bluuebunny/crossref_metadata_2025 huggingface dataset:
Children Who Have Received No Vaccines: Who Are They and Where Do They Live?
Authors: Smith Philip J. , Chu Susan Y. , Barker Lawrence E.
Published: August 2004

Context. Each year 2.1 million children 19 to 35 months of age are undervaccinated. Among these are children who have received no vaccinations. Unvaccinated children are at increased risk of acquiring and transmitting vaccine-preventable diseases.

Objectives. To assess whether the characteristics of children with no vaccinations differ from those of undervaccinated children, to monitor trends in the numbers of unvaccinated children, and to identify states with high rates and counties with large numbers of unvaccinated children.

Design. A nationally representative probability sample of children 19 to 35 months of age was collected annually between 1995 and 2001. Vaccination histories were ascertained from children's medical providers. Undervaccinated children had received ≥1 dose of diphtheria-tetanus-pertussis, polio, measles, Haemophilus influenzae type b, hepatitis B, or varicella vaccine but were not fully vaccinated. Unvaccinated children were children who were reported as having no medical providers and having received no vaccinations or children whose medical providers reported administering no vaccinations.

Participants. A total of 151 720 children sampled between 1995 and 2001, 795 of whom were unvaccinated.

Results. Undervaccinated children tended to be black, to have a younger mother who was not married and did not have a college degree, to live in a household near the poverty level, and to live in a central city. Unvaccinated children tended to be white, to have a mother who was married and had a college degree, to live in a household with an annual income exceeding $75 000, and to have parents who expressed concerns regarding the safety of vaccines and indicated that medical doctors have little influence over vaccination decisions for their children. Unvaccinated children were more likely to be male than female. Annually, ∼17 000 children were unvaccinated. The largest numbers of unvaccinated children lived in counties in California, Illinois, New York, Washington, Pennsylvania, Texas, Oklahoma, Colorado, Utah, and Michigan. States that allowed philosophical exemptions to laws mandating vaccinations for children as they entered school had significantly higher estimated rates of unvaccinated children.

Conclusions. Unvaccinated children have characteristics that are distinctly different from those of undervaccinated children. Unvaccinated children are clustered geographically, increasing the risk of transmitting vaccine-preventable diseases to both unvaccinated and undervaccinated children.
Effect of Chelation Therapy on the Neuropsychological and Behavioral Development of Lead-Exposed Children After School Entry
Authors: Dietrich Kim N. , Ware James H. , Salganik Mikhail , Radcliffe Jerilynn , Rogan Walter J. , Rhoads George G. , Fay Martha E. , Davoli Cecilia T. , Denckla Martha B. , Bornschein Robert L. , Schwarz Donald , Dockery Douglas W. , Adubato Susan , Jones Robert L. ,   for the Treatment of Lead-Exposed Children Clinical Trial Group
Published: August 2004

Objective. Some children in the United States continue to be exposed to levels of lead that increase their risk for lowered intellectual functioning and behavior problems. It is unclear whether chelation therapy can prevent or reverse the neurodevelopmental sequelae of lead toxicity. The objective of this study was to determine whether chelation therapy with succimer (dimercaptosuccinic acid) in children with referral blood lead levels between 20 and 44 μg/dL (0.96-2.12 μmol/L) at 12 to 33 months of age has neurodevelopmental benefits at age 7 years.

Methods. The Treatment of Lead-Exposed Children (TLC) study is a randomized, double-blind, placebo-controlled trial that was conducted between September 1994 and June 2003 in Philadelphia, PA; Newark, NJ; Cincinnati, OH; and Baltimore, MD. Of 1854 referred children who were between the ages of 12 to 33 months and screened for eligibility, 780 were randomized to the active drug and placebo groups stratified by clinical center, body surface area, blood lead level, and language spoken at home. At 7 years of age, 647 subjects remained in the study. Participants were randomly assigned to receive oral succimer or placebo. Up to 3 26-day courses of succimer or placebo therapy were administered depending on response to treatment in those who were given active drug. Eighty-nine percent had finished treatment by 6 months, with all children finishing by 13 months after randomization. All participants received residential lead hazard control measures before treatment. TLC subjects also received a daily multivitamin supplement before and after treatment(s) with succimer or placebo. Scores on standardized neuropsychological measures that tap cognition, behavior, learning and memory, attention, and neuromotor skills were measured.

Results. Chelation therapy with succimer lowered average blood lead levels for ∼6 months but resulted in no benefit in cognitive, behavioral, and neuromotor endpoints.

