bluuebunny/crossref_metadata_2025 huggingface dataset:
Underestimation of Infant Mortality Rates in One Republic of the Former Soviet Union
Authors: Wuhib Tadesse , McCarthy Brian J. , Chorba Terence L. , Sinitsina Tatiana A. , Ivasiv Ivan V. , McNabb Scott J.N.
Published: August 2004

Objectives. Kazakhstan’s live-birth definition—that dates from the former Soviet Union (FSU) era—differs from that used by the World Health Organization (WHO). We studied the impacts of both live-birth definitions on the computations of the infant mortality rate (IMR) and maternal and child health (MCH) planning in Zhambyl Oblast, Kazakhstan.

Methods. We interviewed caregivers and abstracted medical records to obtain birth weight and age-at-death information on infant deaths in Zhambyl Oblast from November 1, 1996, through October 31, 1997. Using the 2 indicators of birth weight and age at death, we created a matrix delineating the respective contribution to infant death (maternal health, newborn care, or infant care) for the cells. We then calculated the IMR, birth weight-specific IMR (BWS-IMR), and birth weight-proportionate IMR (BWP-IMR) for each cell.

Results. The observed IMR in Zhambyl Oblast, in 1996—using the definition of a live birth from the FSU—was 32 per 1000 live births. The recalculated IMR—using the WHO definition—was 58.7 per 1000 live births. Computed estimates of the contribution to infant death, by the categories of maternal health, newborn care, and infant care, were 10%, 23%, and 67%, respectively, when using the live-birth definition from the Soviet era. These estimates shifted to 24%, 41%, and 35%, respectively, when using the WHO definition, yet only 8% of the Zhambyl Oblast MCH budget was earmarked to maternal health and newborn care, which we estimated accounted for 65% of infant deaths.

Conclusions. The live-birth definition commonly used in the FSU underestimated the IMR and undervalued the contributions to infant death by both maternal health and newborn care. We recommend that all republics of the FSU adopt the WHO live-birth definition so that the IMR can serve as a better indicator for MCH planning.
Rapid Increase in Grip Force After Start of Pamidronate Therapy in Children and Adolescents With Severe Osteogenesis Imperfecta
Authors: Montpetit Kathleen , Plotkin Horacio , Rauch Frank , Bilodeau Nathalie , Cloutier Suzanne , Rabzel Mary , Glorieux Francis H.
Published: August 2004

Objective. To examine changes in grip force during pamidronate therapy in children and adolescents with severe osteogenesis imperfecta (OI).

Methods. Maximal isometric grip force of the nondominant hand was prospectively determined in 42 patients (age at the start of the study: 7.3–15.9 years; 18 girls) with severe forms of OI. Patients were treated with intravenous pamidronate infusions given in 4 monthly cycles, each cycle consisting of 3 infusions (1 mg pamidronate/kg body wt) on 3 successive days.

Results. At the start of pamidronate therapy, grip force was low compared with age-specific reference data (age z score mean ± standard deviation: −2.7 ± 2.1) but was normal for weight (weight z score: −0.1 ± 1.8). Four months after the first pamidronate infusion cycle, grip force had increased significantly, whether related to age (age z score: −2.0 ± 1.8) or to weight (weight z score: 0.6 ± 1.5). At 2 years after the start of therapy, grip force z scores were not significantly different from the 4-month results.

Conclusions. Maximal isometric grip force markedly increases after a single cycle of intravenous pamidronate in children with severe forms of OI, and this gain in grip force is maintained for at least 2 years.
Trends in Referral to a Single Encopresis Clinic Over 20 Years
Authors: Fishman Laurie , Rappaport Leonard , Schonwald Alison , Nurko Samuel
Published: August 2004

Objective. To compare the characteristics of children with encopresis referred to a single encopresis clinic over the course of 20 years, including symptoms, previous diagnostic and therapeutic interventions, and parental attitudes.

Methods. A retrospective study was conducted of an encopresis clinic at a tertiary care pediatric hospital. Questionnaires at initial evaluation elicited information about bowel habits, soiling, previous evaluations, previous treatments, and parental attitudes.

Results. In 503 children with encopresis, the average age of referral dropped from 115 months during the earliest 5 years to 77 months during the most recent 5 years. Children who had soiling for >3 years before referral decreased from 63% to 12%. The use of barium enema before referral decreased from 14% to 5%, as did psychological evaluation, from 25% to 14%. Previous therapy with enemas decreased from 45% to 27%. Mineral oil use remained at approximately 50%, and 20% of children had no previous treatment. Symptoms at referral and parental attitudes did not change across the years.

Conclusions. Children are now referred at an earlier age to our tertiary encopresis clinic. The number of invasive and psychological evaluations has decreased before referral. However, treatment by many primary care providers before the referral has not changed. These data may suggest that pediatricians have increased awareness of encopresis and greater appreciation of its primarily physical rather than psychological nature. Additional studies will be needed to determine how these factors affect outcome.
Risk Factors for Tuberculosis Infection in Children in Contact With Infectious Tuberculosis Cases in The Gambia, West Africa
Authors: Lienhardt Christian , Sillah Jackson , Fielding Katherine , Donkor Simon , Manneh Kebba , Warndorff David , Bennett Steve , McAdam Keith
Published: August 2004

Objective. Tuberculosis (TB) infection is highly prevalent in developing countries. As infected children represent a large proportion of the pool from which TB cases will arise, knowledge of the factors that influence TB infection in children are of importance to evaluate transmission of infection in the community and adapt TB control activities. There are limited data on the risk of infection in child populations in developing countries.

