bluuebunny/crossref_metadata_2025 huggingface dataset:
Development and Evaluation of a CD-ROM Computer Program to Teach Residents Telephone Management
Authors: Ottolini Mary C. , Greenberg Larrie
Published: August 2004

Objective. Under managed care, telephone management is crucial to pediatric practice, but an effective method is needed to teach residents telephone skills. Our objective was to design an interactive CD-ROM program to teach residents an organized, consistent approach to telephone complaints and to determine whether use of the program was associated with better subsequent telephone management than reading the same information.

Setting. The general pediatric ambulatory center of a tertiary care children's hospital.

Participants.  A total of 24 PL-2 and PL-3 pediatric residents.

Design. A randomized, prospective, controlled comparison was conducted of resident management of two telephone calls: a 5-year-old with cough and trouble breathing, and a 7-year-old with fever. Thirteen residents were randomized to the computer group and 11 to the reading control group.

Intervention. Scripts, scoring, and feedback for 10 CD-ROM-simulated calls were developed from texts and pediatrician survey using a modified Delphi technique. Volunteers acted out the caller's role in scenario scripts and were recorded onto a CD-ROM. The computer simulated calls by recognizing questions typed in a free-form format and answering with a voice response. Feedback was provided for omissions in history-taking and errors in assessment, triage, and home management. The computer group worked through the CD-ROM calls while the control group had equal time to read the same information.

Evaluation Measures. A trained, standardized patient acted as the mother in pretest calls placed at the beginning of the month and posttest calls at the end. Calls were recorded and scored in a blinded manner using scoring templates and on interpersonal skills using the Patient Perception Questionnaire.

Results. Pretest scores for the two calls were similar in the computer versus the control group (cough, 70.33% ± 8.36 vs 68.46% ± 6.73; fever, 75.64% ± 9.82 vs 73.59% ± 9.06). Posttest scores were significantly higher in the computer group than in the control group on both calls (cough, 79.08% ± 8.17 vs 69 ± 13.3; fever: 83.33% ± 9.96 vs 70.35% ± 9.66). Interpersonal skills also were similar pretest (19 ± 3.4 vs 20 ± 2.7). There was modest improvement in both groups without a statistically significant difference in posttest scores (24.2 ± 2.9 vs 22.5 ± 3.1).

Conclusions. Use of this CD-ROM telephone management program was associated with better postintervention telephone management. The program augments faculty instruction by teaching a consistent, general approach to telephone management.
Blood Cultures in the Evaluation of Children With Cellulitis
Authors: Sadow Karin Berger , Chamberlain James M.
Published: August 2004

Objective. To evaluate the yield of blood cultures obtained from immunocompetent children admitted for cellulitis in the post-Haemophilus influenzae type b (Hib) vaccine era and to determine whether these cultures are cost-effective.

Design. Retrospective case series.

Setting. Urban pediatric emergency department.

Study Population. Patients 2 days to 22 years of age admitted with cellulitis from 1994 through 1995.

Measurements and Results. Of 381 patients identified, 266 (70%) had blood cultures and 243 of these children were enrolled. Data recorded include demographics, immunization status, initial clinical appearance, antibiotic pretreatment, preexisting illness, location and precipitating cause of cellulitis, white blood cell count, and band-to-neutrophil ratio (BNR). Blood cultures were categorized as positive, negative, or contaminant. Five cultures (2%) were positive, and 13 (5.4%) were contaminants. The positive blood cultures grew streptococcus and staphylococcus organisms, and none of the children were bacteremic with H influenzae. All patients with group A β-hemolytic streptococcus had active varicella. The mean age was lower (26 vs 75 months) in those with a positive blood culture, and mean BNR was higher (0.32 vs 0.07). Patient management did not change for bacteremic patients with uncomplicated cellulitis. All repeat cultures were negative. The cumulative charge for all blood cultures was $50 986.

Conclusions. Blood cultures are not cost-effective and are more frequently contaminated than positive in the evaluation of a patient with uncomplicated cellulitis. Since introduction of theH influenzae type b vaccine, the most common organisms are streptococci. Using a BNR = 0.20 as a threshold for sending blood cultures, we would have missed one positive culture, but would have avoided blood cultures in 213 patients (88%) with an estimated savings of $42 850.
Anemia and Elevated Lead Levels in Underimmunized Inner-city Children
Authors: Adams William G. , Geva Judith , Coffman Jerry , Palfrey Sean , Bauchner Howard
Published: August 2004

Objective. Underimmunized children are less frequently screened for anemia and elevated lead levels than those who are up-to-date (UTD). However, the association between underimmunization and actual disease (hemoglobin [Hgb] <11 g/dL or blood lead level [PbB] ≥10 μg/dL) has not been reported. The objective of this study was to evaluate the association between underimmunization, anemia, and elevated lead levels among children attending an inner-city clinic.

Study Design. Data from a computer-based immunization tracking system were integrated with primary care-based laboratory data. Cross-sectional data for immunization coverage, anemia, and elevated lead levels were evaluated for children who were 1, 2, 3, and 4 years of age. The first Hgb or PbB values obtained within 6 months of the child's birthday were used.

Setting. An inner-city hospital-affiliated pediatric primary care center.

Patients. A child was considered to be a pediatric primary care center patient if he/she had at least 3 immunizations in the immunization tracking system and at least 1 Hgb or PbB screening test during February 1993 through February 1996.

