bluuebunny/crossref_metadata_2025 huggingface dataset:
Behavioral and Emotional Adjustment of Teenagers in Mainstream School Who Were Born Before 29 Weeks’ Gestation
Authors: Gardner Frances , Johnson Ann , Yudkin Patricia , Bowler Ursula , Hockley Christine , Mutch Lesley , Wariyar Unni ,   on behalf of ELGA (Extremely Low Gestational Age) Steering Group
Published: November 2004

Objectives. To investigate behavioral and emotional problems and positive adjustment of 15-to 16-year-olds who were born at extremely low gestational age (ELGA), from the perspective of parents, teachers, and teenagers.

Methods. Prospective follow-up was conducted of birth cohorts, with classroom control subjects. All infants who were born before 29 weeks in 1983–1984 (mean gestational age: 27 weeks) to mothers who resided in 3 regions of the United Kingdom were studied. A total of 82% (179 of 218) of survivors were traced at age 15 to 16. The 150 in mainstream school were compared with age- and gender-matched classroom control subjects (n = 108). Behavioral and emotional problems, delinquency, peer relations, self-esteem, and hobbies, were assessed by standardized, well-validated instruments, including the Strengths and Difficulties Questionnaire, administered by mail to parents, teenagers, and teachers.

Results. Parents were more likely to rate ELGA teenagers than control subjects as in the “abnormal” range for hyperactivity (8% vs 1%; difference: 7%; (95% confidence interval [CI]: 2–12), peer relationship problems (19% vs 5%; difference: 14%; 95% CI: 6-21), and emotional problems (18% vs 7%; difference: 11%; 95% CI: 3-19), but not conduct problems (10% vs 5%; difference: 5%; 95% CI: −1 to 12)). Teachers reported a similar pattern. In contrast, compared with control subjects, ELGA teenagers did not rate themselves as having more problems with peers, hyperactivity, conduct, depression, or low self-esteem. They reported more emotional problems but less delinquency, alcohol, cannabis, and other drug use.

Conclusions. Compared with mainstream classmates, children who are born extremely early continue to have higher levels of parent- and teacher-reported emotional, attentional, and peer problems well into their teens. However, despite these problems, they do not show signs of more serious conduct disorders, delinquency, drug use, or depression.
Hospital Staff and Family Perspectives Regarding Quality of Pediatric Palliative Care
Authors: Contro Nancy A. , Larson Judith , Scofield Sarah , Sourkes Barbara , Cohen Harvey J.
Published: November 2004

Background. Development of a pediatric palliative care program was preceded by a needs assessment that included a staff survey and family interviews regarding improving pediatric palliative care.

Methods. Four hundred forty-six staff members and community physicians responded to a written survey regarding comfort and expertise in delivering end of life care. Sixty-eight family members of 44 deceased children were interviewed regarding treatment, transition to palliative care, and bereavement follow-up contact. Frequencies were generated for responses to the staff survey. Five interviewers reviewed the families' narratives and identified frequently occurring themes.

Results. Staff members reported feeling inexperienced in communicating with patients and families about end of life issues, transition to palliative care, and do not resuscitate status. Families reported distress caused by uncaring delivery of bad news and careless remarks made by staff members. Staff members reported feeling inexperienced in symptom and pain management and described occasions when pain could have been better managed. Families believed pain had been managed as well as possible despite observing their children suffer. Fifty-four percent of staff members reported that adequate support was not provided for those who treat dying children. Staff members and family members stated their desire for more support. Staff members who described their most difficult experiences caring for a dying child referenced personal pain and inadequate support most frequently.

Conclusions. Albeit from different perspectives, staff members and family members shared common concerns and experiences regarding pediatric palliative care. These experiences emphasize the need for additional systematic study, improved education and support for staff members, and continued development of more effective and compassionate delivery of pediatric palliative care.
Continuity of Binge and Harmful Drinking From Late Adolescence to Early Adulthood
Authors: McCarty Carolyn A. , Ebel Beth E. , Garrison Michelle M. , DiGiuseppe David L. , Christakis Dimitri A. , Rivara Frederick P.
Published: November 2004

Objective. To test the hypothesis that late adolescent drinking behavior (ages 17–20) is associated with harmful and binge drinking in early adulthood (ages 30–31).

Methods. We used the National Longitudinal Survey of Youth (NLSY), a nationally representative longitudinal data set. We used harmful and binge drinking at ages 17 to 20 to predict harmful and binge drinking at ages 30 to 31, stratifying for gender and controlling for confounders.

Results. Data were available on harmful drinking at both the adolescent and the early adult age period for 3790 individuals and on binge drinking for 2387 individuals. Harmful drinking during adolescence was significantly associated with harmful drinking at ages 30 to 31 for men only. Among male adolescents, 14% of harmful drinkers continued harmful drinking at ages 30 to 31, compared with 4% of nonharmful drinkers who became harmful drinkers. In Poisson regression models, binge drinking during adolescence was associated with binge drinking at ages 30 to 31 for both men and women, generating relative risks of 2.3 (95% confidence interval: 1.8–3.0) and 3.0 (95% confidence interval: 2.4–4.8), respectively. Half of binge-drinking male adolescents and one third of binge-drinking female adolescents engaged in binge drinking into early adulthood, compared with 19% for non–binge-drinking male adolescents and 8% of non–binge-drinking female adolescents.