Conclusion. These new follow-up data confirm our previous finding that the TLC regimen of chelation therapy is not associated with neurodevelopmental benefits in children with blood lead levels between 20 and 44 μg/dL (0.96–2.17 μmol/L). These results emphasize the importance of taking environmental measures to prevent exposure to lead. Chelation therapy with succimer cannot be recommended for children with blood lead levels between 20 and 44 μg/dL (0.96–2.12 μmol/L).
Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations
Authors: Inge Thomas H. , Krebs Nancy F. , Garcia Victor F. , Skelton Joseph A. , Guice Karen S. , Strauss Richard S. , Albanese Craig T. , Brandt Mary L. , Hammer Lawrence D. , Harmon Carol M. , Kane Timothy D. , Klish William J. , Oldham Keith T. , Rudolph Colin D. , Helmrath Michael A. , Donovan Edward , Daniels Stephen R.
Published: August 2004

As the prevalence of obesity and obesity-related disease among adolescents in the United States continues to increase, physicians are increasingly faced with the dilemma of determining the best treatment strategies for affected patients. This report offers an approach for the evaluation of adolescent patients' candidacy for bariatric surgery. In addition to anthropometric measurements and comorbidity assessments, a number of unique factors must be critically assessed among overweight youths. In an effort to reduce the risk of adverse medical and psychosocial outcomes and increase compliance and follow-up monitoring after bariatric surgery, principles of adolescent growth and development, the decisional capacity of the patient, family structure, and barriers to adherence must be considered. Consideration for bariatric surgery is generally warranted only when adolescents have experienced failure of ≥6 months of organized weight loss attempts and have met certain anthropometric, medical, and psychologic criteria. Adolescent candidates for bariatric surgery should be very severely obese (defined by the World Health Organization as a body mass index of ≥40), have attained a majority of skeletal maturity (generally ≥13 years of age for girls and ≥15 years of age for boys), and have comorbidities related to obesity that might be remedied with durable weight loss. Potential candidates for bariatric surgery should be referred to centers with multidisciplinary weight management teams that have expertise in meeting the unique needs of overweight adolescents. Surgery should be performed in institutions that are equipped to meet the tertiary care needs of severely obese patients and to collect long-term data on the clinical outcomes of these patients.
Why Pediatricians Need Lawyers to Keep Children Healthy
Authors: Zuckerman Barry , Sandel Megan , Smith Lauren , Lawton Ellen
Published: August 2004

Pediatricians recognize that social and nonmedical factors influence child health and that there are many government programs and laws designed to provide for children’s basic needs. However, gaps in implementation result in denials of services, leading to preventable poor health outcomes. Physician advocacy in these arenas is often limited by lack of knowledge, experience, and resources to intervene. The incorporation of on-site lawyers into the health care team facilitates the provision of crucial legal services to vulnerable families. Although social workers and case managers play a critical role in assessing family stability and finding appropriate resources for families, lawyers are trained to identify violations of rights and to take the appropriate legal steps to hold agencies, landlords, schools, and others accountable on behalf of families. The incorporation of lawyers in the clinical setting originated at an urban academic medical center and is being replicated at >30 sites across the country. Lawyers can help enhance a culture of advocacy in pediatrics by providing direct legal assistance and case consultation for providers, as well as jointly addressing systemic issues affecting children and families. Until laws to promote health and safety are consistently applied and enforced, pediatricians will need lawyers to effectively care for vulnerable children.
Sudden Infant Death Syndrome and Unclassified Sudden Infant Deaths: A Definitional and Diagnostic Approach
Authors: Krous Henry F. , Beckwith J. Bruce , Byard Roger W. , Rognum Torleiv O. , Bajanowski Thomas , Corey Tracey , Cutz Ernest , Hanzlick Randy , Keens Thomas G. , Mitchell Edwin A.
Published: August 2004

The definition of sudden infant death syndrome (SIDS) originally appeared in 1969 and was modified 2 decades later. During the following 15 years, an enormous amount of additional information has emerged, justifying additional refinement of the definition of SIDS to incorporate epidemiologic features, risk factors, pathologic features, and ancillary test findings. An expert panel of pediatric and forensic pathologists and pediatricians considered these issues and developed a new general definition of SIDS for administrative and vital statistics purposes. The new definition was then stratified to facilitate research into sudden infant death. Another category, defined as unclassified sudden infant deaths, was introduced for cases that do not meet the criteria for a diagnosis of SIDS and for which alternative diagnoses of natural or unnatural conditions were equivocal. It is anticipated that these new definitions will be modified in the future to accommodate new understanding of SIDS and sudden infant death.
Bile Acid Pneumonia: A “New” Form of Neonatal Respiratory Distress Syndrome?
Authors: Zecca Enrico , Costa Simonetta , Lauriola Valeria , Vento Giovanni , Papacci Patrizia , Romagnoli Costantino
Published: August 2004

We describe 3 cases of neonatal respiratory distress syndrome (RDS) in near-term infants, born from mothers with severe intrahepatic cholestasis of pregnancy. Common pictures of the cases were: good indices of lung maturity in the amniotic fluid; severe RDS requiring mechanical ventilation; high serum bile acid (BA) levels in the early days of life; no meconium aspiration; negative cultures; and absence of indirect laboratory signs of infection. After the first case, we hypothesized that abnormally high BA levels could have reversed the action of phospholipase A2 in the lungs, causing a degradation of phosphatidylcholines to lysophosphatidylcholines and the consequent lack of surfactant activity, leading to the severe respiratory distress. Consequently, in cases 2 and 3, we gave intratracheal surfactant to the infants, which, although administered around the first 24 hours of life, showed to be helpful. Our experience suggests that a high level of attention in the management of newborn infants (even near-term infants) born from women with intrahepatic cholestasis of pregnancy is necessary to detect as soon as possible signs and symptoms of this “unexpected” RDS, which can assume a very severe clinical picture. In such instances, we recommend that the diagnosis of BA pneumonia be kept in mind and that exogenous surfactant be given as soon as possible, even in the presence of indices of normal lung maturity in the amniotic fluid. Finding high levels of BA and lysophosphatidylcholines in the bronchoalveolar lavage of affected infants would aid in support of the diagnosis.
Pseudothrombocytopenia in a Preterm Neonate
Authors: Christensen Robert D. , Sola Martha C. , Rimsza Lisa M. , McMahan Michael J. , Calhoun Darlene A.
Published: August 2004

