions.

Although providing EOL care can be challenging, the cognitive and psychologic skills needed can be taught effectively through well-planned and focused learning experiences. The ultimate goals of such instruction are to provide more humane care to very sick children, enhance bereavement outcomes for their survivors, and develop more confident clinicians.

Six specific principles regarding EOL care in the pediatric setting emerged as essential curricular elements that should be taught to all medical care providers to ensure competent patient-centered care. 1) Cognitively and developmentally appropriate communication is most effective. 2) Sharing information with patients helps avoid feelings of isolation and abandonment. 3) The needs of the patient are served when the ethical principles of self-determination and best interests are central to the decision-making process. 4) Minimization of physical and emotional pain and other symptoms requires prompt recognition, careful assessment, and comprehensive treatment. 5) Developing partnerships with families supports them in their caregiving efforts. 6) The personal and professional challenges faced by providers of EOL care deserve to be addressed.

These principles actually transcend patient age and can be used to inform medical education about the care of any terminally ill patient. Similarly, these principles of effective communication, ethical decision-making, and attention to the quality of life of patients, families, and providers apply to the care of all children regardless of diagnosis and prognosis. With this in mind, teaching about EOL care does not require a new and separate curriculum, but rather taking better advantage of the many teachable moments provided by caring for a dying patient.
Does Mothering a Doll Change Teens' Thoughts About Pregnancy?
Authors: Kralewski Judith , Stevens-Simon Catherine
Published: August 2004

Objective.

To determine the effect of age on the efficacy of the computerized, infant simulator doll Baby Think It Over (BTIO) for increasing middle school girls' knowledge about the responsibilities of parenthood and discouraging plans for teen childbearing. We hypothesized: 1) 8th grade students would be less apt than 6th grade students to equate BTIO care with mothering because they would rationalize that their infant would be easier to care for than BTIO; and 2) BTIO would be a more effective teen pregnancy prevention program with 6th grade students than with 8th grade students.

Methods.

Nulliparous 6th (n = 68) and 8th (n = 41) grade girls attending an urban middle school in a predominantly lower socioeconomic, Hispanic, neighborhood were asked to care for BTIO for 3 days and 2 nights. Responses to a self-administered questionnaire were used to assess the girls' understanding of the responsibilities and difficulties associated with parenting, their feelings about the similarity of BTIO care and real infant care, and their childbearing intentions before and after caring for BTIO.

Results.

Only 32 (29%) of the 109 girls thought that real infant care would be like BTIO care. Although 8th grade students were less apt than 6th grade students to equate BTIO care with real infant care (17% vs 37%), 6th grade students were more likely than 8th grade students to endorse statements suggesting that real infant care would be easier than BTIO care (37% vs 24%). Multivariate analyses revealed that this was largely because 6th grade students found BTIO care more difficult than did 8th grade students. Also, regardless of age or grade, the more difficult a girl found it to care for BTIO than anticipated, the more likely she was to endorse statements indicating that it would be easier to care for her own infant than it had been for her to care for BTIO. Little learning about the difficulties of parenting took place during the study. On average, the 6th grade students did not find BTIO care more difficult than anticipated and the 8th grade students actually found it easier than anticipated. Finally, caring for BTIO had no affect on the intent of students to become teen parents; 13 (12%) of the 109 students wanted to be teen parents before they cared for BTIO and 16 (15%) wanted to be teen parents after they cared for the doll.

Conclusion.