Conclusions. Problem drinking during adolescence is associated with problem drinking in early adulthood. Efforts to prevent and treat adolescent problem drinking could have an impact on the progression of alcohol-related disease.
Screening for Domestic Violence in a General Pediatric Clinic: Be Prepared!
Authors: Holtrop Teresa G. , Fischer Howard , Gray Shirley M. , Barry Kathlyn , Bryant Tina , Du Wei
Published: November 2004

Objectives. Exposure to violence, particularly domestic violence (DV), negatively affects children's physical, emotional, and cognitive well-being. The American Academy of Pediatrics recommends routine DV screening of female caretakers of pediatric patients. Few reports of screening in pediatric practices exist, and none have reported outcomes from a resident-run urban academic center. We set out to determine whether the use of the Partner Violence Screen (PVS) increases detection of DV and to test the mechanics of implementing large-scale DV screening in a busy, pediatric residency training clinic.

Methods. Using the PVS, we screened a sample of consecutive female caretakers/guardians of children seen for pediatric care in the general pediatric clinic of Children's Hospital of Michigan from March 1, 2002, through February 28, 2003. Positive screens obtained during the study period were compared with the number of DV referrals received by the clinic social workers from January 1, 2001, through December 31, 2001, before PVS screening began. To test the mechanics of screening, we also analyzed the number of forms returned blank or marked “no opportunity to screen” in the last 8 months of the study period.

Results. In the 12 months before use of the PVS, our social work department received 9 referrals because of DV from the general pediatric clinic, among a total of 5446 caretakers/guardians bringing 6380 children for a total of 13 576 patient care visits. In contrast, the social work department received 164 referrals because of positive screening results among 5445 caretakers/guardians bringing 7429 children for 17 346 patient care visits in the 12-month study period after introduction of the PVS. Fourteen of 164 positive PVSs were found to involve nondomestic violence perpetrated by nonpartners or violence with the patient as the victim, not the mother or female caretaker. A total of 150 PVSs involved true DV. The difference in identification of DV with the PVS, compared with the rate before its introduction, was highly significant. The positive predictive value for the PVS was 91.5%, and the identified prevalence rate was 3.7%. In the last 8 months of the study period, 6301 of 8055 PVS forms (78%) were completed; 1754 of 8055 PVS forms (22%) were left blank, but it was not possible to determine whether these represented duplicate screening forms for instances in which the mother or female caretaker had brought >1 child for care.

Conclusions. Formal screening for DV with the PVS in this study setting of a busy, urban, academic, general pediatric clinic appeared to be very successful, in terms of increasing referrals and documentation of previously unrecognized DV situations. This increase signals the need for resources (time and/or social work services) to provide appropriate referral services. The PVS identifies nonpartner violence occasionally.
Effect of Botulinum Toxin in the Treatment of Drooling: A Controlled Clinical Trial
Authors: Jongerius Peter H. , Hoogen Frank J.A. van den , Limbeek Jacques van , Gabreëls Fons J. , Hulst Karen van , Rotteveel Jan J.
Published: November 2004

Objective. To investigate the clinical effectiveness of botulinum neurotoxin type A (BoNT) to reduce drooling in children with cerebral palsy (CP).

Methods. A controlled clinical trial was performed in which the results of single-dose BoNT injections in the submandibular glands were compared with treatment with scopolamine. Forty-five children who had CP and experienced severe drooling were enrolled. Drooling severity was measured at baseline, during application of scopolamine, and at different intervals after BoNT injections up to 24 weeks, using the Drooling Quotient (DQ), the Teacher Drooling Scale (TDS), and Visual Analog Scales (VAS).

Results. Drooling was reduced during scopolamine application as well as after BoNT injections. Compared with baseline, the mean DQ showed a significant decrease throughout the study. Greatest reductions were achieved 2 to 8 weeks after BoNT injection. No significant differences were found between scopolamine measurements and those up to 24 months after BoNT injection. Using VAS, parents recorded the effect on drooling in which significant differences were found between baseline VAS score and all follow-up assessments. According to our definition of “success to therapy,” demanding a 2-point decrease on the TDS, 61.5% of patients responded to BoNT injections. Analysis of the DQ demonstrated a response rate of 53% of the patients to scopolamine and 48.7% to BoNT until 24 weeks after BoNT injections, the actual duration of this study. As a reaction to scopolamine, 71.1% of the patients had moderate to severe side effects. Only nonsevere, incidental side effects were reported after BoNT injections.

Conclusions. During scopolamine application as well as after intraglandular BoNT injections, a clinically relevant reduction in drooling was achieved in children with CP, demonstrating maximum effect 2 to 8 weeks after injections. This is the first controlled clinical trial that confirmed a significant effect of BoNT injections in the treatment of drooling. General anesthesia was needed for all children. BoNT injections show fewer and less serious side effects than transdermal scopolamine treatment.
Ascertainment Bias in Turner Syndrome: New Insights From Girls Who Were Diagnosed Incidentally in Prenatal Life
Authors: Gunther Daniel F. , Eugster Erica , Zagar Anthony J. , Bryant Constance G. , Davenport Marsha L. , Quigley Charmian A.
Published: November 2004

Objective. To evaluate differences in phenotype and other clinical features between patients who have Turner syndrome diagnosed incidentally (on the basis of a prenatal karyotype performed for reasons unrelated to suspicion of Turner syndrome, eg, advanced maternal age) or traditionally (on the basis of either a prenatal karyotype performed for abnormal ultrasound findings or a postnatal karyotype performed for clinical findings suggesting Turner syndrome).

