bluuebunny/crossref_metadata_2025 huggingface dataset:
Type 1 Diabetes Mellitus and Epilepsia Partialis Continua in a 6-Year-Old Boy With Elevated Anti-GAD65 Antibodies
Authors: Olson Jennifer A. , Olson Donald M. , Sandborg Christy , Alexander Steven , Buckingham Bruce
Published: August 2004

A 6-year-old boy presented with epilepsia partialis continua 6 months after diagnosis of type 1 diabetes. Anti-glutamic acid decarboxylase 65 antibodies were found in his serum and cerebrospinal fluid. Anti-epileptic agents did not improve his seizures. High-dose steroids, plasmapheresis, and intravenous immunoglobulin resulted in decreased anti-glutamic acid decarboxylase 65 antibody levels and resolution of his seizures.
Retropharyngeal Cellulitis in a 5-Week-Old Infant
Authors: Bourgeois Florence T. , Shannon Michael W.
Published: August 2004

An infant who presents with acute, unexplained crying requires a thorough examination to identify the source of distress. We report the case of a 5-week-old infant who had sudden irritability and was found to have retropharyngeal cellulitis caused by group B Streptococcus.
Comparison of Nasogastric and Intravenous Methods of Rehydration in Pediatric Patients With Acute Dehydratio
Authors: Nager Alan L. , Wang Vincent J.
Published: August 2004

Objective. To assess the safety, efficacy, and cost-effectiveness of rapid nasogastric hydration (RNG) and rapid intravenous hydration (RIV) administered in the emergency department (ED) to young children suffering with uncomplicated, acute moderate dehydration.

Methods. Ninety-six children aged 3 to 36 months, who presented with signs and symptoms of uncomplicated, acute moderate dehydration caused by vomiting and/or diarrhea, presumed to be caused by viral gastroenteritis, were randomly assigned to receive either RNG with a standard oral rehydration solution or RIV with normal saline. Each solution was administered at a rate of 50 mL/kg of body weight, delivered over a 3-hour period in our urban pediatric ED. All participants were weighed pretreatment and posttreatment and underwent initial and final measurements of their serum electrolytes, blood urea nitrogen, creatinine, and glucose levels, along with urine chemistry and urine specific gravity. Telephone follow-up by completion of a standardized questionnaire was obtained approximately 24 hours after discharge from the ED.

Results. Ninety-two of 96 enrolled patients completed the study. Three patients failed treatment (2 RIV and 1 RNG) and were excluded and hospitalized because of severe, intractable vomiting, and 1 patient was withdrawn secondary to an intussusception. Among 92 evaluable patients, 2 were found to be severely dehydrated (>10% change in body weight) and were excluded from analysis, leaving 90 patients (RNG: N = 46 and RIV: N = 44), who completed the study. Both RNG and RIV were found to be a safe and efficacious means of treating uncomplicated, acute moderate dehydration in the ED. Determinations of electrolytes, blood urea nitrogen, creatinine, or glucose were not found to be of value on an intent-to-treat basis in the care of these patients. The urine specific gravity and incidence of ketonuria declined from levels commensurate with moderate dehydration in the RNG group, but not as consistently so in the RIV group. Both RNG and RIV were substantially less expensive to administer than standard care with intravenous fluid deficit therapy in-hospital, and RNG was more cost-effective to administer over RIV in the outpatient setting.

Conclusion. RNG and RIV administered in the ED are safe, efficacious, and cost-effective alternatives to the standard treatment for uncomplicated, acute moderate dehydration in young children. RNG is as efficacious as RIV, is no more labor intensive than RIV, and is associated with fewer complications. In addition, we found that most routine laboratory testing is of little value in these patients and should be avoided, except when clearly clinically indicated.
Infant Acceptance of Breast Milk After Maternal Exercise
Authors: Wright Kc S. , Quinn Timothy J. , Carey Gale B.
Published: August 2004

Objective. Previous research reported that breast milk lactic acid (LA) levels increase after lactating women complete a bout of exhaustive exercise, resulting in poor infant acceptance of the postexercise breast milk. This highly publicized finding may not apply to more practical, everyday exercise conditions of lactating women. The purpose of the present study was to reexamine the composition and infant acceptance of postexercise breast milk while controlling maternal diet, exercise intensity, and the method, timing, and assessment of infant feeding.

Research Design and Methods. Twenty-four women, 2 to 4 months’ postpartum, completed 3 test sessions: a maximal oxygen uptake test, a 30-minute bout of moderate exercise, and a resting control session. One hour before and 1 hour after each session, participants fully expressed their milk, placed it in a bottle familiar to the infant, fed their infant, and rated their infant’s acceptance of the milk. Each feeding was videotaped and viewed individually by 3 lactation consultants who rated infant acceptance; consultants were blinded to the test sessions. Milk was analyzed for LA and infant milk consumption was measured.

Results. There were no differences in presession versus postsession values for maternal skin temperature, breast milk temperature, and infant milk acceptance as judged by either the mothers or lactation consultants. These results prevailed despite a small but significant increase in breast milk LA premaximal versus postmaximal exercise (0.09 vs 0.21 mM, respectively); there was no difference in milk LA premoderate versus postmoderate exercise, or prerest versus postrest.

