bluuebunny/crossref_metadata_2025 huggingface dataset:
A 1000-Fold Overdose of Clonidine Caused by a Compounding Error in a 5-Year-Old Child With Attention-Deficit/Hyperactivity Disorder
Authors: Romano Michael J. , Dinh Ann
Published: August 2004

A 5-year-old child who weighed 17.5 kg received 50 mg of clonidine. The amount ingested was confirmed by analysis of the suspension administered (clonidine HCl 9.78 mg/mL). To our knowledge, this represents the largest ingestion in a child and the largest ingestion on a milligram per kilogram basis in the medical literature. The child's initial presentation included hyperventilation, an unusual feature of clonidine toxicity. The child was discharged without sequela 42 hours after admission. A serum concentration of clonidine 17 hours postingestion was 64 ng/mL, the highest reported to date in a pediatric patient. The intoxication was traced to a pharmacy compounding error in which milligrams were substituted for micrograms. Increased prescribing of clonidine in young children coupled with the requirement to compound clonidine in a suspension and the narrow therapeutic index suggests that the frequency of severe ingestions in children will increase in the future.
Optic Neuropathy in Children With Lyme Disease
Authors: Rothermel Holly , Hedges Thomas R. , Steere Allen C.
Published: August 2004

Involvement of the optic nerve, either because of inflammation or increased intracranial pressure, is a rare manifestation of Lyme disease. Of the 4 children reported here with optic nerve abnormalities, 2 had decreased vision months after disease onset attributable to optic neuritis, and 1 had headache and diplopia early in the infection because of increased intracranial pressure associated with Lyme meningitis. In these 3 children, optic nerve involvement responded well to intravenous ceftriaxone therapy. The fourth child had headache and visual loss attributable to increased intracranial pressure and perhaps also to optic neuritis. Despite treatment with ceftriaxone and steroids, he had persistent increased intracranial pressure leading to permanent bilateral blindness. Clinicians should be aware that neuro-ophthalmologic involvement of Lyme disease may have significant consequences. If increased intracranial pressure persists despite antibiotic therapy, measures must be taken quickly to reduce the pressure.
Drug-Induced Hypersensitivity Syndrome in Pediatric Patients
Authors: Carroll Maria C. , Yueng-Yue Kimberly A. , Esterly Nancy B. , Drolet Beth A.
Published: August 2004

The antiepileptic hypersensitivity syndrome is a severe, multiorgan reaction to oral antiepileptics that manifests as fever, rash, lymphadenopathy, and hepatitis. This same reaction pattern also has been described following administration of a few unrelated medications. We report on 11 patients who had drug-induced hypersensitivity syndrome and were admitted to our pediatric service and review 94 cases of this syndrome in pediatric patients identified from the literature. We undertook this study to summarize the findings and alert clinicians to the severe internal organ involvement that can occur with this syndrome.
Technical Report: Knee Brace Use in the Young Athlete
Authors: Martin Thomas J. ,   the Committee on Sports Medicine and Fitness
Published: August 2004

This Technical Report was retired June 2014.

This statement is a revision of a previous statement on prophylactic knee bracing and provides information for pediatricians regarding the use of various types of knee braces, indications for the use of knee braces, and the background knowledge necessary to prescribe the use of knee braces for children.
Assessment of Maltreatment of Children With Disabilities
Authors:   Committee on Child Abuse and Neglect and Committee on Children With Disabilities
Published: August 2004

Widespread efforts are continuously being made to increase awareness and provide education to pediatricians regarding risk factors of child abuse and neglect. The purpose of this statement is to ensure that children with disabilities are recognized as a population that is also at risk for maltreatment. The need for early recognition and intervention of child abuse and neglect in this population, as well as the ways that a medical home can facilitate the prevention and early detection of child maltreatment, should be acknowledged.
School Bus Transportation of Children With Special Health Care Needs
Authors:   Committee on Injury and Poison Prevention
Published: August 2004

School systems are responsible for ensuring that children with special needs are safely transported on all forms of federally approved transportation provided by the school system, and a plan should be developed to provide the most current and proper support to children with special transportation requirements. This statement provides current guidelines for the protection of child passengers with specific health care needs, including those with a tracheostomy, those requiring use of car seats, or those transported in wheelchairs. Guidelines that apply to general school transportation should be followed, including the training of staff, provision of nurses or aides if needed, establishment of a written emergency evacuation plan, and a comprehensive infection control program.

Research provides the basis for recommendations concerning occupant securement for children in wheelchairs and children with other special needs who are transported on a school bus. Pediatricians can help their patients by being aware of guidelines for restraint systems for children with special needs and by remaining informed of new resources. Pediatricians can also play an important role at the state and local level in the development of school bus specifications.
Brain White-Matter Lesions in Celiac Disease: A Prospective Study of 75 Diet-Treated Patients
Authors: Kieslich Matthias , Errázuriz Germán , Posselt Hans Georg , Moeller-Hartmann Walter , Zanella Friedhelm , Boehles Hansjosef
Published: August 2004

Objective.