Methods. Analysis was performed on baseline data from 88 girls, aged 9 months to 4 years, who were randomized into a multicenter growth hormone intervention trial. Baseline information included a detailed medical history (especially of cardiac and renal anomalies), examination for presence of phenotypic features characteristic of Turner syndrome, length or height (depending on age) expressed as a standard deviation score, and weight standard deviation score. Patients were classified to either the “incidental” (N = 16) or the “traditional” (N = 72) diagnosis group as described above.

Results. The incidental group had significantly fewer total phenotypic features of Turner syndrome than the traditional group (3.6 ± 2.9 vs 6.7 ± 2.9). When subgrouped by karyotype, the proportion of patients who manifested phenotypic features was greatest in patients with a 45,X nonmosaic karyotype, lowest in the patients with 45,X/46,XX mosaicism, and intermediate in those with “other” karyotypes. Fewer congenital cardiac defects were observed in the incidental group (31%) compared with the traditional group (64%), but there was no difference between the groups in the prevalence of renal defects. Karyotype distribution differed significantly between the traditional and incidental groups: 74% versus 19% had the nonmosaic 45,X karyotype in the traditional group and 7% versus 56% had the mosaic 45,X/46,XX karyotype.

Conclusions. Patients whose Turner syndrome was diagnosed incidentally had significantly fewer phenotypic features and cardiac defects, as well as a greater proportion of mosaic karyotypes, compared with patients whose Turner syndrome was diagnosed clinically. These results support the theory that significant ascertainment bias exists in our understanding Turner syndrome, with important implications for prenatal counseling.
Neurodevelopmental Outcome and Growth at 18 to 22 Months' Corrected Age in Extremely Low Birth Weight Infants Treated With Early Erythropoietin and Iron
Authors: Ohls Robin K. , Ehrenkranz Richard A. , Das Abhik , Dusick Anna M. , Yolton Kimberly , Romano Elaine , Delaney-Black Virginia , Papile Lu-Ann , Simon Neal P. , Steichen Jean J. , Lee Kimberly G. ,   for the National Institute of Child Health and Human Development Neonatal Research Network
Published: November 2004

Background. Clinical trials evaluating the use of erythropoietin (Epo) have demonstrated a limited reduction in transfusions; however, long-term developmental follow-up data are scarce.

Objective. We compared anthropometric measurements, postdischarge events, need for transfusions, and developmental outcomes at 18 to 22 months' corrected age in extremely low birth weight (ELBW) infants treated with early Epo and supplemental iron therapy with that of placebo/control infants treated with supplemental iron alone.

Methods. The National Institute of Child Health and Human Development Neonatal Research Network completed a randomized, controlled trial of early Epo and iron therapy in preterm infants ≤1250 g. A total of 172 ELBW (≤1000-g birth weight) infants were enrolled (87 Epo and 85 placebo/control). Of the 72 Epo-treated and 70 placebo/control ELBW infants surviving to discharge, follow-up data (growth, development, rehospitalization, transfusions) at 18 to 22 months' corrected age were collected on 51 of 72 Epo-treated infants (71%) and 51 of 70 placebo/controls (73%) by certified examiners masked to the treatment group. Statistical significance was determined using χ2 analysis.

Results. There were no significant differences between treatment groups in weight or length or in the percentage of infants weighing <10th percentile either at the time of discharge or at follow-up, and no difference was found in the mean head circumference between groups. A similar percentage of infants in each group was rehospitalized (38% Epo and 35% placebo/control) for similar reasons. There were no differences between groups with respect to the percentage of infants with Bayley-II Mental Developmental Index <70 (34% Epo and 36% placebo/control), blindness (0% Epo and 2% placebo/control), deafness or hearing loss requiring amplification (2% Epo and 2% placebo/control), moderate to severe cerebral palsy (16% Epo and 18% placebo/control) or the percentage of infants with any of the above-described neurodevelopmental impairments (42% Epo and 44% placebo/control).

Conclusions. Treatment of ELBW infants with early Epo and iron does not significantly influence anthropometric measurements, need for rehospitalization, transfusions after discharge, or developmental outcome at 18 to 22 months' corrected age.
Health Care Preferences and Priorities of Adolescents With Chronic Illnesses
Authors: Britto Maria T. , DeVellis Robert F. , Hornung Richard W. , DeFriese Gordon H. , Atherton Harry D. , Slap Gail B.
Published: November 2004

Background. Efforts to make health care for adolescents with chronic illnesses more patient-centered must be grounded in an understanding and clear measures of adolescents' preferences and priorities.

Objective. To develop a measure of health care preferences of adolescents with chronic illnesses and to determine demographic, developmental, and health factors associated with adolescents' preferences.