Methods. We performed a household contact study in The Gambia (West Africa), in which children who were living in contact with individuals who had proven smear-positive pulmonary TB cases were investigated. A questionnaire was addressed to the mother or caregiver of the child to investigate the presence of various risk factors and assess the degree of exposure of the child to the individual with TB within the household. A tuberculin skin test (TST) was performed on each child. TST sizes ≥5 and 10 mm, respectively, were considered positive.

Results. Households of 206 TB cases were visited, and 384 children aged <5 years were examined. The median age was 2, and 48% were girls. The distribution of TST responses followed a bimodal pattern, with 135 (35%) children presenting a palpable induration. Random effects logistic regression analysis demonstrated that the risk of positive TST response in the child increased with the geographic proximity of the child to the individual with TB within the household and with the degree of activities shared with the individual with TB. It was also associated with the clinical severity of the disease in the index case. Nutritional status and presence of a bacille Calmette-Guérin (BCG) scar were not independent risk factors for TST positivity in this population. On multivariate analysis, the effect of geographic proximity to the individual with TB, household size, and duration of cough in the index case persisted for TST responses ≥5 mm.

Conclusions. In a highly endemic country with high BCG vaccination coverage in Africa, TB infection in children who were in contact with individual with infectious TB was directly related to the intensity of exposure of the child to the individual with TB. Our data suggest that a positive TST in a child reflects most probably TB infection rather than previous BCG vaccination. Contact tracing can play a major role in the control of TB in developing countries.
Race/Ethnicity and Asthma Among Children Presenting to the Emergency Department: Differences in Disease Severity and Management
Authors: Boudreaux Edwin D. , Emond Stephen D. , Clark Sunday , Camargo Carlos A. ,   Behalf of the Multicenter Airway Research Collaboration Investigators
Published: August 2004

Objective. To investigate racial/ethnic differences in acute asthma among children who present to the emergency department (ED).

Method. We analyzed data from 2 prospective cohort studies performed during 1997–1998 as part of the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers at 40 EDs in 18 US states provided 24-hour-per-day coverage for a median of 2 weeks per year. Children with acute asthma were interviewed in the ED and by telephone 2 weeks after discharge.

Results. Among 1095 patients, 679 (62%) were black, 256 (23%) were Hispanic, and 160 (15%) were white. Black and Hispanic children had greater histories of lifetime (63%, 64%, 46%) and past-year (34%, 31%, 14%) hospitalization and more ED visits in the past year (medians: 2, 3, 1). Asthma severity at ED presentation, ED management and course, hospitalization during the index visit, discharge prescriptions, and postdischarge outcomes were equivalent among all race/ethnic groups.

Conclusion. Despite pronounced race/ethnicity-based differences in chronic asthma, all racial/ethnic groups exhibited similar acute asthma severity, ED management, and course. However, given that black and Hispanic children exhibited much higher admission histories and past ED use, the equivalence in inhaled corticosteroid prescriptions on discharge is a disconcerting pattern that mirrors previous literature on outpatient prescription practices. In addition to barriers attributable to socioeconomic factors, health care providers and policy makers should target equalizing deficiencies in preventive medication prescription practices.
Autoimmunity in Wiskott-Aldrich Syndrome: Risk Factors, Clinical Features, and Outcome in a Single-Center Cohort of 55 Patients
Authors: Dupuis-Girod Sophie , Medioni Jacques , Haddad Elie , Quartier Pierre , Cavazzana-Calvo Marina , Le Deist Françoise , de Saint Basile Geneviève , Delaunay Jean , Schwarz Klaus , Casanova Jean-Laurent , Blanche Stephane , Fischer Alain
Published: August 2004

Objectives. To evaluate the occurrence of autoimmune and inflammatory complications in Wiskott-Aldrich syndrome (WAS) and to determine risk factors and the prognosis of such complications with the aim of improving the definition of treatment options.

Methods. We reviewed the records of 55 patients with WAS evaluated at Necker-Enfants Malades Hospital (Paris) from 1980 to 2000.

Results. Forty patients (72%) had at least 1 autoimmune or inflammatory complication. Autoimmune hemolytic anemia was detected in 20 cases (36%); in all cases, onset occurred before the age of 5 years. Other complications included neutropenia (25%), arthritis (29%), skin vasculitis (22%), cerebral vasculitis (7%), inflammatory bowel disease (9%), and renal disease (3%). The median survival of the entire population was 14.5 years. Two autoimmune complications and 1 biological factor were predictive of a poor prognosis in this population: autoimmune hemolytic anemia, severe thrombocytopenia recurring after splenectomy, and high serum immunoglobulin M (IgM) levels before splenectomy. Autoimmune hemolytic anemia was significantly more observed in patients with high serum IgM level.