Celiac disease (CD), or gluten sensitivity, is considered to be a state of heightened immunologic responsiveness to ingested gluten proteins in genetically predisposed individuals. The gastrointestinal manifestation suggests a severe enteropathy of the small intestine with malabsorption, steatorrhea, and weight loss because of a deranged mucosal immune response. Neurologic complications occur, especially epilepsy, possibly associated with occipital calcifications or folate deficiency and cerebellar ataxia. There have been reports of brain white-matter lesions as an extraintestinal manifestation in Crohn disease and ulcerative colitis but not in CD.

Methods.

In this study, 75 diet-treated mainly pediatric patients with biopsy-proven CD underwent prospectively clinical neurologic examinations, laboratory investigations, electroencephalography, computed tomography, and magnetic resonance imaging. The age range was 2.8 to 24.2 years with a mean of 11.6 years. The mean period of gluten exposure was 2.4 years.

Results.

Ten patients had neurologic findings such as febrile seizures, single generalized seizures, mild ataxia, and muscular hypotonia with retarded motor development. No folate deficiency was found. The hippocampal regions showed no abnormalities. Computed tomography did not reveal any cerebral calcifications, but magnetic resonance imaging detected unilateral and bilateral T2-hyperintensive white-matter lesions in 15 patients (20%). There was no correlation between these lesions and dietary compliance or neurologic or electroencephalographic abnormalities. The mean gluten exposure time of these patients was slightly increased (not significant).

Conclusions.

Focal white-matter lesions in the brain may represent an extraintestinal manifestation of CD. They may be ischemic in origin as a result of a vasculitis or caused by inflammatory demyelination. They seem to be more typical of pediatric CD than cerebral calcifications. Their prognostic value is unclear and needs to be elucidated in additional studies. CD should be suggested as a differential diagnosis in children with unclear white-matter lesions even without intestinal symptoms.
Infection With Sin Nombre Hantavirus: Clinical Presentation and Outcome in Children and Adolescents
Authors: Ramos Mary M. , Overturf Gary D. , Crowley Mark R. , Rosenberg Robert B. , Hjelle Brian
Published: August 2004

Objective.

Sin Nombre hantavirus (SNV) is the leading causative agent of hantavirus cardiopulmonary syndrome (HCPS) in the United States and Canada. Relatively few cases of HCPS have involved children. This report describes the clinical characteristics of a series of pediatric cases of SNV infection in the United States and Canada from 1993 through March 2000.

Methods.

We analyzed clinical and laboratory data on 13 patients who were ≤16 years old with SNV infection from 1993 through March 2000 identified from a database at the University of New Mexico.

Results.

The patients ranged from 10 to 16 years of age, with a median of 14. Fifty-four percent were female. Fifty-four percent were Native American. The most common prodromal symptoms were fever, headache, and cough or dyspnea (100%); nausea or vomiting (90%); and myalgia (80%). The most common physical findings at admission were tachypnea (67%) and fever (56%); hypotension was seen in 33% of patients. On admission, all patients manifested thrombocytopenia (median platelet count: 67 000/mm3) and elevated lactate dehydrogenase (median level: 1243 IU/L), and >85% of patients had elevated levels of serum aspartate aminotransferase, alanine aminotransferase, and hypoalbuminemia. Leukocytosis and hemoconcentration were seen in less than one third of patients at admission. HCPS developed in 12 of the 13 patients (92%), and 4 of those 12 died (33% case-fatality ratio). The majority of HCPS patients (8 of 12 [67%]) were critically ill and required mechanical ventilation. Extracorporeal membrane oxygenation was used in 2 patients, 1 of whom survived. An elevated prothrombin time (≥14 seconds) at admission was predictive of mortality.

Conclusions.

Infection with SNV in children and adolescents causes HCPS with a clinical course and mortality rate similar to that described in adults. We believe that early recognition of HCPS in children and adolescents and appropriate referral to tertiary care centers that are experienced with HCPS are important in reducing mortality.
Predictors of Mother–Adolescent Discussions About Condoms: Implications for Providers Who Serve Youth
Authors: Miller Kim S. , Whitaker Daniel J.
Published: August 2004

Objective.

To examine predictors of mother–adolescent communication about condoms.

Methods.

Interviews were conducted with 907 mothers of adolescents aged 14 to 17 years in the Bronx, New York; Montgomery, Alabama; and San Juan, Puerto Rico, to determine whether mothers had talked with their adolescent about condoms.

Results.

By univariate analysis, mother–adolescent communication about condoms was associated with greater knowledge about sexuality and acquired immunodeficiency syndrome, perception of having enough information to discuss condoms, information from a health-related source, less conservative attitudes about adolescent sexuality, perception that the adolescent was at risk for human immunodeficiency virus, greater ability and comfort in discussing condoms, stronger belief that condoms prevent human immunodeficiency virus/acquired immunodeficiency syndrome, and a more favorable endorsement of condoms. In multivariate analyses, mother–adolescent communication about condoms was associated with a less conservative attitude about abstinence until marriage (odds ratio [OR]: 0.73; 95% confidence interval [CI]: 0.54–0.74), greater skill in communicating about sex (OR: 1.13; 95% CI: 1.06–1.20), greater comfort in communicating about sex (OR: 1.31; 95% CI: 1.01–1.69), a more favorable endorsement of condoms (OR: 1.85; 95% CI: 1.17–2.78), and the perception that the adolescent's friends were sexually active (OR: 3.53; 95% CI: 1.97–7.16).