Conclusion. These data support the hypothesis that moderate or even high-intensity exercise during lactation does not impede infant acceptance of breast milk consumed 1 hour postexercise.
Breastfeeding Is Analgesic in Healthy Newborns
Authors: Gray Larry , Miller Lisa W. , Philipp Barbara L. , Blass Elliott M.
Published: August 2004

Context. This study identifies a behavioral and nonpharmacologic means of preventing newborn pain.

Objective. To determine whether breastfeeding is analgesic in newborn infants undergoing heel lance—a routine, painful, hospital procedure.

Design. A prospective, randomized, controlled trial.

Setting. Hospital maternity services at Boston Medical Center, Boston, Massachusetts, and Beverly Hospital, Beverly, Massachusetts.

Participants. A random sample of 30 full-term, breastfed infants.

Interventions. Infants in the intervention group were held and breastfed by their mothers during heel lance and blood collection procedures for the Newborn Screening Program Blood Test. Infants in the control group experienced the same blood test while receiving the standard hospital care of being swaddled in their bassinets.

Outcome Measures. Crying, grimacing, and heart rate differences were analyzed between the breastfeeding and the control infants before, during, and after blood collection.

Results. Crying and grimacing were reduced by 91% and 84%, respectively, from control infant levels during the blood collection. Heart rate was also substantially reduced by breastfeeding.

Conclusions. Breastfeeding is a potent analgesic intervention in newborns during a standard blood collection.
Use of Sleep Aids During the First Year of Life
Authors: Burnham Melissa M. , Goodlin-Jones Beth L. , Gaylor Erika E. , Anders Thomas F.
Published: August 2004

Objective. In an attempt to foster self-soothing during the night, a novel sleep aid infused with maternal odor was introduced to 4 groups of infants ranging in age from 3 to 12 months. Infants’ use of parent-provided sleep aids also was examined.

Methodology. Nighttime sleep and waking behaviors were videotaped for 2 consecutive nights on 3 occasions over a 3-month interval. Using all-night video recording, the study examined the infant’s use of a novel sleep aid and parent-provided sleep aids during sleep onset and after nighttime awakenings.

Results. Results indicated that infants of different ages differed in the types of sleep aids used when falling asleep either at the beginning of the night or after awakenings in the middle of the night. More 3-month-olds used their thumbs/fingers/hands, whereas more 6-month-olds used soft objects. The 6-month-olds were most likely to use the novel sleep aid. Almost all of the infants at all 4 ages used some type of object during the night. Intra-individual analyses showed that infants tended to change their pattern of sleep aid use over the 3-month study period.

Conclusions. The data provide evidence that infants during the first year of life use sleep aids frequently and interchangeably rather than a specific favorite object.
Infant Sleep Placement After the Back to Sleep Campaign
Authors: Pollack Harold A. , Frohna John G.
Published: August 2004

Objectives. The Back to Sleep campaign has been credited with recent declines in the incidence of sudden infant death syndrome. Using survey data for the 1996–1998 birth cohorts, this epidemiologic study examines infant sleep position in a large, population-based sample.

Data and Methods. Data concerning infant sleep position are drawn from the 1996–1998 Pregnancy Risk Assessment Monitoring System for 15 states. Weighted multiple logistic regression analysis is used to examine correlates of infant sleep position.

Results. The prevalence of prone infant sleeping significantly declined between 1996 and 1998 (adjusted odds ratio [AOR] = 0.70; 95% confidence interval [CI] = [0.63, 0.78]). African Americans were more likely than non-Hispanic whites to sleep prone, (AOR = 1.45; 95% CI = 1.33,1.59), and were less likely to sleep supine (AOR = 0.52; 95% CI = 0.48, 0.57). Hispanic/Latinos were less likely overall than non-Hispanic whites to sleep prone (AOR = 0.81; 95% CI = 0.69, 0.95), but were also less likely to sleep supine (AOR = 0.78; 95% CI = 0.69, 0.87). Adherence to sleep position recommended by the American Academy of Pediatrics increased sharply among Hispanic/Latino infants. Very low birth weight infants and infants in larger families were less likely to sleep in the recommended supine position. Infants born between 1001 and 1500 g (AOR = 0.67; 95% CI = 0.57, 0.79), and extremely low birth weight infants between 500 and 1000 g (AOR = 0.57; 95% CI = 0.45, 0.72) were especially unlikely to sleep supine. Infants in households with more than 3 other children (AOR = 1.72; 95% CI = 1.08, 2.74) were more likely to sleep prone.

Conclusions. The prevalence of supine infant sleep increased between 1996 and 1998. Low adherence to sleep position recommendations of the American Academy of Pediatrics among African Americans, very low birth weight infants, and infants in large families remain public health concerns.
Disparities in Infant Health Among American Indians and Alaska Natives in US Metropolitan Areas
Authors: Grossman David C. , Baldwin Laura-Mae , Casey Susan , Nixon Brigitte , Hollow Walter , Hart L. Gary
Published: August 2004

Objective. To determine geographic variation in urban American Indian and Alaska Native (AI/AN) rates of infant mortality, low birth weight, prenatal care use, and maternal-child health care service availability.

Methods. This was a retrospective cohort study using data from the 1989 to 1991 birth-death linked database from the National Center for Health Statistics. We examined births from metropolitan areas with a minimum of 300 AI/AN births during the study period. Key outcomes of interest included rates of low birth weight, neonatal mortality, postneonatal mortality, and women receiving inadequate prenatal care using the modified Kessner index. To determine the type of health services tailored to AI/AN mothers residing in these urban areas, we conducted a telephone survey of the 36 urban Indian health programs operating in 1997 using a semistructured survey. Items in the survey included questions about the availability of prenatal and infant health care.