The results of this study demonstrate that the propensity of people this age for rationalizing their own immunity to the nocuous aspects of potentially desirable situations (the personal fable of omnipotence) allows those who perceive parenthood to be attractive to overlook the negative aspects of any parenting experience they have.
Mercury Intoxication and Arterial Hypertension: Report of Two Patients and Review of the Literature
Authors: Torres Alfonso D. , Rai Ashok N. , Hardiek Melissa L.
Published: August 2004

Two children in the same household with symptomatic arterial hypertension simulating pheochromocytoma were found to be intoxicated with elemental mercury. The first child was a 4-year-old boy who presented with new-onset seizures, rash, and painful extremities, who was found to have a blood pressure of 171/123 mm Hg. An extensive investigation ensued. Elevated catecholamines were demonstrated in plasma and urine; studies did not confirm pheochromocytoma. Mercury levels were elevated. These findings prompted an evaluation of the family. A foster sister had similar findings of rash and hypertension. Both had been exposed to elemental mercury in the home. The family was temporarily relocated and chelation therapy was started.

A Medline search for mercury intoxication with hypertension found 6 reports of patients ranging from 11 months to 17 years old. All patients showed symptoms of acrodynia. Because of the clinical presentation and the finding of elevated catecholamines, most of the patients were first studied for possible pheochromocytoma. Subsequently, elevated levels of mercury were found. Three children had contact with elemental mercury from a broken thermometer, 2 had played with metallic mercury and 1 had poorly protected occupational exposure. All responded to chelation therapy.

Severe systemic arterial hypertension in infants and children is usually secondary to an underlying disease process. The most frequent causes of hypertension in this group include renal parenchymal disease, obstructive uropathy, and chronic pyelonephritis associated with reflux and renal artery stenosis. Less frequent causes include adrenal tumors, pheochromocytomas, neurofibromas, and a number of familial forms of hypertension. Other causes include therapeutic and recreational drugs, notably sympathomimetics and cocaine, and rarely, heavy metals. In children with severe hypertension and elevated catecholamines, the physician should consider mercury intoxication as well as pheochromocytoma. The health hazards of heavy metals need to be reinforced to the medical profession and the general public.
Lymphocytic Choriomeningitis Virus: Reemerging Central Nervous System Pathogen
Authors: Barton Leslie L. , Hyndman N. Joanne
Published: August 2004

Lymphocytic choriomeningitis virus (LCMV), a human zoonosis caused by a rodent-borne arenavirus, has been associated with both postnatal and intrauterine human disease. Infection in man is acquired after inhalation, ingestion, or direct contact with virus found in the urine, feces, and saliva of infected mice, hamsters, and guinea pigs. Congenital LCMV infection is a significant, often unrecognized cause of chorioretinitis, hydrocephalus, microcephaly or macrocephaly, and mental retardation. Acquired LCMV infection, asymptomatic in approximately one third of individuals, is productive of central nervous system manifestations in one half of the remaining cases. Aseptic meningitis or meningoencephalitis are the predominant syndromes, although transverse myelitis, a Guillain-Barré-type syndrome, as well as transient and permanent acquired hydrocephalus have also been reported. Fatalities are rare. We report a patient with meningoencephalitis attributable to LCMV and discuss the spectrum of central nervous system disease, newer diagnostic modalities, and preventive strategies. lymphocytic choriomeningitis virus, aseptic meningitis, meningoencephalitis, zoonosis, hydrocephalus, arenavirus.
A Syndrome Involving Intrauterine Growth Retardation, Microcephaly, Cerebellar Hypoplasia, B Lymphocyte Deficiency, and Progressive Pancytopenia
Authors: Revy Patrick , Busslinger Meinrad , Tashiro Kei , Arenzana Fernando , Pillet Pascal , Fischer Alain , Durandy Anne
Published: August 2004

We report a new complex syndrome involving profound failure to thrive with severe intrauterine growth retardation, cerebellar abnormalities, microcephaly, a complete lack of B lymphocyte development, and secondary, progressive marrow aplasia. B cell differentiation was found to be blocked at the pro-B cell stage. Although not strictly proven, a genetic origin is likely, according to similar cases reported in the literature.

