bluuebunny/crossref_metadata_2025 huggingface dataset:
The Practice of Pediatric Sleep Medicine: Results of a Community Survey
Authors: Owens Judith A.
Published: August 2004

Objective.

To assess knowledge, screening, evaluation, treatment practices, and attitudes regarding sleep disorders in children and adolescents in a large sample of community-based and academic pediatricians.

Design.

Cross-sectional survey.

Participants.

Six hundred twenty-six pediatricians in Rhode Island, Massachusetts, and Connecticut.

Instrument.

The Pediatric Sleep Survey, a 42-item questionnaire assessing general and specific sleep knowledge categories; clinical screening, diagnostic, and treatment practices for common pediatric sleep disorders; and practitioner attitudes regarding the impact of sleep disorders in the clinical setting and as a public health issue.

Results.

On the knowledge section, the mean Total Knowledge score for the respondents was 18.1 ± 3.5 out of 30 items, with 23.5% of the sample responding correctly on half or less of the items. Pediatricians scored highest on items relating to developmental and behavioral aspects of sleep and parasomnias, whereas the mean percentage of correct responses was <50% for items relating to sleep disordered breathing, excessive daytime sleepiness, and sleep movement disorders. Although only 16.5% and 18.2% of the sample reported not screening routinely for sleep disorders in infants and toddlers, this percentage rose to 43.9% in adolescents. Furthermore, only 38.3% regularly question the adolescents themselves about their sleep. Only about one quarter of the respondents screen toddlers and school-aged children for snoring. In evaluating and treating pediatric sleep problems, 53.2% of the sample never or rarely order overnight sleep studies to assess for obstructive sleep apnea and few use alternative treatment strategies, such as continuous positive airway pressure. A quarter of the sample at least occasionally recommends diphenhydramine and almost half suggests a psychological evaluation for children with night terrors. Finally, the percent of pediatricians rating the impact on children of sleep problems in a variety of domains as important or very important ranged from 49.7% (nonintentional injuries) to 92.6% (academic performance). However, only 46% of the sample felt confident or very confident about their own ability to screen for sleep problems, whereas 34.2% and 25.3% similarly rated their ability to evaluate and treat sleep problems in children.

Conclusions.

The results of this survey suggest that there are still significant gaps among practicing pediatricians both in basic knowledge about pediatric sleep disorders, and in the translation of that knowledge into clinical practice. Despite their acknowledgment of the importance of sleep problems, many pediatricians fail to screen adequately for them, especially in older children and adolescents. Additional educational efforts regarding pediatric sleep issues are warranted, and should be targeted at the medical school, postgraduate training, and continuing medical education levels.
An Orange a Day Keeps the Doctor Away: Scurvy in the Year 2000
Authors: Weinstein Michael , Babyn Paul , Zlotkin Stan
Published: August 2004

Scurvy has been known since ancient times, but the discovery of the link between the dietary deficiency of ascorbic acid and scurvy has dramatically reduced its incidence over the past half-century. Sporadic reports of scurvy still occur, primarily in elderly, isolated individuals with alcoholism. The incidence of scurvy in the pediatric population is very uncommon, and it is usually seen in children with severely restricted diets attributable to psychiatric or developmental problems. The condition is characterized by perifollicular petechiae and bruising, gingival inflammation and bleeding, and, in children, bone disease. We describe a case of scurvy in a 9-year-old developmentally delayed girl who had a diet markedly deficient in vitamin C resulting from extremely limited food preferences. She presented with debilitating bone pain, inflammatory gingival disease, perifollicular hyperkeratosis, and purpura. Severe hypertension without another apparent secondary cause was also present, which has been previously undescribed. The signs of scurvy and hypertension resolved after treatment with vitamin C. The diagnosis of scurvy is made on clinical and radiographic grounds, and may be supported by finding reduced levels of vitamin C in serum or buffy-coat leukocytes. The response to vitamin C is dramatic. Clinicians should be aware of this potentially fatal but easily curable condition that is still occasionally encountered among children.
Femur Fracture in Infants: A Possible Accidental Etiology
Authors: Grant Penny , Mata Maria B. , Tidwell Michael
Published: August 2004

Femoral fractures in nonambulating infants are generally felt to be attributable to abuse in the absence of significant trauma or underlying organic pathology. The investigation of such fractures includes a report to appropriate social service and law enforcement agencies, and legal involvement. This paper describes 2 nonambulatory infants who sustained identical oblique distal femoral metaphyseal fractures extending through the growth plate after playing in an infant stationary activity center called an Exersaucer. It is possible that the twisting motion provided by the Exersaucer (Evenflo, Picqua, OH) might be consistent with the generation of forces necessary to cause these fractures.
Bladder Retention of Urine as a Result of Continuous Intravenous Infusion of Fentanyl: 2 Case Reports
Authors: Das Utpala G. , Sasidharan P.
Published: August 2004

Sedation has been commonly used in the neonate to decrease the stress and pain from the noxious stimuli and invasive procedures in the neonatal intensive care unit, as well as to facilitate synchrony between ventilator and spontaneous breaths. Fentanyl, an opioid analgesic, is frequently used in the neonatal intensive care unit setting for these very purposes. Various reported side effects of fentanyl administration include chest wall rigidity, hypotension, respiratory depression, and bradycardia. Here, 2 cases of urinary bladder retention leading to renal pelvocalyceal dilatation mimicking hydronephrosis as a result of continuous infusion of fentanyl are reported.
Acetaminophen Toxicity in Children
Authors:   Committee on Drugs
Published: August 2004

This Policy Statement was retired June 2013.

