bluuebunny/crossref_metadata_2025 huggingface dataset:
Cost-effectiveness of Care for Very Low Birth Weight Infants
Authors: Rogowski Jeannette
Published: August 2004

Objective. Very low birth weight (VLBW)infants (those with birth weights <1500 g) account for only 1.2% of births but 46% of infant deaths. Large improvements in neonatal technology in the last 2 decades have significantly improved survival prospects for infants with low birth weights, but at a high cost. Due largely to a lack of data, the costs of medical care during the period in which infant mortality is measured (the first year of life), as well as the cost-effectiveness of that care for VLBW infants, have not been quantified. Despite this fact, public policies both toward providing insurance coverage for their care, as well as denying payment for their treatment, have either been proposed or implemented on cost-effectiveness grounds.

Patients. The study includes all VLBW single live births in the state of California during 1986 and 1987 that were continuously eligible (through traditional channels) for the state's Medicaid program.

Main Outcome Measures. Treatment costs were measured for all medical care received during the first year of life, including all inpatient and outpatient care received. The cost-effectiveness of care is measured by aggregate treatment costs for all singleton VLBW liveborns divided by the number of first-year survivors.

Results. Average treatment costs per first-year survivor for infants <1500 g was $93 800 (in 1987 constant dollars). Treatment costs per survivor were twice as high for infants <750 g ($273 900) as for the next highest birth weight group 750 to 999 g ($138 800) which was itself almost twice as high as for the 1000 to 1249 g group ($75 100). The gradient in cost-effectiveness with birth weight then drops off to $58 000 per survivor for infants with birth weights between 1250 and 1499 g.

Conclusion. Public policies aimed at improving birth outcomes by providing insurance coverage for pregnant women and children, such as the recent Medicaid expansions, can potentially be very cost-effective. Although maternal interventions such as prenatal care are relatively inexpensive, each normal birth that results instead in a VLBW birth saves $59 700 in first year medical expenses. However, cost savings attributable to increased birth weights depend on where in the birth weight distribution the increase occurs as well as the size of the birth weight increase. For infants with birth weights >750 g, significant gains can accrue from even a small shift in the birth weight distribution. A shift of 250 g at birth saves an average of $12 000 to $16 000 in first year medical costs and a shift of 500 g generates $28 000 in savings. However, there is a threshold effect on birth weight. For infants <750 g, increases in birth weight may increase medical expenditures. For instance, a shift in birth weight to the 750 to 999 g range increases costs by $29 000.
A Randomized, Placebo-Controlled Trial of Granulocyte Colony-stimulating Factor Administration to Newborn Infants With Neutropenia and Clinical Signs of Early-onset Sepsis
Authors: Schibler Kurt R. , Osborne Karen A. , Leung Ling Y. , Le Trong V. , Baker Shawna I. , Thompson Dixie D.
Published: August 2004

Objective. To determine whether recombinant human granulocyte colony-stimulating factor (G-CSF) administration: 1) accelerates production of neutrophils; 2) increases bone marrow stored and precursor neutrophils; and 3) is safe in newborn infants with neutropenia and clinical signs of early-onset sepsis.

Study Design. We randomized 20 infants with neutropenia and clinical signs of early-onset sepsis in the first 3 days of life to receive G-CSF (10 μg/kg/d) or placebo for 3 days. Entry criteria included neutropenia as defined by Manroe criteria, an elevated immature to total neutrophil ratio [(I/T) ≥0.25], and a requirement for ventilatory support. Cultures were obtained and antibiotics initiated on all study infants. Circulating absolute neutrophil count (ANC), I/T ratio, bone marrow neutrophil storage pool (NSP) and neutrophil proliferative pool (NPP), and plasma G-CSF concentrations were evaluated. Also, severity of illness as determined using the Score for Neonatal Acute Physiology (SNAP), morbidity, and mortality were recorded.

Results. Circulating ANC increased in both G-CSF and placebo recipients by day 1. Also, the I/T neutrophil ratio decreased in both G-CSF and placebo recipients. There were no significant differences in the ANC or I/T ratio between the two groups during the study period. Similarly, bone marrow NSP and NPP did not differ between G-CSF and placebo recipients at study entry or day 2. No differences were observed in the secondary outcome measures including severity of illness, morbidity, and mortality.

Conclusions. Administration of recombinant G-CSF to infants with neutropenia and clinical signs of early-onset sepsis did not increase circulating ANC, or bone marrow NSP and NPP compared with placebo. No differences were observed between G-CSF and placebo recipients in severity of illness, morbidity, or mortality. No adverse effects of G-CSF administrations were noted.
A Comparison of Supination/Flexion to Hyperpronation in the Reduction of Radial Head Subluxations
Authors: Macias Charles G. , Bothner Joan , Wiebe Robert
Published: August 2004

Objective. To compare supination at the wrist followed by flexion at the elbow (the traditional reduction technique) to hyperpronation at the wrist in the reduction of radial head subluxations (nursemaid's elbow).

