bluuebunny/crossref_metadata_2025 huggingface dataset:
Hypospadias Trends in Two US Surveillance Systems
Authors: Paulozzi Leonard J. , Erickson J. David , Jackson Richard J.
Published: August 2004

Objective. Hypospadias is a common congenital anomaly, the cause of which is unknown. Unexplained increases in the rates of hypospadias occurred in five European countries in the 1970s and 1980s. We examined data from two birth defects surveillance systems in the United States for evidence of similar trends.

Methodology. The Metropolitan Atlanta Congenital Defects Program (MACDP) provided birth prevalence rates from 1968 to 1993. The nationwide Birth Defects Monitoring Program (BDMP) provided rates from 1970 to 1993. MACDP data are population-based and could be categorized by the severity of the hypospadias. BDMP data allowed analysis of rate trends for the four census regions of the United States.

Results. Data from both surveillance systems showed an approximate doubling of hypospadias rates in the 1970s and 1980s. MACDP data showed that the rate of severe cases increased while the ratio of mild to severe cases decreased. BDMP data showed that hypospadias rates increased markedly in all four regions of the United States.

Conclusions. The observed increases are unlikely to be attributable to increased sensitivity of the surveillance systems or the identification of more mild cases by physicians over time, because either trend would have increased rather than decreased the ratio of mild to severe cases. If real, these trends represent the largest number of cases and the first report of an increase in hypospadias rates outside of Europe. Additional investigation of a possible increase in hypospadias rates is warranted.
Illnesses and Absence Due to Illness Among Children Attending Child Care Facilities in Seattle-King County, Washington
Authors: Cordell Ralph L. , MacDonald Jean K. , Solomon Steven L. , Jackson Lisa A. , Boase Janice
Published: August 2004

Objectives. Although much of the economic impact of child care-associated illness in the United States is due to parents' time lost from work, there are no data on the incidence of absence due to illness among children in various types of out-of-home child care settings in the United States. The goals of this study were to compare the incidence of illness and absence due to illness among children attending child care homes (CCHs) and child care centers (CCCs).

Methods. From July 1992 through June 1993, child care providers from 91 CCHs and 41 CCCs in Seattle-King County, Washington, provided information on absenteeism and illness for 96 792 child-weeks of observation.

Results. The age-adjusted incidence of provider-reported illness episodes among children in CCHs (10.4 episodes per 100 child-weeks) was greater than that among children in CCCs (6.7 episodes per 100 child-weeks). The incidence density ratio of illness among children <1 year of age in comparison to those ≥5 years of age in CCCs (4.5) was greater than that among similar groups in CCHs (2.3). The age-adjusted incidence of absence due to illness among children in CCHs (5.1 days per 100 child-weeks) was less than that among children in CCCs (8.9 days per 100 child-weeks).

Conclusions. Results comparing the incidence of illness between children in various types of child care settings may be influenced by information sources. The incidence of illness among children in CCHs may be greater than that among children in CCCs. The increased incidence of absence due to illness among children in CCCs compared with that among children in CCHs probably reflects differences in exclusion and attendance policies and practices between these two types of settings.
The Effect of Changes in Dietary Fat on the Food Group and Nutrient Intake of 4- to 10-Year-Old Children
Authors: Dixon Lori Beth , McKenzie Jeannie , Shannon Barbara M. , Mitchell Diane C. , Smiciklas-Wright Helen , Tershakovec Andrew M.
Published: August 2004

Objective. To determine how young children changed their overall diet when they changed their fat intake after 3 months of participating in a nutrition education demonstration study designed to lower low-density lipoprotein cholesterol and cardiovascular risk.

Methods. Three 24-hour dietary recalls were collected from 303 4- to 10-year-old children at baseline and 3 months later. At both times, mean number of servings from food groups, grams of fat contributed from food groups, and intake of calories and nutrients were calculated and compared among quartiles of children formed according to change in their percent of calories from total fat after 3 months.

Results. Children who reduced their percent of calories from total fat most (ie, by an average of 8.5%) after 3 months consumed fewer servings from meats, eggs, dairy, fats/oils, and breads but tended to increase their number of servings from lower-fat foods within those food groups, particularly from dairy foods. These children also increased their mean intake of fruits, vegetables, and desserts, and maintained average intakes of all nutrients (except vitamin D) in excess of two thirds of the respective recommended dietary allowance.

Conclusions. Young children who reduced their percent of calories from total fat in accordance with the current National Cholesterol Education Program recommendations accomplished this by reducing their overall intake of higher-fat foods, replacing higher-fat foods with lower-fat foods within several food groups, particularly within the dairy group (eg, drinking skim milk instead of whole milk) and by consuming more servings of fruits, vegetables, and very-low-fat desserts. These behaviors did not compromise their mean calorie or nutrient intakes, showing that it is possible for young children to lower their fat intake safely to reduce their risk of future heart disease.
Safety and Effectiveness of Homemade and Reconstituted Packet Cereal-based Oral Rehydration Solutions: A Randomized Clinical Trial
Authors: Meyers Alan , Sampson Amy , Saladino Richard , Dixit Sujata , Adams William , Mondolfi Alejandro
Published: August 2004

Objectives. Parents may be deterred from obtaining commercial oral rehydration solutions (ORS) for their young children with acute diarrheal disease because of its availability and/or cost, especially if they are poor. We conducted a randomized clinical trial to determine 1) whether low-income parents could safely mix and administer cereal-based ORS (CBORS) both from ingredients commonly found in the home and from a premixed packet; 2) whether these CBORS were as effective in maintaining hydration as commercial glucose-based ORS; and 3) whether CBORS were more effective in reducing severity and duration of illness.