Acetaminophen is widely used in children, because its safety and efficacy are well established. Although the risk of developing toxic reactions to acetaminophen appears to be lower in children than in adults, such reactions occur in pediatric patients from intentional overdoses. Less frequently, acetaminophen toxicity is attributable to unintended inappropriate dosing or the failure to recognize children at increased risk in whom standard acetaminophen doses have been administered. Because the symptoms of acetaminophen intoxication are nonspecific, the diagnosis and treatment of acetaminophen intoxication are more likely to be delayed in unintentional cases of toxicity. This statement describes situations and conditions that may contribute to acetaminophen toxicity not associated with suicidal intentions.
Relation Between Infantile Colic and Asthma/Atopy: A Prospective Study in an Unselected Population
Authors: Castro-Rodrı́guez José A. , Stern Debra A. , Halonen Marilyn , Wright Anne L. , Holberg Catharine J. , Taussig Lynn M. , Martinez Fernando D.
Published: August 2004

Objective.

To assess whether children with history of infantile colic may be at increased risk of subsequently developing asthma and/or atopy.

Methods.

We used data collected in a large, prospective study from an unselected population. Infantile colic and concurrent feeding method were determined from the 2-month well-infant visit form completed by the physician for 983 children who were enrolled at birth. Markers of atopy (total serum immunoglobulin E and allergy skin prick test), allergic rhinitis, asthma, wheezing, and peak flow variability were the main outcome measures studied at different ages between infancy and 11 years.

Results.

Ninety (9.2%) children had infantile colic. Prevalence of colic was similar among children fed either breast milk or formula. There was no association between infantile colic and markers of atopy, asthma, allergic rhinitis, wheezing, or peak flow variability at any age.

Conclusion.

Our data cannot support the hypothesis that infantile colic provides increased risk for subsequent allergic disease or atopy.
Who Cares for Medicaid-Enrolled Children With Chronic Conditions?
Authors: Kuhlthau Karen , Ferris Timothy G. G. , Beal Anne C. , Gortmaker Steven L. , Perrin James M.
Published: August 2004

Objective.

To estimate generalist, pediatric subspecialist, and any subspecialist use by Medicaid-enrolled children with chronic conditions and to determine the correlates of use.

Methods.

We analyzed Medicaid claims data collected from 1989 to 1992 from 4 states for 57 328 children and adolescents with 11 chronic conditions. We calculated annual rates of generalist, subspecialist, and pediatric subspecialist use. We used logistic regression to determine the association of demographics, urban residence, and case-mix (Adjusted Clinical Groups) with the use of relevant pediatric and any subspecialist care.

Results.

Most children with chronic conditions had visits to generalists (range per condition: 78%–90% for children with Supplemental Security Income [SSI] and 85%–94% for children without SSI) during the year studied. Fewer children visited any relevant subspecialists (24%–59% for children with SSI and 13%–56% for children without SSI) or relevant pediatric subspecialists (10%–53% for children with SSI and 3%–37% for children without SSI). In general, children who were more likely to use pediatric subspecialists were younger, lived in urban areas, were white (only significant for non-SSI children), and had higher Adjusted Clinical Groups scores. Use of any subspecialists followed a similar pattern except that urban residence is statistically significant only for children with SSI and the youngest age group does not differ from the oldest age group for children without SSI.

Conclusions.

Children who had chronic conditions and were enrolled in Medicaid received a majority of their care from generalist physicians. For most conditions, a majority of children did not receive any relevant subspecialty care during the year and many of these children did not receive care form providers with pediatric-specific training.
Inter-Neonatal Intensive Care Unit Variation in Discharge Timing: Influence of Apnea and Feeding Management
Authors: Eichenwald Eric C. , Blackwell Mary , Lloyd Janet S. , Tran Tai , Wilker Richard E. , Richardson Douglas K.
Published: August 2004

Background.

Premature infants need to attain both medical stability and maturational milestones (specifically, independent thermoregulation, resolution of apnea of prematurity, and the ability to feed by mouth) before safe discharge to home. Current practice also requires premature infants to be observed in hospital before discharge for several days (margin of safety) after physiologic maturity is recognized.

Objective.

To compare postmenstrual age (PMA) at discharge in a homogeneous population of premature infants cared for in different neonatal intensive care units (NICUs) and to assess the impact on hospital stay of the recognition and recording of physiologic maturity and the required margin of safety.

Methods.

We studied premature infants delivered at 30 to 34 6/7 weeks gestational age (GA), free of significant medical or surgical complications. Medical records of 30 eligible infants consecutively discharged from the hospital before July 1997 from each of 15 NICUs in Massachusetts (9 level 2 and 6 level 3) were reviewed.

Results.