Three candidate genes, PAX5, encoding B cell-specific activator protein, a factor involved in B cell lineage commitment, stromal cell-derived factor 1, and CXCR4, encoding a chemokine and its receptor, respectively, were thought to be responsible for this disease, given the similarity between the phenotype of the corresponding knock-out mice and the clinical features of the patient. However, the genomic DNA sequences of these 3 genes were normal, and normal amounts of stromal cell-derived factor 1 and CXCR4 were present.

These data strongly suggest that another molecule is involved in early B cell differentiation, hematopoiesis, and cerebellar development in humans.
Infants With a Thumb-in-Fist Posture
Authors: Jaffe Michael , Tal Yoram , Dabbah Husein , Ganelis Leonid , Cohen Ayala , Even Lea , Tirosh Emanuel
Published: August 2004

Objective.

In early infancy the infant's thumb is not infrequently enclosed within the palm, ie, thumb-in-fist (TIF). This posture has received scant attention in the neurodevelopmental literature. Its prevalence, resolution, and clinical associations were investigated in this study.

Methodology.

Two hundred sequentially born, apparently healthy full-term newborn infants comprised the cohort. The whole study group was followed up until the disappearance of the TIF occurred. In the first 150 of the cohort, additional data on development and the neurological status were obtained at 12 months of life.

Results.

In 125 infants (62.5%) of the total cohort, a TIF was noted. The mean age of disappearance was 1.5 months, and no TIF persisted after 7 months old. No relationship was noted between the TIF resolution and abnormal neurological signs or gross or fine motor development. The only association noted between age of resolution of the TIF and the neurodevelopmental status was a delay in language attainment at the 12-month screening.

Conclusions.

The TIF posture in infancy was noted in 65% of our cohort, and it had resolved in all infants by 7 months old. Therefore, a TIF posture after this age should alert the clinician to the possibility of possible neurological dysfunction. An unanticipated association of a delay in the 12-month language milestone attainment was noted in those infants with later resolution of the TIF posture. No data on language development in this group were obtained after 12 months old; therefore, the clinical significance of this finding is not yet elucidated.
A Guideline Implementation System Using Handheld Computers for Office Management of Asthma: Effects on Adherence and Patient Outcomes
Authors: Shiffman Richard N. , Freudigman MCIS*‡; Kimberly A. , Brandt Cynthia A. , Liaw Yischon , Navedo Deborah D.
Published: August 2004

Objective.

To evaluate effects on the process and outcomes of care brought about by use of a handheld, computer-based system that implements the American Academy of Pediatrics guideline on office management of asthma exacerbations.

Design.

A before–after trial with randomly selected, office-based Connecticut pediatricians. In both the control and intervention phases, physicians collected data from 10 patient encounters for acute asthma exacerbations. During the intervention phase, the computer provided for structured encounter documentation and offered recommendations based on the guideline of the American Academy of Pediatrics. Patients were contacted by telephone 7 to 14 days after the visit to assess outcomes.

Results.

Nine study-physicians enrolled 91 patients in the control phase and 74 in the intervention phase. Follow-up information was available for 93% of encounters. Use of the intervention was associated with increased mean frequency/visit of: 1) measurements of peak expiratory flow rate (2.18 vs 1.57) and oxygen saturation (1.12 vs .42), and 2) administration of nebulized β2-agonists (1.25 vs .71). Visits in the intervention phase lasted longer and fees were higher ($145.61 vs $103.11). There were no significant differences in immediate disposition or subsequent emergency department visits, hospitalizations, missed school, or caretaker's missed work during the 7 days post visit.

Conclusion.

Use of handheld computers that provide guideline-based decision support was associated with increased physician adherence to guideline recommendations; however, visits were prolonged, fees were higher, and no improvement could be demonstrated with regard to the observed intermediate-term patient outcomes. Guideline implementers (and users) should be cautious about putting unvalidated recommendations into practice.
Echocardiographic Diagnosis of Heart Disease in Apparently Healthy Adolescents
Authors: Steinberger Julia , Moller James H. , Berry James M. , Sinaiko Alan R.
Published: August 2004

Objective.