Severe and prolonged thrombocytopenia is not uncommon among ill preterm infants. Pseudothrombocytopenia, which has the appearance of severe and prolonged thrombocytopenia, has not been described in this population. We observed a preterm neonate who had EDTA-independent pseudothrombocytopenia and conclude that this condition should be considered when severe and prolonged thrombocytopenia occurs in a neonate in the absence of clinical signs of platelet-type hemorrhage.
Microangiopathy of Brain, Retina, and Inner Ear (Susac’s Syndrome) in an Adolescent Female Presenting as Acute Disseminated Encephalomyelitis
Authors: Hahn Jin S. , Lannin W. Craig , Sarwal Minnie M.
Published: August 2004

Susac’s syndrome is a rare disorder that consists of microangiopathy of the brain, retina, and inner ear and usually affects young women in young adulthood. The triad of clinical manifestations consists of acute encephalopathy with neurologic signs, branch retinal artery occlusion (BRAO), and sensorineural hearing loss. We present a case of an adolescent female who presented at age 16 years with clinical and neuroimaging features of acute disseminated encephalomyelitis (ADEM). The full triad did not develop until 2.5 years after the initial neurologic presentation.
Virilization of Young Children After Topical Androgen Use by Their Parents
Authors: Kunz Gregory J. , Klein Karen O. , Clemons Robert D. , Gottschalk Michael E. , Jones Kenneth Lee
Published: August 2004

Children were virilized by contact with adults using cutaneous steroid preparations. Parents were unaware of the dangers of passive transfer. Laboratory data were consistent with exogenous androgen exposure. Each child had opportunity for passive exposure, and discontinuation of contact resulted in a decrease of androgen levels or regression of symptoms.
Cerebral Metabolism in Severe Neonatal Hyperbilirubinemia
Authors: Groenendaal Floris , Grond Jeroen van der , Vries Linda S. de
Published: August 2004

The metabolism of the basal ganglia was examined by using proton magnetic resonance spectroscopy in 5 neonates with severe hyperbilirubinemia. A decreased N-acetylaspartate/choline ratio, indicating neuronal injury, and an abnormally high lactate/N-acetylaspartate ratio were found only in the neonate with neonatal magnetic resonance imaging abnormalities and subsequent cerebral palsy.
E-mail Communication Between Pediatricians and Their Patients
Authors: Gerstle Robert S. ,   and Task Force on Medical Informatics
Published: August 2004

This Clinical Report was retired August 2014.

This report addresses specific e-mail patient communication issues relevant to pediatricians and their appropriate use of e-mail in the office setting. The report briefly reviews: 1) e-mail privacy and security concerns; 2) e-mail in the office environment; 3) the legal status of e-mail; and 4) available e-mail technologic solutions.
Neurobehavioral Implications of Habitual Snoring in Children
Authors: O’Brien Louise M. , Mervis Carolyn B. , Holbrook Cheryl R. , Bruner Jennifer L. , Klaus Carrie J. , Rutherford Jennifer , Raffield Troy J. , Gozal David
Published: August 2004

Objective. Current guidelines for the treatment of children with obstructive sleep apnea (OSA) suggest that primary snoring (PS) in children is benign. However, PS has not been well evaluated, and it is unknown whether PS is associated with serious morbidity. This study investigated whether PS is associated with neurobehavioral deficits in children.

Methods. Parents of 5- to 7-year-old snoring children in public schools were surveyed about their child’s sleeping habits. Children with a history of snoring and nonsnoring children were invited for overnight polysomnographic assessment and a battery of neurobehavioral tests. Only children who did not have a history of attention-deficit/hyperactivity disorder and were not considered hyperactive by parental report were tested.

Results. Children with a history of snoring, an obstructive apnea index of <1/hour of total sleep time (hrTST), an apnea/hypopnea index <5/hrTST, and no gas exchange abnormalities were classified as PS (n = 87). Control subjects were defined as children without a history of snoring, an obstructive apnea index <1/hrTST, an apnea/hypopnea index <5/hrTST, and no gas exchange abnormalities (n = 31). Although means for both groups were in the normal range, the PS children were found to perform worse on measures related to attention, social problems, and anxious/depressive symptoms. In addition, although within the normal range, both overall cognitive abilities and certain language and visuospatial functions were significantly lower for the PS group than for the control subjects.

Conclusions. PS seems to be associated with significant neurobehavioral deficits in a subset of children, possibly related to increased susceptibility to sleep fragmentation. Larger studies are urgently required because current guidelines for treatment of snoring in children may require reevaluation.
Executive Functioning in School-Aged Children Who Were Born Very Preterm or With Extremely Low Birth Weight in the 1990s
Authors: Anderson Peter J. , Doyle Lex W. ,   Victorian Infant Collaborative Study Group
Published: August 2004

Objective. To determine the frequency, nature, and severity of executive dysfunction (EDF) at 8 years of age in extremely low birth weight (ELBW)/very preterm infants who were born in the 1990s, compared with normal birth weight (NBW) control subjects.