A total of 435 infants were included in the study sample. Mean (± standard deviation) GA and birth weight of the study population were 33.2 ± 1.2 weeks and 2024 ± 389 g, respectively. Infants were discharged at a similar PMA regardless of GA at birth. Considerable variation in the PMA at discharge between hospital sites was observed (range, 35.2 ± 0.5 weeks to 36.5 ± 1.2 weeks). Despite the homogeneous study population, hospitals in which infants had the latest PMA at discharge also recorded mature cardiorespiratory and feeding behavior at an older age. Longer duration of pulse oximetry use was associated with later resolution of apnea. Differences in the duration of the margin of safety between sites did not contribute to variation in hospital stay.

Conclusion.

NICUs vary widely in length of hospital stay for healthy premature infants. We speculate that this variation results in part from differences in monitoring for and documentation of apnea of prematurity and feeding behavior.
Psychopharmacology for Young Children: Clinical Needs and Research Opportunities
Authors: Vitiello Benedetto
Published: August 2004

In response to concerns about the increasing use of psychotropic medications in preschoolers, the National Institute of Mental Health and the Food and Drug Administration convened a workshop in October 2000 to examine the current state of knowledge regarding psychopharmacology for young children and discuss a variety of topics relevant to research in this age group, including safety, efficacy, investigational methods, and ethical aspects. The meeting gathered researchers, practitioners, ethicists, industry staff, and family and patient representatives. Efficacy and safety of psychotropics have not been systematically evaluated in preschoolers. The major limitation to this research is the diagnostic uncertainty surrounding most manifestations of psychopathology in early childhood. Research in developmental psychopathology is needed to clarify diagnosis and provide sensitive and specific methods for clinical trials. Possible approaches to expanding the research basis of this area of clinical practice, including a recently started study of methylphenidate in preschoolers, are reported here.
Reactive Hyperemia and Interleukin 6, Interleukin 8, and Tumor Necrosis Factor-α in the Diagnosis of Early-Onset Neonatal Sepsis
Authors: Martin Helena , Olander Bodil , Norman Mikael
Published: August 2004

Objective.

To evaluate the diagnostic value of peripheral circulatory reactive hyperemia and serum levels of interleukin-6 (IL-6), IL-8, and tumor necrosis factor-α (TNF-α) in early-onset neonatal sepsis.

Methods.

Reactive hyperemia in the dorsal hand and serum levels of IL-6, IL-8, and TNF-α were studied in newborn infants (n = 32; gestational age 39 ± 3 weeks) who had been admitted to the neonatal unit because of suspected sepsis <48 hours after birth. On admission, reactive hyperemia after a standardized arterial occlusion was measured with laser Doppler technique, and blood samples were taken for cytokine analyses. On the basis of predetermined criteria, the infants subsequently were classified as septic (n = 12) or not (n = 20).

Results.

The degree of reactive hyperemia was higher in the group with sepsis (median + 170% perfusion increase) than in that without (+37%). On admission, serum levels of IL-6, IL-8, and TNF-α all were higher in septic (median values: 1620, 331, and 22 pg/mL, respectively) than in nonseptic neonates (median values: 42, 63, and 13 pg/mL, respectively). In the group with sepsis, the degree of reactive hyperemia correlated to log IL-6 (r = 0.80) and log IL-8 values (r = 0.71).

Conclusion.

Newborn infants with septicemia have increased reactive hyperemia and elevated cytokine levels very early in their disease. Reactive hyperemia in skin can be analyzed at the bedside and noninvasively and therefore may serve as an additional diagnostic tool in neonatal sepsis.
Limb Deficiencies in Newborn Infants
Authors: McGuirk Caroline K. , Westgate Marie-Noel , Holmes Lewis B.
Published: August 2004

Objective.

The prevalence rate of all types of limb reduction defects in general and those that potentially are caused by vascular disruption in particular is needed to provide a baseline for the evaluation of infants who are exposed in utero to teratogens that cause vascular disruption. The objective of this study was to determine this prevalence rate.

Methods.

All infants with any limb deficiency among 161 252 liveborn and stillborn infants and elective terminations were identified in a hospital-based Active Malformations Surveillance Program in Boston in the years 1972 to 1974 and 1979 to 1994. An extensive search was made to identify infants who were missed by the Surveillance Program; an additional 8 infants (7.3% of total) were identified. The limb reduction defects were classified in 3 ways: 1) by the anatomic location of the defect, that is longitudinal, terminal, intercalary, etc; 2) for infants with absence/hypoplasia of fingers or toes, a tabulation of which digit or digits were affected; and 3) by apparent cause.

Results.

The prevalence rate for all types of limb deficiency was 0.69/1000. The apparent causes included single mutant genes, familial occurrence, and known syndromes (24%); chromosome abnormalities (6%); teratogens (4%); vascular disruption (35%); and unknown cause (32%).

Conclusions.

A hospital-based surveillance program can be used to establish the prevalence of limb reduction defects, if ascertainment is extended to include elective terminations for fetal abnormalities. An apparent cause can be established for most limb defects when the clinical findings are used rather than reliance only on the International Classification of Diseases, Ninth Revision, codes of the discharge diagnoses. The prevalence rate of limb reduction defects as a result of presumed vascular disruption was 0.22/1000.
Breastfeeding and Early Weaning Practices in Northeast Brazil: A Longitudinal Study
Authors: Marques Neusa M. , Lira Pedro I. C. , Lima Marilia C. , da Silva Nara Lacerda , Filho Malaquias Batista , Huttly Sharon R.A. , Ashworth Ann
Published: August 2004

Objectives.