Methods. Children 4 to 36 months of age discharged from emergency departments and health centers with acute diarrheal disease were randomized to receive either homemade CBORS, reconstituted packet CBORS, or Pedialyte. A study nurse saw the child at home each day until the illness resolved, and obtained capillary blood for serum sodium at enrollment and at 24 to 48 hours; a sample of CBORS for sodium concentration; stool for pathogen analysis; and daily fluid intake, stool frequency, and weight.

Results. A total of 232 children were enrolled, of whom 203 (88%) completed the study. Two parents (3%) in the homemade CBORS group and one parent (1%) in the packet CBORS group made mixing errors resulting in a high sodium concentration (>100 mEq/L); their children refused the solution and had normal serum sodium values. Mean CBORS sodium concentration for the remainder of the homemade CBORS group was 60 ± 10 mEq/L, and for the packet CBORS group, 54 ± 13. Eighteen children (11%) had abnormal serum sodium values at presentation, which returned to normal in all groups in most cases. Three children (4.5%) in the homemade CBORS group, 4 (6%) in the packet CBORS group, and 1 child (1.4%) in the Pedialyte group failed therapy.

Children refused to take homemade CBORS and packet CBORS (43% and 32%, respectively) more often than Pedialyte (9%), and those in the CBORS groups tended to take less ORS and total fluids. There were no significant differences among the three groups in incidence of daily vomiting or stooling, duration of diarrhea, or weight gain.

Conclusions. CBORS do not offer a clinically significant advantage over glucose-based ORS. Homemade CBORS represent a treatment option in carefully selected cases, but it is not the safest alternative for regular clinical use.
Elective High-frequency Oscillatory Ventilation Versus Conventional Ventilation in Preterm Infants With Pulmonary Dysfunction: Systematic Review and Meta-analyses
Authors: Bhuta Tushar , Henderson-Smart David J.
Published: August 2004

Objectives. To systematically review the evidence to determine whether the routine use of high-frequency oscillatory ventilation (HFOV) as compared with conventional ventilation (CV) is beneficial or harmful in preterm infants requiring mechanical ventilation for pulmonary failure principally due to respiratory distress syndrome.

Methods. All randomized controlled trials of elective HFOV versus CV in preterm infants <36 weeks' gestation with respiratory failure mainly attributable to respiratory distress syndrome were identified from the literature through a search of MEDLINE, EMBASE, Oxford database of Perinatal trials, and previous reviews including cross-references and abstracts. Meta-analyses using event rate ratios (ERR), event rate difference, and if significant, number needed-to-treat were calculated (95% confidence limits were used for all analyses). Two prespecified subgroup analyses were performed.

Results. Four published trials918 were included. Meta-analyses revealed the following ERR (95% confidence intervals) for HFOV versus CV: mortality at 28 to 30 days, 1.02 (0.76, 1.39); chronic lung disease (CLD) at 28 days, 0.86 (0.73, 1.01); mortality or CLD, 0.9 (0.80, 1.01); air-leak syndromes, 1.13 (0.97, 1.33); mechanical ventilation at 28 days, 1.06 (0.84, 1.33); supplemental oxygen at discharge, 0.59 (0.37, 0.92); intraventricular hemorrhage (IVH) all grades, 1.11 (0.95, 1.29); IVH (grades 3 or 4), 1.32 (1.01, 1.72); and periventricular leukomalacia, 1.39 (0.91, 2.13). In the subgroup of trials in which a high volume strategy (HVS) was used18 the ERR for CLD was 0.53 (0.36, 0.78); mortality or CLD, 0.56 (0.40, 0.77); supplemental oxygen at discharge, 0.57 (0.36, 0.92); IVH (all grades), 0.90 (0.61, 1.33); and IVH (grades 3 or 4), 0.84 (0.39, 1.84). Results were similar to these for the trials using surfactant.1920 One recent trial suggests that HFOV may reduce the cost of in-hospital care.19

Conclusions. The overall meta-analysis is dominated by the HIFI study,9 which was criticized for its methodology11 and surfactant was not used. Subsequent studies, most of which used HVS and/or surfactant, have shown benefits in measures of CLD without an increase in rates of IVH. Caution is warranted in interpreting these results because: 1) the treatment is not blinded and this could affect some outcomes; 2) except for one small trial20 postneonatal survival, lung function, and neurodevelopment have not been reported from HVS trials; and 3) the benefits and disadvantages have not been reported in infants born at different gestational ages or different birth weights. Importantly, results from groups experienced in the use of HFOV may not be readily generalizable.
Breastfeeding and the Use of Human Milk
Authors:   Work Group on Breastfeeding
Published: August 2004

This Policy Statement was revised. See https://doi.org/10.1542/peds.2022-057988.

This policy statement on breastfeeding replaces the previous policy statement of the American Academy of Pediatrics, reflecting the considerable advances that have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, in the mechanisms underlying these benefits, and in the practice of breastfeeding. This document summarizes the benefits of breastfeeding to the infant, the mother, and the nation, and sets forth principles to guide the pediatrician and other health care providers in the initiation and maintenance of breastfeeding. The policy statement also delineates the various ways in which pediatricians can promote, protect, and support breastfeeding, not only in their individual practices but also in the hospital, medical school, community, and nation.
Respiratory Syncytial Virus Immune Globulin Treatment of RSV Lower Respiratory Tract Infection in Previously Healthy Children
Authors: Rodriguez William J. , Gruber William C. , Groothuis Jessie R. , Simoes Eric A. F. , Rosas Angela J. , Lepow Martha , PhD Andrew Kramer , Hemming Val ,   the RSV-IGIV Study Group
Published: August 2004

Objective. To evaluate the efficacy of high titer respiratory syncytial virus (RSV) immune globulin (RSVIG) in the treatment of previously healthy children hospitalized with proven RSV lower tract infection (LRI).