Materials and Methods. This prospective, randomized study involved a consecutive sampling of children younger than 6 years of age who presented to one of two urban pediatric emergency departments and two suburban pediatric ambulatory care centers with a clinical diagnosis of radial head subluxation. Patients were randomized to undergo reduction by one of the two methods and were followed every 5 minutes for return of elbow function. The initial procedure was repeated if baseline functioning did not return 15 minutes after the initial reduction attempt. Failure of that technique 30 minutes after the initial reduction attempt resulted in a cross-over to the alternate method of reduction. The alternate procedure was repeated if baseline functioning did not return 15 minutes after the alternate procedure was attempted. If the patient failed both techniques, radio-graphy of the elbow was performed.

Results. A total of 90 patients were enrolled in the study. Five patients were removed from further analysis secondary to a final diagnosis of fracture, 84 were reduced successfully, and 1 failed both techniques. Demographic characteristics of each group were similar. Thirty-nine of 41 patients (95%) randomized to hyper-pronation were reduced successfully on the first attempt versus 34 of 44 patients (77%) randomized to supination. Two patients in the hyperpronation group required two attempts versus 10 patients in the supination group. Hyperpronation was more successful; 40 of 41 patients (97.5%) in the hyperpronation group were reduced successfully versus 38 of 44 patients (86%) in the supination group. Of the 6 patients who crossed over from supination to hyperpronation, 5 were reduced on the first attempt and 1 was reduced on the second attempt.

Conclusions. In the reduction of radial head subluxations, the hyperpronation technique required fewer attempts at reduction compared with supination, was successful more often than supination, and was often successful when supination failed.
Clinical Features of Acute Allergic Reactions to Peanut and Tree Nuts in Children
Authors: Sicherer Scott H. , Burks A. Wesley , Sampson Hugh A.
Published: August 2004

Background. Peanut (PN) and tree nut (TN) allergies are potentially life-threatening, rarely outgrown, and appear to be increasing in prevalence. However, there is relatively little reported about the clinical features of acute reactions to these foods and their potential association.

Objective. To describe the clinical features of acute reactions during initial and subsequent accidental ingestions of PN and TN among children with a history of at least one acute allergic reaction to these foods.

Design. Questionnaire survey, examination, and serologic testing for specific IgE antibody of patients with convincing histories of acute reactions (at least one organ system involved within 60 minutes of ingestion) to PN or TN.

Results. A total of 122 patients (63% males; median age, 8 years at time of study) had acute reactions; 68 had reactions only to PN, 20 only to TN, and 34 to both PN and TN. Of those reacting to TN, 34 had reactions to one, 12 to two, and 8 to three or more different TN, the most common being walnut, almond, and pecan. Initial reactions usually occurred at home (median age, 24 months for PN and 62 months for TN) and were considered to result from a first exposure in 72% of cases. Eighty-nine percent of the reactions involved the skin (urticaria, angioedema), 52% the respiratory tract (wheezing, throat tightness, repetitive coughing, dyspnea), and 32% the gastrointestinal tract (vomiting, diarrhea). Two organ systems were affected in 31% of initial reactions, and all three in 21% of reactions. Thirty-eight of 190 first reactions to PN or TN were treated with epinephrine. Accidental ingestions occurred in 55% of PN-allergic children (average of two accidents per patient with an accidental ingestion) and in 30% of TN-allergic children over a median period of 5.5 years. On average, symptoms after accidental exposure were generally similar to those at initial exposure. Accidents occurred commonly in school but also at home and in restaurants. Modes of accidental ingestion included sharing food, hidden ingredients, cross-contamination, and school craft projects using peanut butter. Eighty-three percent of the children were breastfed, with >90% of the mothers ingesting PN and at least one TN during lactation. Among patients reporting no history of exposure (>60% of patients for each TN), IgE antibodies were found to a particular TN in 50% to 82% of patients and to PN in 100% of patients.

Conclusions. Acute allergic reactions to PN occur early in life. PN and TN allergic reactions coexist in one third of PN-allergic patients, frequently occur on first known exposure, and may be life-threatening, requiring emergency treatment. Accidental ingestions are common, occur frequently outside of the home, and often require emergency treatment. Consequently, early diagnosis followed by education on avoidance and treatment measures (including self-administered epinephrine) is imperative.
Educational Disabilities of Neonatal Intensive Care Graduates
Authors: Resnick Michael B. , Gomatam Shanti V. , Carter Randy L. , Ariet Mario , Roth Jeffrey , Kilgore Karen L. , Bucciarelli Richard L. , Mahan Charles S. , Curran John S. , Eitzman Donald V.
Published: August 2004

Objective. To determine the relationship between perinatal and sociodemographic factors in low birth weight and sick infants hospitalized at regional neonatal intensive care units (NICUs) and subsequent educational disabilities.

Method. NICU graduates born between 1980 and 1987 at nine statewide regionalized level III centers were located in Florida elementary schools (kindergarten through third grade) during academic year 1992–1993 (n = 9943). Educational disability was operationalized as placement into eight mutually exclusive types of special education (SE) classifications determined by statewide standardized eligibility criteria: physically impaired, sensory impaired (SI), profoundly mentally handicapped, trainable mentally handicapped, educable mentally handicapped, specific learning disabilities, emotionally handicapped, and speech and language impaired (SLI). Logistic regression was used to estimate the odds of placement in SE for selected perinatal and sociodemographic variables.