Conclusions. High serum IgM concentration before splenectomy was identified as a risk factor for autoimmune hemolytic anemia; however, it must be confirmed. Autoimmune hemolytic anemia and severe thrombocytopenia recurring after splenectomy were 2 indicators of a poor prognosis. Those results suggest that patients with WAS and IgM levels more than mean + 2 standard deviations before splenectomy should be placed under strict surveillance. Furthermore, severe autoimmune complications should lead, as early as possible, to hematopoietic stem cell transplantation using the best available donor.
Hemophagocytic Lymphohistiocytosis Masquerading as Child Abuse: Presentation of Three Cases and Review of Central Nervous System Findings in Hemophagocytic Lymphohistiocytosis
Authors: Rooms Laura , Fitzgerald Nancy , McClain Kenneth L.
Published: August 2004

Hemophagocytic lymphohistiocytosis (HLH) is a rare disease resulting from abnormal proliferation of histiocytes in tissues and organs. Although the disease generally presents with systemic symptoms such as pancytopenia, coagulopathy, and organomegaly, HLH may also present with central nervous system (CNS) manifestations. CNS events can range from irritability to encephalopathy and coma. Retinal and intracranial hemorrhages are among the neuropathologic findings in these children. Patients who present with CNS findings may have symptoms that mimic those of inflicted injury. These children are at risk, therefore, for misdiagnosis as victims of child abuse. Such an error causes not only unnecessary additional trauma to the family but also, more important, a delay in initiating effective therapy. We present 3 cases of children with HLH who initially came to medical attention with neurologic findings, all suspected to be victims of child abuse. Subsequent laboratory evaluations, however, were consistent with the diagnosis of HLH. No additional evidence of child abuse was obtained, and the charges eventually were dropped. Two of the 3 children died from their disease shortly after presentation; the third is surviving with no evidence of HLH several months after allogeneic bone marrow transplantation. Although the diagnosis of child abuse certainly is all too common, clinicians need to be diligent and informed to avoid assigning this label erroneously. Several laboratory findings of HLH may alert physicians to the possibility of this diagnosis. The timely diagnosis of and institution of therapy for HLH may reduce ultimate morbidity and mortality.
Current Concepts in Minimal Access Surgery for Children
Authors: Zitsman Jeffrey L.
Published: August 2004

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.
Isolated Hepatocyte Transplantation in an Infant With a Severe Urea Cycle Disorder
Authors: Horslen Simon P. , McCowan Timothy C. , Goertzen Timothy C. , Warkentin Phyllis I. , Cai Hung Bo , Strom Stephen C. , Fox Ira J.
Published: August 2004

Objective. Transplantation of isolated hepatocytes in animal models has been shown to correct inborn errors of metabolism. Based on these studies and our experience with hepatocyte transplantation in a child with Crigler-Najjar syndrome, isolated hepatocyte transplantation was performed to attempt metabolic reconstitution in a male infant with severe ornithine transcarbamylase (OTC) deficiency.

Methods. An infant with an antenatal diagnosis of OTC deficiency was managed intensively to prevent hyperammonemia. Isolated hepatocytes were obtained by collagenase perfusion of donated livers not used for transplantation. Hepatocytes were infused in batches over the first 4 weeks of life via an umbilical venous catheter positioned in the portal vein. Immunosuppression consisted of tacrolimus and corticosteroids.

Results. Over 4 billion viable hepatocytes were transplanted during the first 3.5 weeks of life. A period of metabolic stability was achieved between days 20 and 31 during which normal protein intake was tolerated while phenylbutyrate was weaned. During this time, plasma ammonia and glutamine remained within normal limits. Hyperammonemia reappeared abruptly on day 31 of life. Protein tolerance diminished to baseline; metabolic stability was subsequently reattained only following successful liver transplantation at 6 months of age.

Conclusions. Isolated hepatocyte transplantation appeared to result in temporary relief of hyperammonemia and protein intolerance attributable to OTC deficiency. The metabolic stability achieved was lost after 11 days presumably because of rejection of the transplanted cells because of insufficient immunosuppression. Future attempts at isolated hepatocyte transplantation for inborn errors of metabolism in humans should include adequate immunosuppression and a liver biopsy as a means of proving hepatocyte engraftment and function.
Adult Patient Visits to Children’s Hospital Emergency Departments
Authors: Bourgeois Florence T. , Shannon Michael W.
Published: August 2004

Background. Adults frequently seek medical services in children’s hospital emergency departments (CHEDs), and are required to be admitted to CHEDs under the provisions of the Emergency Medical Transfer and Active Labor Act (EMTALA), which requires medical evaluation and stabilization of every patient who presents to an emergency department. In recent years visits by adults to CHEDs appear to have increased.

Objective. There were 3 objectives to the current study: 1) to examine secular trends in the number of adult patients visiting CHEDs, 2) to determine if perceived increases are related to the implementation of EMTALA, and 3) to examine the characteristics, evaluation, and disposition of adult patients presenting for first-time visits to a CHED.

Methods. A database of all visits to an urban CHED between 1992 and 2002 was queried to collect information on adult patients (22 years or older). New adult patients were identified based on the assignment of new medical record numbers. The medical records of all adult patients presenting during the 1-year interval before and after the institution’s full implementation of EMTALA were reviewed and relevant data collected.