Design. Mixed-method questionnaire development and survey.

Setting. Subspecialty clinics of a tertiary care children's hospital.

Participants. All adolescents (age: 11–19 years) with juvenile rheumatoid arthritis, sickle cell disease, inflammatory bowel disease, or cystic fibrosis of at least 2-year duration who were being treated at the participating center were eligible to participate, and 155 of 251 did so (62%). The participants had a mean age of 15.5 ± 2.4 years, 45% were male, and 75% were white.

Intervention. None.

Main Outcome Measures. Ratings of 65 items related to quality of care and 17 items related to physician-patient communication styles.

Results. An 82-item questionnaire, devised from qualitative analysis of focus group results, contained 65 Likert scale items that adolescents considered important for health care quality and 17 forced-choice items related to adolescents' preferences for communication. Among the first 65 items, the group of questions related to physician trust and respect had the highest rating of 5.24 ± 0.62 of 6, followed by patient power and control (mean rating: 4.72 ± 0.77) and then caring and closeness in the patient-doctor relationship (mean rating: 4.19 ± 0.91). For the communication items, the adolescents, on average, preferred communication directly to them rather than to their parents and were nearly neutral regarding physicians' inquiries about personal issues.

Conclusions. Participants rated aspects of interpersonal care (especially honesty, attention to pain, and items related to respect) as most important in their judgments of quality. As in most previous studies of adults, technical aspects of care were also rated highly, suggesting that adolescents understand and value both scientific and interpersonal aspects of care.
Prevalence, Stability, and Predictors of Clinically Significant Behavior Problems in Low Birth Weight Children at 3, 5, and 8 Years of Age
Authors: Gray Ronald F. , Indurkhya Alka , McCormick Marie C.
Published: November 2004

Objectives. To examine the prevalence, stability, and predictors of clinically significant behavior problems in 869 preterm low birth weight (LBW) infants at 3, 5, and 8 years of age.

Methods. A prospective cohort study was conducted. Clinically significant behavior problems were assessed using dichotomized total problem Child Behavior Checklist scores in LBW children at ages 3, 5, and 8 years. Baseline sociodemographic and obstetric data were collected. Maternal General Health Questionnaire performed at 40 weeks' gestation was dichotomized at a score of 12 to give a measure of maternal psychological distress. Prevalence and stability of behavior problems at ages 3, 5, and 8 were determined and potential predictors of behavior problems at age 3, 5, and 8 were examined using multiple logistic regression.

Results. Prevalence of behavior problems remained at ∼20% at 3, 5, and 8 years. Stability of behavior problems between different ages was ∼50%. Significant behavior problems at ages 3, 5, and 8 were predicted by maternal psychological distress at 40 weeks (odds ratio [OR]: 1.59; 95% confidence interval [CI]: 1.21–2.09), maternal cigarette smoking during pregnancy (OR: 1.57; 95% CI: 1.20–2.04), Hispanic ethnicity (OR: 2.00; 95% CI: 1.24–3.24), and maternal age (OR: 0.97; 95% CI: 0.94–0.99).

Conclusions. This sample had double the prevalence of behavior problems expected in the general child population. These problems showed stability over time. Cigarette smoking in pregnancy, maternal psychological distress at 40 weeks' gestation, maternal age, and Hispanic ethnicity all were significant predictors of the development of behavior problems from ages 3 to 8. These findings have implications for health policies on smoking and postnatal depression.
Thimerosal Exposure in Infants and Developmental Disorders: A Prospective Cohort Study in the United Kingdom Does Not Support a Causal Association
Authors: Heron Jon , Golding Jean ,   and the ALSPAC Study Team
Published: November 2004

Objective. There is an established link between exposure to mercury and impaired childhood cognitive development and early motor skills. Thimerosal (also known as thiomersal), a preservative used in a number of children's vaccines, contains ethylmercury (an organic compound of mercury), and there has been concern that this exposure to mercury may be of some detriment to young children. The aim of this research was to test in a large United Kingdom population–based cohort whether there is any evidence to justify such concerns.

Methods. We used population data from a longitudinal study on childhood health and development. The study has been monitoring >14 000 children who are from the geographic area formerly known as Avon, United Kingdom, and were delivered in 1991–1992. The age at which doses of thimerosal-containing vaccines were administered was recorded, and measures of mercury exposure by 3, 4, and 6 months of age were calculated and compared with a number of measures of childhood cognitive and behavioral development covering the period from 6 to 91 months of age.

Results. Contrary to expectation, it was common for the unadjusted results to suggest a beneficial effect of thimerosal exposure. For example, exposure at 3 months was inversely associated with hyperactivity and conduct problems at 47 months; motor development at 6 months and at 30 months; difficulties with sounds at 81 months; and speech therapy, special needs, and “statementing” at 91 months. After adjustment for birth weight, gestation, gender, maternal education, parity, housing tenure, maternal smoking, breastfeeding, and ethnic origins, we found 1 result of 69 to be in the direction hypothesized—poor prosocial behavior at 47 months was associated with exposure by 3 months of age (odds ratio: 1.12; 95% confidence interval: 1.01-1.23) compared with 8 results that still supported a beneficial effect.