Results. Placement into SE ranged from .8% for SI to 9.9% for SLI. Placement was related to four perinatal factors (birth weight, transport, medical conditions [congenital anomalies, seizures or intraventricular hemorrhage] and ventilation), and five sociodemographic factors (child's sex, mother's marital status, mother's race, mother's educational level, and family income). Perinatal factors primarily were associated with placement in physically impaired, SI, profoundly mentally handicapped, and trainable mentally handicapped. Perinatal and sociodemographic factors both were associated with placement in educable mentally handicapped and specific learning disabilities whereas sociodemographic factors primarily were associated with placement in emotionally handicapped and SLI.

Conclusions. Educational disabilities of NICU graduates are influenced differently by perinatal and sociodemographic variables. Researchers must take into account both sets of these variables to ascertain the long-term risk of educational disability for NICU graduates. Birth weight alone should not be used to assess NICU morbidity outcomes.
Abnormal Magnetic Resonance Signal in the Internal Capsule Predicts Poor Neurodevelopmental Outcome in Infants With Hypoxic-Ischemic Encephalopathy
Authors: Rutherford Mary A. , Pennock Jacqueline M. , Counsell Serena J. , Mercuri Eugenio , Cowan Frances M. , Dubowitz Lilly M. S. , Edwards A. David
Published: August 2004

Objective. The aim of this study was to establish whether abnormal signal intensity in the posterior limb of the internal capsule (PLIC) on magnetic resonance imaging is an accurate predictor of neurodevelopmental outcome at 1 year of age in infants with hypoxic-ischemic encephalopathy (HIE).

Methods. We have examined 73 term neonates with HIE between 1 and 17 days after birth with cranial magnetic resonance imaging and related the magnetic resonance imaging findings to neurodevelopmental outcome at 1 year of age.

Results. All infants with an abnormal signal intensity in the PLIC developed neurodevelopmental impairment although in 4 infants with very early scans the abnormal signal was not apparent until up to 4 days after birth. A normal signal intensity was associated with a normal outcome in all but 4 cases; 3 of these infants had minor impairments and all had persistent imaging changes within the white matter. The 4th infant with a normal signal intensity on day 2 died before a further image could be obtained. The absence of normal signal predicted abnormal outcome in term infants with HIE with a sensitivity of 0.90, a specificity of 1.0, a positive predictive value of 1.0, and a negative predictive value of 0.87. The test correctly predicted outcome in 93% of infants with grade II HIE, according to the Sarnat system. Applying a Bayesian approach, the predictive probability of the test (the probability that the test would predict an outcome correctly) was distributed with a mean of 0.94 and 95% confidence limits of 0.89 to 1.0.

Conclusion. Abnormal signal intensity in the PLIC is an accurate predictor of neurodevelopmental outcome in term infants suffering HIE.
Cerebral Blood Flow Is Independent of Mean Arterial Blood Pressure in Preterm Infants Undergoing Intensive Care
Authors: Tyszczuk Lidia , Meek Judith , Elwell Clare , Wyatt J. S.
Published: August 2004

Objective. Preterm infants are often presumed to have a pressure passive cerebral circulation implying that a low mean arterial blood pressure (MABP) results in reduced cerebral perfusion. The aim of this study was to determine whether cerebral blood flow (CBF) was compromised in preterm infants whose MABP fell below 30 mm Hg (4 kPa).

Methods. Thirty preterm infants undergoing intensive care were studied within the first 24 hours of life. CBF was measured using near infrared spectroscopy. The infants were analyzed in two groups on the basis of their MABP at the time of study: group 1 had a MABP below 30 mm Hg and group 2 more than 30 mm Hg. CBF in the two groups was compared.

Results. There was no significant difference in the mean CBF between the two groups. In group 1 the median MABP was 27.2 mm Hg (range, 23.7–29.9 mm Hg) and CBF was 13.9 (standard deviation, ±6.9) mL · 100 g−1 · min−1. In group 2 the median MABP was 35.3 mm Hg (range, 30.1–39.3 mm Hg) and CBF was 12.3 (standard deviation, ±6.4) mL · 100 g−1 · min−1. Mortality and incidence of cranial ultrasound scan abnormalities were also not significantly different.

Conclusion. These results indicate that preterm infants undergoing intensive care are able to maintain adequate cerebral perfusion at a MABP in the range of 23.7 to 39.3 mm Hg.
Birth Weight Influences the Initial Response to Growth Hormone Treatment in Growth Hormone-insufficient Children
Authors: Achermann John C. , Hamdani Karima , Hindmarsh Peter C. , Brook Charles G. D.
Published: August 2004

Objective. To determine the influence of birth weight on the first year response to growth hormone (GH) replacement in children with isolated GH insufficiency.

Study Design. A longitudinal study of response to daily GH treatment (15–26 IU/m2/week) was performed in 16 singleton Caucasian prepubertal children (11 boys, 5 girls) with isolated GH insufficiency (peak GH response to insulin tolerance test <13.5 mU/L) attending a pediatric endocrinology clinic. Change in height velocity standard deviation scores, during the 6 to 12 months before starting GH and the 12 months after, were used to reflect responsivity to GH treatment. Potential influencing variables considered by regression analysis were birth weight standard deviation score (BWSDS), peak GH response to insulin tolerance testing, midparental height standard deviation score, age at treatment, and dose of GH administered.