Results. Over the study period, there were 501 033 patient visits to the CHED. Of these, 5512 (1.1%) were by adult patients, which included 536 (9.7%) new adult patients. Using the χ2, test we found a significant increase in the total number of adult visits and the number of new adult visits, particularly after the implementation of EMTALA. The mean age of the new adult patients was 34.9 ± 11.9 years. Their most frequent chief complaints were injuries (24.4%), cardiac-related problems (7.6%), and syncope (6.7%). A total of 427 (79.7%) of the new adult patients were treated and released, 81 (15.1%) were transferred to an outside hospital for additional care, and 15 (2.8%) were admitted to our hospital. There were no significant differences between the new adult populations in 1997 and 1999. Comparing new and established adult populations in 1999, the population of new adults was significantly older (28.1 ± 6.8 vs 34.9 ± 11.9 years) and more likely to present with injuries or syncopal episodes. Among the total cohort of new adult patients in the study, chest pain also occurred at a significantly higher rate compared with established adults (6.7% vs 3.8%).

Conclusions. Adult visits to CHEDs appear to be increasing in frequency in association with the implementation of EMTALA regulations. It is therefore essential that physicians staffing CHEDs be properly trained in the stabilization of common adult medical emergencies. We recommend that the language of EMTALA be revised to allow adult patients with nonemergent problems to be directly referred to adult emergency departments, which are more appropriate than CHEDs.
The Risks of Adverse Neonatal Outcome Among Preterm Small for Gestational Age Infants According to Neonatal Versus Fetal Growth Standards
Authors: Zaw Win , Gagnon Robert , da Silva Orlando
Published: August 2004

Objective. To evaluate neonatal and fetal growth standards in determining the impact of small for gestational age (SGA) on neonatal mortality and morbidity.

Design. A hospital-based cohort study of infants born in a regional tertiary care center and admitted to the neonatal intensive care unit.

Setting and Participants. A total of 1267 singleton neonates of <34 weeks gestational age, without any congenital anomalies, born between January 1, 1993 and December 31, 2001.

Outcome Measures. Each outcome variable including mortality, respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage (IVH), periventricular leukomalacia, and necrotizing enterocolitis was related to growth status as defined by fetal and neonatal growth standards after adjustment for potential confounders.

Results. The number of SGA infants was 11.6% (n = 147) of the study population according to neonatal growth standards, but it was increased to 23.3% (n = 295) when fetal growth standards were used. According to fetal growth standards, when SGA was compared with appropriate for gestational age infants, it was associated with an increased risk of respiratory distress syndrome (odds ratio [OR] 1.40; 95% confidence interval [CI] 1.00–1.95), bronchopulmonary dysplasia (OR 2.18; 95% CI 1.33–3.59), IVH (OR 1.67; 95% CI 1.13–2.45), and retinopathy of prematurity (OR 3.88; 95% CI 2.33–6.48). However, only neonatal mortality (OR 3.64; 95% CI 1.64–8.09), retinopathy of prematurity (OR 5.38; 95% CI 2.87–10.90), and necrotizing enterocolitis (OR 2.47; 95% CI 1.21–5.07) were positively associated with SGA when using neonatal growth standards.

Conclusions. Compared with the neonatal growth standards, the fetal growth standards are better in identifying increased risk of respiratory morbidity and IVH among preterm SGA infants.
Counting the Shots: A Model for Immunization Screening and Referral in Nonmedical Settings
Authors: Rickert Donna L. , Shefer Abigail M. , Rodewald Lance E. , McCauley Mary M.
Published: August 2004

Background. Clinics of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) have become important partners in efforts to improve vaccination coverage in low income children. However, the time required to assess all antigens in each child’s vaccination record may exceed the capacity of many of these clinics. Seeking a solution, experts recommended assessing up-to-date (UTD) status only for the diphtheria-tetanus-acellular-pertussis (DTaP) vaccine and treating this as a proxy measure for all vaccines in the childhood schedule. Whether this single vaccine screening method represents an acceptable alternative to the traditional multiple-vaccine method as a basis for improving overall immunization coverage levels in this vulnerable population has not been demonstrated.

Objective. To evaluate the validity of the proposed simplified method for assessing immunization status in a nationally representative population of infants and children who had ever been enrolled in WIC before 35 months old.

Methods. This was a cross-sectional analysis of the 2000 National Immunization Survey representing children ages 3 to 24 months who had ever been enrolled in WIC. For the 6277 children in the study population, we compared personal records of completion status for DTaP with personal records of completion status for all immunizations appropriate for age in the combination 4:3:1:3 schedule to see which of the 2 (single vs multiple screening) methods would better predict the child’s true (provider-reported) status for the 4:3:1:3 series. The main outcome measures were the comparative sensitivity, specificity, and overall test efficiency of the 2 methods in correctly identifying underimmunized WIC children.

Results. Completion status for DTaP was less sensitive than completion status for all vaccinations in correctly identifying truly underimmunized children (sensitivity = 70% and 77%, respectively). However, it was more specific in correctly identifying children who were truly UTD for age (specificity = 86% and 82%, respectively). The 2 methods were essentially identical with respect to overall test efficiency (82% and 81% for DTaP assessment and assessment of all vaccines, respectively).