To describe breastfeeding practices from 0 to 12 months of age in 4 small towns that are representative of urban northeast Brazil and to identify factors associated with introduction of other milk in the first month of life.

Methods.

From January to August 1998, 364 mothers were interviewed at delivery to ascertain antenatal care; delivery room practices; and their intentions regarding breastfeeding, pacifiers, and introduction of water, teas, and other milk. Their perceptions of home support and the advantages of breastfeeding also were assessed. Thereafter, daily information about feeding practices was collected at twice-weekly home visits. When other milk was started, a second interview was conducted to ascertain initial and current breastfeeding problems and use of a pacifier. Reasons for starting other milk were investigated using 5-point Likert scales.

Results.

Mothers were positive toward breastfeeding, and 99% breastfed their new infant. Few intended to breastfeed exclusively, and in the first week 80% gave water/tea and 56% used a pacifier. The median duration of exclusive breastfeeding was 0 days, and the median age for starting other milk was 24 days. The median duration of breastfeeding was 65 days for mothers who started other milk within 1 month and 165 days for other mothers. After adjustment for confounding variables, the main factors associated with introduction of other milk within 1 month were pacifier use in the first week (odds ratio [OR], 4.01; 95% confidence interval [CI]: 2.07–7.78), intention to start other milk in the first month (OR, 3.79; 95% CI: 1.74–8.24), giving water/tea in the first week (OR, 3.07; 95% CI: 1.56–6.03), and leaving the maternity ward before breastfeeding was started (OR, 2.59; 95% CI: 1.34–5.04).

Conclusion.

Although breastfeeding is common in this community, it rarely is exclusive and takes place for a relatively short duration. Identification of risk factors for early introduction of other milk offers potential avenues for future intervention, including improvement of breastfeeding support in antenatal and maternity services.
Exclusive Breastfeeding Reduces Acute Respiratory Infection and Diarrhea Deaths Among Infants in Dhaka Slums
Authors: Arifeen Shams , Black Robert E. , Antelman Gretchen , Baqui Abdullah , Caulfield Laura , Becker Stan
Published: August 2004

Objectives.

To describe breastfeeding practices and investigate the influence of exclusive breastfeeding in early infancy on the risk of infant deaths, especially those attributable to respiratory infections (ARI) and diarrhea.

Methods.

A prospective observational study was conducted on a birth cohort of 1677 infants who were born in slum areas of Dhaka in Bangladesh and followed from birth to 12 months of age. After enrollment at birth, the infants were visited 5 more times by 12 months of age. Verbal autopsy, based on a structured questionnaire, was used to assign a cause to the 180 reported deaths. Proportional hazards regression models were used to estimate the effect of breastfeeding practices, introduced as a time-varying variable, after accounting for other variables, including birth weight. Overall neonatal, postneonatal and infant mortality, and mortality attributable to ARI and diarrhea were measured.

Results.

The proportion of infants who were breastfed exclusively was only 6% at enrollment, increasing to 53% at 1 month and then gradually declining to 5% at 6 months of age. Predominant breastfeeding declined from 66% at enrollment to 4% at 12 months of age. Very few infants were not breastfed, whereas the proportion of partially breastfed infants increased with age. Breastfeeding practices did not differ between low and normal birth weight infants at any age. The overall infant mortality rate was 114 deaths per 1000 live births. Compared with exclusive breastfeeding in the first few months of life, partial or no breastfeeding was associated with a 2.23-fold higher risk of infant deaths resulting from all causes and 2.40- and 3.94-fold higher risk of deaths attributable to ARI and diarrhea, respectively.

Conclusion.

The important role of appropriate breastfeeding practices in the survival of infants is clear from this analysis. The reduction of ARI deaths underscores the broad-based beneficial effect of exclusive breastfeeding in prevention of infectious diseases beyond its role in reducing exposure to contaminated food, which may have contributed to the strong protection against diarrhea deaths.
Effect of a Single-Use Sterile Catheter for Each Void on the Frequency of Bacteriuria in Children With Neurogenic Bladder on Intermittent Catheterization for Bladder Emptying
Authors: Schlager Theresa A. , Clark Maureen , Anderson Susan
Published: August 2004

Objective.

The frequency of bacteriuria is high in children with neurogenic bladder on intermittent catheterization for bladder emptying. In an effort to decrease bacteriuria, we examined whether the method of catheter care was responsible for the high rate of bacteriuria. For this, the frequency of bacteriuria was examined in the same patient on single-use sterile catheters and on reused clean catheters.

Methods.

A prospective, randomized, crossover trial was conducted with 10 patients who were randomized to 4 months of a new, sterile catheter for intermittent catheterization and 4 months of reuse of a clean catheter for intermittent catheterization. Each week, a urine sample was collected and symptoms of infection and medication use were recorded.

Results.

A total of 158 urine samples were collected during 164 patient-weeks on the new catheter method for each void; 115 (73%) were positive for a pathogen. Of the 161 samples collected during 169 patient-weeks on the standard, reuse method for voiding, 123 (76%) were positive (115 [73%] of 158 vs 123 [76%] of 161). Escherichia coli was the most common pathogen detected during both method periods.

Conclusion.