Results. Mean BWSDS was −0.51 (SD, 1.0). Change in height velocity standard deviation score was correlated positively with BWSDS (r = 0.64) and negatively with peak GH (r = −0.59). Stepwise linear regression analysis confirmed the influence of BWSDS on response to GH treatment.

Conclusions. The continuum of birth weight influences initial responsivity to GH treatment in GH-insufficient children. This may reflect relative insensitivity in the growth hormone or insulin-like growth factor axis. The influence of birth weight on final height and benefit of using higher doses of GH in these children remains to be seen.
Otitis Media, the Caregiving Environment, and Language and Cognitive Outcomes at 2 Years
Authors: Roberts Joanne E. , Burchinal Margaret R. , Zeisel Susan A. , Neebe Eloise C. , Hooper Stephen R. , Roush Jackson , Bryant Donna , Mundy Martha , Henderson Frederick W.
Published: August 2004

Objective. To examine the relationship between otitis media with effusion (OME) and associated hearing loss between 6 and 24 months of age and children's language and cognitive development at 2 years of age.

Study Design. A prospective cohort design in which 86 African-American infants who attended group child-care centers were recruited between 6 and 12 months of age. Between 6 and 24 months, assessments included serial ear examinations using otoscopy and tympanometry, serial hearing tests, two ratings of the childrearing environment at home and in child care, and language and cognitive outcomes at 2 years.

Results. Children experienced either unilateral or bilateral OME an average of 63% and reduced hearing sensitivity an average of 44% of the time between 6 and 24 months of age. Although proportion of time with OME or with hearing loss was modestly correlated with measures of language and cognitive skills, these relationships were no longer significant when the ratings of the home and child-care environments were also considered. Children with more OME or hearing loss tended to live in less responsive caregiving environments, and these environments were linked to lower performance in expressive language and vocabulary acquisition at 2 years.

Conclusions. Both OME and hearing loss were more strongly related to the quality of home and child-care environments than to children's language and cognitive development. Study results might be explained either by suggesting that children in less responsive caregiving environments experience conditions that make them more likely to experience OME and/or by suggesting that it may be more difficult for caregivers to be responsive and stimulating with children with more OME.
Hospital Discharge of the High-Risk Neonate—Proposed Guidelines
Authors:   Committee on Fetus and Newborn
Published: August 2004

This policy statement is the first formal statement of the American Academy of Pediatrics on the issue of hospital discharge of the high-risk neonate. It has been developed, to the extent possible, on the basis of published, scientifically derived information. Four categories of high risk are identified: 1) the preterm infant, 2) the infant who requires technological support, 3) the infant primarily at risk because of family issues, and 4) the infant whose irreversible condition will result in an early death. The unique home care issues for each are reviewed within a common framework. Recommendations are given for four areas of readiness for hospital discharge: infant, home care planning, family and home environment, and the community and health care system. The need for individualized planning and physician judgment is emphasized.
Prevention of Medication Errors in the Pediatric Inpatient Setting
Authors:   Committee on Drugs and Committee on Hospital Care
Published: August 2004

Medication errors that occur on a pediatric medical/surgical inpatient care unit are usually avoidable. Several steps are recommended to reduce these errors, beginning with the physician and including every member of the health care team. Pediatricians should help hospitals develop effective programs for safely providing treatment with medications to hospitalized children.
Who Gets Missed: Coverage in a Provincial Newborn Screening Program for Metabolic Disease
Authors: Spady Donald W. , Saunders L. Duncan , Bamforth Fiona
Published: August 2004

Objective. To determine coverage of the newborn screening program (NSP) for metabolic disease in Alberta, Canada, and to determine reasons for not being screened.

Study Design. Coverage was estimated by deterministic matching of live birth registration data with newborn screening data for the year 1992. Demographic characteristics of not-matched infants were compared with good-match infants using logistic regression.

Results. For 42 392 live births, there were 41 553 screening records, of which 40 593 infants were very good matches to NSP records. Another 960 were possible matches. A total of 839 infants were not matched at all, and coverage was estimated at 98.0%. Determinants of infant not-matched status were death in week 1 (adjusted odds ratio [OR]: 383); birth weight of <1500 g (adjusted OR: 18.9) or between 1500 and 2500 g (adjusted OR: 3.2); having a mother who was single (adjusted OR: 2.7) or formerly married (adjusted OR: 12.9); or being born out of hospital (OR: 19.2). The calculated 98% coverage is close to an estimate of 98.3% made by the NSP comparing total births with initial screenings.

Conclusion. The matched data give insight as to who was missed and point to the need for closer attention for infants at greater risk of not being screened for metabolic disease.
Children's Contributions to Pediatric Outpatient Encounters
Authors: van Dulmen Alexandra Maria
Published: August 2004

Objective.

Generally, increasing attention is being paid to the quality of doctor-patient communication. However, children's contributions have been, until now, primarily ignored in communication research, although there are indications that considering their views increases satisfaction and compliance. In the present study, we examined how children contributed to communication during outpatient pediatric encounters and what factors were associated with children's contributions.

Patients.

Twenty-one consulting pediatricians videotaped a total of 302 consecutive outpatient encounters.

Design.

Multilevel analysis was used to take into account the similarity among encounters with the same pediatrician.