Results. During the 1989 to 1991 study period, there were 72 730 singleton births to AI/AN mothers and/or fathers residing in urban areas, representing 49% of all AI/AN births in the United States. Overall 14.4% of urban AI/AN births were to women who received inadequate care during pregnancy, 5.7% of pregnancies resulted in low birth weight infants, and 11.0 infants died per 1000 live births. Death rates for the neonatal period (5.5 per 1000 births) and postneonatal period (5.4 per 1000 births) were similar. Marked disparity in these indicators exist between pregnancies to AI/AN and white women. Among the 54 metropolitan areas, 46 had a rate ratio (AI/AN: white) for inadequate care of ≥1.5 (range: 0.9–8.5). The mean rate ratios for neonatal and postneonatal mortality were 1.6 (range: 0.3–4.0) and 2.0 (range: 0.5–5.5). There was also considerable geographic variation of AI/AN mortality rates between metropolitan areas in all of the outcomes studied. All of the 20 metropolitan areas with the highest birth counts had some type of direct medical care or outreach services available from an urban clinic targeted toward AI/AN patients.

Conclusions. Considerable variation also exists among rates of AI/ANs between metropolitan areas. Disparity exists in rates of perinatal outcomes between AI/ANs and whites living in the same metropolitan areas Although AI/AN urban health programs exist in most cities with large birth counts, it seems that many have inadequate resources to meet existing needs to improve perinatal outcomes and infant health.
Prevalence, Correlates, and Trajectory of Television Viewing Among Infants and Toddlers
Authors: Certain Laura K. , Kahn Robert S.
Published: August 2004

Objectives. Recognizing the negative effects of television on children, the American Academy of Pediatrics (AAP) recommends that children 2 years and older watch <2 hours of television per day and that children younger than 2 years watch no television. However, relatively little is known about the amount of television viewed by infants and toddlers. The objective of this study was to describe the prevalence and correlates of television viewing that exceeds the AAP guidelines for 0- to 35-month-olds and to examine the trajectory of a child’s viewing over time.

Methods. Data from the National Longitudinal Survey of Youth, 1990 to 1998, were used to analyze reported television viewing at 0 to 35 months of age and to follow the trajectory of a child’s viewing from infancy through age 6. Logistic regression models were used to determine risk factors associated with greater television viewing at 0 to 35 months and the association of early viewing habits with school-age viewing.

Results. Seventeen percent of 0- to 11-month-olds, 48% of 12- to 23-month-olds, and 41% of 24- to 35-month-olds were reported to watch more television than the AAP recommends. Compared with college graduates, less-educated women were more likely to report that their children watched more television than recommended. Children who watched >2 hours per day at age 2 were more likely to watch >2 hours per day at age 6 (odds ratio: 2.7; 95% confidence interval: 1.8–3.9), controlling for maternal education, race, marital status and employment, household income, and birth order.

Conclusions. A substantial number of children begin watching television at an earlier age and in greater amounts than the AAP recommends. Furthermore, these early viewing patterns persist into childhood. Preventive intervention research on television viewing should consider targeting infants and toddlers and their families.
Significant Selective Head Cooling Can be Maintained Long-Term After Global Hypoxia Ischemia in Newborn Piglets
Authors: Tooley James , Satas Saulius , Eagle Rebecca , Silver Ian A. , Thoresen Marianne
Published: August 2004

Objective. Selective head cooling (SHC) combined with mild body cooling is currently being evaluated as a potentially therapeutic option in the management of neonatal hypoxic-ischemic encephalopathy. It is proposed that SHC enables local hypothermic neuroprotection while minimizing the deleterious side effects of systemic hypothermia. However, there is little evidence that it is possible to cool the brain more than the body for a prolonged period of time. The aim of this study was to examine whether the brain (Tdeep brain) could be cooled to below the rectal temperature (Trectal) in our piglet hypoxia ischemia (HI) model for a period of 24 hours, using a head-cooling cap.

Methods. Eight anesthetized piglets (median age: 15 hours) had subdural and intracerebral basal ganglia temperature probes inserted. After a 45-minute global HI insult (known to produce permanent brain damage), SHC using a cap perfused with cold water (5°C–24°C) combined with overhead body heating to maintain Trectal at 34 to 35°C was performed for 24 hours.

Results. The piglets were cooled to a median Trectal of 35.0°C (interquartile range [IQR]: 34.7–35.3) for 24 hours. During this time, the median Tdeep brain was 31.4°C (IQR: 30°C–32.2°C), with a median Trectal to Tdeep brain gradient of 3.4°C (IQR: 2.7°C–4.8°C). At the end of the cooling period, this gradient was still maintained at a median of 3.3°C (IQR: 2.9°C–3.7°C). The ability to obtain the gradient was not influenced by the size of the piglet (1300–1840 g). Cap cooling lowered scalp temperature (Tscalp) to a median of 24.9°C (IQR: 22.2°C–29.2°C) and subdural temperature to a median of 28.1°C (IQR: 25.8°C–29.5°C) but did not result in either skin injury or superficial brain hemorrhage. There was no clinically useful correlation between Tscalp and Tdeep brain or between Tscalp and Tsubdural.