A new, sterile catheter for each void did not decrease the high frequency of bacteriuria in patients with neurogenic bladder on intermittent catheterization.
A Randomized, Controlled Trial of Kangaroo Mother Care: Results of Follow-Up at 1 Year of Corrected Age
Authors: Charpak Nathalie , Ruiz-Peláez Juan G. , Figueroa de C. Zita , Charpak Yves
Published: August 2004

Objective.

To assess the effectiveness and safety of Kangaroo Mother Care (KMC) for infants of low birth weight.

Methods.

An open, randomized, controlled trial of a Colombian social security referral hospital was conducted. A total of 1084 consecutive infants who were born at ≤2000 g were followed, and 746 newborns were randomized when eligible for minimal care, with 382 to KMC and 364 to “traditional” care. Information on vital status was available for 693 infants (93%) at 12 months of corrected age. KMC consisted of skin-to-skin contact on the mother's chest 24 hours/day, nearly exclusive breastfeeding, and early discharge, with close ambulatory monitoring. Control infants remained in incubators until the usual discharge criteria were met. Both groups were followed at term and at 3, 6, 9, and 12 months of corrected age. The main outcomes measured were morbidity, mortality, growth, development, breastfeeding, hospital stay, and sequelae.

Results.

Baseline variables were evenly distributed, except for weight at recruitment (KMC: 1678 g; control participants: 1713 g). The risk for death was lower among infants who were given KMC, although the difference was not significant (KMC: 11 [3.1%] of 339; control participants: 19 [5.5%] of 324; relative risk: 0.57; 95% confidence interval: 0.17–1.18). The growth index of head circumference was statistically significantly greater in the group given KMC, but the developmental indices of the 2 groups were similar. Infants who weighed ≤1500 g at birth and were given KMC spent less time in the hospital than those who were given standard care. The number of infections was similar in the 2 groups, but the severity was less among infants who received KMC. More of these infants were breastfed until 3 months of corrected age.

Conclusion.

These results support earlier findings of the beneficial effects of KMC on mortality and growth. Use of this technique would humanize the practice of neonatology, promote breastfeeding, and shorten the neonatal hospital stay without compromising survival, growth, or development.
Maternal Epidural Use and Neonatal Sepsis Evaluation in Afebrile Mothers
Authors: Goetzl Laura , Cohen Amy , Frigoletto Fredric , Ringer Steven A. , Lang Janet M. , Lieberman Ellice
Published: August 2004

Objective.

Epidural use has been associated with a higher rate of neonatal sepsis evaluation. Epidural-related fever explains some of the increase but not the excess of neonatal sepsis evaluations in afebrile women

Methods.

We studied 1109 women who had singleton term pregnancies and who presented in spontaneous labor and were afebrile during labor (<100.4°F). Neonatal sepsis evaluation generally was performed on the basis of the presence of 1 major or 2 minor criteria. Major criteria included rupture of membranes for >24 hours or sustained fetal heart rate of >160 beats per minute. Minor criteria included a maternal temperature of 99.6°F to 100.4°F, rupture of membranes for 12 to 24 hours, maternal admission white blood cell count of >15 000 cells/mL3, or an Apgar score of <7 at 5 minutes.

Results.

Infants of afebrile women with epidural analgesia were more likely to be evaluated for sepsis than infants of women without epidural (20.4% vs 8.9%), although not more likely to have neonatal sepsis. An increased risk of sepsis evaluation persisted in regression analysis (odds ratio: 3.1; 95% confidence interval: 2.0, 4.7) after controlling for confounders and was not explained by longer labors with epidural. Women with epidural were significantly more likely to have major and minor criteria for sepsis evaluation, including fetal tachycardia (4.4% vs 0.4%), rupture of membranes for >24 hours (6.2% vs 3.4%), low-grade fever of 99.6°F to 100.4°F (24.3% vs 5.2%), and rupture of membranes for 12 to 24 hours (21.4% vs 5.2%) than women without epidural.

Conclusions.

Epidural analgesia is associated with increased rates of major and minor criteria for neonatal sepsis evaluations in afebrile women.
Differences in Brain Temperature and Cerebral Blood Flow During Selective Head Versus Whole-Body Cooling
Authors: Laptook Abbot R. , Shalak Lina , Corbett Ron J. T.
Published: August 2004

Objective.

To compare brain temperature and cerebral blood flow (CBF) during head and body cooling, with and without systemic hypoxemia.

Methods.

Seventeen newborn swine were studied for either measurement of brain temperature alone (n = 9) or measurement of brain temperature and CBF (n = 8). All animals were ventilated and instrumented, and temperature probes were inserted into the rectum, into the brain at depths of 2 and 1 cm from the cortical surface, and on the dural surface. Blood flow was measured with microspheres. The protocol consisted of a control period, an interval of either head or body cooling, and cooling with 15 minutes of superimposed hypoxia. After a 1-hour recovery period, animals were exposed to the same sequence except that the alternate mode of cooling was evaluated.

Results.

Head cooling with a constant rectal temperature resulted in an increase in the temperature gradient across the brain from the warmer central structures to the cooler periphery (brain 2 cm − dura temperature: 1.3 ± 1.1°C at control to 7.5 ± 3.5°C during cooling). Hypoxia superimposed on head cooling decreased the temperature gradient by at least 50%. In contrast, body cooling was associated with an unchanged temperature gradient across the brain (brain 2 cm − dura temperature: 1.5 ± 1.2°C at control to 1.1 ± 0.9°C during cooling). Hypoxia superimposed on body cooling did not change brain temperature. Both modes of brain cooling resulted in similar reductions of global CBF (∼40%) and O2 uptake.