Method. Infants and young children ≤2 years of age with RSV LRI of ≤4 days duration, and respiratory scores ≥2.5 were enrolled.

Results. One hundred and one previously healthy children hospitalized with RSV LRI received either 1500 mg/kg of RSVIG (RespiGam, MedImmune Inc, Gaithersburg, MD) or albumin placebo in a randomized, double-blind, placebo-controlled trial. Forty-six RSVIG and 52 recipients of placebo met all eligibility criteria. Demographic characteristics of the two groups were similar. More RSVIG recipients (46% vs 29%) had an SaO2 ≤85% at entry than did placebo recipients, but a higher proportion of placebo recipients required intensive care unit (ICU) care and mechanical ventilation at study entry. The mean RSV hospital stay was 5.52 ± 0.69 days (SE) for placebo and 4.58 ± 0.40 days for RSVIG. Additionally, there was an interaction between treatment group and entry respiratory score, which led to subgroup analysis. Children with modest respiratory illness did not receive any benefit from RSVIG therapy. RSVIG recipients with more severe illness (entry respiratory scores ≥3.0) had 1.6 fewer hospital days and 2.7 days less ICU stays.

Conclusion. RSVIG infusions seemed safe and generally well tolerated. Although some beneficial effect trends were seen for those with more severe disease who were treated there was no evidence that treatment with RSVIG resulted in reduced hospitalization and reduced ICU stays in all children with RSV disease.
Renal Function After Short-term Ibuprofen Use in Infants and Children
Authors: Lesko Samuel M. , Mitchell Allen A.
Published: August 2004

Objective. To test the hypothesis that short-term use of ibuprofen increases the risk of impaired renal function in children.

Study Design. Randomized, double-blind acetaminophen-controlled clinical trial. Children with a febrile illness were enrolled from outpatient pediatric and family medicine practices and randomly assigned to receive either acetaminophen suspension or one of two dosages of ibuprofen suspension (5 mg/kg or 10 mg/kg) for fever control.

Results. Mean blood urea nitrogen levels on admission among children admitted to hospital and assigned ibuprofen 5 mg/kg (n = 96), ibuprofen 10 mg/kg (n = 102), and acetaminophen 12 mg/kg (n = 87) were 4.1, 3.8, and 3.9 mmol/L, respectively. The corresponding creatinine levels were 43, 41, and 43 μmol/L, respectively. The prevalence of a creatinine level >62 μmol/L was 9.5% overall and did not vary by antipyretic assignment. Among 83 children hospitalized with dehydration, the mean creatinine level was 44 μmol/L, and the prevalence of an elevated creatinine was 14%; neither measure varied by antipyretic assignment.

Conclusion. Although renal failure in children has been reported after ibuprofen use, these data suggest that for short-term use the risk of less severe renal impairment, as reflected by blood urea nitrogen and creatinine levels, is small and not significantly greater than that after acetaminophen use.
Predictors of Posttraumatic Stress Symptoms in Childhood Cancer Survivors
Authors: Stuber Margaret L. , Kazak Anne E. , Meeske Kathleen , Barakat Lamia , Guthrie Donald , Garnier Helen , Pynoos Robert , Meadows Anna
Published: August 2004

Objective. The diagnosis and treatment of childhood cancer are extremely stressful experiences, with psychological sequelae which can persist many years after the end of treatment. This study investigated the relative contributions of general anxiety, treatment intensity, medical sequelae of treatment, and the subjective appraisal of life threat and treatment intensity to later posttraumatic stress symptoms, such as intrusive memories, avoidance, and hypervigilance.

Method. One hundred eighty-six childhood cancer survivors ages 8 through 20 years, off of treatment for more than 1 year, and their parents completed questionnaires. Medical sequelae of treatment and intensity of treatment were rated by a pediatric oncologist.

Results. Significant, independent predictors of persistent posttraumatic stress symptoms included: 1) the survivor's retrospective subjective appraisal of life threat at the time of treatment, and the degree to which the survivor experienced the treatment as “hard” or “scary”; 2) the child's general level of anxiety; 3) history of other stressful experiences; 4) time since the termination of treatment (negative association); 5) female gender; and 6) family and social support. Mother's perception of treatment and life threat contributed to anxiety and subjective appraisal for the survivor, but did not independently contribute to posttraumatic stress symptoms.

Conclusions. Symptoms of posttraumatic stress seem to decrease with time, but are persistent in a subset of childhood cancer survivors. Other than time and gender, the predictors of posttraumatic stress symptoms are primarily subjective factors (ie, anxiety and subjective appraisal) rather than objective stressors of treatment and medical sequelae.
Subcutaneous Granuloma Annulare: A Review of 47 Cases
Authors: Felner Eric I. , Steinberg Joel B. , Weinberg Arthur G.
Published: August 2004

Objective. The purpose of this study was to review and provide information regarding characteristic findings, diagnostic work-up, course, and treatment associated with subcutaneous granuloma annulare (SGA).

Materials and Methods. The medical and surgical records of 47 patients with SGA, who were diagnosed and treated at our institution over the past 26 years, were reviewed.