Methods. A geographically determined cohort study was conducted in Victoria, Australia. The ELBW/very preterm cohort comprised 298 consecutive survivors at 2 years of age who had gestational ages <28 completed weeks or birth weights <1000 g and were born during 1991-1992. The NBW cohort comprised 262 randomly selected children of birth weight >2499 g matched on date of birth, gender, ethnicity, and health insurance status. The participation rate was 92% (275 of 298) for the ELBW/very preterm cohort and 85% (223 of 262) for the NBW cohort. Cognitive and behavioral measures of executive functioning were administered.

Results. The ELBW/very preterm cohort exhibited significant EDF compared with their NBW peers in all areas assessed. The cognitive assessment revealed global impairment rather than deficits in specific executive domains. The ELBW/very preterm children also displayed more behavioral problems indicative of EDF than the NBW children. Severe impairments were exhibited in only a small minority of ELBW/very preterm children. No statistical conclusions were altered after adjustment for sociodemographic variables or when children with substantial neurosensory impairment were excluded.

Conclusions. School-aged children who were born in the 1990s and were very preterm or had ELBW are at greater risk for developing EDF and require ongoing neuropsychological review throughout middle childhood.
Specific Newborn Individualized Developmental Care and Assessment Program Movements Are Associated With Acute Pain in Preterm Infants in the Neonatal Intensive Care Unit
Authors: Holsti Liisa , Grunau Ruth E. , Oberlander Tim F. , Whitfield Michael F.
Published: August 2004

Objective. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is widely used in neonatal intensive care units and comprises 85 discrete infant behaviors, some of which may communicate infant distress. The objective of this study was to identify developmentally relevant movements indicative of pain in preterm infants.

Methods. Forty-four preterm infants were assessed at 32 weeks’ gestational age (GA) during 3 phases (baseline, lance/squeeze, and recovery) of routine blood collection in the neonatal intensive care unit. The NIDCAP and Neonatal Facial Coding System (NFCS) were coded from separate continuous bedside video recordings; mean heart rate (mHR) was derived from digitally sampled continuous electrographic recordings. Analysis of variance (phase × gender) with Bonferroni corrections was used to compare differences in NIDCAP, NFCS, and mHR. Pearson correlations were used to examine relationships between the NIDCAP and infant background characteristics.

Results. NFCS and mHR increased significantly to lance/squeeze. Eight NIDCAP behaviors also increased significantly to lance/squeeze. Another 5 NIDCAP behaviors decreased significantly to lance/squeeze. Infants who had lower GA at birth, had been sicker, had experienced more painful procedures, or had greater morphine exposure showed increased hand movements indicative of increased distress.

Conclusions. Of the 85 NIDCAP behaviors, a subset of 8 NIDCAP movements were associated with pain. Particularly for infants who are born at early GAs, addition of these movements to commonly used measures may improve the accuracy of pain assessment.
Functional Gastrointestinal Disorders in Children: An Italian Prospective Survey
Authors: Miele Erasmo , Simeone Domenico , Marino Antonio , Greco Luigi , Auricchio Renata , Novek Steven J. , Staiano Annamaria
Published: August 2004

Objectives. To assess the prevalence and natural history of functional gastrointestinal disorders (FGIDs) in children using the Rome Criteria.

Methods. Thirteen primary care pediatricians were randomly selected from the Campania region of the Italian National Health Service. Each pediatrician completed a detailed FGID questionnaire on consecutive patients seen during a 3-month period. A total of 9660 patients aged birth to 12 years were enrolled prospectively during this 3-month period. Follow-up was performed at 1-, 3-, and 12-month intervals.

Results. A total of 194 children initially met strict criteria for at least 1 FGID. A total of 72 (37.1%) children had infant regurgitation, 26 (13.4%) had functional dyspepsia, 27 (13.9%) had irritable bowel syndrome, and 66 (34.1%) had functional constipation or other defecation disorders. All children who had a diagnosis of FGIDs were reevaluated at 1, 3, and 12 months to study the natural history of the illnesses. Additional evaluation revealed 5 children who had developed an organic diagnosis. Therefore, 5 (2.5%) of 194 children who had a diagnosis of FGIDs by the Rome criteria had a change in diagnosis to an organic disease during the study period, none of whom experienced permanent sequelae.

Conclusions. Of 194 children who received a prospective diagnosis of FGIDs using the Rome criteria, 97.5% continued to satisfy the diagnostic criteria or were improved at follow-up. The low prevalence of functional dyspepsia and irritable bowel syndrome in our population is most likely explained by the lack of adolescents in our sample.
Daily Multivitamins With Iron to Prevent Anemia in High-Risk Infants: A Randomized Clinical Trial
Authors: Geltman Paul L. , Meyers Alan F. , Mehta Supriya D. , Brugnara Carlo , Villon Ivan , Wu Yen A. , Bauchner Howard
Published: August 2004

Objective. The goal of this study was to assess the effectiveness of multivitamins with iron as prophylaxis against iron deficiency and anemia in infancy.