Conclusions. We could find no convincing evidence that early exposure to thimerosal had any deleterious effect on neurologic or psychological outcome.
Integrating Adherence to Highly Active Antiretroviral Therapy Into Children's Daily Lives: A Qualitative Study
Authors: Hammami Naïma , Nöstlinger Christiana , Hoerée Tom , Lefèvre Pierre , Jonckheer Tyl , Kolsteren Patrick
Published: November 2004

Objective. To acquire a deeper understanding of factors that influence adherence to highly active antiretroviral therapy (HAART) in a pediatric population.

Methods. We performed a qualitative study of adherence in children who receive HAART in a Belgian pediatric acquired immune deficiency syndrome referral center. Eleven primary caregivers were interviewed to assess their child's adherence and influencing factors. The interview guidelines were developed on the basis of an extensive literature review. Adherence to treatment was assessed using caregivers' self-report and laboratory results. Content analysis for common items was performed, and statements of adherent and less-adherent patients were compared.

Results. Three main factors influenced adherence. Adherent patients were found to internalize the medical information to a stronger extent than less-adherent patients. Adherent patients showed stronger motivation to stick to the medical regimen on the basis of personal cost-benefit analyses, ie, perceived benefits outweighed the costs or difficulties experienced. Adherent patients developed greater problem-solving capacities, ie, ways to deal with practical complications of medication intake. The interviews revealed a fourth, more dynamic component: knowledge, motivation, and capacities evolved in a progressive way, related to individual stages of coping with human immunodeficiency virus (HIV).

Conclusions. The data suggest that coping with HIV and the process of establishing good adherence may be interrelated. Caregivers who accept the disease may be more likely to internalize the received information and thus develop a stronger motivation to fight for the child's life. Problem-solving skills sustain this adherence, and medication becomes a priority in the adherent caregivers' daily lives. On the contrary, less-adherent caregivers may be situated at less advanced stages of the coping process. Thus, tailor-made approaches adapted to the individual HIV-related coping strategies need to be developed to improve adherence in children and caregivers.
The State of Pediatrics Residency Training: A Period of Transformation of Graduate Medical Education
Authors: Sectish Theodore C. , Zalneraitis Edwin L. , Carraccio Carol , Behrman Richard E.
Published: November 2004

Graduate medical education is in a period of transformation. This article reviews the state of pediatrics residency training by summarizing the changing demographics within training programs, examining the new educational paradigm with an emphasis on competency-based education and continuous professional development, and describing forces influencing the workplace and the focus on work-life balance. Strategies are suggested for leaders in graduate medical education to meet the challenges experienced during this period of transformation.
Prognosis for Ambulation in Cerebral Palsy: A Population-Based Study
Authors: Wu Yvonne W. , Day Steven M. , Strauss David J. , Shavelle Robert M.
Published: November 2004

Objectives. To determine independent predictors of ambulation among children with cerebral palsy and to develop a simple tool that estimates the probability that a child will walk.

Methods. In a retrospective study of all children with cerebral palsy who were not yet walking at 2 to 3 \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \({1}/{2}\) \end{document} years of age, while receiving services from the California Department of Developmental Services during the years 1987–1999, we analyzed medical and functional data obtained annually by Department of Developmental Services physicians and social workers. Using logistic regression analyses, we determined independent predictors of a child's ability to walk well alone at least 20 feet, without assistive devices, by age 6. We then estimated the probabilities of walking at various levels of ability over time, using multistate survival analysis.

Results. Of 5366 study subjects, 2295 (43%) were evaluated at age 6; 12.8% could walk independently and 18.4% walked with support. Independent predictors of successful ambulation included early motor milestones such as sitting (odds ratio: 12.5; 95% confidence interval: 5.8–27.2) and pulling to a stand (odds ratio: 28.5; 95% confidence interval: 13.4–60.4) when compared with lack of rolling at age 2, cerebral palsy type other than spastic quadriparesis (odds ratio: 2.2; 95% confidence interval: 1.5–3.1), and preserved visual function (odds ratio: 2.4; 95% confidence interval: 1.1–5.4). Our ambulation charts depict the probability of remaining nonambulatory, transitioning to 1 of 3 possible ambulatory states, or expiring at all subsequent ages through age 14.

Conclusion. The ambulation charts provide a simple straightforward way to estimate the probability that a child with cerebral palsy who is nonambulatory at 2 to 3 \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \({1}/{2}\) \end{document} years of age will eventually walk with or without support.
Group A Streptococci Among School-Aged Children: Clinical Characteristics and the Carrier State
Authors: Martin Judith M. , Green Michael , Barbadora Karen A. , Wald Ellen R.
Published: November 2004

Objective. A 4-year longitudinal study of school-aged children was conducted to describe the clinical characteristics and epidemiologic features of infections with group A streptococci (GAS).

Methods. Between 1998 and 2002, surveillance throat cultures were performed twice per month (October to May) for a cohort of elementary school children in Pittsburgh, Pennsylvania. In addition, throat cultures were obtained during any respiratory illness. Erythromycin and clindamycin susceptibility testing was performed for all isolates. Molecular typing was performed with field-inversion gel electrophoresis. Representative isolates from each field-inversion gel electrophoresis group were emm typed. Strict definitions were used to characterize each GAS infection. Children were classified into 4 categories each year, ie, single episode, recurrent episodes, carriers of GAS, and no infections.