Comprehensive data are currently unavailable on the prevalence of cardiac abnormalities in children after the newborn/infant period. The present report describes the prevalence of echocardiographically detected cardiac disease in a cohort of randomly selected healthy junior high school children.

Methods.

The cohort for this report consists of 357 children (mean age: 13 years) randomly selected after blood pressure screening of 12 043 fifth through eighth grade students and having an echocardiographic examination as part of a study of insulin resistance in childhood.

Results.

A physical examination performed by a board-certified pediatrician reported no cardiac abnormalities. However, echocardiography and Doppler studies identified 13 (3.6%) children (7 males and 6 females), with previously unknown cardiac abnormalities, as follows: abnormal mitral valve with mitral regurgitation (4), bicuspid aortic valve (2), atrial septal defect (2), coronary artery to pulmonary artery fistula (1), patent ductus arteriosus (1), pulmonary hypertension (1), cardiomyopathy (1), and pulmonary artery stenosis (1). Physical examination performed by a pediatric cardiologist detected abnormal cardiac findings in 7 (54%) of the children. Cardiac catheterization was required in 3 for additional diagnostic evaluation and in 2 for therapeutic intervention; 1 patient underwent open-heart surgery. Bacterial endocarditis prophylaxis was recommended in 8 (62%) of the 13 children.

Conclusions.

The results suggest that: 1) clinically significant cardiac disease in childhood is more prevalent than previously reported; and 2) improved screening methods should be considered to detect asymptomatic but significant cardiac abnormalities that may result in long-term complications. echocardiography, prevalence, incidence, heart disease, children.
School Health Assessments
Authors:   Committee on School Health
Published: August 2004

Comprehensive health assessments often are performed in school-based clinics or public health clinics by health professionals other than pediatricians. Pediatricians or other physicians skilled in child health care should participate in such evaluations. This statement provides guidance on the scope of in-school health assessments and the roles of the pediatrician, school nurse, school, and community.
Systemic Corticosteroids in Infant Bronchiolitis: A Meta-analysis
Authors: Garrison Michelle M. , Christakis Dimitri A. , Harvey Eric , Cummings Peter , Davis Robert L.
Published: August 2004

Objective.

To determine whether corticosteroids are efficacious in treating bronchiolitis in hospitalized infants.

Methods.

Online bibliographic databases (Medline, Embase, and Cochrane Clinical Trials Registry) were searched for: 1) bronchiolitis or respiratory syncytial virus, and 2) corticosteroid or glucocorticoid or steroidal antiinflammatory agents or adrenal cortex hormones. Reference lists from all selected articles were also examined. Randomized, placebo-controlled trials of systemic corticosteroids in treatment of infants hospitalized with bronchiolitis were selected by 2 investigators. Of 12 relevant publications identified in the literature search, 6 met the selection criteria and had relevant data available. Investigators independently extracted data for 3 outcomes: length of stay (LOS), duration of symptoms (DOS), and clinical scores.

Results.

In the pooled analysis, infants who received corticosteroids had a mean LOS or DOS that was .43 days less than those who received the placebo treatment (95% confidence interval: −.81 to −.05 days). The effect size for mean clinical score was −1.60 (95% confidence interval: −1.92 to −1.28), favoring treatment. Secondary analyses of mean LOS or DOS were performed on 5 trials that had clearly identified methods of randomization, 5 trials that measured LOS, and 4 trials that clearly excluded infants with previous wheezing. The estimates of effect were similar to the primary analysis but were not statistically significant.

Conclusions.

Combined, published reports of the effect of systemic corticosteroids on the course of bronchiolitis suggest a statistically significant improvement in clinical symptoms, LOS, and DOS.
Ketogenic Diet for the Treatment of Refractory Epilepsy in Children: A Systematic Review of Efficacy
Authors: Lefevre Frank , Aronson Naomi
Published: August 2004

Objectives.