Results.

Children's contributions to the outpatient encounters were limited to 4%. Pediatricians directed one out of every four statements to the child. Although pediatricians asked children a lot of medical questions (26%), only a small part of the medical information (13%) was directed at the children. Apart from social talk and laughter, the amount of pediatrician-child communication increased with children's age. Communication with children suffering from disorders of the nervous system seemed to differ from that with children suffering from other diseases. Allowing children more room in the medical visit did not seem to increase the duration of the visit.

Conclusions.

Although recent legislation requires children to be adequately informed, in pediatric outpatient encounters information still tends to be directed primarily at the parents. Children do get the opportunity to talk about social and psychosocial issues. Pediatricians may need to acquire similar communication skills to discuss medical-technical issues with the children. conversational contribution, information exchange, pediatrician-child communication, social talk, video recordings.
Height as a Marker of Childhood Development and Late-life Cognitive Function: The Honolulu–Asia Aging Study
Authors: Abbott Robert D. , White Lon R. , Ross G. Webster , Petrovitch Helen , Masaki Kamal H. , Snowdon David A. , Curb J. David
Published: August 2004

Objective.

Growing evidence suggests that structural and functional brain reserves, thought to develop in childhood and adolescence, may be crucial in determining when cognitive impairment begins. The purpose of this report is to examine the relationship of height, as a marker of childhood development, to late-life cognitive function in a sample of elderly Japanese-American men.

Method.

Cognitive performance was assessed from 1991 to 1993 in the Honolulu–Asia Aging Study in 3733 men aged 71 to 93 years and related to height that was measured 25 years earlier.

Results.

Among the study sample, shorter men were older, leaner, and less educated than taller men. Shorter men also spent more years of their childhood living in Japan and were more likely to have had fathers in unskilled professions. After adjustment for age, the prevalence of poor cognitive performance declined consistently with increasing height from 25% in men shorter than 154 cm (61 in) to 9% in those taller than 174 cm (69 in). Excluding men with stroke or dementia did not alter the association between height and cognitive performance. Apolipoprotein E4 was unrelated to height and did not effect the association between height and cognitive function. The prevalence of Alzheimer's disease was higher in men who were 154 cm (61 in) or shorter as compared with men who were taller (4.7% vs 2.9%, respectively). There was no association between height and vascular dementia.

Conclusion.

Efforts to improve prenatal and early life conditions to maximize growth in childhood and adolescence could diminish or delay the expression of cognitive impairments that occur later in life. Prevention of some late-life cognitive impairments may have pediatric origins.
Unrecognized Microscopic Hyphema Masquerading as a Closed Head Injury
Authors: Coats David K. , Paysse Evelyn A. , Kong Jerome
Published: August 2004

Objective.

To present a child with an unrecognized microscopic traumatic hyphema and acute glaucoma who was initially treated as a closed head injury patient.

Design.

Case report and discussion.

Results.

Symptoms attributable to unrecognized occult ocular injury in a child with sickle cell trait resulted in evaluation and treatment of the child for a closed head injury. Evaluation included a computed tomography scan of the head and lumbar puncture. An ophthalmologic consultation later revealed a microscopic hyphema and acute glaucoma as the etiology of the child's signs and symptoms.

Conclusions.

Children who present with neurologic symptoms and a history of ocular trauma should undergo an ophthalmologic examination as soon as possible. Hyphema, even if not readily visible on physical examination, can result in the development of acute glaucoma with signs and symptoms that resemble a closed head injury.
Managed Care and Children With Special Health Care Needs: A Subject Review
Authors:   Committee on Children With Disabilities
Published: August 2004

Barriers to access to health care frequently overshadow the opportunities for improvement through managed care, especially regarding children with special health care needs. This statement discusses such opportunities, identifies challenges, and proposes active roles for pediatricians, and families of patients to improve some aspects of managed care for children with special health care needs.
Noninvasive Estimation of Serum Bilirubin
Authors: Tayaba Roland , Gribetz Donald , Gribetz Irwin , Holzman Ian R.
Published: August 2004

Objective.

The aim of this study was to evaluate the accuracy and clinical usefulness of a new computer-driven, hand-held device (Chromatics Colormate III) to estimate serum bilirubin from skin-reflectance (skin color) of neonates.

Study Design.

A total of 2441 infants (both term and premature) at two hospitals had repeated measurements of transcutaneous bilirubin. Of these infants, 900 had one or more laboratory determinations of serum bilirubin. Many of the infants had early measurements of skin color before the onset of jaundice. A visual estimate of the degree of jaundice was made by a health care worker when the laboratory study was drawn. A subgroup of 61 infants was also studied while undergoing phototherapy with a total of 284 comparisons obtained. The reproducibility of the instrument was assessed separately using standardized color tiles and repeated measurements by multiple operators.

Results.

The range of serum bilirubin measurements that had concurrent skin color measurements was 3.22 to 338.1 μmol/L (0.2 to 21 mg/dL). The linear regression indicated an r = 0.956, and 95% of the skin color measurements were within 32.2 μmol/L (2.0 mg/dL). There was no interference with the accuracy of the device because of infant race or weight, or because of the use of phototherapy. The device provided reproducible information when infants were tested repeatedly over 30 minutes; the coefficient of variation for the transcutaneous bilirubin measurement was 3.1% around a mean estimate of 135.32 μmol/L (8.4 mg/dL).