Conclusion.

Parents who communicate effectively about sexuality and safer sex behaviors can influence their adolescents' risk-taking behavior. Health care providers, particularly physicians, can facilitate this communication by providing to parents information about the sexual behavior of adolescents, the risks that adolescents encounter, condom use, condom effectiveness, and how to discuss condoms. They also can make referrals to programs that teach communication skills.
Disseminated Vaccine Strain Varicella as the Acquired Immunodeficiency Syndrome-Defining Illness in a Previously Undiagnosed Child
Authors: Kramer J. Michael , LaRussa Philip , Tsai Wan C. , Carney Paul , Leber Steven M. , Gahagan Sheila , Steinberg Sharon , Blackwood R. Alexander
Published: August 2004

The Food and Drug Administration licensed a live-virus varicella vaccine (Varivax; Merck & Co Inc, West Point, PA) in March 1995. Prelicensure adverse events were minimal; however, since licensure and increased vaccine use, rare previously undetected risks have arisen. Presented here is the clinical course of a previously undiagnosed, human immunodeficiency virus-infected boy who developed dissemination of the vaccine strain of varicella zoster after immunization. chickenpox, human immunodeficiency virus, pneumonia, encephalopathy, varicella vaccine, adverse events, dissemination.
A Community Intervention Trial to Promote Judicious Antibiotic Use and Reduce Penicillin-ResistantStreptococcus pneumoniaeCarriage in Children
Authors: Belongia Edward A. , Sullivan Bradley J. , Chyou Po-Huang , Madagame Elisabeth , Reed Kurt D. , Schwartz Benjamin
Published: August 2004

Objective.

Inappropriate use of antibiotics is common in primary care, and effective interventions are needed to promote judicious antibiotic use and reduce antibiotic resistance. The objective of this study was to assess the impact of parent and clinician education on pediatric antibiotic prescribing and carriage of penicillin-nonsusceptible Streptococcus pneumoniae in child care facilities.

Methods.

A nonrandomized, controlled, community intervention trial was conducted in northern Wisconsin Clinicians. Clinic staff received educational materials and small-group presentations; materials were distributed to parents through clinics, child care facilities, and community organizations. Prescribing data were analyzed for 151 clinicians who provided primary pediatric care; nasopharyngeal carriage of penicillin-nonsusceptible S pneumoniae was assessed for 664 children in the baseline period (January–June 1997) and for 472 children in the postintervention period (January–June 1998).

Results.

The median number of solid antibiotic prescriptions per clinician declined 19% in the intervention region and 8% in the control region. The median number of liquid antibiotic prescriptions per clinician declined 11% in the intervention region, compared with an increase of 12% in the control region. Retail antibiotic sales declined in the intervention region but not in the control region. Among participating children in child care facilities, there were no significant differences in antibiotic use or penicillin-nonsusceptible S pneumoniae colonization between the intervention and control regions.

Conclusions.

A multifaceted educational program for clinicians and parents led to community-wide reductions in antibiotic prescribing, but in child care facilities, there was no apparent impact on judicious antibiotic use or colonization with drug-resistantS pneumoniae. Longer follow-up time or greater reductions in antibiotic use may be required to identify changes in the pneumococcal susceptibility.
Prevalence of Infectious Diseases Among Internationally Adopted Children
Authors: Saiman Lisa , Aronson Jane , Zhou Juyan , Gomez-Duarte Cabilla , Gabriel Pablo San , Alonso Maria , Maloney Susan , Schulte Joann
Published: August 2004

Objective.

Internationally adopted children are at increased risk of infections acquired in their country of origin. Ongoing surveillance of this unique population is needed to detect changing epidemiology and provide appropriate care.

Methods.

We performed a retrospective cohort study of 504 children adopted from abroad and evaluated from 1997 to 1998 to determine the prevalence of and factors associated with various infectious diseases.

Results.

The mean age of the study participants at medical evaluation was 1.6 years; 71% were girls, and they were adopted from 16 countries, including China (48%), Russia (31%), Southeast Asia (8%), Eastern Europe (8%), and Latin America (5%). Overall, 75 (19%) of 404 children tested had tuberculin skin tests ≥10 mm, but all had normal chest radiographs. BCG vaccination (odds ratio [OR]: 7.37; 95% confidence interval [CI]: 3.29, 17.16) and being Russian born (OR: 2.90; 95% CI: 1.68, 5.00) were risk factors for latent tuberculosis infection. Fourteen (2.8%) children had detectable hepatitis B surface antigen, but no child had active hepatitis C, human immunodeficiency virus, or syphilis. Giardia lambliaantigen was detected in 87 (19%) of 461 tested children, and such children were older (mean: 22 months vs 15.5 months) and more likely to have been born in Eastern Europe (OR: 2.82; 95% CI: 1.70, 4.68).