Methods. The study was a double-blinded, randomized, pragmatic, clinical trial conducted at 3 urban primary care clinics. Subjects included healthy, full-term infants who were enrolled at their 6-month well-child visit. Infants were randomly assigned to receive standard-dose multivitamins with or without iron (10 mg/day). Parents administered multivitamins by mouth daily for 3 months. Laboratory results at 9 months of age were analyzed for the presence of anemia and/or iron deficiency. Anemia was defined as hemoglobin level <11.0 g/dL. Iron deficiency was initially defined as any abnormal laboratory value of the following: mean corpuscular volume combined with red cell distribution width or zinc protoporphyrin (with blood lead level <10 μg/dL) for most subjects and ferritin, transferrin saturation, or reticulocyte hemoglobin content for a subset. Subsequent analyses defined iron deficiency as any 2 abnormalities of the above laboratory outcomes, except hemoglobin.

Results. The control (n = 138) and intervention (n = 146) groups were equivalent with respect to all important sociodemographic and nutritional variables. At 9 months of age, anemia was found in 21% of infants (n = 58). A total of 229 (81%) had iron deficiency on the basis of 1 abnormal laboratory indicator and 139 (49%) on the basis of 2 abnormal laboratory indicators. No difference existed in the occurrence of anemia and iron deficiency between the intervention and control groups. In the intervention group, 22% and 78% of 138, respectively, were anemic or had 1 abnormal laboratory outcome indicative of iron deficiency. In the control group, 19% and 84% of 144 were anemic or iron deficient. When stratified by adherence, no differences in hematologic outcomes between groups were noted. However, in multivariate logistic regression, infants whose mothers were anemic during pregnancy were 2.15 times more likely than others to have any laboratory abnormality (95% confidence interval: 1.14–4.07). Increasing adherence, regardless of group assignment, was associated with a 0.56 times reduced risk of any abnormality (95% confidence interval: 0.41–0.76).

Conclusion. On the basis of intention-to-treat analysis, multivitamins with iron was not effective in preventing iron deficiency or anemia in 9-month-old infants. However, effective prevention and treatment of maternal anemia during pregnancy and giving multivitamins with or without additional iron during infancy may prove to be important approaches to the prevention of iron deficiency among high-risk children. Because of the consequences of iron deficiency and its high prevalence among low-income infants, additional investigation in these areas is warranted.
Juvenile Recurrent Parotitis: A New Method of Diagnosis and Treatment
Authors: Nahlieli Oded , Shacham Rachel , Shlesinger Menahem , Eliav Eli
Published: August 2004

Objective. Juvenile recurrent parotitis (JRP) is a nonobstructive, nonsuppurative parotid inflammation in young children. Causative factors, such as local autoimmune manifestation, allergy, infection, and genetic inheritance, have been suggested, but none of them has been proved to date. Until now, treatment of JRP was divided into conservative observation and antibiotic treatment, and no preventive therapy was available.

Methods. Twenty-six cases symptomatic JRP in children were diagnosed and treated with a combined endoscopic approach. Sialography and sialoendoscopy were performed bilaterally in all children. The treatment modality was composed of lavage, ductal dilation, and hydrocortisone injection.

Results. Sialography showed multiple sialectasis in the affected gland and in the contralateral one as well. Dilations and strictures were noticed in the main duct, and kinks could be identified in 31% of the glands. The main endoscopic finding was a white appearance of the ductal layer without the healthy blood vessel coverage. Recurrence of the symptoms occurred in only 2 (8%) children.

Conclusions. The endoscopic technique provides the possibility of a correct diagnosis and treatment. In this article, we present a new treatment modality of irrigation and dilation under direct vision by endoscopically guided miniature surgical instruments.
Children's Violent Television Viewing: Are Parents Monitoring?
Authors: Cheng Tina L. , Brenner Ruth A. , Wright Joseph L. , Sachs Hari Cheryl , Moyer Patricia , Rao Malla R.
Published: August 2004

Objective. Violent media exposure has been associated with aggressive behavior, and it has been suggested that child health professionals counsel families on limiting exposure. Effective violence prevention counseling requires an understanding of norms regarding parental attitudes, practices, and influencing factors. Both theories of reasoned action and planned behavior emphasize that subjective norms and attitudes affect people's perceptions and intended behavior. Few data exist on violent television viewing and monitoring from a cross-section of families. By understanding the spectrum of parental attitudes, community-sensitive interventions for violence prevention can be developed. The objective of this study was to assess attitudes about and monitoring of violent television viewing from the perspective of parents.

Methods. An anonymous self-report assisted survey was administered to a convenience sample of parents/guardians who visited child health providers at 3 sites: an urban children's hospital clinic, an urban managed care clinic, and a suburban private practice. The parent questionnaire included questions on child-rearing attitudes and practices and sociodemographic information.

Results. A total of 1004 adults who accompanied children for health visits were recruited for the study; 922 surveys were completed (participation rate: 92%). A total of 830 (90%) respondents were parents and had complete child data. Of the 830 respondents, 677 had questions on television viewing included in the survey and were the focus of this analysis. Seventy-five percent of families reported that their youngest child watched television. Of these, 53% reported always limiting violent television viewing, although 73% believed that their children viewed television violence at least 1 time a week. Among television viewers, 81% reported usually or always limiting viewing of sexual content on television and 45% reported usually or always watching television with their youngest child. Among children who watched television, parents reported that they spent an average of 2.6 hours per day watching television. Limitation of television violence was associated with female parents and younger children.