Conclusion.

The Chromatics Colormate III allows for a clinically useful estimate of serum bilirubin in a wide variety of infants. By using a color discrimination algorithm and obtaining a skin measurement before the onset of icterus, this instrument can provide valuable clinical information that obviates the need for serum bilirubin determinations. Its use in newborn nurseries may allow physicians to shorten length of stay more safely and decrease the use of invasive blood tests.
Obesity Evaluation and Treatment: Expert Committee Recommendations
Authors: Barlow Sarah E. , Dietz William H.
Published: August 2004

Objectives.

The development of recommendations for physicians, nurse practitioners, and nutritionists to guide the evaluation and treatment of overweight children and adolescents.

Methods.

The Maternal and Child Health Bureau, Health Resources and Services Administration, the Department of Health and Human Services convened a committee of pediatric obesity experts to develop the recommendations.

Results.

The Committee recommended that children with a body mass index (BMI) greater than or equal to the 85th percentile with complications of obesity or with a BMI greater than or equal to the 95th percentile, with or without complications, undergo evaluation and possible treatment. Clinicians should be aware of signs of the rare exogenous causes of obesity, including genetic syndromes, endocrinologic diseases, and psychologic disorders. They should screen for complications of obesity, including hypertension, dyslipidemias, orthopedic disorders, sleep disorders, gall bladder disease, and insulin resistance. Conditions that indicate consultation with a pediatric obesity specialist include pseudotumor cerebri, obesity-related sleep disorders, orthopedic problems, massive obesity, and obesity in children younger than 2 years of age. Recommendations for treatment evaluation included an assessment of patient and family readiness to engage in a weight-management program and a focused assessment of diet and physical activity habits. The primary goal of obesity therapy should be healthy eating and activity. The use of weight maintenance versus weight loss to achieve weight goals depends on each patient's age, baseline BMI percentile, and presence of medical complications. The Committee recommended treatment that begins early, involves the family, and institutes permanent changes in a stepwise manner. Parenting skills are the foundation for successful intervention that puts in place gradual, targeted increases in activity and targeted reductions in high-fat, high-calorie foods. Ongoing support for families after the initial weight-management program will help families maintain their new behaviors.

Conclusions.

These recommendations provide practical guidance to pediatric clinicians who evaluate and treat overweight children.
Ethylene Glycol Poisoning in a Child Treated With 4-Methylpyrazole
Authors: Harry Patrick , Jobard Eric , Briand Maryvonne , Caubet Alain , Turcant Alain
Published: August 2004

Objective.

The alcohol dehydrogenase inhibitor 4-methylpyrazole (4-MP) is a new antidote of ethylene glycol (EG) intoxication. The purpose of the present case report was to demonstrate 4-MP efficiency in EG poisoning in a 4-year-old child.

Method and Results.

4-MP Treatment was performed 7 hours after EG ingestion. Plasma EG and 4-MP concentrations were measured 2 hours after each infusion of 4-MP. Plasma 4-MP concentrations were in the range of the values reported to block EG metabolism. The efficiency of 4-MP treatment was confirmed by the rapid correction of metabolic acidosis without alkalization and by the increase in EG half-life. No adverse effect of 4-MP was observed.

Conclusion.

This child ingested a potentially lethal dose of EG despite a high concentration of bittering agent in antifreeze. EG poisoning was treated efficiently by 4-MP without recourse to hemodialysis.
Trends and Predictors of Infant Sleep Positions in Georgia, 1990 to 1995
Authors: Saraiya Mona , Serbanescu Florina , Rochat Roger , Berg Cynthia J. , Iyasu Solomon , Gargiullo Paul M.
Published: August 2004

Background.

In recent years, the prone sleeping position has emerged as the strongest modifiable risk factor for sudden infant death syndrome, the leading cause of infant mortality between 1 month and 1 year of age in the United States. Since April 1992, sudden infant death syndrome risk-reduction strategies have included the promotion of the back or side sleeping position (nonprone) for healthy infants younger than 1 year of age. Most recently, the back position has been advocated as the best sleeping position and the side position as an alternative.

Methods.

To evaluate trends in prevalence of the prone position from 1990 to 1995, we used data available from the Georgia Women's Health Survey, a random digit-dialed telephone survey of 3130 women 15 to 44 years of age. We examined the position in which women put their infant to sleep in the first 2 months of life for their most recent live birth (N = 868) and determined independent predictors of prone sleep position among women who consistently used the prone or the back/side position (n = 636) using multiple logistic regression.

Results.

The prevalence of mothers who put their infant to sleep in the prone position significantly decreased, from 49% in 1990 to 15% in 1995. This decrease is primarily attributable to a major shift to the side position rather than to the back. Using multiple logistic regression, we found the prone sleeping position to be significantly higher among women who entered prenatal care after the first trimester (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.4–9.2), were black (OR, 2.1; 95% CI, 1.4–3.1), had less than a high school education (OR, 2.2; 95% CI, 1.4–3.4), and were living in rural Georgia (OR, 1.9; 95% CI, 1.3–2.7). For the period after April 1992, women who had previous children were 2.6 (OR, 95% CI, 1.7–4.1) times more likely to use the prone sleep position than were first-time mothers.