Results. All patients presented with a painless soft tissue nodule(s) of the extremities or scalp. The mean age at presentation was 4.3 years, with 19% of the patients encountering one or more recurrences. The mean time of recurrence was 10 months. Definitive diagnosis in all patients was made by biopsy, and no patient progressed to any recognized systemic illness or connective tissue disorder.

Conclusions. SGA is a benign inflammatory skin lesion that should be considered in the differential diagnosis of a subcutaneous nodule(s) of the scalp and/or distal extremities of an otherwise healthy child. Because the nodule(s) are benign and may recur with or without surgical biopsy, reassurance is the best management.
Effectiveness of Postprandial Humalog in Toddlers With Diabetes
Authors: Rutledge K. Suchari , Chase H. Peter , Klingensmith Georgeanna J. , Walravens Philip A. , Slover Robert H. , Garg Satish K.
Published: August 2004

Objective. The purpose of this study was to determine whether postprandial administration of the new rapid-acting insulin analog Humalog could effectively reduce glucose excursions in children <5 years old.

Design. Human Regular insulin given before a meal was compared with the same dose of Humalog after a meal of equal carbohydrate content in five toddlers with insulin-dependent (type 1) diabetes mellitus. In addition, the use of Humalog before a meal was compared with Humalog given after a meal of equal carbohydrate content in five other toddlers. The dose of long-acting insulin was not changed during the study period. Blood glucose levels were determined at fasting and at 1, 2, and 4 hours postprandially.

Results. The 2-hour glucose excursions were significantly lower when postprandial Humalog administration was compared with preprandial Human Regular insulin administration. In contrast, glucose excursions were similar when Humalog was taken before or after the meal.

Conclusion. These data show that it is efficacious to give Humalog insulin postprandially in toddlers with type 1 diabetes, allowing increased safety for the young child. The insulin dose can be both matched to the actual food intake and timed to give families increased flexibility and control at mealtime.
Effective Prophylactic Therapy for Cyclic Vomiting Syndrome in Children Using Amitriptyline or Cyproheptadine
Authors: Andersen John M. , Sugerman Kathryn S. , Lockhart Jennifer R. , Weinberg Warren A.
Published: August 2004

Objective. To evaluate our experience using the antimigraine prophylactic drugs, amitriptyline and cyproheptadine, for the prophylactic management of cyclic vomiting syndrome (CVS) in children.

Methods and Patients. Twenty-seven patients (16 males) ranging in age from 2 to 16 years at diagnosis, fulfilling the diagnostic criteria for CVS and treated prophylactically with either amitriptyline (22) or/and cyproheptadine (6) were identified through retrospective chart review. Individual patient data were corroborated by the attending physician and/or interviews with patients and families. Minimum follow-up time before entry into the study group was 5 months. Patients were stratified according to three treatment outcomes: 1) complete response—no attacks, 2) partial response—50% or greater reduction in frequency of attacks, and 3) no response—less than 50% decrease in frequency of attacks.

Results. Of the 22 patients treated with amitriptyline, 16 (73%) had a complete response while 4 (18%) had a partial response. Of the 6 patients treated with cyproheptadine, 4 (66%) had a complete response and 1 (17%) had a partial response. Thus, 91% of the amitriptyline group and 83% of the cyproheptadine group had at least a partial response to therapy. No patients experienced significant side effects to either medication.

Conclusion. The antimigraine prophylactic drugs, amitriptyline and cyproheptadine, represent effective prophylactic agents for the management of CVS in the vast majority of patients fulfilling the diagnostic criteria for this syndrome.
Discontinuation of Methotrexate Treatment in Juvenile Rheumatoid Arthritis
Authors: Gottlieb Beth S. , Keenan Gregory F. , Lu Theresa , Ilowite Norman T.
Published: August 2004

Objective. Children with juvenile rheumatoid arthritis (JRA) treated with methotrexate (MTX) were examined for their course after the discontinuation of the drug to define the relapse and remission rates and to identify predictors of relapse.

Methodology. A retrospective chart review of all patients with JRA was conducted in two pediatric rheumatology centers. A total of 101 patients being treated with MTX were identified. Dose, response to the drug, and length of time until reaching a state of complete control were noted. The outcome of patients with a complete response in whom the drug was discontinued was examined with regards to length of time to relapse or continued remission.

Results. In 25 patients, MTX was discontinued after reaching complete control of the disease. There were no statistically significant predictors of response to MTX identified. Of 25 whose MTX was discontinued, relapse occurred in 13 (52%) after a mean of 11 months after discontinuation. There was no significant difference among patients who relapsed or those who remained in remission as to sex, subtype of JRA, number of months to complete control, or number of months in complete control until discontinuing MTX. Patients younger than 4½ years at diagnosis were found to be more likely to relapse than patients diagnosed at a later age. In 10 of the patients who relapsed, complete control was induced within a mean of 7 months after restarting MTX.

Conclusion. The optimal time for discontinuing MTX in children with JRA who have achieved complete control is unknown. Relapse occurred in approximately half of the patients in whom MTX was discontinued. Because response to reinstitution of the drug is good, it is reasonable to discontinue MTX after prolonged complete control. It remains to be seen whether the relapse rate can be improved by waiting for longer periods of time in complete control before its discontinuation.
Breastfeeding Infants Who Were Extremely Low Birth Weight
Authors: Blaymore Bier Jo Ann , Ferguson Anne E. , Morales Yesenia , Liebling Jill A. , Oh William , Vohr Betty R.
Published: August 2004

Objective. To compare the clinical effect of breastfeedings and bottle feedings in extremely low birth weight (ELBW) infants (birth weight ≤800 g).