Conclusion.

Brain hypothermia achieved through head or body cooling results in different brain temperature gradients. Alterations in systemic variables (ie, hypoxemia) alters brain temperature differently in these 2 modes of brain cooling. The mode of brain cooling may affect the efficacy of modest hypothermia as a neuroprotective therapy.
Treatment of Extensive Toxic Epidermal Necrolysis in Children
Authors: Spies Marcus , Sanford Arthur P. , Low J. F. Aili , Wolf Steven E. , Herndon David N.
Published: August 2004

Objective.

Toxic epidermal necrolysis (TEN) is a rare but life-threatening disease of the skin and mucous membranes. We report our experience in the treatment of pediatric TEN patients with early debridement of necrotic skin and coverage with human allograft skin.

Methods.

From 1984 to 2000, 15 children (6 girls, 9 boys, 7.2 ± 1.5 years) with a histologic diagnosis of TEN and involvement of >30% total body surface area were treated at the Shriners Hospitals for Children in Galveston. All were treated in a specialized pediatric burn intensive care unit after our standard treatment protocol, including operative debridement of sloughing skin and allografting within 24 hours of admission. Outcome parameters were mortality, length of hospital stay, wound healing, clinical complications, causative drugs, corticosteroid use, and delay in referral to a burn center.

Results.

Taking a new medication (antibiotics, anticonvulsive drugs) was associated with all cases of TEN. Patients who were treated with early debridement and coverage with allograft skin showed no wound infection, and overall mortality was 7%. Total length of hospital stay was 26 ± 3 days. Long-term sequelae were changes in skin pigmentation (100%), ophthalmologic problems (40%), and diffuse itching early after wound healing (53%).

Conclusion.

Although a rare disease in children, TEN was managed successfully in a burn center environment, using early debridement and wound coverage with allograft skin as a biological dressing. The use of corticosteroids and referral patterns seems unchanged during the past 2 decades, indicating an additional need for information and education about the disease.
Unexplained Reduced Microbiological Efficacy of Intramuscular Benzathine Penicillin G and of Oral Penicillin V in Eradication of Group A Streptococci From Children With Acute Pharyngitis
Authors: Kaplan Edward L. , Johnson Dwight R.
Published: August 2004

Objective.

To evaluate the efficacy of oral penicillin V and intramuscular benzathine penicillin G (BPG) in eradicating group A streptococci from the upper respiratory tract.

Methodology.

Two randomized, single-blind, multicenter antibiotic efficacy trials in children using recommended doses of either oral penicillin V or intramuscular BPG for treatment of acute-onset pharyngitis associated with isolation of group A streptococci were conducted. Throat examinations and cultures were obtained at enrollment and on days 5 to 8, 10 to 14, and 29 to 31.

Results.

Thirty-five percent of 284 evaluable patients treated with oral penicillin V and 37% of BPG-treated patients were microbiologic treatment failures at either 10 to 14 or 29 to 31 days.

Conclusions.

Although these findings do not provide sufficient evidence to change current treatment recommendations or public health policy, important questions are raised about currently recommended penicillin doses, about the role of the carrier state, and possibly about adequate bioavailability of intramuscular BPG. These findings require confirmation.
Restraint Use on Aircraft
Authors:   Committee on Injury and Poison Prevention
Published: August 2004

Occupant protection policies for children younger than 2 years on aircraft are inconsistent with all other national policies on safe transportation. Children younger than 2 years are not required to be restrained or secured on aircraft during takeoff, landing, and conditions of turbulence. They are permitted to be held on the lap of an adult. Preventable injuries and deaths have occurred in children younger than 2 years who were unrestrained in aircraft during survivable crashes and conditions of turbulence. The American Academy of Pediatrics recommends a mandatory federal requirement for restraint use for children on aircraft. The Academy further recommends that parents ensure that a seat is available for all children during aircraft transport and follow current recommendations for restraint use for all children. Physicians play a significant role in counseling families, advocating for public policy mandates, and encouraging technologic research that will improve protection of children in aircraft.
Media Violence
Authors:   Committee on Public Education
Published: August 2004

The American Academy of Pediatrics recognizes exposure to violence in media, including television, movies, music, and video games, as a significant risk to the health of children and adolescents. Extensive research evidence indicates that media violence can contribute to aggressive behavior, desensitization to violence, nightmares, and fear of being harmed. Pediatricians should assess their patients' level of media exposure and intervene on media-related health risks. Pediatricians and other child health care providers can advocate for a safer media environment for children by encouraging media literacy, more thoughtful and proactive use of media by children and their parents, more responsible portrayal of violence by media producers, and more useful and effective media ratings.
The Role of the School Nurse in Providing School Health Services
Authors:   Committee on School Health
Published: August 2004

The school nurse has a crucial role in the provision of school health services. This statement describes the school nurse as a member of the school health services team and its relation to children with special health care needs. Recommendations for the professional preparation and education of school nurses also are provided.
Acute Helicobacter pylori Infection Is Followed by an Increase in Diarrheal Disease Among Peruvian Children
Authors: Passaro Douglas J. , Taylor David N. , Meza Rina , Cabrera Lilia , Gilman Robert H. , Parsonnet Julie
Published: August 2004

Background.