To systematically review and synthesize the available evidence on the efficacy of the ketogenic diet in reducing seizure frequency for children with refractory epilepsy.

Data Sources.

Medline searches were performed using the keywords epilepsy/therapy, dietary therapy, and epilepsy, and the text word ketogenic diet. The Cochrane Library of clinical trials was searched using the term ketogenic diet. Bibliographies of recent review articles and relevant primary research reports, as well asCurrent Contents were reviewed for additional relevant citations.

Study Selection.

Studies were selected for inclusion in the review that reported the reduction of seizure frequency following treatment with the ketogenic diet in children with refractory epilepsy. The outcome measures used were the percentage of patients with: 1) complete elimination of seizures, 2) >90% reduction in seizures, and 3) >50% reduction in seizures.

Results.

The evidence consists entirely of uncontrolled studies. Of 11 studies identified for this review, 9 are retrospective series of patients from a single institution. Two studies are prospective, 1 of which is a multicenter trial. The results of these studies are consistent in showing that some children benefit from the ketogenic diet, demonstrated by a significant reduction in seizure frequency. Estimates of the rates of improvement by combined analysis (confidence profile method) are complete cessation of all seizures in 16% of children (95% confidence interval [CI]: 11.0–21.7); a greater than 90% reduction in seizures in 32% (95% CI: 25.3–39.8); and a greater than 50% reduction in seizures in 56% (95% CI: 41.2–69.7). It is unlikely that this degree of benefit can result from a placebo response and/or spontaneous remission.

Conclusions.

Although controlled trials are lacking, the evidence is sufficient to determine that the ketogenic diet is efficacious in reducing seizure frequency in children with refractory epilepsy.
Voiding Cystourethrograms and Urinary Tract Infections: How Long to Wait?
Authors: McDonald Anu , Scranton Maria , Gillespie Robert , Mahajan Vandana , Edwards George A.
Published: August 2004

Objectives.

Many authorities recommend an interval of at least 3 to 6 weeks after a urinary tract infection (UTI) before performing a voiding cystourethrogram (VCUG). However, such an interval may reduce the likelihood of completing the procedure. This study was performed to investigate whether the length of the interval between a UTI and the performance of the VCUG influences the presence or severity of reflux, and whether it influences the likelihood of actually having the study performed.

Design.

We reviewed 352 admissions of children under 10 years old whose discharge diagnoses indicated UTIs. These admissions occurred over a 27-month period between October 1994 and December 1996 at the Children's Hospital of Austin, Texas. We identified 213 patients with confirmed UTIs and no other previously defined urinary tract pathology. These patients were divided into 2 groups according to whether they had a VCUG scheduled to be performed either within 1 week after the diagnosis of a UTI (the early group), or later than 1 week after the diagnosis (the late group). We compared the presence and severity of reflux in the 2 groups as well as the proportion of scheduled VCUGs that were actually performed.

Results.

Reflux was present in 19% of the patients studied within 1 week after UTI (95% confidence interval [CI]: 12.9–26.4) and in 18% of those studied after 1 week (95% CI: 6.7–34.5). This difference was not statistically significant (χ2 = .034; DF = 1). However there was a substantial difference between the 2 groups with regard to the number of scheduled VCUGs actually performed. Whereas 100% of the scheduled VCUGs in the early group were performed, only 48% (95% CI: 35.9–60.1) of those scheduled in the late group were performed. This difference is statistically significant (χ2 = 89.6; DF = 1).

Conclusions.