Methods. A total of 12 ELBW infants (mean birth weight, 672 ± 95 g; mean gestation, 26 ± 2 weeks) served as their own controls in this prospective study comparing physiologic parameters during bottle and breastfeeding. The infants were put to breast the same week they began on bottle feedings of human milk or premature infant formula (mean gestation, 35 weeks). One breastfeeding and one bottle feeding were observed each day for 10 days. Pre- and postfeeding weights were measured, and oxygen saturation, respiratory rate, heart rate, and axillary temperature were monitored continuously and recorded every minute during feedings.

Results. The infants demonstrated a higher oxygen saturation and a higher temperature during breastfeeding than during bottle feeding, and were less likely to desaturate to <90% oxygen during breastfeeding. Mean weight gain was greater during bottle feeding than during breastfeeding (31 vs 9 g).

Conclusions. Breastfeeding the ELBW infant is desirable from a standpoint of improved physiologic responses, but such practice requires breastfeeding support and possible supplementation to optimize weight gain.
A Comparative Efficacy Trial in Germany in Infants Who Received Either the Lederle/Takeda Acellular Pertussis Component DTP (DTaP) Vaccine, the Lederle Whole-Cell Component DTP Vaccine, or DT Vaccine
Authors: Stehr Klemens , Cherry James D. , Heininger Ulrich , Schmitt-Grohé Sabina , Überall Michael , Laussucq Suzanne , Eckhardt Thomas , Meyer Martin , Engelhardt Rita , Christenson Peter ,   the Pertussis Vaccine Study Group
Published: August 2004

Background. The goal of the trial was to determine the efficacy of a multicomponent acellular pertussis vaccine against Bordetella illnesses in comparison with a whole-cell product and DT.

Design. In a randomized, double-blind fashion, 2- to 4-month-old infants received 4 doses of either DTP or DTaP vaccine at 3, 4.5, 6, and 15 to 18 months of age. The controls received 3 doses (3, 4.5, 15 to 18 months of age) of DT vaccine. The DTP vaccine was Lederle adsorbed vaccine (licensed in the United States) and DTaP was Lederle/Takeda adsorbed vaccine. Follow-up for vaccine efficacy started 2 weeks after the third dose (DTP/DTaP) and at the same age (6.5 months) in DT recipients. Reactogenicity of all doses of all three vaccines was documented by standardized parent diary cards. In addition, all subjects were monitored for respiratory illnesses and serious adverse events by biweekly phone calls.

Results. From May 1991 to January 1993, a total of 10 271 infants were enrolled: 8532 received either DTP or DTaP and 1739 received DT. Specific efficacy against B pertussisinfections with cough ≥7 days duration was 83% (95% confidence interval [CI]: 76–88) and 72% (95% CI: 62–79) for DTP and DTaP, respectively; results for DTP and DTaP based on ≥21 days of cough with either paroxysms, whoop or posttussive vomiting (PWV) were 93% (95% CI: 89–96) and 83% (95% CI: 76–88), respectively. For DTaP vaccine, efficacy was higher after the fourth dose as compared with its efficacy after the third dose (78% vs 62% for cough ≥7 days and 85% vs 76% for cough ≥21 days with PWV). For DTP vaccine, efficacy was less varied after the third and fourth dose (78% vs 85% for cough ≥7 days and 93% vs 93% for cough ≥21 days with PWV). In contrast with DTP, the DTaP vaccine had some efficacy against B parapertussisinfection (point estimate for cough ≥7 days: 31% [95% CI: −10–56]). All vaccines were generally well-tolerated. However, side reactions were significantly less after DTaP compared with DTP.

Conclusions. Like other multicomponent acellular pertussis vaccines, the Lederle/Takeda DTaP vaccine demonstrated good efficacy against mild and typical pertussis due to B pertussisinfections. Interestingly, it also may have some efficacy againstB parapertussis. Based on the results of this trial, the vaccine was licensed in the United States in December 1996 for all 5 doses of the currently recommended immunization schedule in this country.
Severe Invasive Group A Streptococcal Infections: A Subject Review
Authors:   Committee on Infectious Diseases
Published: August 2004

This Policy Statement was retired October 2004.

The course of severe invasive group A β-hemolytic streptococcal (GABHS) infections is often precipitous, requiring prompt diagnosis and rapid initiation of appropriate therapy. Therefore, physicians must have a high index of suspicion of this disease, particularly in patients at increased risk (eg, those with varicella or diabetes mellitus). Although a relationship between the use of nonsteroidal antiinflammatory drugs and severe invasive GABHS infections has been suggested, at present data on which to base a clinical decision about the use or restriction of nonsteroidal antiinflammatory drugs in children with varicella are insufficient. When necrotizing fasciitis is suspected, prompt surgical drainage, debridement, fasciotomy, or amputation often is necessary. Many experts recommend intravenously administered penicillin G and clindamycin for the treatment of invasive GABHS infections on the basis of animal studies. Some evidence exists that intravenous immunoglobulin given in addition to appropriate antimicrobial and surgical therapy may be beneficial. Although chemoprophylaxis for household contacts of persons with invasive GABHS infections has been considered by some experts, the limited available data indicate that the risk of secondary cases is low (2.9 per 1000) and data about the effectiveness of any drug are insufficient to make recommendations. Because of the low risk of secondary cases of invasive GABHS infections in schools or child care facilities, chemoprophylaxis is not indicated in these settings. Routine immunization of all healthy children against varicella is recommended and is an effective means to decrease the risk of invasive GABHS infections.
Soy Protein-based Formulas: Recommendations for Use in Infant Feeding
Authors:   Committee on Nutrition
Published: August 2004