Conclusions. This study using our piglet HI model shows that it is possible by means of a head-cooling cap to cool the brain more than the body for a 24-hour period while keeping the core temperature mildly hypothermic. However, we were unable to predict temperatures inside the brain using surface temperature probes on the head.
Where Do Children With Complex Chronic Conditions Die? Patterns in Washington State, 1980–1998
Authors: Feudtner Chris , Silveira Maria J. , Christakis Dimitri A.
Published: August 2004

Objective. Little is known about factors that influence whether children with chronic conditions die at home. We sought to test whether deaths attributable to underlying complex chronic conditions (CCCs) were increasingly occurring at home and to determine what features were associated with home deaths.

Design. A retrospective case series was conducted of all deaths that occurred to children age 0 to 18 years in Washington state from 1980 to 1998 using death certificate data, augmented with 1990 US Census data regarding median household income by zip code in 1989, to determine the site of death.

Results. Of the 31 455 deaths identified in infants, children, and adults younger than 25 years, 52% occurred in the hospital, 17.2% occurred at home, 8.5% occurred in the emergency department or during transportation, 0.4% occurred in nursing homes, and 21.7% occurred at other sites. Among children who died as a result of some form of CCC (excluding injury, sudden infant death syndrome, and non-CCC medical conditions), the percentage of cases younger than 1 year who died at home rose slightly from 7.8% in 1980 to 11.6% in 1998, whereas the percentage of older children and young adults who had a CCC and died at home rose substantially from 21% in 1980 to 43% in 1998. Children who had lived in more affluent neighborhoods were more likely to have died at home. Using leukemia-related deaths as a benchmark, deaths as a result of congenital, genetic, neuromuscular, and metabolic conditions and other forms of cancer all were more likely to have occurred at home. Significant variation in the likelihood of home death, not explained by the individual attributes of the cases, also existed across the 39 counties in Washington state.

Conclusions. Children who die with underlying CCCs increasingly do so at home. Age at death, specific condition, local area affluence, and the location of home all influence the likelihood of home death. These findings warrant additional study, as they have implications for how we envision pediatric palliative care, hospice, and other supportive services for the future.
Trends in Postneonatal Aspiration Deaths and Reclassification of Sudden Infant Death Syndrome: Impact of the “Back to Sleep” Program
Authors: Malloy Michael H.
Published: August 2004

Objective. The introduction of the “Back to Sleep” campaign for the prevention of sudden infant death syndrome (SIDS) brought with it concern that there might be an increase in the incidence of aspiration-related deaths. The objective of this analysis was to describe the trends in postneonatal mortality and proportionate mortality ratios for the United States for the years 1991 to 1996 for aspiration-related deaths and other causes to which a SIDS death could conceivably be reclassified.

Methods. Linked birth and infant death vital statistic files for the United States were used for the years 1991, 1995, and 1996. US Vital Statistic Mortality files for the years 1992, 1993, and 1994 were used because of the absence of linked files for those years.

Results. The overall postneonatal mortality rate between 1991 and 1996 declined 21.9%, whereas the SIDS rate declined 38.9%. The proportion of the postneonatal mortality (PNPMR) contributed by SIDS declined from 37.1% in 1991 to 28.8% in 1996. There was no significant increase in the PNPMR for aspiration, asphyxia, or respiratory failure. There was, however, a significant increase in the PNPMR for suffocation in bed or cradle from 0.9 to 1.3.

Conclusions. These data show no evidence of an increased risk of death from aspiration as a result of the “Back to Sleep” program. Although there has been an increase in the proportion of postneonatal mortality attributable to suffocation, this represents a very small proportion of postneonatal mortality and thus potentially a very small number of SIDS deaths reclassified as suffocation.
Interchangeability of 2 Diphtheria-Tetanus-Acellular Pertussis Vaccines in Infancy
Authors: Greenberg David P. , Pickering Larry K. , Senders Shelly D. , Bissey Jeffrey D. , Howard Robert A. , Blatter Mark M. , Reisinger Keith , Pichichero Michael E. , Howe Barbara J.
Published: August 2004

Objective. Currently, 4 diphtheria-tetanus-acellular pertussis (DTaP) vaccines are licensed for pediatric use in the United States, and 2 are commercially available. Although a single manufacturer’s DTaP vaccine should be used for all 3 doses of the primary immunization series, some circumstances result in infants receiving DTaP vaccines from more than 1 manufacturer. The purpose of this study was to evaluate the safety and immunogenicity of a mixed sequence of 2 different DTaP vaccines.

Methods. In this multicenter, observer-blinded, controlled study, 449 infants were randomized into 1 of 3 groups (1:1:1 ratio) to receive Tripedia at 2, 4, and 6 months of age (control group); Tripedia at 2 and 4 months of age and Infanrix at 6 months of age; or Tripedia at 2 months and Infanrix at 4 and 6 months of age. Other vaccines were administered concurrently as separate injections according to the recommended childhood immunization schedule. Safety was monitored closely, and standard enzyme immunoassays were used to measure antibody concentrations to each antigen of the DTaP vaccines.

Results. The rates of injection-site and systemic adverse events were similar in each study group, and there were no clinically significant differences among groups after any dose. Infants in all 3 groups responded well to each antigen contained in both vaccines, with 97% to 100% seroprotection or vaccine response rates after the 3-dose primary series. Postvaccination geometric mean antibody concentrations and seroprotection or vaccine response rates to nearly all vaccine antigens were as high or higher in the mixed-sequence groups as in the control group.