In the hospitalized children who underwent VCUGs within a week after diagnosis of UTI, the presence of reflux is not significantly different from those studied later. Furthermore, late scheduling of VCUGs resulted in failure to perform the procedure in more than half of the patients. Some of the patients who were not evaluated would be expected to have vesicoureteral reflux and thus be at risk for chronic renal disease. Therefore, the traditional recommendation to perform the VCUG at 3 to 6 weeks after the diagnosis of UTI should be reconsidered, especially for hospitalized children.
Preventable Childhood Tuberculosis in Alabama: Implications and Opportunity
Authors: Kimerling Michael E. , Barker Jill T. , Bruce Frank , Brook Nancy L. , Dunlap Nancy E.
Published: August 2004

Childhood tuberculosis (TB) cases indicate recent community transmission and thus reflect the effectiveness of TB control efforts, particularly the contact investigation.

Objective. To evaluate all preventable childhood TB cases and implications in the context of TB morbidity trends.

Design. Statewide morbidity trends are presented from 1983 to 1997. Since 1992, each child TB case is classified as either preventable or not preventable, based on a standard definition.

Main Outcome Measures. Case characteristics (preventable and not preventable), TB disease rates over time, and reasons for preventable case classification.

Setting. Alabama TB control program, from January 1, 1983 through December 31, 1997.

Results. For the period 1983–1997, nonwhite children had a higher disease rate (rate ratio: 5.7; 95% confidence interval: 4.3,7.6) than white children. Since 1990, the overall child rate has increased significantly despite a decline in the adult rate. Among 120 child cases diagnosed from 1992 to 1997, 25 (21%) were classified as preventable. The causes were contact investigation interview failure (12/25 = 48%), delay to evaluation (16%), source case noncompliance with previously prescribed preventive therapy (16%), and source case diagnosed out of state (16%) with no initial investigation performed in Alabama. All preventable cases identified were black children; the proportion of preventable cases did not vary by age group or sex. During 1996, the case rate for nonwhite children exceeded that of adult whites.

Conclusions. Childhood TB in Alabama for nonwhites is rising despite a national downward trend. TB is clearly a disproportionate disease burden for the state's African American population, and the median case age is falling. Additional research and improved training in contact investigation are required to assess this situation and effectively intervene.
Diminished Inducible Nitric Oxide Synthase Expression in Fulminant Early-Onset Neonatal Pneumonia
Authors: Aikio Outi , Vuopala Katri , Pokela Marja-Leena , Hallman Mikko
Published: August 2004

Objective.

Fulminant early-onset neonatal pneumonia is associated with ascending intrauterine infection (IUI), prematurity, persistent pulmonary hypertension (PPHN), and septicemia. Nitric oxide (NO) as an inflammatory mediator is included in antimicrobial defense and has a role in pathogenesis of septic shock. The aim was to study the role of inflammatory NO in neonatal pneumonia.

Methods.

Lungs from 36 autopsies were studied: 12 had fulminant early-onset neonatal pneumonia, 5 pneumonia of later onset, and 19 controls had similar gestational and postnatal age. In addition, airway specimens from 21 intubated newborns were analyzed: 7 with fulminant early-onset pneumonia, 7 apparently noninfected infants born prematurely attributable to IUI, and 7 premature infants of similar gestation. Specimens were analyzed for inducible NO synthase (NOS2) and nitrotyrosine, an indicator of NO toxicity. The degree of staining was analyzed.

Results.

In fulminant pneumonia, alveolar macrophages (AM) showed significantly less NOS2 immunoactivity than the controls. In the airway specimens, the infants with fulminant pneumonia 0 to 2 days after birth had significantly lower intracellular NOS2 and nitrotyrosine and significantly lower interleukin-1β and surfactant protein-A than apparently noninfected IUI infants. NOS2 and the other indices increased significantly during the recovery.

Conclusions.

For the first time, we report NOS2 expression by macrophages from human neonates. In fulminant early-onset neonatal pneumonia, delayed production rather than excess of pulmonary inflammatory NO is associated with severe symptoms.
A Comparison of Neonatal Mortality Risk Prediction Models in Very Low Birth Weight Infants
Authors: Pollack Murray M. , Koch Matthew A. , Bartel Doris A. , Rapoport Irina , Dhanireddy Ramasubbareddy , El-Mohandes Ayman A. E. , Harkavy Kenneth , Subramanian K. N. Siva ,   the District of Columbia Neonatal Network
Published: August 2004

Background.