Conclusions. Given limited resources to do immunization screening and referral in nonmedical settings such as WIC, simplifying the process by using DTaP from the personal vaccination record as a proxy for the 4:3:1:3 series is a viable option. Loss in sensitivity may well be offset by gains in the capacity of WIC clinics to screen more children.
Infants With Bilirubin Levels of 30 mg/dL or More in a Large Managed Care Organization
Authors: Newman Thomas B. , Liljestrand Petra , Escobar Gabriel J.
Published: August 2004

Objective. To describe the incidence, etiology, treatment, and outcome of newborns with total serum bilirubin (TSB) levels ≥30 mg/dL (513 μmol/L).

Design. Population-based case series.

Setting. Eleven Northern California Kaiser Permanente Medical Care Program hospitals and 1 affiliated hospital.

Patients. Eleven infants with TSB levels of ≥30 mg/dL in the first 30 days after birth, identified using computer databases from a cohort of 111 009 infants born 1995–1998.

Outcome Measures. Clinical data from the birth hospitalization, rehospitalization, and outpatient visits in all infants; psychometric testing at age 5 (N = 3), neurologic examinations by child neurologists at age 5 (N = 3), or primary care providers (N = 7; mean age: 2.2 years); Parent Evaluation of Developmental Status (N = 8; mean age: 4.2 years).

Results. Maximum TSB levels of the 11 infants ranged from 30.7 to 45.5 mg/dL (525 μmol/L to 778 μmol/L; mean: 34.9 mg/dL [597 μmol/L]). Four were born at 35 to 36 weeks gestation, and 7 were exclusively breastfed. Two had apparent isoimmunization; the etiology for the other 9 remained obscure, although only 4 were tested for glucose-6-phosphate dehydrogenase deficiency and 1 was bacteremic. None had acute neurologic symptoms. All received phototherapy and 5 received exchange transfusions. One infant died of sudden infant death syndrome; there was no kernicterus at autopsy. Two were lost to follow-up but were neurologically normal when last seen for checkups at 18 and 43 months. One child was receiving speech therapy at age 3. There were no significant parental concerns or abnormalities in the other children.

Conclusions. In this setting, TSB levels ≥30 mg/dL were rare and generally unaccompanied by acute symptoms. Although we did not observe serious neurodevelopmental sequelae in this small sample, additional studies are required to quantify the known, significant risk of kernicterus in infants with very high TSB levels.
Psychosocial Health Among Young Victims and Offenders of Direct and Indirect Bullying
Authors: van der Wal Marcel F. , de Wit Cees A. M. , Hirasing Remy A.
Published: August 2004

Objective. To assess the association between bullying (both directly and indirectly) and indicators of psychosocial health for boys and girls separately.

Study Design. A school-based questionnaire survey of bullying, depression, suicidal ideation, and delinquent behavior.

Setting. Primary schools in Amsterdam, The Netherlands.

Participants. A total of 4811 children aged 9 to 13.

Results. Depression and suicidal ideation are common outcomes of being bullied in both boys and girls. These associations are stronger for indirect than direct bullying. After correction, direct bullying had a significant effect on depression and suicidal ideation in girls, but not in boys. Boy and girl offenders of bullying far more often reported delinquent behavior. Bullying others directly is a much greater risk factor for delinquent behavior than bullying others indirectly. This was true for both boys and girls. Boy and girl offenders of bullying also more often reported depressive symptoms and suicidal ideation. However, after correction for both sexes only a significant association still existed between bullying others directly and suicidal ideation.

Conclusions. The association between bullying and psychosocial health differs notably between girls and boys as well as between direct and indirect forms of bullying. Interventions to stop bullying must pay attention to these differences to enhance effectiveness.
Smoking During Pregnancy and Newborn Neurobehavior
Authors: Law Karen L. , Stroud Laura R. , LaGasse Linda L. , Niaura Raymond , Liu Jing , Lester Barry M.
Published: August 2004

Objective. This was a prospective study of the effects of maternal smoking during pregnancy on newborn neurobehavior, including dose-response relationships using self-report and a bioassay of nicotine exposure.

Methods. The sample included 27 nicotine exposed and 29 unexposed full-term newborn infants with no medical problems from comparable social class backgrounds. Mothers were excluded for using illegal drugs during pregnancy, using antidepressant medication, or if they consumed >3 alcoholic drinks per month. Nicotine exposure was determined by maternal self-report and cotinine in maternal saliva. The NICU Network Neurobehavioral Scale (NNNS) was administered by masked examiners in hospital to measure neurobehavioral function. NNNS scores were compared between nicotine-exposed and -unexposed groups including adjustment for covariates. Dose-response relationships with NNNS scores were computed for maternal salivary cotinine and maternal report of number of cigarettes per day during pregnancy.

Results. After adjustment for covariates, the tobacco-exposed infants were more excitable and hypertonic, required more handling and showed more stress/abstinence signs, specifically in the central nervous system (CNS), gastrointestinal, and visual areas. Dose-response relationships showed higher maternal salivary cotinine values related to more stress/abstinence signs (r = .530) including CNS (r = .532) and visual stress (r = .688) and higher excitability scores (r = .617). Cigarettes per day during pregnancy was related to more stress/abstinence signs (r = .582) including CNS (r = .561) and visual stress (r = .640).