Conclusions.

We demonstrated increased rates of latent tuberculosis infection and G lamblia infection than previously reported. Thus, ongoing surveillance of internationally adopted children, international trends in infectious diseases, and appropriate screening will ensure the long-term health of adopted children as well as their families.
Respiratory Instability of Term and Near-Term Healthy Newborn Infants in Car Safety Seats
Authors: Merchant Jennifer R. , Worwa Cathy , Porter Sharon , Coleman J. M. , deRegnier Raye-Ann O.
Published: August 2004

Objective.

Premature infants who are discharged from intensive care nurseries are known to be at increased risk for apnea, bradycardia, and oxygen desaturation while in the upright position. These small infants also do not fit securely in standard infant car seats. Because of these problems, the American Academy of Pediatrics recommends a period of observation in a car seat for all infants who are born at <37 weeks' gestation. It is not clear whether this recommendation should apply to the minimally preterm infants (born at 35–36 weeks' gestation) who are healthy at birth and are hospitalized in the normal newborn nursery. The objective of this study was to evaluate the respiratory stability and safety requirements of healthy, minimally preterm infants in car seats compared with term infants.

Methods.

Fifty healthy, nonmonitored, preterm infants (mean gestational age: 35.8 ± 0.6 weeks) and 50 term infants (mean gestational age: 39.5 ± 1.4 weeks) were recruited from a level I newborn nursery in a community hospital. Appropriateness of car seat fit was documented for each infant. Heart rate, respiratory rate, and pulse oximetry were evaluated while infants were supine and in their car seats. Apneic and bradycardic events were recorded in addition to a continuous recording of oxygen saturation values.

Results.

Twenty-four percent of preterm and 4% of term newborn infants did not fit securely into suitable car seats despite the use of blanket rolls. Mean oxygen saturation values declined significantly in both preterm and term infants from 97% in the supine position (range: 92%–100%) to 94% after 60 minutes in their car seats (range: 87%–100%). Seven infants (3 preterm and 4 term) had oxygen saturation values of <90% for longer than 20 minutes in their car seats. Twelve percent of the preterm infants (95% confidence interval: 4.5%–24.3%) but no term infants had apneic or bradycardic events in their car seats.

Conclusions.

Our data support the current American Academy of Pediatrics recommendations that all infants who are born at <37 weeks' gestation, including those who are admitted to level I community hospitals, be observed for respiratory instability and secure fit in their car seats before hospital discharge. Because lowering of oxygen saturation values was seen uniformly in all newborn infants, car seats should be used only for travel, and travel should be minimized during the first months of life.
End-of-Life Care for Neonates and Infants: The Experience and Effects of a Palliative Care Consultation Service
Authors: Pierucci Robin L. , Kirby Russell S. , Leuthner Steven R.
Published: August 2004

Objective.

Neonates and infants have the highest death rate in the pediatric population, yet there is a paucity of data about their end-of-life care and whether a palliative care service can have an impact on that care. The objective of this study was to describe end-of-life care for infants, including analysis of palliative care consultations conducted in this population. We hypothesized that the palliative care consultations performed had an impact on the infants' end-of-life care.

Design.

A retrospective chart review using the “End of Life Chart Review” from the Center to Improve Care for the Dying was conducted. The participants were the patients at Children's Hospital of Wisconsin who died at <1 year of age during the 4-year period between January 1, 1994, and December 31, 1997. The patients' place of death, medical interventions performed, and emotionally supportive services provided to families were analyzed.

Results.

Among the 196 deaths during the study period, 25 (13%) of these infants and families had palliative care consultations. The rate of consultations increased from 5% of the infant deaths in 1994 to 38% of the infant deaths in 1997. Infants of families that received consultations had fewer days in intensive care units, blood draws, central lines, feeding tubes, vasopressor and paralytic drug use, mechanical ventilation, cardiopulmonary resuscitation, and x-rays, and the families had more frequent referrals for chaplains and social services than families that did not have palliative care consultations.

Conclusions.