Conclusions.

The prevalence of the use of the prone sleep position for infants decreased significantly over the study period. This decrease coincided with national efforts to promote the back or side sleeping position. Increased efforts should target groups who are more likely to use the prone position to attain the national goal of ≤10% of prone position prevalence by the year 2000, with emphasis on placing the infant on the back.
Bone Mineral Density in Children With Myelomeningocele
Authors: Quan Albert , Adams Richard , Ekmark Elaine , Baum Michel
Published: August 2004

Background.

Difficulties with ambulation in patients with myelomeningocele often lead to physical inactivity, osteoporosis, and subsequent development of pathologic fractures.

Objective.

The purpose of this study was to examine bone mineral density and biochemical markers of bone metabolism in patients with myelomeningocele.

Design and Methods.

A total of 35 patients between 6 and 19 years of age with myelomeningocele (ambulatory and nonambulatory) were randomly chosen at the Texas Scottish Rite Hospital for Children. We measured bone mineral density of the distal radius in these patients using single photon absorptiometry and measured the biochemical markers of bone metabolism including parathyroid hormone, 1,25 vitamin D, osteocalcin, urinary pyridinolines/deoxypyridinolines, and urinary calcium excretion.

Results.

Bone mineral density of the distal radius in the patients with myelomeningocele was ∼1 to 2 standard deviation units below the mean of the normal population. There were no significant differences between ambulators and nonambulators. However, bone mineral density of the 8 patients who suffered multiple fractures (19) was significantly lower than that for those remaining patients without fractures. Elevated urinary pyridinoline levels, which indicate elevated bone reabsorption, were found more frequently in both non- and limited ambulators than in full-time ambulators. Urinary calcium excretion also was greater than twofold higher in nonambulatory patients versus ambulatory patients. There were no other differences in the biochemical markers of bone metabolism (osteocalcin, parathyroid hormone, 1,25 vitamin D, and urinary deoxypyridinolines) between ambulators and nonambulators. Bone mineral density rises in normal growing children 6 to 19 years of age. When the boys and girls were considered separately, bone mineral density rises with age in boys, but not in girls.

Conclusion.

Patients with myelomeningocele have decreased bone mineral density and are at risk of suffering pathologic bone fractures. The measurement of bone mineral density may help to identify those patients at greatest risk of suffering multiple fractures. The urinary calcium excretion of nonambulators was higher than that of ambulators and likely contributes to their decreased bone mineral density. Bone mineral density increases with age in boys, but not in girls.
Hormonal Findings in African-American and Caribbean Hispanic Girls With Premature Adrenarche: Implications for Polycystic Ovarian Syndrome
Authors: Banerjee Swati , Raghavan Susan , Wasserman Ethan J. , Linder Barbara L. , Saenger Paul , DiMartino-Nardi Joan
Published: August 2004

Background.

Premature adrenarche refers to the early maturation of the adrenal zona reticularis such that the resultant modest hyperandrogenism causes the early appearance of pubic hair before the age of 8 years in girls and 9 years in boys. The precise etiology of premature adrenarche is not known. However, recent studies indicate that certain girls with premature adrenarche are at risk of developing functional ovarian hyperandrogenism, polycystic ovarian syndrome, and hyperinsulinism. Caribbean Hispanic women in general are at increased risk of developing polycystic ovarian syndrome, and African-Americans are at increased risk of developing the complications of hyperinsulinism. Previously, girls with premature adrenarche were reported to have androgens in the range found in normal children in the early stages of puberty. We noted that many of our African-American and Caribbean Hispanic patients with premature adrenarche had androgens that were much higher than what has been reported previously.

Objective.

This retrospective study was performed to characterize the adrenocorticotropin-stimulated androgen response in an African-American and Caribbean Hispanic population of girls with premature adrenarche.

Methodology.

The androgen response to adrenocorticotropin stimulation in 72 African-American and Caribbean Hispanic girls with premature adrenarche was compared with those reported for normal girls in early puberty (Tanner stages II and III). The mean age was 6.8 ± 0.8 years, bone age was 8 ± 1.5 years, pubic hair was Tanner stages II and III, and body mass index was 18.6 ± 4.

Results.

Of the girls, 28% were found to have elevated stimulated 17OHPregnenolone (17OHPreg) levels that were >2 SD units above the mean for normal early pubertal children. The stimulated ratio of 17OHPreg/17OHProgesterone also was elevated in 18% of the girls and showed a modest correlation with body mass index.

Conclusion.

In contrast to previous studies of girls of mixed ethnic backgrounds with premature adrenarche, 28% of the 72 African-American and Caribbean Hispanic girls with premature adrenarche had adrenocorticotropin-stimulated 17OHPreg levels that were significantly higher than those seen in early pubertal girls. Because 17OHPreg hyperresponsiveness has been described previously in women with hirsutism or polycystic ovarian syndrome, the similar finding in many African-American and Caribbean Hispanic girls with premature adrenarche suggests that the two conditions may share a common mechanism for their hyperandrogenism. Therefore, the hyperandrogenism in certain African-American and Caribbean Hispanic girls with premature adrenarche may not be benign and may be the first presentation of polycystic ovarian syndrome.
Factors Associated With Restraint Use of Children in Fatal Crashes
Authors: Agran Phyllis F. , Anderson Craig L. , Winn Diane G.
Published: August 2004

Objective.