Cohort and case-crossover studies were conducted to evaluate whether new Helicobacter pylori infections are followed by increased diarrhea.

Methods.

Participants were 6-month-old to 12-year-old shantytown residents living near Lima, Peru. Baseline data were collected from community households. Health interviews were completed daily, and sera, drawn every 4 months, were tested for H pylori immunoglobulin G. Diarrhea rates among newly H pylori-infected (seroconverting) children were compared with rates among persistently uninfected and infected children using cohort and case-crossover analyses.

Results.

Sera were obtained from 345 children from January 1, 1995, through September 1, 1997. H pylori incidence was 12% per year (36 H pylori infections in 109 866 seronegative days). In adjusted cohort analyses, seroconverters had more diarrhea days (rate ratio: 2.0; 95% confidence interval: 1.6–2.4), episodes, and sick days in the year after infection than did uninfected children; and more diarrhea days and sick days than did persistently infected children. This effect was strongest in the first 2 months. Case-crossover analyses supported these findings.

Conclusion.

Preventing H pylori infection may help reduce pediatric diarrheal disease.
Eosinophil-Associated Inflammation and Elaboration of Eosinophil-Derived Proteins in 2 Children With Raccoon Roundworm (Baylisascaris procyonis)Encephalitis
Authors: Moertel Christopher L. , Kazacos Kevin R. , Butterfield Joseph H. , Kita Hirohito , Watterson Jan , Gleich Gerald J.
Published: August 2004

Objective.

Eosinophil-associated proteins, especially eosinophil-derived neurotoxin, may be important contributors to the neurologic pathology and symptoms caused byBaylisascaris procyonis infection.

Methods.

Two cases of severe B procyonisencephalitis with evidence of marked eosinophil degranulation in the central nervous system are presented. Serial cerebrospinal fluid (CSF) specimens were collected from each patient during the course of their illness. Antibodies against B procyonis were measured in the patients' serum and CSF. Levels of the eosinophilopoietin interleukin-5 (IL-5) and 2 important eosinophil proteins, eosinophil-derived neurotoxin and major basic protein, were assayed in the CSF.

Results.

Both patients had rapidly progressive central nervous system disease with evidence of eosinophilic meningoencephalitis. Both tested positive for antibodies to B procyonis in serum and CSF and had progressively worsening deep white matter changes on magnetic resonance images of the brain. CSF levels of IL-5, eosinophil-derived neurotoxin, and major basic protein were markedly elevated over controls.

Conclusions.

This is the first report of the measurement of IL-5, eosinophil-derived neurotoxin, and major basic protein in human CSF. In addition to traumatic damage and necrosis caused by migrating larvae, eosinophil-derived neurotoxin from associated eosinophilic inflammation may be an important contributory factor in the pathogenesis of B procyonis encephalitis. parasite, eosinophil-derived-neurotoxin, major basic protein, eosinophilia, hypereosinophilia, interleukin-5, encephalitis, child.
Congenital Hypomyelination Neuropathy in a Newborn Infant: Unusual Cause of Diaphragmatic and Vocal Cord Paralyses
Authors: Hahn Jin S. , Henry Marion , Hudgins Louanne , Madan Ashima
Published: August 2004

We report a case of congenital hypomyelination neuropathy presenting at birth. The infant had generalized hypotonia and weakness. There was decreased respiratory effort along with a right phrenic nerve and left vocal cord paralyses. Tongue fasciculations were present. Deep tendon reflexes were absent in the upper extremities and hypoactive (1+) in the lower extremities. Magnetic resonance imaging of the head revealed no intracranial abnormalities, including normal cerebral myelination. Nerve conduction study showed absence of motor and sensory action potentials in the hands when the nerves in the upper limbs were stimulated. A motor response could be elicited only in the proximal leg muscles. Needle electromyography study was normal in the proximal limb muscles, but showed active denervation in the distal muscles of the arm and leg. These findings were thought to be consistent with a length-dependent sensorimotor peripheral polyneuropathy of axonal type with greater denervation of the distal muscles. A biopsy of the quadriceps muscle showed mild variability in fiber diameter, but no group typing or group atrophy. The muscle fibers showed no intrinsic abnormalities. Biopsy of the sural nerve showed scattered axons with very thin myelin sheaths. There was also a nearly complete loss of large diameter myelinated fibers. No onion bulb formations were noted. These findings were thought to be consistent with congenital hypomyelination neuropathy with a component of axonopathy. DNA analysis for identification of previously characterized mutations in the genes MPZ, PMP22, and EGR2 was negative.

Several attempts at extubation failed and the infant became increasingly ventilator-dependent with increasing episodes of desaturation and hypercapnea. He also developed increasing weakness and decreased movement of all extremities. He underwent surgery at 2 months of age for placement of a gastrostomy tube and a tracheostomy. He was discharged from the hospital on a ventilator at 6 months of age. The infant was 13 months old at the time of submission of this report. Although he appears cognitively normal, he remains profoundly hypotonic and is on a home ventilator. There was no evidence of progressive weakness.