Conclusion. Initiating the primary immunization series with 1 or 2 doses of Tripedia and completing the 3-dose series with Infanrix is as safe and at least as immunogenic as administering Tripedia for all 3 doses.
Detection of Pulsus Paradoxus Associated With Large Pericardial Effusions in Pediatric Patients by Analysis of the Pulse-Oximetry Waveform
Authors: Tamburro Robert F. , Ring John C. , Womback Kimberly
Published: August 2004

Objective. To determine whether analysis of the pulse-oximetry waveform can be useful in detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients.

Methods. A retrospective review of charts of 8 pediatric patients (age range: 5–19 years) who had echocardiographic evidence of large pericardial effusion, subsequently underwent pericardiocentesis, and had pulse-oximetry waveform tracings obtained before and after pericardiocentesis within an 18-month period was conducted in 2 tertiary-care pediatric intensive care units. We analyzed the pulse-oximetry waveform tracings for the presence of a pulsus paradoxus. Other abstracted data included clinical evidence of tamponade, echocardiographic findings, and the volume of pericardial fluid aspirated.

Results. Before pericardiocentesis, a decrease in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform was observed during inspiration in each patient. Echocardiographic evidence of large pericardial effusion with compromised cardiac filling was also present in each patient. Only 6 of these patients had clinical evidence of cardiac tamponade at that time, 4 with a documented pulsus paradoxus using standard methods of blood pressure analysis. After pericardiocentesis, the inspiratory fall in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform lessened in every patient. Echocardiography documented a decrease in the size of the effusion and resolution of the compromised cardiac filling in every patient.

Conclusions. Analysis of pulse-oximetry waveforms may be a widely available, easily interpretable, and reliable method of detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients.
LactobacillusTherapy for Acute Infectious Diarrhea in Children: A Meta-analysis
Authors: Van Niel Cornelius W. , Feudtner Chris , Garrison Michelle M. , Christakis Dimitri A.
Published: August 2004

Objective. Childhood diarrhea accounts for substantial morbidity and mortality worldwide. Multiple studies in children have shown that Lactobacillus, administered orally, may have antidiarrheal properties. We conducted a meta-analysis of randomized, controlled studies to assess whether treatment with Lactobacillus improves clinical outcomes in children with acute infectious diarrhea.

Methods. Studies were sought in bibliographic databases of traditional biomedical as well as complementary and alternative medicine literature published from 1966 to 2000. Search terms were “competitive inhibition,” “diarrhea,” “gastroenteritis,” “Lactobacillus,” “probiotic,” “rotavirus,” and “yog(h)urt.” We included studies that were adequately randomized, blinded, controlled trials in which the treatment group received Lactobacillus and the control group received an adequate placebo and that reported clinical outcome measures of diarrhea intensity. These inclusion criteria were applied by blind review and consensus. The original search yielded 26 studies, 9 of which met the criteria. Multiple observers independently extracted study characteristics and clinical outcomes. Data sufficient to perform meta-analysis of the effect of Lactobacillus on diarrhea duration and diarrhea frequency on day 2 were contained in 7 and 3 of the included studies, respectively.

Results. Summary point estimates indicate a reduction in diarrhea duration of 0.7 days (95% confidence interval: 0.3–1.2 days) and a reduction in diarrhea frequency of 1.6 stools on day 2 of treatment (95% confidence interval: 0.7–2.6 fewer stools) in the participants who received Lactobacillus compared with those who received placebo. Details of treatment protocols varied among the studies. A preplanned subanalysis suggests a dose-effect relationship.

Conclusion. The results of this meta-analysis suggest that Lactobacillus is safe and effective as a treatment for children with acute infectious diarrhea.
Diagnosis and Management of Suspected Cases of Bioterrorism: A Pediatric Perspective
Authors: Patt Hanoch A. , Feigin Ralph D.
Published: August 2004

Since October 3, 2001, the Centers for Disease Control and Prevention and other organizations have been investigating potential bioterrorist-related anthrax cases. The pediatrician may be faced with complex issues related to diagnosis and treatment of illnesses caused by intentionally released biological agents. The agents that pose a major potential bioterrorist threat are reviewed by the clinical syndromes they produce: acute respiratory distress with fever, influenza-like illnesses, acute rash with fever, neurologic syndromes, and blistering syndromes. Specific and detailed diagnostic, treatment, and prophylaxis information is provided for anthrax, plague, tularemia, smallpox, botulism, viral hemorrhagic fevers, and other diseases. In cases of suspected bioterrorism, the pediatrician must be able to obtain diagnostic and treatment information efficiently and expeditiously. The system controlling the interaction between public and nonpublic health laboratories in suspected cases of bioterrorism is described. Finally, information regarding emergency contacts and links to educational resources is provided.
Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome
Authors:   Section on Pediatric Pulmonology,   Subcommittee on Obstructive Sleep Apnea Syndrome
Published: August 2004

This clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of obstructive sleep apnea syndrome (OSAS).

The Section on Pediatric Pulmonology of the American Academy of Pediatrics selected a subcommittee composed of pediatricians and other experts in the fields of pulmonology and otolaryngology as well as experts from epidemiology and pediatric practice to develop an evidence base of literature on this topic. The resulting evidence report was used to formulate recommendations for the diagnosis and management of childhood OSAS.