Risk-adjusted severity of illness is frequently used in clinical research and quality assessments. Although there are multiple methods designed for neonates, they have been infrequently compared and some have not been assessed in large samples of very low birth weight (VLBW; <1500 g) infants.

Objectives.

To test and compare published neonatal mortality prediction models, including Clinical Risk Index for Babies (CRIB), Score for Neonatal Acute Physiology (SNAP), SNAP-Perinatal Extension (SNAP-PE), Neonatal Therapeutic Interventions Scoring System, the National Institute of Child Health and Human Development (NICHD) network model, and other individual admission factors such as birth weight, low Apgar score (<7 at 5 minutes), and small for gestational age status in a cohort of VLBW infants from the Washington, DC area.

Methods.

Data were collected on 476 VLBW infants admitted to 8 neonatal intensive care units between October 1994 and February 1997. The calibration (closeness of total observed deaths to the predicted total) of models with published coefficients (SNAP-PE, CRIB, and NICHD) was assessed using the standardized mortality ratio. Discrimination was quantified as the area under the curve (AUC) for the receiver operating characteristic curves. Calibrated models were derived for the current database using logistic regression techniques. Goodness-of-fit of predicted to observed probabilities of death was assessed with the Hosmer-Lemeshow goodness-of-fit test.

Results.

The calibration of published algorithms applied to our data was poor. The standardized mortality ratios for the NICHD, CRIB, and SNAP-PE models were .65, .56, and .82, respectively. Discrimination of all the models was excellent (range: .863–.930). Surprisingly, birth weight performed much better than in previous analyses, with an AUC of .869. The best models using both 12- and 24-hour postadmission data, significantly outperformed the best model based on birth data only but were not significantly different from each other. The variables in the best model were birth weight, birth weight squared, low 5-minute Apgar score, and SNAP (AUC = .930).

Conclusion.

Published models for severity of illness overpredicted hospital mortality in this set of VLBW infants, indicating a need for frequent recalibration. Discrimination for these severity of illness scores remains excellent. Birth variables should be reevaluated as a method to control for severity of illness in predicting mortality.
Parental Prevention Practices for Young Children in the Context of Maternal Depression
Authors: McLennan John D. , Kotelchuck Milton
Published: August 2004

Objective.

To assess the relationship between maternal depression and 4 parent-based prevention practices (use of car seats and electrical plug covers, presence of syrup of ipecac in the home, and reading to their child), using a large nationally representative follow-back sample.

Methods.

The maternal self-report components of 2 databases were used for this study, the 1988 National Maternal and Infant Health Survey and the linked companion 1991 Longitudinal Follow-Up Survey. A total of 7537 mothers with newborns in 1988 served as the subjects. Measures of the 4 prevention practices were extracted from the 1991 survey. Depressive symptom measures were derived from both surveys using the Center for Epidemiologic Studies-Depression Scale. Weighted bivariate and multivariate logistic analyses were used to assess the relationship between maternal depressive symptoms (trichotomized to depression at both time points, at 1 time point, and at neither time point) and parental prevention practices, while controlling for a wide variety of sociodemographic variables.

Results.

Mothers reporting a high level of depressive symptoms (Center for Epidemiologic Studies-Depression Scale score ≥16) reported significantly poorer prevention practices for car seat use, covering electrical plugs, and having syrup of ipecac in the home. High depressive symptoms were also related to a lower likelihood of daily reading, but only for those mothers presently living with a male partner. Engagement in all prevention practices, except having syrup of ipecac in the home, were less likely if the mother reported high levels of depressive symptoms at both time points versus a single time point.

Conclusion.