The American Academy of Pediatrics is committed to the use of maternal breast milk as the ideal source of nutrition for infant feeding. Even so, by 2 months of age, most infants in North America are formula-fed. Despite limited indications, the use of soy protein-based formula has nearly doubled during the past decade to achieve 25% of the market in the United States. Because an infant formula provides the largest, if not sole, source of nutrition for an extended interval, the nutritional adequacy of the formula must be confirmed and the indications for its use well understood. This statement updates the 1983 Committee on Nutrition review1 and contains some important recommendations on the appropriate use of soy protein-based formulas.
Lead Levels in High-risk and Low-risk Young Children in the Minneapolis-St Paul Metropolitan Area
Authors: Nordin James , Rolnick Sharon , Ehlinger Ed , Nelson Andrew , Arneson Tom , Cherney-Stafford Linda , Griffin Joan
Published: August 2004

Objectives. To determine distribution of lead levels among children in a low-risk area; to validate a prescreening questionnaire; and to determine if universal lead screening is necessary in children in this area.

Design. Blood lead levels and questionnaires were obtained on eligible patients. Data were analyzed using stepwise regression analysis.

Setting. Community clinics and a health maintenance organization (HMO) in the Minneapolis-St Paul metropolitan area.

Patients. A total of 9603 children at well-child visits, age 6 months to 6 years at community clinics, and 6 months to 3 years at the HMO.

Outcome Measures. Whole blood lead levels (WBLs) and questionnaires.

Results. The total sample rate of WBLs at ≥10 μg/dL was 12%, at ≥15 μg/dL was 3½%, and at ≥20 μg/dL was 1.2%. At both 10 μg/dL and 15 μg/dL, the non-HMO group was at higher risk. For both groups, risk factors included living in the central cities, and living in housing built before 1950. For the non-HMO group a history of the child eating paint chips, or the child or a sibling having previous lead poisoning were also risk factors.

Conclusions. Not all children need lead screening. Children living in the central cities, or with the risk factors of living in housing built before 1950 or a previous history of lead poisoning should be screened.
The Apgar Score and Its Components in the Preterm Infant
Authors: Hegyi Thomas , Carbone Tracy , Anwar Mujahid , Ostfeld Barbara , Hiatt Mark , Koons Anne , Pinto-Martin Jennifer , Paneth Nigel
Published: August 2004

Objective. The Apgar score is well-characterized in full-term infants but not in premature infants. The objective of this study was to assess the Apgar score in preterm infants with respect to the relationships between the 1- and 5-minute scores, the correlation of the Apgar score with pH and with other variables, and the relationship among the individual Apgar components.

Methodology. We recorded Apgar scores at 1 and 5 minutes in a population-based cohort of preterm infants (n = 1105) with birth weight <2000 g, from three intensive care nurseries in central New Jersey. Linear correlation analysis was used to examine the relationship between 1- and 5-minute Apgar scores and between the individual components of the Apgar score. Multiple regression analysis was used to explore the relationship between various perinatal characteristics and the Apgar score, and between pH and Apgar score. Stepwise logistic regression analysis was used to assess the determinants of mortality.

Results. The 1-minute Apgar score median (25%, 75%) was 6(4,8) and correlated with the 5-minute score of 8(7,9) atr = .78. Slight but significant differences were seen between male (n = 557) and female (n = 508) infants in the 1-minute (6[4,8] and 7[4,8]) Apgar scores. One- and 5-minute scores of white infants (7[4,8] and 8[7,9]; n = 713) were significantly higher than those of black infants (5[3,7] and 8[6,9]; n = 280). Birth weight and gestational age were both linearly related to both Apgar scores. Low Apgar score (<3 at 1 minute and <6 at 5 minutes) was significantly associated with birth weight, gestational age and mode of delivery. Low arterial blood pH (<7.01) at birth was significantly related to low Apgar score. One hundred fifty-nine infants died; these infants were significantly smaller (983 ± 382 vs 1462 ± 369 g), less mature (27 vs 31 weeks), had lower arterial blood pH (7.20 ± 0.18 vs 7.31 ± 0.11), had lower 1- (3[2,6] vs 7[4,8]) and 5-minute Apgar scores (6[4,8] vs 8[7,9]), and a greater incidence of low Apgar score (32% vs 6%) than did survivors.

Conclusions. Among the components of the Apgar score, respiratory effort, muscle tone, and reflex activity correlated well with one another; heart rate correlated less well; and color the least. Our data confirms the limited use of the Apgar score in preterm infants and demonstrates the different responses of the Apgar score's components.
Increasing Prevalence of Overweight Among US Low-income Preschool Children: The Centers for Disease Control and Prevention Pediatric Nutrition Surveillance, 1983 to 1995
Authors: Mei Zuguo , Scanlon Kelley S. , Grummer-Strawn Laurence M. , Freedman David S. , Yip Ray , Trowbridge Frederick L.
Published: August 2004

Objective. To determine whether the prevalence of overweight in preschool children has increased among the US low-income population.

Design. Analysis using weight-for-height percentiles of surveillance data adjusted for age, sex, and race or ethnicity.

Setting. Data from 18 states and the District of Columbia were examined.a

Subjects. Low-income children <5 years of age who were included in the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System.