Results. A total of 48 to 100 children per year were studied for 4 years; 61 (49%) were male. The mean age was 9.6 years (range: 5–15 years). A total of 5658 throat cultures were performed; 878 (15.5%) were positive for GAS. Antimicrobial agents were used to treat 209 episodes of infection. Thirteen emm types were observed during the 4-year period. GAS were isolated most often from children who were carriers; isolates from single episodes were next most common. Children carried a single emm type for a mean of 10.8 weeks (range: 3–34 weeks). Carriers were likely to be classified again as carriers in subsequent years and frequently switched emm types. Sixty-two percent of the children had ≥1 year with no infections.

Conclusions. GAS infections are common among school-aged children. The majority of positive throat cultures observed in this longitudinal study were obtained from children who were carriers of GAS. Carriers switched emm types but tended to become carriers repeatedly during the study. Practitioners should consider treating children known to be GAS carriers when they develop a new illness that is consistent with streptococcal pharyngitis, because they may acquire new emm types and be at risk for rheumatic heart disease.
Inequality of Access to Surgical Specialty Health Care: Why Children With Government-Funded Insurance Have Less Access Than Those With Private Insurance in Southern California
Authors: Wang Edward C. , Choe Meeryo C. , Meara John G. , Koempel Jeffrey A.
Published: November 2004

Objective. More than 25 million children in the United States are dependent on federal and state medical insurance programs for their health care needs. In California, 3.25 million children depend on Medi-Cal for their health insurance. In Southern California alone, the figure is as high as 1.81 million. However, 9.30 million children nationally and 1.55 million in California have no health insurance. Various public policies that would increase enrollment in these programs are being discussed to address this problem. However, before their implementation, it is important to understand what impact such policies would have on the actual delivery of health care to this patient population. In California, 2 predominant health care delivery models exist for Medi-Cal: a fee-for-service (so-called regular or straight Medi-Cal) and a managed care plan. One third of the children in Medi-Cal in the state are enrolled in the fee-for-service plan with the remainder in the managed care plan, whereas in Southern California, this figure is slightly lower at 28% in the fee-for-service plan. The objective of this study was to determine the number of otolaryngologists in Southern California who would offer a new patient appointment for an evaluation for tonsillectomy for a child with commercial insurance versus government-funded (Medi-Cal) insurance through direct contact with the physician and to determine whether the surgeon would offer to perform the procedure or refer the patient to another institution and to identify the specific reason(s) for any disparity in access to health care.

Methods. A written questionnaire was sent via regular mail to 303 otolaryngologists in the Southern California area in 2003.

Results. A total of 100 fully completed questionnaires were received. Ninety-seven surgeons would offer an office appointment to a child with commercial insurance as compared with only 27 for a child with Medi-Cal. Of those 27 surgeons, 8 would then refer the child to another physician to perform the surgery, and only 19 would actually offer to perform surgery, if indicated. Reasons provided for not offering an office appointment or surgery for the child with Medi-Cal include excessive paperwork and/or administrative burdens (96%), low monetary reimbursement for the surgery (92%), and low monetary reimbursement for the office visit (87%).

Conclusions. There is a tremendous inequality of access to surgical specialty health care for children with government-funded insurance when compared with those with commercial insurance in Southern California. Physicians indicate that this disparity is related to excessive administrative burdens and low monetary reimbursement. The implications of our findings on public health care policies are discussed.
Palivizumab Use in Very Premature Infants in the Neonatal Intensive Care Unit
Authors: Wu Shou-Yien , Bonaparte Joel , Pyati Suma
Published: November 2004

Objective. The purpose of this study was to determine the ability of young hospitalized premature (born ≤30 weeks’ gestational age) infants to achieve serum levels of palivizumab that are protective against RSV infection.

Methods. Palivizumab, 15 mg/kg per dose intramuscularly, was administered every 28 days to stable premature infants who were hospitalized in the neonatal intensive care unit starting at 1 month of postnatal life. Palivizumab concentrations were assayed in serum samples that were drawn from infants who remained in the hospital at 14 days (midpoint concentration) and at 28 days (trough concentration) after each dose was administered.

Results. The gestational age of the 24 infants who were enrolled was 27.5 ± 1.8 weeks (mean ± standard deviation), and birth weight was 928 ± 159 g. Midpoint palivizumab concentrations in the 24 infants after the first dose were 45.6 ± 13.0 μg/mL; 71% (17 of 24) of the infants maintained optimal palivizumab concentrations (≥40 μg/mL). The concentrations dropped subsequently; trough concentrations just before the second dose were 32.2 ± 10.5 μg/mL, and only 23% (5 of 22) of the infants had concentrations in the optimal range. Sixteen infants were given 2 doses and 6 were given three doses of palivizumab while in the neonatal intensive care unit. Midpoint concentrations after the second dose were significantly higher than those after the first dose. Likewise, trough concentrations before the third dose were 51.9 ± 7.8 μg/mL and higher than those before the second dose; the concentrations were >40 μg/ml in all 6 infants tested.