Conclusions. These findings suggest neurotoxic effects of prenatal tobacco exposure on newborn neurobehavior. Dose-response relationships could indicate neonatal withdrawal from nicotine. Research directed at understanding the effects of cigarette smoking during pregnancy on infants can lead to improved public health outcome.
The Effect of a Parenting Education Program on the Use of Preventive Pediatric Health Care Services Among Low-Income, Minority Mothers: A Randomized, Controlled Study
Authors: El-Mohandes Ayman A. E. , Katz Kathy S. , El-Khorazaty M. Nabil , McNeely-Johnson Doris , Sharps Phyllis W. , Jarrett Marian H. , Rose Allison , White Davene M. , Young Michal , Grylack Larry , Murray Kennan D. B. , Katta Pragathi S. , Burroughs Melissa , Atiyeh Ghassan , Wingrove Barbara K. , Herman Allen A.
Published: August 2004

Objective. To determine if a community-based intervention program focusing on parenting education will have an impact on preventive health care utilization behaviors among low-income, minority mothers in Washington, DC.

Design. The experimental design was a randomized, controlled study in which 286 mother-infant dyads were assigned to either the standard social services (control) group or to the intervention group. Women and their newborn infants were recruited during the immediate postpartum period in 4 Washington, DC, hospital sites from April 1995 to April 1997. The year-long multicomponent intervention included home visits and hospital-based group sessions in addition to the standard social services available at the hospital sites. A total of 286 postpartum women with inadequate prenatal care were assigned randomly to the control or the intervention group. Women and their infants were followed for 1 full year. Outcome measures included usage of preventive health care services including well care infant visits and adherence to immunization schedules during the first year of the infant’s life.

Results. Infants in the intervention group initiated well care at an earlier age than controls (by 6 weeks, 62.5% vs 50% had received their first well infant visit). Infants in the intervention group had more frequent well visits (by 12 months of age, 3.5 vs 2.7 visits). Multivariate analyses showed infants in the intervention group to be more likely to complete their scheduled immunizations (by 9 months, odds ratio = 2.2, 95% confidence interval: 1.09–4.53). Those in the intervention group with more frequent contacts (30+ visits) with study personnel were most likely to have followed age-appropriate immunization schedules when compared with controls (at 9 months odds ratio = 3.63, 95% confidence interval: 1.58–8.33).

Conclusions. It is possible to influence health care usage patterns of high-risk minority populations through public health interventions that are global in their perspective. Focusing on parental knowledge and beliefs regarding health-related issues and life skills in a self-efficacy model is associated with improved usage of infant health care resources.
Evaluation of Cytomegalovirus Infections Transmitted via Breast Milk in Preterm Infants With a Real-Time Polymerase Chain Reaction Assay
Authors: Yasuda Ayako , Kimura Hiroshi , Hayakawa Masahiro , Ohshiro Makoto , Kato Yuichi , Matsuura Onrai , Suzuki Chizuko , Morishima Tsuneo
Published: August 2004

Objective. Preterm infants are at greater risk of symptomatic cytomegalovirus (CMV) infection than term infants. Breast milk is the main source of perinatal CMV infections. This study evaluated the kinetics of CMV load in breast milk and the rate of postnatal CMV transmission via breast milk from mothers to their preterm infants.

Methods. This was a prospective study of 30 mothers and their 43 preterm infants. The infants either had a gestational age of <34 weeks or weighed <2000 g at birth. Breast milk, serum, and urine samples were collected every 2 weeks until discharge, and screened for CMV infection using a real-time PCR assay. Most of the breast milk had been preserved at −20°C before feeding to the preterm infants.

Results. Twenty-four mothers (24 of 30, 80%), who had 34 preterm infants, were CMV immunoglobulin G positive. Twenty-one (87.5%) of the 24 seropositive mothers, who had 30 preterm infants, had detectable CMV deoxyribonucleic acid (DNA) in breast milk during the study period. Most breast milk became positive for CMV DNA 2 weeks after delivery. Viral DNA copy numbers increased until they peaked at 4 to 6 weeks. Afterward, the CMV DNA copy numbers decreased. Of the 30 infants who were fed CMV DNA-positive breast milk, CMV infection was confirmed in 3 infants. However, they had no clinical symptoms of CMV infection.

Conclusions. Despite the high rate of CMV DNA in breast milk, symptomatic infections in the preterm infants did not occur. These results might be associated with the method of breast milk preservation and the population we studied. CMV infections transmitted via breast milk feeding did not have much impact on preterm infants in our institutes.
Initiation of Breastfeeding Among Mothers of Very Low Birth Weight Infants
Authors: Smith Melanie M. , Durkin Maureen , Hinton Veronica J. , Bellinger David , Kuhn Louise
Published: August 2004

Objective. To examine factors that predict the initiation of expressed milk feedings and the transition to direct breastfeedings among mothers of very low birth weight (VLBW) infants.