This study describes the end-of-life care that infants and their families received. Fewer medical procedures were performed, and more supportive services were provided to infants and families that had a palliative care consultation. This suggests that palliative care consultation may enhance end-of-life care for newborns.
The Assessment and Management of Acute Pain in Infants, Children, and Adolescents
Authors:   Committee on Psychosocial Aspects of Child and Family Health,   Task Force on Pain in Infants, Children, and Adolescents
Published: August 2004

Acute pain is one of the most common adverse stimuli experienced by children, occurring as a result of injury, illness, and necessary medical procedures. It is associated with increased anxiety, avoidance, somatic symptoms, and increased parent distress. Despite the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated. Numerous myths, insufficient knowledge among caregivers, and inadequate application of knowledge contribute to the lack of effective management. The pediatric acute pain experience involves the interaction of physiologic, psychologic, behavioral, developmental, and situational factors. Pain is an inherently subjective multifactorial experience and should be assessed and treated as such. Pediatricians are responsible for eliminating or assuaging pain and suffering in children when possible. To accomplish this, pediatricians need to expand their knowledge, use appropriate assessment tools and techniques, anticipate painful experiences and intervene accordingly, use a multimodal approach to pain management, use a multidisciplinary approach when possible, involve families, and advocate for the use of effective pain management in children.
Screening Examination of Premature Infants for Retinopathy of Prematurity
Authors:   Section on Ophthalmology
Published: August 2004

This statement revises a previous statement on screening of premature infants for retinopathy of prematurity originally published in 1997.
How Much Activity Do Youth Get? A Quantitative Review of Heart-Rate Measured Activity
Authors: Epstein Leonard H. , Paluch Rocco A. , Kalakanis Lisa E. , Goldfield Gary S. , Cerny Frank J. , Roemmich James N.
Published: August 2004

Objective.

Recommendations for adult physical activity have shifted from 20 to 60 minutes of continuous vigorous activity 3 to 5 times a week to accumulation of 30 minutes of moderate to vigorous physical activity most days of the week. Variations of these guidelines also have been suggested for children, based on the idea of accumulating moderate to vigorous physical activity throughout the day, rather than attaining vigorous physical activity in continuous blocks. The goal of this study was to assess accumulated amounts of physical activity at different intensities in children.

Methods.

We reviewed 26 studies (n = 1883) in youth aged 3 to 17 years that used heart-rate recording to measure physical activity in children to determine accumulated daily activity. Included were studies that provided time being active for at least 2 heart rate intensities at or above 120 beats/minute. Descriptive characteristics of the study groups were determined, and the influence of age, gender, and hours and days of observation on the slope of activity time as a function of percentage of heart rate reserve (HRR) was determined using hierarchical linear regression.

Results.

Youth attained 128.0 ± 45.6, 47.1 ± 14.9, 29.3 ± 13.7, and 14.7 ± 6.0 minutes/day between 20% to 40%, 40% to 50%, 50% to 60%, and greater than 60% HRR, respectively. Age was a significant predictor of the intercept and slope of the physical activity and %HRR relationship.

Conclusion.

Youth of all ages attain >60 minutes/day of low-intensity physical activity and approximately 30 minutes/day of activity at traditional cardiovascular fitness training levels of 50% or more of HRR. Recommendations for youth activity are discussed.
Rates of Pediatric and Adolescent Injuries by Year of Age
Authors: Agran Phyllis F. , Winn Diane , Anderson Craig , Trent Roger , Walton-Haynes Lynn
Published: August 2004

Objective.

The purpose of this study was to analyze causes of injury hospitalization/death by individual year of age and by specific causes of injury and to examine how well aggregate age groups represented individual year-of-age rates.

Methods.

Hospital discharge data and death certificate data for California residents age 0 to 19 years with a principal external cause of injury code (E-code) of E800 to E869, E880 to E929, or E950 to E999, calendar year 1997, were analyzed. Annual rates of injury hospitalization/death by year of age were calculated using combined hospital discharges and deaths as the numerator for major causes and important subcategories. For comparison, rates of injury hospitalization/death were calculated for conventional vital statistics age groups: <1 year, 1 to 4 years; 5 to 9 years, 10 to 14 years, and 15 to 19 years.

Results.

In 1997 in California, 35 277 children and adolescents 0 to 19 years were hospitalized and 1934 died as a result of injury, a ratio of 17 hospitalizations to 1 death. The distribution was bimodal with rates highest among 18-year-olds (732/100 000) and 1-year-olds (495/100 000). Except for children who were 5 to 9 years of age, the group rates for all injuries were not reflective of the individual year-of-age rates. In specific categories of injuries, variation in rates by year of age were masked by age group rates for unintentional poisoning among 1- to 4-year-olds, self-inflicted poisoning for 10- to 19-year-olds, falls from playground equipment among 5- to 9-year-olds, falls from furniture among 1- to 4-year-olds, and motor vehicle occupant injury rates among 10- to 19-year-olds. The peak rate of falls from playground equipment among 6-year-olds (34/100 000) was more than twice the rate for 9-year-olds (15/1000,000). Motor vehicle occupant injury rates doubled between 10 and 14 years of age and quadrupled between 14 and 18 years of age.

Conclusions.

Analyses using conventional age groups did not identify the age of highest risk for many causes of childhood injury. Changes in the rates often transected the traditional age groups and were not apparent with conventional age group analysis. These data can inform on the age at which to begin a specific injury intervention and on how to allocate resources. These data allow pediatricians and other health professionals to be anticipatory in providing injury prevention counseling. The greatest impact can be achieved by making the counseling topic most age appropriate in anticipation of the high-risk period.
The Association of Foster Care or Kinship Care With Adolescent Sexual Behavior and First Pregnancy
Authors: Carpenter Sara C. , Clyman Robert B. , Davidson Arthur J. , Steiner John F.
Published: August 2004

Objective.