Maternal depression may significantly impede parental prevention practices. As maternal depression is a treatable condition, screening and treating this disorder may contribute to improvement in childhood prevention practices and ultimately child health.
Rectal Methohexital Sedation for Computed Tomography Imaging of Stable Pediatric Emergency Department Patients
Authors: Pomeranz Elaine S. , Chudnofsky Carl R. , Deegan Thomas J. , Lozon Marie M. , Mitchiner James C. , Weber James E.
Published: August 2004

Objective.

Rapid onset of sleep, brief duration of action, and ease of administration are properties that make rectal methohexital (MXT) an attractive choice for sedating stable pediatric emergency department (ED) patients for computed tomography (CT) imaging.

Methodology.

One hundred stable patients between 3 and 60 months of age who presented to any of 3 participating EDs and required sedation to undergo CT scanning were given 25 mg/kg of rectal MXT ∼15 minutes before their imaging. Vital signs and oxygen saturation were recorded at regular intervals. Data collected included indication for CT imaging, time to achieve sleep, time to reach discharge criteria, adequacy of sedation, adverse effects, and parental satisfaction.

Results.

Ninety-five percent of the patients were adequately sedated with rectal MXT. It took an average of 8 minutes to achieve full sedation and the duration of action averaged 79.3 minutes. Ten percent had transient side effects, but all recovered completely. None required intubation. Parental satisfaction was 90%.

Conclusion.

Rectal MXT compares favorably to other methods of nonintravenous sedation for CT scanning of stable pediatric ED patients in terms of rapidity of onset and reliability but does cause a significant amount of transient respiratory depression. Its use requires careful monitoring of oxygen saturation and should be used only in a setting where physicians skilled in airway management are present. If these requirements are met, it may be a good choice for the relatively noninvasive sedation of pediatric ED patients undergoing painless but anxiety-provoking procedures. methohexital, pediatric procedure sedation, rectal administration, computerized tomography imaging.
What Is the Yield of Screening Echocardiography in Pediatric Syncope?
Authors: Ritter Saskia , Tani Lloyd Y. , Etheridge Susan P. , Williams Richard V. , Craig Janet E. , Minich L. LuAnn
Published: August 2004

Objective.

To determine the yield of screening echocardiography in the evaluation of pediatric syncope.

Design.

All patients diagnosed with syncope from January 1993 to January 1999 were identified and their records were reviewed for age, weight, sex, year of presentation, personal and family history, physical examination, and cardiac diagnostic testing. Cardiac defects were identified by reviewing echocardiograms and reports.

Results.

The 480 patients (268 females) ranged in age from 1.5 to 18.0 years old and ranged in weight from 10.3 to 113.6 kg. Final diagnoses included noncardiac causes in 458, long QT syndrome in 14, arrhythmias in 6, and cardiomyopathy in 2. An abnormal history, physical examination, or electrocardiogram identified 21 of the 22 patients with a cardiac cause of syncope. Of the 322 (67%) echocardiograms performed, abnormalities were detected in 37. These abnormalities included 26 minor valve anomalies, 7 hemodynamically insignificant shunt lesions, 2 mildly decreased left ventricular shortening fractions, and 2 cardiomyopathies. Only the 2 cardiomyopathies were considered to be potential causes of syncope, and in both cases, the electrocardiogram was markedly abnormal. A similar percentage of echocardiograms were ordered during the first and last 3 years of the study (61% vs 71%).

Conclusion.

History, physical examination, and electrocardiography provide a screening protocol that allows the identification of a cardiac cause of syncope in the overwhelming majority of pediatric patients. In the absence of a positive screen result, the echocardiogram does not contribute to the evaluation of syncope in children. We speculate that primary care providers and pediatric cardiologists continue to use echocardiography because of the paucity of data regarding its value in pediatric syncope. However, this study shows little benefit of screening echocardiography and should discourage its routine use.