The guideline contains the following recommendations for the diagnosis of OSAS: 1) all children should be screened for snoring; 2) complex high-risk patients should be referred to a specialist; 3) patients with cardiorespiratory failure cannot await elective evaluation; 4) diagnostic evaluation is useful in discriminating between primary snoring and OSAS, the gold standard being polysomnography; 5) adenotonsillectomy is the first line of treatment for most children, and continuous positive airway pressure is an option for those who are not candidates for surgery or do not respond to surgery; 6) high-risk patients should be monitored as inpatients postoperatively; 7) patients should be reevaluated postoperatively to determine whether additional treatment is required.

This clinical practice guideline is not intended as a sole source of guidance in the evaluation of children with OSAS. Rather, it is designed to assist primary care clinicians by providing a framework for diagnostic decision-making. It is not intended to replace clinical judgment or to establish a protocol for all children with this condition and may not provide the only appropriate approach to this problem.
Continuity of Care Is Associated With High-Quality Careby Parental Report
Authors: Christakis Dimitri A. , Wright Jeffrey A. , Zimmerman Frederick J. , Bassett Alta L. , Connell Frederick A.
Published: August 2004

Context. The benefits of continuity of pediatric care remain controversial.

Objective. To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and improved quality of care by parental report.

Design. Cross-sectional study.

Setting and Population. Seven hundred fifty-nine patients presenting to a primary care clinic completed surveys, which included validated measures of provider and clinic quality of care from the Consumer Assessment of Health Plan Survey.

Main Exposure Variable. A continuity of care index that quantifies the degree to which a patient has experienced continuous care with a provider.

Main Outcome Measures. The likelihood of parents reporting quality of care as high in several provider- specific items including reporting that providers respected what they had to say, treated them with courtesy and respect, listened to them carefully, explained things in a way they could understand, and spent enough time with their children. In addition, participants were asked to rate the overall quality of the clinic and their child’s provider on a 10-point scale.

Results. In ordered logistic regression models, continuity of care was associated with statistically significantly higher Consumer Assessment of Health Plan Survey scores for 5 of the 6 items, including feeling that providers respected what parents had to say; listened carefully to them; explained things in a way that they could understand; asked about how their child was feeling, growing, and behaving; and spent enough time with their child. In addition, greater continuity of care was associated with a higher clinic rating, as well as a higher provider rating.

Conclusions. Greater continuity of primary care is associated with higher quality of care as reported by parents. Efforts to improve and maintain continuity may be warranted.
Growth and Biochemical Markers of Growth in Children With Snoring and Obstructive Sleep Apnea
Authors: Nieminen Peter , Löppönen Tuija , Tolonen Uolevi , Lanning Peter , Knip Mikael , Löppönen Heikki
Published: August 2004

Objective. The pathophysiological mechanisms of growth impairment frequently associated with the obstructive sleep apnea syndrome (OSAS) in children are poorly defined. The main objective of this study was to evaluate whether nighttime upper airway obstruction attributable to adenotonsillar hypertrophy and subsequent surgical treatment affect the circulating concentrations of insulin-like growth factor-I (IGF-I) and IGF-binding protein 3 (IGFBP-3) along with other growth parameters in children.

Patients and Methods. We initially studied 70 children (mean age: 5.8 years; range: 2.4–10.5 years) admitted to a university hospital because of clinical symptoms of OSAS. Their sleep was monitored with a 6-channel computerized polygraph. Data on anthropometry and circulating concentrations of IGF-I and IGFBP-3 were generated and compared with corresponding characteristics in control children (N = 35). Thirty children with an obstructive apnea-hypopnea index (OAHI) of 1 or more were categorized as children with OSAS (mean OAHI: 5.4 [95% confidence interval for mean (CI): 3.8–6.9]), whereas 40 children with an OAHI of <1 were considered as primary snorers (PS) (mean OAHI 0.13 [95% CI: 0.05–0.21]). Nineteen children with OAHI >2 underwent adenotonsillectomy attributable to OSAS and were reassessed 6 months later together with 34 nonoperated children with OAHI <2.

Results. There were no initial differences in relative height and weight for height between the 3 groups of children. No differences were observed in peripheral IGF-I concentrations, but both OSAS and PS children had reduced peripheral IGFBP-3 levels. The operated children with initial OSAS experienced a highly significant reduction in their OAHI from 7.1 (95% CI: 5.1–9.1) to 0.37 (95% CI: 0.2–0.95). Weight-for-height, body mass index, body fat mass, and fat-free mass increased during the follow-up in the operated children with OSAS, whereas only fat-free mass and relative height increased in the PS children. Both the IGF-I and the IGFBP-3 concentrations increased significantly in the operated children, whereas no significant changes were seen in the PS children.

Conclusions. These observations indicate that growth hormone secretion is impaired in children with OSAS and PS. Respiratory improvement after adenotonsillectomy in children with OSAS results in weight gain and restored growth hormone secretion.
Postpartum Consequences of an Overlap of Breastfeeding and Pregnancy: Reduced Breast Milk Intake and Growth During Early Infancy
Authors: Marquis Grace S. , Penny Mary E. , Diaz Judith M. , Marín R. Margot
Published: August 2004

Objective. Despite cultural pressure to wean when a new pregnancy occurs, some women choose to continue breastfeeding. We determined the effect of an overlap of lactation and late pregnancy on breastfeeding and growth in early infancy.