Conclusions. Very premature infants had sustained optimal protective serum concentrations only after the second dose of palivizumab; 77% of infants tested had trough concentrations <40 μg/mL before the second dose. Additional studies are needed to establish the optimal timing of the initial dose and optimal dosing interval of palivizumab in this most vulnerable population.
Duration of Mechanical Ventilation in Life-Threatening Pediatric Asthma: Description of an Acute Asphyxial Subgroup
Authors: Maffei Frank A. , van der Jagt Elise W. , Powers Karen S. , Standage Stephen W. , Connolly Heidi V. , Harmon William G. , Sullivan John S. , Rubenstein Jeffrey S.
Published: November 2004

Objective. Acute asphyxial asthma (AAA) is well described in adult patients and is characterized by a sudden onset that may rapidly progress to a near-arrest state. Despite the initial severity of AAA, mechanical ventilation often restores gas exchange promptly, resulting in shorter durations of ventilation. We believe that AAA can occur in children and can lead to respiratory failure that requires mechanical ventilation. Furthermore, children with rapid-onset respiratory failure that requires intubation in the emergency department (ED) are more likely to have AAA and a shorter duration of mechanical ventilation than those intubated in the pediatric intensive care unit (PICU).

Methods. An 11-year retrospective chart review (1991-2002) was conducted of all children who were aged 2 through 18 years and had the primary diagnosis of status asthmaticus and required mechanical ventilation.

Results. During the study period, 33 (11.4%) of 290 PICU admissions for status asthmaticus required mechanical ventilation. Thirteen children presented with rapid respiratory failure en route, on arrival, or within 30 minutes of arrival to the ED versus 20 children who progressed to respiratory failure later in their ED course or in the PICU. Mean duration of mechanical ventilation was significantly shorter in the children who presented with rapid respiratory failure versus those with progressive respiratory failure (29 ± 43 hours vs 88 ± 72 hours). Children with rapid respiratory failure had greater improvements in ventilation and oxygenation than those with progressive respiratory failure as measured by pre- and postintubation changes in arterial carbon dioxide pressure, arterial oxygen pressure/fraction of inspired oxygen ratio, and alveolar-arterial gradient. According to site of intubation, 23 children required intubation in the ED, whereas 10 were intubated later in the PICU. Mean duration of mechanical ventilation was significantly shorter in the ED group versus the PICU group (42 ± 63 hours vs 118 ± 46 hours). There were significantly greater improvements in ventilation and oxygenation in the ED group versus the PICU group as measured by pre- and postintubation changes in arterial carbon dioxide pressure and arterial oxygen pressure/fraction of inspired oxygen ratio.

Conclusions. AAA occurs in children and shares characteristics seen in adult counterparts. Need for early intubation is a marker for AAA and may not represent a failure to maximize preintubation therapies. AAA represents a distinct form of life-threatening asthma and requires additional study in children.
Increased Use of Second-Generation Macrolide Antibiotics for Children in Nine Health Plans in the United States
Authors: Stille Christopher J. , Andrade Susan E. , Huang Susan S. , Nordin James , Raebel Marsha A. , Go Alan S. , Chan K. Arnold , Finkelstein Jonathan A.
Published: November 2004

Background. Widespread use of broad-spectrum antibiotics contributes to increasing rates of bacterial resistance to antibiotics. Second-generation macrolides have become popular for use among children because of their broad spectrum and favorable dosing and side-effect profiles, although experts do not generally recommend them for use as initial treatment of infections among younger children.

Objective. To assess trends in second-generation macrolide use from 1996 to 2000 among children treated as outpatients in 9 US health plans, including associated diagnoses and use as initial treatment.

Methods. We sampled claims data for 25000 children, 3 months to <18 years of age, who were enrolled between September 1, 1995, and August 31, 2000, in each of 9 US health plans. Medications dispensed were linked with ambulatory visit claims to assign diagnoses. Dispensings without another antibiotic dispensing recorded in the previous 42 days were analyzed as initial treatment of a new illness episode. We analyzed trends in prescribing overall, for initial therapy, and, within specific diagnoses, for differences among health plans.

Results. From 1995–1996 to 1999–2000, although overall antibiotic use decreased from 1.15 to 0.91 dispensings per person-year, second-generation macrolide use increased from 0.022 to 0.063 dispensings per person-year. Use as a proportion of all antibiotic dispensings increased from 1.9% to 6.9%, and use as initial therapy increased from 1.4% to 6%. For children <6 years of age, second-generation macrolide use as initial therapy increased from 0.9% to 5.0% for otitis media and from 5.2% to 24.0% for pneumonia. There was a wide range of prescribing rates among health plans during the last year of the study, from 0.006 to 0.135 dispensings per person-year.