Each year more than 500 000 children enter out-of-home placement. Few outcome studies of these children specifically address high-risk sexual behavior and adolescent pregnancy. Our study investigated the relationship between living in kinship or foster care and high-risk reproductive behaviors in a nationally representative sample of women.

Methods.

Data from 9620 women ages 15 to 44 years in the 1995 National Survey of Family Growth were analyzed in a cross-sectional study. Three groups—foster (n = 89), kinship (n = 513), and comparison (n = 9018)—were identified on the basis of self-reported childhood living situations. Bivariate and multiple linear regression analyses were performed. The outcome variables were age at first sexual intercourse and at first conception and the number of sexual partners.

Results.

After adjustment for multiple predictor variables, foster care was associated with younger age at first conception (difference: 11.3 months) and having greater than the median number of sexual partners (odds ratio: 1.7, 1.0–2.8). Kinship care was associated with younger age both at first intercourse (difference = 6 months) and at first conception (difference: 8.6 months) and having greater than the median number of sexual partners (odds ratio: 1.4, 1.1–1.8). There were no differences between the kinship and foster groups.

Conclusions.

A history of living in either foster or kinship care is a marker for high-risk sexual behaviors, and the risk is comparable in both out-of-home living arrangements. Recognition of these risks may enable health care providers to intervene with high-risk youth to prevent early initiation of sexual intercourse and early pregnancy.
Toxicity of Over-the-Counter Cough and Cold Medications
Authors: Gunn Veronica L. , Taha Samina H. , Liebelt Erica L. , Serwint Janet R.
Published: August 2004

Over-the-counter (OTC) cough and cold medications are marketed widely for relief of common cold symptoms, and yet studies have failed to demonstrate a benefit of these medications for young children. In addition, OTC medications can be associated with significant morbidity and even mortality in both acute overdoses and when administered in correct doses for chronic periods of time. Physicians often do not inquire about OTC medication use, and parents (or other caregivers) often do not perceive OTCs as medications. We present 3 cases of adverse outcomes over a 13-month period—including 1 death—as a result of OTC cough and cold medication use. We explore the toxicities of OTC cough and cold medications, discuss mechanisms of dosing errors, and suggest why physicians should be more vigilant in specifically inquiring about OTCs when evaluating an ill child.
Screening for Anemia in Children: AAP Recommendations—A Critique
Authors: Kohli-Kumar Mudra
Published: August 2004

The American Academy of Pediatrics (AAP) recommends screening for anemia between the ages of 9 to 12 months with additional screening between the ages of 1 and 5 years for patients at risk. The screening may be universal or selective depending on the prevalence of iron deficiency anemia in the population. Improved infant rearing practices—including wider availability, acceptance, and use of iron-fortified formulas; iron fortification of foods; and increased awareness of the importance of dietary iron supplementation especially early in life—have lead to significant decline in the incidence of anemia in the first year of life. However, incidence of iron deficiency and ensuing anemia in children between 1 and 2 years continues to be significant and an important issue.

Although iron deficiency may develop soon after cessation of or inadequate iron intake, anemia secondary to iron deficiency develops gradually over a period of several weeks to months. For children who have received/are receiving iron-fortified infant formulas and foods, hemoglobin screening at 9 to 12 months of age is inappropriate as there may not have been sufficient time to develop anemia, despite the rapid growth rate at this age. Widespread implementation of hemoglobin electrophoresis included in the neonatal metabolic screening programs in many states in the United States now has resulted in earlier diagnosis of hemoglobinopathies. Screening children at 9 to 12 months of age for hemoglobinopathies is somewhat redundant now. Screening for anemia before or around 1 year of age should continue to be important for communities and children at risk.

Universal screening of toddlers at a later time allows sufficient time for nutritional anemia to become evident after the child has been weaned off iron-fortified formulas, for the influence of toddler dietary fads to manifest, and for evaluation of tolerance of cow's milk protein. This may be addressed via 2 approaches. The first involves postponing the currently recommended screening or an additional screening for anemia between 15 to 18 months of age.

Determination of hemoglobin (or hematocrit) is not the optimal way to identify children at risk from effects of iron deficiency as it fails to identify patients who are iron-deficient but are not anemic. Long-term psychomotor, behavioral, and developmental effects secondary to iron deficiency anemia are known but sufficient data are lacking regarding the role of iron deficiency without anemia. Development and evaluation of sensitive, specific, and cost-effective screening tools to identify children at risk for iron deficiency is important. Until such methods are instituted, the AAP should emphasize and recommend universal screening for anemia during the second year of life.
Management of Febrile Children in the Age of the Conjugate Pneumococcal Vaccine: A Cost-Effectiveness Analysis
Authors: Lee Grace M. , Fleisher Gary R. , Harper Marvin B.
Published: August 2004

Objectives.