Congenital hypomyelination neuropathy is a rare form of neonatal neuropathy that should be considered in the differential diagnosis of a newborn with profound hypotonia and weakness. It appears to be a heterogeneous disorder with some of the cases being caused by specific genetic mutations.
Comparison of Continuity in a Resident Versus Private Practice
Authors: Darden Paul M. , Ector Walton , Moran Colleen , Quattlebaum Thomas G.
Published: August 2004

Background. There is widespread agreement among pediatric educators that continuity (following a panel of patients on a first contact basis for all their health care) is an important part of the education of pediatricians.

Objective. To measure continuity in a pediatric residency practice and to compare this continuity with 2 nearby private general pediatric group practices. We also examined measures of continuity suggested in the literature.

Design. Visit data were obtained from the practice billing system for a resident continuity practice and 2 nearby private practices for the 3-year period from July 1, 1992, to June 30, 1995. Visit data used were restricted to patients seen in the office of the practices during regular office hours. Continuity was measured using 5 different indices: 1) the usual provider of care index, visits by the usual clinician/total visits, 2) continuity for patient, the average proportion of visits that an individual patient was seen by his or her own physician, 3) continuity for physician (PHY), the average proportion of visits that an individual physician saw his or her own patients, 4) Continuity of Care Index (COC), and 5) the Modified, Modified Continuity Index. During the period examined, pediatric residents were present in the continuity practice for 1 half-day each week. The resident continuity practice (RCP) had 57 residents and saw 3386 patients for 18 955 visits. Private practice 1 (PP1) had 4 pediatricians who saw 4968 patients for 33 537 visits. Private practice 2 (PP2) had 5 pediatricians who saw 11 953 patients for 75 778 visits.

Results. For all visit types, continuity in the RCP was not as high as in the private practices, PHY-RCP versus PP1, PP2; 53% versus 70%, 77%. However, continuity in RCP was greater than 50% for all measures except the COC index, which precipitously decreases as the number of clinicians seen increases. Examining continuity for health maintenance visits (PHY-RCP, PP2 vs PP1; 96%, 96% vs 82%) RCP was equal to the best of the private practices. The percentage of patients not seen for a health maintenance visit during the study period was lowest in the resident practice (RCP/PP1/PP2, 15/22/30).

Conclusion. Although continuity for all visits in this RCP was less than in private practice, it was surprisingly high, considering the limited time residents spend in clinic. In a particularly important area for continuity, health maintenance visits, continuity was identical to one and superior to the other private practice.
C-Reactive Protein in Febrile Children 1 to 36 Months of Age With Clinically Undetectable Serious Bacterial Infection
Authors: Pulliam Patrick N. , Attia Magdy W. , Cronan Kathleen M.
Published: August 2004

Objective. To determine the diagnostic properties of quantitative C-reactive protein (CRP) associated with clinically undetectable serious bacterial infection (SBI) in febrile children 1 to 36 months of age.

Methods. Febrile children presenting to a pediatric emergency department (ED) with ages ranging from 1 to 36 months, temperatures ≥39°C, and clinically undetectable source of fever were enrolled in this prospective cohort study. Demographic information, ED temperature, duration of fever, and clinical evaluation using the Yale observation scale were recorded at the time of the initial evaluation. The white blood cell count (WBC), band count, absolute neutrophil count (ANC), and CRP concentration were measured at the same time. All patients received blood cultures and either a screening urinalysis or urine culture. A chest radiograph was obtained at the discretion of the ED physician. Patients with history of using antibiotics within 1 week of their presentation to the ED were excluded. The main outcome result was the presence of laboratory or radiographically proven SBI (bacteremia, meningitis, urinary tract infection, pneumonia, septic arthritis, and osteomyelitis).

Results. Seventy-seven patients were enrolled in the study. Fourteen (18%) had a SBI (6 urinary tract infection; 4 pneumonia, including 1 patient with Streptococcus pneumoniae bacteremia; and 4 occult S pneumoniae bacteremia), and 63 had no SBI. The 2 groups were indistinguishable in age, sex, ED temperature, duration of fever, and Yale observation scale. CRP concentration, WBC, and ANC were significantly different between the 2 groups. In a multivariate logistic regression analysis, only CRP remained as a predictor of SBI (Beta = 0.76, 95% confidence interval [CI]: 0.64, 0.89). Receiver-operating characteristic analysis demonstrated CRP (area under curve [AUC] 0.905, standard error [SE] 0.05, 95% CI: 0.808, 1.002) to be superior to ANC (AUC 0.805, SE 0.051, 95% CI: 0.705, 0.905) and to WBC (AUC 0.761, SE 0.068, 95% CI: 0.628, 0.895). A CRP cutoff point of 7 was determined to maximize both sensitivity and specificity (sensitivity 79%, specificity 91%, likelihood ratio 8.3, 95% CI: 3.8, 27.3). Multilevel likelihood ratios and posttest probabilities were calculated for a variety of CRP levels. A CRP concentration of <5 mg/dL effectively ruled out SBI (likelihood ratio 0.087, 95% CI: 0.02, 0.38, posttest probability of SBI 1.9%).

Conclusions. Quantitative CRP concentration is a valuable laboratory test in the evaluation of febrile young children who are at risk for occult bacteremia and SBI, with a better predictive value than the WBC or ANC.