Methods. The sample consists of 361 mother-infant pairs enrolled in a follow-up study of children aged 6 to 8 years who were born weighing <1501 g in 1 of 5 hospitals between 1991–1993. Chart review at birth provided data on neonatal characteristics and demographic factors at delivery were obtained by postpartum maternal interview. Information regarding infant feeding practices was obtained at follow-up.

Results. In this study, 60% of mothers initiated expressed milk feedings for their VLBW infants. However, the duration of these feedings was brief with 52% of infants receiving 1 to 3 months or less of human milk feedings. Greater educational attainment, private insurance, and breastfeeding experience were each independently associated with the decision to provide expressed milk feedings. Only 27% of mothers reported directly breastfeeding their VLBW infants. The transition from expressed milk feedings to direct breastfeedings was positively associated with sociodemographic factors including maternal age, insurance status, and breastfeeding experience as well as the length of hospitalization, an indicator of infant health.

Conclusions. Sociodemographic factors were associated with both the decision to initiate expressed milk feedings and the transition to direct breastfeedings. However, factors relating to infant health only influenced the transition to direct breastfeedings. Intervention programs need to consider the sociodemographic factors that influence infant feeding decisions as well as specific challenges encountered by mothers of VLBW infants.
Appendectomy During Childhood and Adolescence and the Subsequent Risk of Cancer in Sweden
Authors: Cope Judith U. , Askling Johan , Gridley Gloria , Mohr Adam , Ekbom Anders , Nyren Olof , Linet Martha S.
Published: August 2004

Objective. Researchers have speculated that surgical excision of lymphoid tissue, such as appendectomy, early in life might confer an increased risk of cancer. In this study, we determined the risks of cancer for people who had appendectomy performed during childhood.

Methods. We studied the risk of cancer in a large Swedish cohort of children who had appendectomy performed during the period of 1965–1993. Standardized incidence ratios (SIRs) were computed using age-, gender-, and period-specific incidence rates derived from the entire Swedish population as comparison. Hospital discharge diagnosis data were used to examine cancer risks by categories of surgery, medical conditions, and type of appendicitis. The average length of follow-up was 11.2 years.

Results. We found no excess overall cancer risk but noted a significant excess for stomach cancer (SIR: 2.45; 95% confidence interval [CI]: 1.1–4.8) and a borderline increase of non-Hodgkin’s lymphoma (NHL; SIR: 1.55; 95% CI: 1.0–2.3). The elevated risks for both cancers were only evident 15 or more years after appendectomy (stomach cancer, SIR: 3.82; 95% CI: 1.7–7.5; NHL, SIR: 2.49; 95% CI: 1.4–4.2).

Conclusions. It is reassuring that there was no overall increase of cancer several years after childhood appendectomy. Increased risks for NHL and stomach cancer, occurring 15 or more years after appendectomy, were based on small absolute numbers of excess cancers. As 95% of the subjects were younger than 40 years at exit, this cohort requires continuing follow-up and monitoring.
Pediatricians’ Reported Practices Regarding Early Education and Head Start Referral
Authors: Silverstein Michael , Grossman David C. , Koepsell Thomas D. , Rivara Frederick P.
Published: August 2004

Background. Early learning programs have proven benefits for impoverished children; Head Start is the most widespread of such programs. The current involvement of pediatricians in the Head Start enrollment process is unknown.

Objectives. 1) To assess the knowledge, attitudes, and reported practices of pediatricians on referring families to Head Start; 2) to assess pediatricians’ receptivity to a potential practice-based intervention to enhance their ability to make Head Start referrals.

Methods. Mail survey to stratified random sample of pediatricians practicing in poor and non-poor US zip codes. Prevalence estimates and logistic regression models were estimated using weighted data.

Results. Of 1000 surveys distributed, 472 of 772 presumed-eligible subjects completed surveys for a response rate of 61%. Respondents and nonrespondents were similar with regard to age, gender, years in practice, and urban/rural practice setting. Eighty percent of pediatricians reported discussing child care arrangements with a majority of their preschool-aged patients’ families, while only 14% reported actually assisting these families in applying to Head Start. Lack of time (77% of pediatricians) and nonphysician office staff (71%) were listed as the most significant barriers to helping families apply to Head Start. Unfamiliarity with early childhood education (10%) was generally not seen as a barrier to this practice. Head Start knowledge (adjusted odds ratio [aOR]: 1.43; 95% confidence interval [CI]: 1.01, 2.02), self-efficacy in advising families how to access local Head Start programs (aOR: 3.49; 95% CI: 1.46, 8.38), and the belief that it is the pediatrician’s responsibility to do so (aOR: 9.98; 95% CI: 3.91, 25.48) were significantly associated with assisting families with Head Start enrollment. The majority of respondents (77%) reported a willingness to participate in a proposed computer-based intervention to aid eligible families in applying to Head Start. Having access to a social worker (aOR: 2.48; 95% CI: 1.17, 5.21) and respondent age (aOR: 0.96 for each year; 95% CI: 0.93, 0.99) were significantly associated with likely participation in the intervention.