The optimal practice management of highly febrile 3- to 36-month-old children without a focal source has been controversial. The recent release of a conjugate pneumococcal vaccine may reduce the rate of occult bacteremia and alter the utility of empiric testing and treatment. The objective of this study was to determine the cost-effectiveness of 6 different management strategies of febrile 3- to 36-month-old children at current and declining rates of occult pneumococcal bacteremia.

Methods.

A cost-effectiveness (CE) analysis was performed to compare the strategies of “no work-up,” “clinical judgment,” “blood culture,” “blood culture + treatment,” “complete blood count (CBC) + selective blood culture and treatment,” and “CBC and blood culture + selective treatment.” A hypothetical cohort of 100 000 children who were 3 to 36 months of age and had a fever of ≥39°C and no source of infection was modeled for each strategy. Our main outcome measures were cases of meningitis prevented, life-years saved compared with “no work-up,” total cost (1999 dollars), and incremental CE ratios.

Results.

When compared with “no work-up,” the strategy of “CBC + selective blood culture and treatment” using a white blood cell (WBC) cutoff of 15 × 109/L prevents 48 cases of meningitis, saves 86 life-years per 100 000 patients, and is less costly at the current rate of bacteremia (1.5%). Using the strategy of “CBC + selective blood culture and treatment” with a lower WBC cutoff of 10 × 109/L costs an additional $72 300 per life-year saved. If the rate of bacteremia declines to 0.5%, then the incremental CE ratio of “clinical judgment” compared with “no work-up” is $38 000 per life-year saved; however, strategies that include empiric testing or treatment result in CE ratios greater than $300 000 per life-year saved.

Conclusions.

“CBC + selective blood culture and treatment” using a WBC cutoff of 15 × 109/L is cost-effective at the current rate of pneumococcal bacteremia. If the rate of occult bacteremia falls below 0.5% with widespread use of the conjugate pneumococcal vaccine, then strategies that use empiric testing and treatment should be eliminated.
Effect of Practice Variation on Resource Utilization in Infants Hospitalized for Viral Lower Respiratory Illness
Authors: Willson Douglas F. , Horn Susan D. , Hendley J. Owen , Smout Randall , Gassaway Julie
Published: August 2004

Objective.

Hospital care for children with viral lower respiratory illness (VLRI) is highly variable, and its relationship to severity and impact on outcome is unclear. Using the Pediatric Comprehensive Severity Index, we analyzed the correlation of institutional practice variation with severity and resource utilization in 10 children's medical centers.

Methods.

Demographics, clinical information, laboratory results, interventions, and outcomes were extracted from the charts of consecutive infants with VLRI from 10 children's medical centers. Pediatric Component of the Comprehensive Severity Index scoring was performed at admission and at maximum during hospitalization. The correlation of patient variables, interventions, and resource utilization at the patient level was compared with their correlation at the aggregate institutional level.

Results.

Of 601 patients, 1 died, 6 were discharged to home health care, 4 were discharged to rehabilitative care, and 2 were discharged to chronic nursing care. Individual patient admission severity score correlated positively with patient hospital costs (r = 0.48), but institutional average patient severity was negatively correlated with average institutional costs (r = −0.26). Maximal severity score correlated well with costs (r = 0.66) and length of stay (LOS;r = 0.64) at the patient level but poorly at the institutional level (r = 0.07 costs; r= 0.40 LOS). The institutional intensity of therapy was negatively correlated with admission severity (r = −0.03) but strongly correlated with costs (r = 0.84) and LOS (r = 0.83).

Conclusions.

Institutional differences in care practices for children with VLRI were not explained by differences in patient severity and did not affect the children's recovery but correlated significantly with hospital costs and LOS.
Age of Drinking Onset and Involvement in Physical Fights After Drinking
Authors: Hingson Ralph , Heeren Timothy , Zakocs Ronda
Published: August 2004

Objective.

To explore whether people who start drinking at an early age are more likely to have been in physical fights after drinking, independent of respondent history of alcohol dependence and frequency of heavy drinking.

Design.

In 1992, the US Census Bureau interviewed, in person, 42 862 randomly selected adults age 18 or older, mean age 44, household response rate 91.9%, and in-person response rate 97.4%. The survey included questions regarding the age respondents started drinking, frequency of heavy drinking, and whether respondents were ever or in the past year in a physical fight after drinking alcohol.

Results.

Relative to respondents who did not begin drinking until age 21 or older, those who started drinking before age 17 were 2.9 to 4.1 times more likely ever in their lives, and at least 3 times more likely in the past year, to have been in a fight after drinking. These relationships were found even after controlling for personal history of alcohol dependence, years of drinking, frequency of heavy drinking, smoking, drug use, and other personal characteristics associated with the age respondents started drinking.

Conclusions.

An early age of drinking onset was associated with alcohol-related violence not only among persons under age 21 but among adults as well. Physicians need to query adolescent patients about the age they began drinking and counsel them about the increased risks associated with early drinking onset, such as an increased risk of being involved in alcohol-related violence.
Excessive Infant Crying: The Impact of Varying Definitions
Authors: Reijneveld Sijmen A. , Brugman Emily , Hirasing Remy A.
Published: August 2004

Objective.