Conclusions. There was variability in attitudes and practices regarding television violence viewing and monitoring among parents. Attitudes and practices varied on the basis of the age of the child and the gender of the parent.
Cultural Competence Policies and Other Predictors of Asthma Care Quality for Medicaid-Insured Children
Authors: Lieu Tracy A. , Finkelstein Jonathan A. , Lozano Paula , Capra Angela M. , Chi Felicia W. , Jensvold Nancy , Quesenberry Charles P. , Farber Harold J.
Published: August 2004

Objective. More than half of Medicaid enrollees are now in managed care. Scant information exists about which policies of practice sites improve quality of care in managed Medicaid. Children with asthma are a sentinel group for Medicaid quality monitoring because they are at elevated risk for adverse outcomes. The objective of this study was to identify practice-site policies and features associated with quality of care for Medicaid-insured children with asthma.

Methods. A prospective cohort study with 1-year follow-up was conducted in 5 health plans in California, Washington, and Massachusetts. Data were collected via telephone interviews with parents at baseline and 1 year, surveys of practice sites and clinicians, and computerized databases. The practice site survey asked about policies to promote cultural competence, the use of several types of reports to clinicians, support for self-management of asthma, case management and care coordination, and access to and continuity of care. Quality of care was evaluated on the basis of 5 measures: 1) preventive medication underuse based on parent report; 2) the parent’s rating of asthma care; 3) the 1-year change in the child’s asthma physical status based on a standardized measure; 4) preventive medication underprescribing based on computerized data; and 5) the occurrence of a hospital-based episode.

Results. Of the 1663 children in the study population, 67% had persistent asthma at baseline based on parent report of symptoms and medications. At 1-year follow-up, 65% of the children with persistent asthma were underusing preventive medication based on parent report. In multivariate analyses, patients of practice sites with the highest cultural competence scores were less likely to be underusing preventive asthma medications based on parent report at follow-up (odds ratio [OR]: 0.15; 95% confidence interval [CI]: 0.06–0.41 for the highest vs lowest categories) and had better parent ratings of care. The use of asthma reports to clinicians was predictive of less preventive medication underprescribing based on computerized data (OR: 0.33; 95% CI: 0.16–0.69), better parent ratings of care, and better asthma physical status at follow-up. Patients of practice sites with policies to promote access and continuity had less underuse of preventive medications (OR: 0.56; 95% CI: 0.34–0.93). Among the 83 practice sites, the practice site’s size, organizational type, percentage of patients insured by Medicaid, mechanism of payment for specialty care, and other primary care features were not consistently associated with quality measures.

Conclusions. Practice-site policies to promote cultural competence, the use of reports to clinicians, and access and continuity predicted higher quality of care for children with asthma in managed Medicaid.
Nutritional Rickets in Ichthyosis and Response to Calcipotriene
Authors: Thacher Tom D. , Fischer Philip R. , Pettifor John M. , Darmstadt Gary L.
Published: August 2004

Nutritional rickets has occasionally been described in children with lamellar ichthyosis, but their vitamin D endocrine status has not been described. We report 3 cases of vitamin D-deficiency rickets associated with ichthyosis in African children.

A 13-month-old Nigerian boy with lamellar ichthyosis had rib beading, elevated alkaline phosphatase, and rachitic changes on radiographs. His rickets did not resolve with calcium therapy, and his 25-hydroxyvitamin D level was low. His rickets resolved with parenteral vitamin D treatment, but his skin did not improve. Topical 0.005% calcipotriene (an analog of 1,25-dihydroxyvitamin D that has been useful in treating adults with psoriasis) was similarly ineffective in improving the child's skin condition.

An 8-year-old Nigerian boy with life-long skin findings consistent with lamellar ichthyosis had windswept deformity of the legs with rib beading and enlargement of the wrists and ankles. Radiographs showed active rickets, and the boy had an elevated alkaline phosphatase level and a decreased calcium level. Before knowing that his 25-hydroxyvitamin D level was low, he was treated with calcium and showed radiologic improvement. The skin did not improve with resolution of the rickets but did improve with unilateral topical application of 0.005% calcipotriene.

A 7-year-old South African girl presented with progressive windswept deformities of the legs and a 4-year history of skin disease (and a skin biopsy consistent with X-linked ichthyosis). Radiographs and biochemical data confirmed active rickets. Her rickets improved dramatically with vitamin D treatment.

Thus, 3 African children with ichthyosis developed vitamin D-deficiency rickets, probably because of a combination of impaired skin production and sunlight avoidance. This is consistent with previous findings of hypovitaminosis D in adults with ichthyosis and other disorders of keratinization. Measurement of 25-hydroxyvitamin D may be indicated in children with ichthyosis to identify those at risk for vitamin D-deficiency rickets, because it is possible that the cutaneous synthesis of vitamin D in such children is impaired.