Conclusions. Despite recent trends toward decreased antibiotic use among children, the use of second-generation macrolides among children has increased dramatically, even among younger children, for whom use for initial treatment of illness is not recommended. Large differences in prescribing rates exist among health plans. Continued efforts to promote the use of narrower-spectrum agents when appropriate are needed.
Children With Unexplained Chronic Pain: Do Pediatricians Agree Regarding the Diagnostic Approach and Presumed Primary Cause?
Authors: Konijnenberg Antoinette Y. , De Graeff-Meeder Elisabeth R. , Kimpen Jan L. L. , van der Hoeven Joost , Buitelaar Jan K. , Uiterwaal Cuno S. P. M. ,   and the Pain of Unknown Origin in Children Study Group
Published: November 2004

Objective. To investigate the opinions of general pediatricians regarding children with unexplained chronic pain (UCP), with respect to the presumed cause of the pain and the optimal diagnostic approach for these children.

Design. Diagnostic follow-up study.

Setting. Outpatient clinic of a university children’s hospital.

Participants. A total of 134 consecutive patients, 8 to 18 years of age, referred for pain of ≥3-month duration without a satisfactory explanation at presentation.

Methods. A full copy of the patient records from routine medical practice and data from standardized psychiatric assessments, standardized questionnaires, and standardized follow-up assessments were provided to 17 pediatricians assigned to 3 panels.

Main Outcome Measures. Agreement regarding the presumed primary cause and diagnostic approach for children with UCP, with consensus being defined as ≥80% agreement among the pediatricians.

Results. The mean age of the children (73% girls) was 11.8 years (SD: 2.6 years). Psychiatric (co)morbidity was present for 60% of the children. Consensus regarding the presumed primary cause was reached for 43% of the patients (58 of 134 patients), ie, 72% (42 of 58 patients) primarily dysfunctional, 17% (10 of 58 patients) primarily psychologic, and 10% (6 of 58 patients) primarily somatic. Consensus regarding the diagnostic approach was reached for 63% of the children (84 of 134 children), leaving more than one-third of the children (37%) without diagnostic consensus.

Conclusions. The relatively high rates of disagreement regarding the optimal diagnostic approach and presumed primary cause illustrate the difficulties of diagnostic evaluation and subsequent therapeutic strategy design for this patient group. Therefore, children with UCP might be at risk for suboptimal care.
Effects of Atopic Dermatitis on Young American Children and Their Families
Authors: Chamlin Sarah L. , Frieden Ilona J. , Williams Mary L. , Chren Mary-Margaret
Published: November 2004

Objective. The psychologic, physical, and social impact of atopic dermatitis is complex and varies among children of different ages, and the effects of atopic dermatitis on the quality of life of very young American children and their families are not well understood. This study was conducted to document these effects of atopic dermatitis on young children and their families.

Methods. Directed focus sessions were performed with parents of 26 young children with atopic dermatitis and 6 expert clinicians. Specific mentions of the ways in which atopic dermatitis affected the children and parents were reviewed, rank ordered, and categorized according to similarity in content. The categories were examined to determine the domains represented, and the domains were used to compose a conceptual framework of all of the ways that atopic dermatitis affects children and their families.

Results. Parents and experts mentioned a total of 181 specific quality-of-life effects. A conceptual framework, developed from the 181 effects, contains the domains of physical health, emotional health, physical functioning, and social functioning; each domain includes effects on both the child and the parents.

Conclusions. Atopic dermatitis greatly affects the quality of life of afflicted children and their families. The comprehensive conceptual framework summarizes the ways in which atopic dermatitis affects the quality of life in young American children. This conceptual framework forms the basis from which quality-of-life instruments can be developed.
Perinatal Stroke in Children With Motor Impairment: A Population-Based Study
Authors: Wu Yvonne W. , March Whitney M. , Croen Lisa A. , Grether Judith K. , Escobar Gabriel J. , Newman Thomas B.
Published: November 2004

Objective. Risk factors for perinatal arterial stroke (PAS) are poorly understood. Most previous studies lack an appropriate control group and include only infants with symptoms in the newborn period. We set out to determine prenatal and perinatal risk factors for PAS.

Methods. In a population-based, case-control study nested within the cohort of 231 582 singleton infants who were born at ≥36 weeks’ gestation in Northern California Kaiser hospitals from 1991 to 1998, we searched electronically for children with motor impairment and reviewed their medical records to identify diagnoses of PAS. Control subjects were randomly selected from the study population. A medical record abstractor reviewed delivery records without knowledge of case status.

Results. The prevalence of PAS with motor impairment was 17/100 000 live births. Of 38 cases, 26 (68%) presented after 3 months of age with hemiparesis or seizures. All 12 newborns with acute stroke symptoms had seizures. A delayed presentation was more common in children with moderate to severe motor impairment than among infants with only mild motor abnormalities (24 of 31 vs 2 of 7). Prepartum risk factors significantly associated with PAS in multivariate analysis were preeclampsia (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.1–11.4) and intrauterine growth restriction (OR: 5.3; 95% CI: 1.5–18.6). Newborns with PAS were also at higher risk of delivery complications, such as emergency cesarean section (OR: 6.8; 95% CI: 2.7–16.6), 5-minute Apgar <7 (OR: 23.6; 95% CI: 4.1–237), and resuscitation at birth (OR: 4.5; 95% CI: 1.6–12.3).

Conclusions. Preeclampsia and intrauterine growth restriction (IUGR) may be independent risk factors for perinatal stroke resulting in motor impairment. Large multicenter studies that include all children with perinatal stroke are needed to determine further the risk factors and outcome of perinatal stroke.