Conclusions. Although pediatricians report commonly discussing child care issues, few actively assist patients in the application process for Head Start. An intervention to facilitate Head Start referral from the physician’s office must address time and staff limitations; education of pediatricians is a secondary need.
Patient Safety Events During Pediatric Hospitalizations
Authors: Miller Marlene R. , Elixhauser Anne , Zhan Chunliu
Published: August 2004

Objective. Our objective was to describe potential patient safety events for hospitalized children, using the patient safety indicators (PSIs), and examine associations with these events.

Methods. PSI algorithms, developed by researchers at the Agency for Healthcare Research and Quality to identify potential in-hospital patient safety problems using administrative data, were applied to 3.8 million discharge records for children under 19 years from 22 states in the 1997 Healthcare Cost and Utilization Project. Prevalence of PSI events and associations with patient-level and hospital-level characteristics, length of stay, in-hospital mortality, and total charges were examined.

Results. The prevalence of pediatric patient safety events is significant with the highest rate found for birth trauma at 1.5 cases per every 100 births. The majority of these events for birth trauma consist of long bone and skull fractures, excluding the clavicle. Compared with records without PSI events, discharges with PSI events had 2- to 6-fold longer lengths of stay, 2- to 18-fold higher rates of in-hospital mortality, and 2- to 20-fold higher total charges. Bivariate and multivariate analyses found that all PSI events except birth trauma were directly associated with factors related to greater severity of illness and large urban teaching institutions. Birth trauma, however, was directly associated with black and Hispanic ethnicity but was not consistently associated with technologically sophisticated teaching institutions.

Conclusions. The prevalence of birth trauma and other potential patient safety events for hospitalized children is high and comparable to hospitalized adults. These events are associated with increased length of stay, in-hospital mortality, and total charges. Associated factors differ significantly for birth trauma compared with other PSI events. Institutional application of the PSIs may be useful to identify processes of care that warrant further evaluation as the health care industry tackles the problem of patient safety, particularly for children.
Risk of Sudden Infant Death Syndrome and Week of Gestation of Term Birth
Authors: Smith Gordon C. S. , Pell Jill P. , Dobbie Richard
Published: August 2004

Objective. We sought to determine if the risk of sudden infant death syndrome (SIDS) varied according to week of delivery at term among elective and nonelective births.

Design. Retrospective cohort study.

Participants. All single infants live born between 37 and 42 weeks gestation in Scotland between 1992 and 1995 documented in the Scottish Morbidity Record.

Outcome. Death in the first year of life where SIDS was in the principal position on the death certificate.

Results. There were 202 622 eligible births and 119 deaths attributed to SIDS. Among infants delivered electively, there was no significant association between risk of SIDS and week of delivery. Among those delivered nonelectively, the risk of SIDS declined significantly with each week of gestation (odds ratio .72, 95% confidence interval .60–.86). This trend was only minimally attenuated by adjustment for maternal age, parity, smoking and socioeconomic deprivation category, infant sex, Apgar score, mode of delivery, and birth weight decile (adjusted odds ratio .78, 95% confidence interval .65–.93).

Conclusions. We hypothesize that early spontaneous labor at term and SIDS may be linked because of a common association with suboptimal intrauterine environment.
Health-Related Quality of Life in Urban Elementary Schoolchildren
Authors: Mansour Mona E. , Kotagal Uma , Rose Barbara , Ho Mona , Brewer David , Roy-Chaudhury Ashwini , Hornung Richard W. , Wade Terrance J. , DeWitt Thomas G.
Published: August 2004

Background. Health disparities between children from urban minority backgrounds and children from more affluent backgrounds are well-recognized. Few studies specifically address urban children’s perceptions of their health-related quality of life (HRQOL) or the factors that contribute to these perceptions. Since schools are pivotal to children’s intellectual, social, and emotional development, school connectedness may be a factor that contributes to their perception of HRQOL.

Objective. To examine children’s perceptions of HRQOL in an elementary school-based population of urban children.

Methods. The study population consisted of 2nd, 3rd, and 5th graders from 6 urban kindergarten to 8th grade schools and their parents. Children completed a survey that included questions on HRQOL and school connectedness. Parents completed a telephone survey that assessed demographics, the child’s health, health care usage, and parental health status. Data on school absences and mobility from the computerized school database were linked to survey data. Bivariate analyses were used to evaluate the association between child report of HRQOL and collected variables, including school connectedness. Multivariable linear regression was conducted to identify the factors best predicting HRQOL in these urban children.

Results. Of the 1150 eligible students, parent and child survey data were available for 525 (45.6%). Fifty-one percent of students were male and 89% were black. Ninety-four percent of parents were female, 29% were married, and 62% had family incomes below $20 000 per year. The mean total score for HRQOL was 67.2, with a possible range of 0 to 100 (higher scores reflecting better HRQOL). In the multivariable analysis, child grade, the relationship of the “ parent” to the child, employment, family income, type/presence of insurance, and school connectedness were significantly associated with the HRQOL total score.

Conclusions. Young urban children self-report low HRQOL scores and do so as early as the 2nd grade. These low scores, which reflect children’s own perceptions of impaired psychological and physical health, have potential implications for the success of urban children in their learning environments. The association between HRQOL and school connectedness might suggest that health and educational programs that improve a child’s attachment to school could result in improved perceptions of health by urban children.