Although the ichthyosis did not improve with resolution of vitamin D deficiency and rickets, 1 of 2 children treated with topical calcipotriene showed improvement in the treated areas of skin. Calcipotriene does not seem to be effective in reversing systemic vitamin D deficiency but can be effective in improving the severity of skin disease in children with ichthyosis.
A Novel CIAS1 Mutation and Plasma/Cerebrospinal Fluid Cytokine Profile in a German Patient With Neonatal-Onset Multisystem Inflammatory Disease Responsive to Methotrexate Therapy
Authors: Stojanov Silvia , Weiss Michael , Lohse Peter , Belohradsky Bernd H.
Published: August 2004

The clinical features, the underlying CIAS1 mutation, and the results of cytokine analyses are described for a 10-year-old German boy with neonatal-onset multisystem inflammatory disease, whose condition improved with age. Disease onset occurred at 26 months of age with predominantly cutaneous (urticarial rash) and neurologic (headache, chronic meningitis) symptoms including early bilateral optic nerve atrophy, whereas articular manifestations were mild. Sequence analysis of exon 3 of the CIAS1 gene revealed heterozygosity for a novel missense mutation. A T515C transition led to the replacement of isoleucine by threonine at amino acid position 172 (I172T) in a region of cryopyrin flanking the PYRIN and NACHT domains. This mutation was not present in the parents or in 11 controls and therefore was considered to be a de novo mutation. Enzyme-linked immunosorbent assays were performed to determine interleukin-6 and soluble tumor necrosis factor receptor superfamily 1B levels in the patient's serum and cerebrospinal fluid (CSF). Concentrations were highly elevated in the CSF, whereas corresponding serum levels remained low. The strong cytokine activation in the CSF corresponded with the neurologic symptoms. Local activation of intrathecal macrophages may therefore be an important pathogenetic mechanism. CSF cytokine levels decreased to normal under corticosteroid and intrathecal methotrexate therapy. When the boy reached the age of 5.5 years, treatment was stopped, and he has remained relapse-free.
An Evidence-Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia
Authors: Ip Stanley , Chung Mei , Kulig John , O'Brien Rebecca , Sege Robert , Glicken Stephan , Maisels M. Jeffrey , Lau Joseph ,   Subcommittee on Hyperbilirubinemia
Published: August 2004

This Technical Report was revised. See https://doi.org/10.1542/peds.2022-058865.

This article is adapted from a published evidence report concerning neonatal hyperbilirubinemia with an added section on the risk of blood exchange transfusion (BET). Based on a summary of multiple case reports that spanned more than 30 years, we conclude that kernicterus, although infrequent, has at least 10% mortality and at least 70% long-term morbidity. It is evident that the preponderance of kernicterus cases occurred in infants with a bilirubin level higher than 20 mg/dL. Given the diversity of conclusions on the relationship between peak bilirubin levels and behavioral and neurodevelopmental outcomes, it is apparent that the use of a single total serum bilirubin level to predict long-term outcomes is inadequate and will lead to conflicting results. Evidence for efficacy of treatments for neonatal hyperbilirubinemia was limited. Overall, the 4 qualifying studies showed that phototherapy had an absolute risk-reduction rate of 10% to 17% for prevention of serum bilirubin levels higher than 20 mg/dL in healthy infants with jaundice. There is no evidence to suggest that phototherapy for neonatal hyperbilirubinemia has any long-term adverse neurodevelopmental effects. Transcutaneous measurements of bilirubin have a linear correlation to total serum bilirubin and may be useful as screening devices to detect clinically significant jaundice and decrease the need for serum bilirubin determinations. Based on our review of the risks associated with BETs from 15 studies consisting mainly of infants born before 1970, we conclude that the mortality within 6 hours of BET ranged from 3 per 1000 to 4 per 1000 exchanged infants who were term and without serious hemolytic diseases. Regardless of the definitions and rates of BET-associated morbidity and the various pre-exchange clinical states of the exchanged infants, in many cases the morbidity was minor (eg, postexchange anemia). Based on the results from the most recent study to report BET morbidity, the overall risk of permanent sequelae in 25 sick infants who survived BET was from 5% to 10%.
Underimmunization Among Children: Effects of Vaccine Safety Concerns on Immunization Status
Authors: Gust Deborah A. , Strine Tara W. , Maurice Emmanuel , Smith Philip , Yusuf Hussain , Wilkinson Marilyn , Battaglia Michael , Wright Robert , Schwartz Benjamin
Published: August 2004

Objective. To examine the attitudes, beliefs, and behaviors of parents whose children were underimmunized with respect to ≥2 vaccines that have recently received negative attention, compared with parents whose children were fully immunized with respect to the recommended vaccines.

Design. Case-control study.

Setting. A sample of households that participated in the National Immunization Survey were recontacted in 2001.

Main Outcome Measure. Vaccination status was assessed. Case subjects were underimmunized with respect to ≥2 of 3 vaccines (diphtheria-tetanus-pertussis or diphtheria-tetanus-acellular pertussis, hepatitis B, or measles-containing vaccines), and control subjects were fully immunized.