This study was designed to characterize the restraint use of children in fatal crashes and to determine factors that were related to child restraint use.

Methods.

Crashes in which a vehicle occupant died were selected from the 1994 Fatal Analysis Reporting System data. Restraint use of children (0–9 years) in these crashes was characterized and examined in relation to vehicle and driver characteristics.

Results.

Restraint use declined with increasing age of children and increasing number of occupants. Restraint use was also lower in older vehicles, in pickups and large vans, between 3am and 6 am, and in rural areas. Driver characteristics associated with lower restraint use of child passengers included unrestrained drivers, younger drivers, and alcohol use at the time of crash. Driver restraint use was the strongest predictor of child restraint use. Differences in restraint use by age of the child, number of occupants, time, urban/rural area, and driver restraint use persisted in a logistic model.

Conclusion.

Restraint use in crashes is substantially lower than that in observational studies, suggesting that these studies are not reflective of high-risk conditions for crashes in which children are involved. Child occupant protection counseling must stress restraint use under all conditions of travel. Local, state, and national efforts must be aimed at increasing family occupant protection for the entire family.
Prospective Study of Persistence and Excretion of Human Herpesvirus-6 in Patients With Exanthem Subitum and Their Parents
Authors: Suga Sadao , Yoshikawa Tetsushi , Kajita Yuji , Ozaki Takao , Asano Yoshizo
Published: August 2004

Objective.

To elucidate persistence of human herpesvirus-6 (HHV-6) in the blood and excretion of the virus into several body fluids of patients with exanthem subitum (ES), and to examine serologic and virologic findings of the parents caring for the patients in the family setting.

Materials and Methods.

During a 15-month period, 20 infants from 20 families (11 boys and 9 girls; mean age, 7.7 months; range, 4–11 months) with primary HHV-6 infection and a typical clinical course of ES, and 15 parents from the 20 families (2 males and 13 females; mean age, 28.2 years; range, 21–34 years) were enrolled in the study and examined clinically and virologically. Primary infection with HHV-6 was confirmed by isolation of the virus from peripheral blood mononuclear cells (MNCs), and seroconversion or a significant increase in the antibody titers to HHV-6 by a neutralization test. Viral persistence or excretion was examined by amplifying the viral deoxyribonucleic acid (DNA) in serially collected peripheral blood MNCs, plasma, saliva, stool, and urine samples with a nested polymerase chain reaction method. Data on saliva from the parents were compared with those of 21 age-matched controls.

Results.

Twenty infants with virologically confirmed ES had HHV-6 DNA in MNCs persistently during and after the disease but in plasma only in the first 5 days of ES. The viral DNA was also detected persistently or intermittently in saliva and stool during and after the disease but rarely in urine. On the other hand, the 15 parents examined of the 20 infants had no HHV-6 viremia nor viral DNA in peripheral blood MNCs and plasma except 1, but half of them excreted viral DNA in saliva during and after ES. The frequency of excretion of viral DNA into saliva was not significantly different from that of 21 control parents. Only 1 of the 15 showed a fourfold increase in antibody titers to HHV-6 after possible exposure from their children.

Conclusions.

After systemic replication of HHV-6 in the blood of patients with ES during the first 5 days of the disease, the virus is excreted into saliva and stool persistently or intermittently but rarely into urine. The presence of HHV-6 DNA in plasma suggested active infection with the virus. Excretion of the virus into the saliva of infants with ES and their parents suggests the source and transmission route of infection with HHV-6.
Dietary Sources of Nutrients Among US Children, 1989–1991
Authors: Subar Amy F. , Krebs-Smith Susan M. , Cook Annetta , Kahle Lisa L.
Published: August 2004

Objective.

To identify major food sources of nutrients and dietary constituents for US children.

Methods.

Twenty-four-hour dietary recalls were collected from a nationally representative sample of children age 2 to 18 years (n = 4008) from the US Department of Agriculture's 1989–1991 Continuing Survey of Food Intakes by Individuals. For each of 16 dietary constituents, the contribution of each of 113 food groups was obtained by summing the amount provided by the food group for all individuals and dividing by total intake from all food groups for all individuals.

Results.

Milk, yeast bread, cakes/cookies/quick breads/donuts, beef, and cheese are among the top 10 sources of energy, fat, and protein. Many of the top 10 sources of carbohydrate (yeast bread, soft drinks/sodas, milk, ready-to-eat cereal, cakes/cookies/quick breads/donuts, sugars/syrups/jams, fruit drinks, pasta, white potatoes); protein (poultry, ready-to-eat cereal, pasta); and fat (potato chips/corn chips/popcorn) also contributed >2% each to energy intakes. Ready-to-eat cereal is among the top contributors to folate, vitamin A, vitamin C, iron, and zinc intakes. Fruit drinks, containing little juice, contribute ∼14% of total vitamin C intakes.

Conclusions.

Fortified foods are influential contributors to many vitamins and minerals. Low nutrient-dense foods are major contributors to energy, fats, and carbohydrate. This compromises intakes of more nutritious foods and may impede compliance with current dietary guidance.