Results. The prevalence of overweight increased from 18.6% in 1983 to 21.6% in 1995 based on the 85th percentile cutoff point for weight-for-height, and from 8.5% to 10.2% for the same period based on the 95th percentile cutoff point. Analyses by single age, sex, and race or ethnic group (non-Hispanic white, non-Hispanic black, and Hispanic) all showed increases in the prevalence of overweight, although changes are greatest for older preschool children.

Conclusion. Overweight is an increasing public health problem among preschool children in the US low-income population. Additional research is needed to explore the cause of the trend observed and to find effective strategies for overweight prevention beginning in the preschool years.
Fluoride Supplement Prescribing and Dental Referral Patterns Among Academic Pediatricians
Authors: Roberts Michael W. , Keels Martha Ann , Sharp Michael C. , Lewis Jasper L.
Published: August 2004

Objective. To determine how well the current fluoride supplementation schedule was known by academic pediatricians and to examine the fluoride supplement prescribing and dental referral practices among primary care faculty pediatricians at four medical centers.

Setting. Four university medical centers in North Carolina.

Subjects. Primary care faculty pediatricians.

Method. A questionnaire pretested for clarity was distributed to all identified full-time primary care pediatric faculty (42 members).

Results. A total of 40 completed questionnaires were returned. Thirty-seven (93%) primary care faculty pediatricians reported that they routinely addressed the need for fluoride supplements for their patients, but only 28 (70%) determined the fluoride content of the drinking water before prescribing supplements. Thirty-five (87.5%) began supplements at the correct age, but fewer knew the correct doses for children of various ages. Only 23 (58%) referred their patients for oral examination and preventive care before the age of 36 months, contrary to American Academy of Pediatrics recommendations.

Conclusions. Pediatricians in an academic setting would be expected to be more knowledgeable of current recommendations than those in private practice. Failure to know and teach correct fluoride supplement recommendations and failure to recommend early professional dental involvement can result in less than optimum oral health.
Effect of Allopurinol on Postasphyxial Free Radical Formation, Cerebral Hemodynamics, and Electrical Brain Activity
Authors: Van Bel Frank , Shadid Majidah , Moison Ralf M. W. , Dorrepaal Caroline A. , Fontijn Jehudith , Monteiro Louisa , Van De Bor Margot , Berger Howard M.
Published: August 2004

Objective. Free radical-induced postasphyxial reperfusion injury has been recognized as an important cause of brain tissue damage. We investigated the effect of high-dose allopurinol (ALLO; 40 mg/kg), a xanthine-oxidase inhibitor and free radical scavenger, on free radical status in severely asphyxiated newborns and on postasphyxial cerebral perfusion and electrical brain activity.

Methods. Free radical status was assessed by serial plasma determination of nonprotein-bound iron (μm), antioxidative capacity, and malondialdehyde (MDA; μm). Cerebral perfusion was investigated by monitoring changes in cerebral blood volume (ΔCBV; mL/100 g brain tissue) with near infrared spectroscopy; electrocortical brain activity (ECBA) was assessed in microvolts by cerebral function monitor. Eleven infants received 40 mg/kg ALLO intravenously, and 11 infants served as controls (CONT). Plasma nonprotein-bound iron, antioxidative capacity, and MDA were measured before 4 hours, between 16 and 20 hours, and at the second and third days of age. Changes in CBV and ECBA were monitored between 4 and 8, 16 and 20, 58 and 62, and 104 and 110 hours of age.

Results. Six CONT and two ALLO infants died after neurologic deterioration. No toxic side effects of ALLO were detected. Nonprotein-bound iron (mean ± SEM) in the CONT group showed an initial rise (18.7 ± 4.6 μm to 21.3 ± 3.4 μm) but dropped to 7.4 ± 3.5 μm at day 3; in the ALLO group it dropped from 15.5 ± 4.6 μm to 0 μm at day 3. Uric acid was significantly lower in ALLO-treated infants from 16 hours of life on. MDA remained stable in the ALLO group, but increased in the CONT group at 8 to 16 hours versus <4 hours (mean ± SEM; 0.83 ± 0.31 μm vs 0.50 ± 0.14 μm). During 4 to 8 hours, ΔCBV–CONT showed a larger drop than ΔCBV–ALLO from baseline. During the subsequent registrations CBV remained stable in both groups. ECBA–CONT decreased, but ECBA–ALLO remained stable during 4 to 8 hours of age. Neonates who died had the largest drops in CBV and ECBA.

Conclusion. This study suggests a beneficial effect of ALLO treatment on free radical formation, CBV, and electrical brain activity, without toxic side effects.
Modulation of the Immune System by Human Milk and Infant Formula Containing Nucleotides
Authors: Pickering Larry K. , Granoff Dan M. , Erickson Julie Reed , Masor Marc L. , Cordle Christopher T. , Schaller Joseph P. , Winship Timothy R. , Paule Charles L. , Hilty Milo D.
Published: August 2004

Objective. To determine whether human milk and nucleotides added to infant formula at levels present in human milk enhance development of the immune system during infancy.

Methods. A 12-month, controlled, randomized and blinded, multisite feeding trial was conducted on two infant formulas: iron-fortified, milk-based control formula (Control) or the same formula fortified with nucleotides (Nucleotide). The level (72 mg/L) and ratio of individual nucleotides selected were patterned after those available in human milk. A third group fed human milk exclusively for 2 months and then human milk or Similac with iron until 12 months of age also was studied. Response to immunizations was chosen to assess development of the immune system. Infants followed the immunization schedule recommended by the American Academy of Pediatrics in 1991.