Results. The response rate was 52.1% (2315 of 4440 subjects). Compared with control households, case households were more likely to make $0 to $30 000 (adjusted odds ratio [OR]: 2.7; 95% confidence interval [CI]: 1.5–4.6) than at least $75 000, to have ≥2 providers (OR: 2.0; 95% CI: 1.3–3.1) than 1, and to have ≥4 children (OR: 3.1; 95% CI: 1.5–6.3) than 1 child. With control for demographic and medical care factors, case subjects were more likely than control subjects to not want a new infant to receive all shots (OR: 3.8; 95% CI: 1.5–9.8), to score vaccines as unsafe or somewhat safe (OR: 2.0; 95% CI: 1.2–3.4), and to ask the doctor or nurse not to give the child a vaccine for reasons other than illness (OR: 2.7; 95% CI: 1.2–6.1). Among case subjects, 14.8% of underimmunization was attributable to parental attitudes, beliefs, and behaviors.

Conclusions. Attitudes, beliefs, and behaviors indicative of vaccine safety concerns contribute substantially to underimmunization in the United States. Although concerns were significantly more common among parents of underimmunized children, many parents of fully immunized children demonstrated similar attitudes, beliefs, and behaviors, suggesting a risk to the currently high vaccination levels. Efforts to maintain and improve immunization coverage need to target those with attitudes/beliefs/behaviors indicative of vaccine safety concerns, as well as those with socioeconomic and health care access problems.
Predicting Preschooler Obesity at Birth: The Role of Maternal Obesity in Early Pregnancy
Authors: Whitaker Robert C.
Published: August 2004

Objective. Knowing risk factors at birth for the development of childhood obesity could help to identify children who are in need of early obesity prevention efforts. The objective of this study was to determine whether children whose mothers were obese in early pregnancy were more likely to be obese at 2 to 4 years of age.

Methods. A retrospective cohort study was conducted of 8494 low-income children who were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Ohio and were followed from the first trimester of gestation until 24 to 59 months of age. Measured height and weight data from WIC were linked to birth certificate records for children who were born in the years 1992–1996. Obesity among 2- to 4-year-olds was defined as a body mass index (BMI) ≥95th percentile for age and gender. Mothers were classified as obese (BMI ≥30 kg/m2) or nonobese (BMI <30 kg/m2) on the basis of BMI measured in the first trimester of the child’s gestation.

Results. The prevalence of childhood obesity was 9.5%, 12.5%, and 14.8% at 2, 3, and 4 years of age, respectively, and 30.3% of the children had obese mothers. By 4 years of age, 24.1% of children were obese if their mothers had been obese in the first trimester of pregnancy compared with 9.0% of children whose mothers had been of normal weight (BMI ≥18.5 and <25 kg/m2). After controlling for the birth weight, birth year, and gender of the children plus the mothers’ age, race/ethnicity, education level, marital status, parity, weight gain, and smoking during pregnancy, the relative risk of childhood obesity associated with maternal obesity in the first trimester of pregnancy was 2.0 (95% confidence interval [CI]: 1.7–2.3) at 2 years of age, 2.3 (95% CI: 2.0–2.6) at 3 years of age, and 2.3 (95% CI: 2.0–2.6) at 4 years of age.

Conclusion. Among low-income children, maternal obesity in early pregnancy more than doubles the risk of obesity at 2 to 4 years of age. In developing strategies to prevent obesity in preschoolers, special attention should be given to newborns with obese mothers.
The Disappearing Income Gradient in New York City Birth Outcomes: Thirteen Years of Convergence From 1988 to 2001
Authors: Racine Andrew D. , Joyce Theodore J.
Published: August 2004

Objective. Income has long been identified as a potent determinant of infant mortality, yet little is known about the stability of its influence over time in defined populations. The objective of this study was to characterize trends in the income gradient in infant mortality in New York City from 1988 to 2001.

Methods. An ecological analysis was conducted of infant, neonatal, and postneonatal mortality rates in 30 health districts from 14 years (1988-2001) of birth cohorts of the 5 boroughs of New York City divided by quartile of income based on the 1990 census (N = 1 692 721 births). Infant mortality (deaths occurring at <365 days of age), neonatal mortality (deaths occurring at <28 days of age), and postneonatal mortality (deaths occurring from 28 to 364 days of age) expressed as rates per 1000 live births were measured.

Results. From 1988 to 2001, infant mortality in the highest income quartile in New York City fell 50.5% from 10.5 to 5.2, whereas in the lowest income quartile, it fell 62.6% from 17.4 to 6.5 per 1000 live births. The equivalent declines in neonatal mortality were 46.6% from 7.3 to 3.9 in the highest income quartile and 61.4% from 11.4 to 4.4 per 1000 live births in the lowest income quartile. For postneonatal mortality, rates fell 58.1% from 3.1 to 1.3 in the highest income quartile and 65% from 6 to 2.1 per 1000 live births in the lowest income quartile. Adjusted for covariates, relative to the highest income quartile, infant, neonatal, and postneonatal morality rates in the lowest income quartile declined 0.36 (95% confidence interval [CI]: −0.52 to −0.19), 0.20 (95% CI: −0.34 to −0.07), and 0.15 (95% CI: −0.23 to −0.07) per 1000 live births more per year.

Conclusions. From 1988 to 2001, New York City witnessed a significant convergence in the income gradients of infant, neonatal, and postneonatal mortality rates. Understanding the origins of this trend should constitute an important public policy priority.