Methods. We studied 133 Peruvian pregnant women who were ≥18 years of age, had a child <4 years old, and who then had a vaginal birth with a healthy, normal weight infant. Of the 133 women, 68 breastfed during the last trimester of pregnancy (BFP), and 65 had not breastfed during pregnancy (NBFP). On day 2 and at 1-month postpartum, 24-hour intake of breast milk and other liquids was measured. Twice weekly home surveillance documented infant morbidity and dietary intakes. Anthropometry was taken at birth and at 1 month. Maternal anthropometric, health, and socioeconomic status data were collected pre- and postpartum.

Results. Pregnant BFP mothers breastfed 5.3 ± 4.3 times/day. BFP and NBFP infants did not differ in breastfeeding behavior or in colostrum intake on day 2. BFP infants breastfed longer per feed and per 24 hours (35.2 minutes/24 hours) than did NBFP infants; however, 1-month intakes per feed tended to be lower among the BFP infants. After controlling for confounders, BFP infants gained 125 g less than did NBFP infants (about 15% of mean weight gain). A sustained decline would result in a −0.7 z score change in weight-for-age by 6 months.

Conclusions. A lactation-pregnancy overlap had a negative effect on early infant outcomes. Additional studies are needed to determine whether the effect continues past 1 month of age.
Correlates of Lactation in Mothers of Very Low Birth Weight Infants
Authors: Furman Lydia , Minich Nori , Hack Maureen
Published: August 2004

Objective. We sought to determine the correlates of intent to breastfeed and of successful lactation and nursing at the breast in mothers of very low birth weight (VLBW; <1.5 kg) infants.

Methods. We conducted a prospective observational study of 119 mothers of singleton VLBW infants (mean birth weight: 1056 g; mean gestational age: 28 weeks), 87 (73%) of whom intended to breastfeed. Mothers completed questionnaires at 3 weeks’ postnatal age and at 35 and 40 weeks’ (term) and 4 months’ corrected ages (CAs).

Results. Of the 87 mothers who intended to breastfeed, 30 mothers (34%) continued lactation beyond 40 weeks’ CA (postmenstrual plus postnatal age). Compared with mothers who discontinued lactation before this time, those who continued were older (31 vs 26 years), more were married (80% vs 39%), they had more than a high school education (70% vs 42%), and they were white (63% vs 35%). There were no significant differences in their infants’ birth data or rates of neonatal morbidity. Significant correlates of lactation beyond 40 weeks’ CA included beginning milk expression before 6 hours postdelivery, expressing milk ≥5 times per day, and kangaroo care. These correlates remained significant after controlling for maternal age, race, marital status, and education beyond high school. At 4 months’ CA, 14 mothers (16%) were still lactating, 12 of whom were nursing at the breast.

Conclusions. Increased maternal support specifically directed toward behavioral factors, including early and more frequent milk expression and kangaroo care, may improve the rates of successful lactation among mothers of VLBW infants who choose to breastfeed.
Economic Evaluation of Different Methods of Screening for Amblyopia in Kindergarten
Authors: König Hans-Helmut , Barry Jean-Cyriaque
Published: August 2004

Objective. To compare the cost-effectiveness of 5 methods of screening for untreated amblyopia in kindergarten from a third-party-payer perspective: A) uncorrected monocular visual acuity testing with pass threshold ≥0.5 (20/40) and ≤1 line difference between eyes; B) same as A, but pass threshold ≥0.6 (20/32); C) same as A, plus cover tests and examination of eye motility and head posture; D) same as C, but pass threshold ≥0.6 (20/32); and E) refractive screening without cycloplegia using the Nikon Retinomax autorefractor.

Methods. A decision-analytic model was used with a time horizon until diagnostic examination. According to the model, all 3-year-old children were screened in kindergarten with 1 of the screening methods. Children with positive screening results were referred to an ophthalmologist for diagnostic examination. Children with inconclusive screening results were either referred to an ophthalmologist directly (option 1) or rescreened by the same method after 1 year and referred to an ophthalmologist if rescreening was positive or inconclusive (option 2). Screening test characteristics and costs were estimated on the basis of a field study in which 1180 3-year-old children were examined by orthoptists in 121 German kindergartens.

Results. Compared with methods A option 1 (A-1), B-1, C-1, C-2, E-1, and E-2, there was at least 1 other method that was both less costly and more effective. The average costs per detected case were lowest for method A-2 (878 Euro), followed by methods B-2 (886 Euro), D-2 (908 Euro), and D-1 (965 Euro). When these methods were compared with each other, the additional costs per extra case detected were 1058 Euro (B-2 vs A-2), 1359 Euro (D-2 vs B-2), and 13 448 Euro (D-1 vs D-2).

Conclusions. Monocular visual acuity screening with rescreening of inconclusive results had a favorable cost-effectiveness. By adding additional test items, few more cases could be detected. Because of a great proportion of false-negative, false-positive, and inconclusive results, refractive screening was less effective with an unfavorable cost-effectiveness.
Zidovudine and Perinatal Human Immunodeficiency Virus Type 1 Transmission: A Population-Based Approach
Authors: Harris Norma S. , Thompson Shirley J. , Ball Robert , Hussey James , Sy Francisco
Published: August 2004

Objective. This study examined the impact of the full 3-arm zidovudine regimen on the perinatal transmission of human immunodeficiency virus type 1 (HIV-1) using population-based data.