Outcome Variables. Antibody responses were determined at 6, 7, and 12 months of age to Haemophilus influenzae type b polysaccharide (Hib), to diphtheria and tetanus toxoids, and to oral polio virus (OPV) immunizations.

Results. Of 370 full-term, healthy infants enrolled, 311 completed the study (107 Control, 101 Nucleotide, 103 human milk/Similac with iron). Intake, tolerance, and growth of infants were similar in all three groups. Compared with the Control group 1 month after the third immunization (7 months of age), the Nucleotide group had a significantly higher Hib antibody concentration (geometric mean concentrations of 7.24 vs 4.05 μg/mL, respectively), and a significantly higher diphtheria antibody concentration (geometric mean of 1.77 vs 1.38 U/mL). The significantly higher Hib antibody response in the Nucleotide group persisted at 12 months. The antibody responses to tetanus and OPV were not enhanced by nucleotide fortification. There also was an effect of breastfeeding on immune response. Infants who breastfed had significantly higher neutralizing antibody titers to polio virus than either formula-fed group (1:346 vs 1:169 and 1:192 in the Control and Nucleotide groups, respectively) at 6 months of age.

Conclusion. Infant formula fortified with nucleotides enhanced H influenzae type b and diphtheria humoral antibody responses. Feeding human milk enhanced antibody response to OPV. Dietary factors play a role in the antibody response of infants to immunization.
Safety of Hospitalized Ventilator-dependent Children Outside of the Intensive Care Unit
Authors: Ambrosio Iris U. , Woo Marlyn S. , Jansen Mary T. , Keens Thomas G.
Published: August 2004

Objective. Hospitalization of clinically stable ventilator-dependent children in an intensive care unit (ICU) remains the standard in most pediatric centers. The aim of this study was to determine whether chronically ventilator-dependent children could be hospitalized safely in a non-ICU setting.

Methods. All ventilator-dependent children who were hospitalized on the pediatric wards at Childrens Hospital Los Angeles from December 1992 through June 1996 were reviewed retrospectively (N = 63) and compared with the general pediatric ward population hospitalized during the same period. Data collected included the number of unexpected ICU transfers from the pediatric ward and the number of deaths that occurred on the ward.

Results. The ventilator-dependent children on the pediatric wards had 11 emergency readmissions to the ICU for unexpected deterioration. This represented an unexpected ICU transfer rate of 2.7 per 1000 patient-days on the wards. The general pediatric ward population had an unexpected ICU transfer rate of 3.3 per 1000 patient-days, which was not significantly different from that of ventilator-dependent children on the wards. There were three ward deaths among the ventilator-dependent children, but all of these patients had advance directive status (do not resuscitate). This represented a rate of seven deaths per 10 000 patient-days on the wards, which was not significantly different from those of nonventilator-dependent ward patients (eight deaths per 10 000 patient-days).

Conclusions. We conclude that ventilator-dependent children hospitalized outside of the ICU do not have an increased incidence of deaths and unexpected ICU admissions compared with nonventilator-dependent inpatients. We speculate that hospital care of stable ventilator-dependent children can be provided safely outside of an ICU and at lower cost.
Mutation Screening of the BTK Gene in 56 Families With X-Linked Agammaglobulinemia (XLA): 47 Unique Mutations Without Correlation to Clinical Course
Authors: Holinski-Feder Elke , Weiss Michael , Brandau Oliver , Jedele Kerry B. , Nore Beston , Bäckesjö C. Magnus , Vihinen Mauno , Hubbard Stevan R. , Belohradsky Bernd H. , Smith C.I. Edvard , Meindl Alfons
Published: August 2004

Objectives. To determine the utility of single-stranded conformation polymorphism (SSCP) analysis for mutation screening in the BTK (Bruton's tyrosine kinase) gene, we investigated 56 X-linked agammaglobulinemia (XLA) families. To obtain genotype/phenotype correlations, predicted protein aberrations were correlated with the clinical course of the disease.

Patients. This study included 56 patients with XLA, with or without a positive family history, who were diagnosed on the basis of their clinical features, low peripheral B-cell count, and low immunoglobulin levels. Ten patients with isolated hypogammaglobulinemia and 50 healthy males served as controls.

Methods. SSCP analysis was performed for the entire BTK gene, including the exon–intron boundaries and the promoter region. Structural implications of the missense mutations were investigated by molecular modeling, and the functional consequences of some mutations also were evaluated by in vitro kinase assays and Western blot analysis.

Results. We report the largest series of patients with XLA to date. All but 5 of the 56 index patients with XLA screened with SSCP analysis showed BTK gene abnormalities, and in 2 of the 5 SSCP-negative patients, no BTK protein was found by Western blot analysis. There were 51 mutations, including 37 novel ones, distributed across the entire gene. This report contains the first promoter mutation as well as 14 novel missense mutations with the first ones described for the Tec homology domain and the glycine-rich motif in the SH1 domain. Each index patient had a different mutation, except for four mutations, each in two unrelated individuals. This result supports the strong tendency for private mutations in this disease. No mutations were found in the controls.

Conclusions. Our results demonstrate that molecular genetic testing by SSCP analysis provides an accurate tool for the definitive diagnosis of XLA and the discrimination of borderline cases, such as certain hypogammaglobulinemia or common variable immunodeficiency patients with overlapping clinical features. Genotype/phenotype correlations are not currently possible, making prediction of the clinical course based on molecular genetic data infeasible.