To assess the impact of varying definitions of excessive crying and infantile colic on prevalence estimates and to assess to what extent these definitions comprise the same children.

Methods.

Parents of 3345 infants aged 1, 3, and 6 months (response: 96.5%) were interviewed on the crying behavior of their infant in a Dutch cross-sectional national population-based study. We computed the prevalence of excessive crying according to 10 published definitions regarding parent-reported duration of infant crying and the parents' experience. We measured concordance between pairs of definitions by Cohen's κ (agreement adjusted for chance agreement).

Results.

Overall prevalence rates of excessive crying varied strongly between definitions, from 1.5% to 11.9%. They were always highest in 1-month-old infants. Concordance between definitions was only excellent (κ > 0.75) if they were closely related, such as crying for >3 hours/day for >3 days/week for the preceding 2 or 3 weeks. Concordance between less closely related definitions was much weaker. Concordance between definitions that were based on duration and on parental experience was mostly poor (κ: 0.17–0.53 for infants aged 1 and 3 months).

Conclusions.

Different definitions of excessive crying lead to the inclusion of very dissimilar groups of infants. We recommend presenting study results using clearly described definitions, preferably concerning both duration of crying and parental distress. This may improve the comparability of studies on the cause and treatment of excessive infant crying. The impact of the method of data collection on this comparability needs additional study.colic, preventive child health care, prevention, infancy.
Estimating the Cost of Developmental and Behavioral Screening of Preschool Children in General Pediatric Practice
Authors: Dobrez Deborah , Sasso Anthony Lo , Holl Jane , Shalowitz Madeleine , Leon Scott , Budetti Peter
Published: August 2004

Objective.

Despite increased recognition of the importance of development and growth of young children, formal developmental and behavioral screening often is not included in general pediatric practice. Barriers to the provision of developmental and behavioral screening are considerable; among them are the need for specialized training and uncertain reimbursement. This article develops a model for estimating the cost of providing pediatric developmental and behavioral screening that can be scaled to reflect a pediatric practice's patient population and choice of screening offered.

Methods.

The framework for our scaleable cost model was drawn from work done in estimating the Resource-Based Relative Value Scale (RBRVS). RBRVS provides estimates of the work effort involved in the provision of health care services for individual Current Procedural Terminology codes. The American Academy of Pediatrics has assigned descriptions of pediatric services, including developmental and behavioral screening, to the Current Procedural Terminology codes originally created for adult health care services. The cost of conducting a screen was calculated as a function of the time and staff required and was loaded for practice costs using the RBRVS valuation. The cost of the follow-up consultation was calculated as a function of the time and staff required and the number of relative value units assigned in the RBRVS scale.

Results.

The practice cost of providing developmental and behavioral screening is driven primarily by the time and staff required to conduct and evaluate the screens. Administration costs are lowest for parent-administered developmental screens ($0 if no assistance is required) and highest ($67) for lengthy, pediatric provider–administered screens, such as the Neonatal Behavioral Assessment Scale. The costs of 3 different groups of developmental and behavioral screening are estimated. The estimated per-member per-month cost per 0- to 3-year-old child ranges from $4 to >$7 in our 3 examples.

Conclusions.

Cost remains a significant barrier to greater provision of formal developmental and behavioral screening. Our scaleable cost model may be adjusted for a given practice to account for the overall level of developmental risk. The model also provides an estimate of the time and cost of providing new screening services. This model allows pediatric practices to select the mix of developmental screens most appropriate for their particular patient population at an acceptable cost.
Association Between Sudden Infant Death Syndrome and Prone Sleep Position, Bed Sharing, and Sleeping Outside an Infant Crib in Alaska
Authors: Gessner Bradford D. , Ives George C. , Perham-Hester Katherine A.
Published: August 2004

Objective.

To determine the contribution of prone sleeping, bed sharing, and sleeping outside an infant crib to sudden infant death syndrome (SIDS).

Methods.

We conducted a retrospective descriptive study of all SIDS cases in Alaska from January 1, 1992, through December 31, 1997. Reviewed data sources included maternal and infant medical records, autopsy reports, birth and death certificates, police and state trooper death scene investigations, and occasionally home interviews.

Results.

The death certificate identified SIDS as a cause of death for 130 infants (cause-specific infant mortality rate: 2.0 per 1000 live births). Among infants for whom this information was known, 113 (98%) of 115 were found in the prone position, sleeping outside an infant crib, or sleeping with another person. By contrast, 2 (1.7%) were found alone and supine in their crib (1 of whom was found with a blanket wrapped around his face). Of 40 infants who slept with a parent at the time of death, only 1 infant who slept supine with a non–drug-using parent on an adult nonwater mattress was identified.

Conclusion.

Almost all SIDS deaths in Alaska occurred in association with prone sleeping, bed sharing, or sleeping outside a crib. In the absence of other risk factors, SIDS deaths associated with parental bed sharing were rare.