Methods. We retrospectively ascertained information on zidovudine prescription and other characteristics of HIV-infected pregnant women and children for birth cohort years 1993, 1995, 1996, and 1997 using HIV/acquired immunodeficiency syndrome registry data from a state health department supplemented by medical record reviews.

Results. The transmission rate decreased from 12.5% in 1993 to 4.6% in 1997. The proportions of HIV-1-infected mothers and children who were prescribed all 3 arms of zidovudine increased from 68% in 1995 to 93% in 1997. Unadjusted and adjusted odds ratios for the relationship between the prescription of 3 arms of zidovudine and the infants’ HIV status were 0.19 (95% confidence interval: 0.05–0.84) and 0.15 (95% confidence interval: 0.02–0.96), respectively.

Conclusion. Perinatal HIV-1 transmission rates have decreased over time. This study demonstrates the effectiveness of the rapid implementation of the United States Public Health Service recommendations for the comprehensive use of zidovudine among HIV-1-infected pregnant women in a predominantly rural state.
Reported Adherence as a Determinant of Response to Highly Active Antiretroviral Therapy in Children Who Have Human Immunodeficiency Virus Infection
Authors: Van Dyke Russell B. , Lee Sophia , Johnson George M. , Wiznia Andrew , Mohan Kathleen , Stanley Kenneth , Morse Edward V. , Krogstad Paul A. , Nachman Sharon ,   Pediatric AIDS Clinical Trials Group Adherence Subcommittee,   Pediatric AIDS Clinical Trials Group 377 Study Team
Published: August 2004

Objective. The complexity of highly active antiretroviral therapy (HAART), with multiple medications, formulations, and dosing intervals, makes adherence challenging. Little is known about the adherence of children to HAART. The objective of this study was to identify correlates of adherence to HAART and the relationship between adherence and study outcomes in a pediatric clinical trial.

Methods. Pediatric AIDS Clinical Trials Group 377 is a phase I/II randomized trial of 4 HAART regimens in antiretroviral-experienced, clinically stable children aged 4 months to 17 years. The 4 treatment arms include various 3- or 4-drug combinations of d4T, 3TC, nevirapine, ritonavir, and nelfinavir. After informed consent was obtained, 193 children were enrolled between December 1997 and September 1998. Questionnaires were developed to collect subject- or caregiver-reported adherence to study medications and to identify problems associated with medication administration. Every 3 months, the number of doses of each medication missed during the 3 days preceding the study visit was recorded. Full adherence (FA) and non-full adherence were defined as missing no doses and missing at least 1 dose, respectively.

Results. Adherence data from study week 48 or the most recent study visit were available for 125 children (week 48 for 109 children). Overall, 70% of children reported FA and 30% reported non-full adherence. Adherence did not differ by treatment arm, age, or the child’s knowledge of his or her human immunodeficiency virus infection status. There was a suggestion that adherence was less for white than nonwhite children (40% vs 73% FA) and did not differ between black and Hispanic children. Rates of FA were 82% for d4T, 79% for 3TC, 83% for nevirapine, 84% for ritonavir, and 68% for nelfinavir. Despite the similar rates of FA, difficulties with taking specific medications were reported most frequently for ritonavir and nelfinavir. These included poor taste, patient refusal, and scheduling problems. Adherence was associated with the virologic response: FA was seen in 92% of children with ≥2 log10 drop in viral load and in 64% with <2 log10 drop in viral load.

Conclusion. In children, reported adherence predicts the virologic response to HAART therapy and is a useful measure of adherence. Interventions and regimens to increase adherence to HAART should result in an improved outcome.
Ondansetron Decreases Vomiting Associated With Acute Gastroenteritis: A Randomized, Controlled Trial
Authors: Reeves John J. , Shannon Michael W. , Fleisher Gary R.
Published: August 2004

Objective. Relatively little research has examined the role of antiemetic agents in the treatment of acute gastroenteritis. The use of the selective 5-HT3 receptor antagonists (eg, ondansetron) offers a potentially valuable treatment option. The objective of this study was to evaluate the efficacy of ondansetron for the treatment of vomiting associated with acute gastroenteritis in children.

Methods. A randomized, double blind, placebo-controlled trial was conducted in the emergency department of a tertiary-care children’s hospital. Eligible patients were 1 month to 22 years old and required intravenous fluids for gastroenteritis. Of 172 patients approached, 107 were enrolled (54 to intravenous ondansetron, 53 to placebo). The mean age was 5.3 years, and 53% of the patients were male. The frequency of vomiting, admission rate, and occurrence of complications were measured.

Results. After drug administration, 38 (70%) of the 54 patients in the ondansetron group had complete cessation of vomiting compared with 27 (51%) of the 53 patients in the placebo group. Sixteen (30%) of the 53 patients in the placebo group required admission compared with 14 (26%) of the 54 in the ondansetron group. An analysis of previously untreated patients with a measured serum carbon dioxide ≥15 mEq/L showed that 11 (23%) of the 47 who received placebo were admitted compared with 3 (7%) of the 43 who received ondansetron. No significant complications were detected.

Conclusions. Intravenous ondansetron decreases vomiting in children with gastroenteritis. In addition, ondansetron reduces the need for admission in those who are treated at an initial visit to the emergency department and have a measured serum carbon dioxide ≥15 mEq/L. The safety and low cost of this therapy suggests that ondansetron can be valuable in treating gastroenteritis in children.