Results. A total of 4045 Hgb tests from 2672 children were available for analysis (1198, 1102, 945, and 800 at 1, 2, 3, and 4 years of age, respectively). Anemia was common during the first 4 years of life (21.2%, 15.8%, 11.0%, and 10.3% at 1, 2, 3, and 4 years of age, respectively). At 2 and 3 years of age, underimmunized children were significantly more likely to be anemic compared with UTD children (relative risk [RR] = 1.49, 95% confidence interval [CI] = 1.24–1.79 at 2 years of age; RR = 1.43, 95% CI = 1.12–1.83 at 3 years of age). Underimmunized children with anemia at 1 year of age were less likely than UTD children to resolve their anemia by 2 years of age (52.5% vs 20.8%, RR = 2.39; 95% CI = 1.47–3.87). Underimmunized children were also significantly more likely to have elevated lead levels at 2 years of age (RR = 1.24; 95% CI = 1.03–1.5).

Conclusion. Underimmunized children in the inner city are at especially high risk for anemia and elevated lead levels. These children need routine preventive health services, as well as immunization. Integrating laboratory screening data with immunization tracking systems would be an important step toward improving the health of inner-city children.
Evaluation of a Bicycle Helmet Giveaway Program—Texas, 1995
Authors: Logan Pamela , Leadbetter Steven , Gibson Raina E. , Schieber Richard , Branche Christine , Bender Patricia , Zane David , Humphreys Johnny , Anderson Steve
Published: August 2004

Objective. To determine the effect of a bicycle helmet giveaway program on helmet use among children.

Methods. In 1995, a bicycle helmet giveaway program was conducted in two rural towns in Texas. Helmets were given to all 403 school children in kindergarten through grade 8. Helmet education, a bicycle rodeo, and incentives to increase helmet use were part of the program. Observations of helmet use were made before the helmet program began and after the program at several intervals throughout the school year and during the summer. A self-reported survey questionnaire was administered to children in grades 4 through 8 before the helmet program began and at several intervals during the school year to determine their attitudes about helmet use, safety perceptions, and peer pressure. A questionnaire also was administered to the parents of these children to determine attitudes and bicycle helmet use among parents.

Results. Helmet use increased from 3% before the giveaway to 38% at the end of the school year, 7 months later. However, during the subsequent summer, helmet use decreased to 5%. Helmet use among 7th- and 8th-grade students was 0% at all observations periods after the giveaway. Even though 96% of all students thought that helmet use increased riding safety and 68% thought helmets should be worn at all times when riding, only 25% thought that their friends would approve of helmet use. Most parents also believed that helmets increased riding safety and should be worn, but only 23% reported always wearing one when riding a bicycle.

Conclusions. Bicycle helmet giveaway programs can increase helmet use temporarily, but they may not be sufficient to sustain it. This program was not effective among 7th- and 8th-grade students.
Results of Screening 1.9 Million Texas Newborns for 21-Hydroxylase-Deficient Congenital Adrenal Hyperplasia
Authors: Therrell Bradford L. , Berenbaum Sheri A. , Manter-Kapanke Valerie , Simmank Jennifer , Korman Kristina , Prentice Linda , Gonzalez Jose , Gunn Sheila
Published: August 2004

Objective. To assess results of newborn screening for 21-hydroxylase-deficient congenital adrenal hyperplasia (CAH) in Texas over 6 years of screening 1.9 million infants.

Methods. In 1989, CAH was incorporated into the ongoing Texas Newborn Screening Program, which requires two screens on each newborn. 17-Hydroxyprogesterone was assayed, without extraction, by radioimmunoassay of blood collected from heel sticks onto filter paper collection cards. Infants with elevated levels of 17-hydroxyprogesterone were referred for evaluation, and those considered to have CAH were studied with respect to disease characteristics. Data were collected by pediatric endocrinologists using standardized forms that included type of CAH, results of laboratory tests, treatment regimen, disease symptoms and signs, and, for girls, degree of genital virilization.

Results. The incidence of classic CAH in Texas is 1:16 008, with a ratio of salt-wasting to simple-virilizing of 2.7:1. A majority of infants detected were undiagnosed until screened, despite signs of salt-wasting or ambiguous genitalia. It was difficult to differentiate salt-wasting from simple-virilizing CAH in infants who were identified before the onset of adrenal insufficiency or electrolyte abnormalities. A substantial number of infants with nonclassic (NC) CAH also were detected. Not all infants were detected on the initial screen; 14% of infants with classic CAH and 87% with NC CAH were detected on the second routine screening test.

Conclusions. Our findings confirm the benefits of newborn screening for CAH and the importance of a second screening test, and suggest that programs for newborn CAH screening must consider complex issues in diagnosis and treatment. These results also confirm that CAH is a continuum of disorders, rather than a disorder with discrete subtypes. In addition, the difficulties in differentiating CAH subtypes in newborns, and thus deciding appropriate treatment, and the high incidence of NC CAH suggest that standard diagnostic criteria and treatment regimens for CAH may need modification. Where screening exists, physicians will encounter more cases of CAH than in the past.
Personal, Financial, and Structural Barriers to Immunization in Socioeconomically Disadvantaged Urban Children
Authors: Bates Ann S. , Wolinsky Fredric D.
Published: August 2004

Objective. To evaluate personal, financial, and structural barriers to vaccination in socioeconomically disadvantaged urban children in the first 2 years of life.

Design. Prospective cohort study.

Setting. A large municipal teaching hospital in the Midwest.

Participants. Healthy term newborns discharged to the care of their mothers. Mothers were interviewed 24 to 72 hours postpartum regarding personal and financial barriers, and 2 years later regarding personal, financial, and structural barriers to care.

Main Outcome Measure. Vaccination status at age 2 years.

Results. Of 399 children with documented vaccination status, 47% had not received all recommended vaccinations by 2 years of age. After adjusting for mother's age, race, and education, mothers who were unmarried (adjusted odds ratio [AOR] 1.74; 95% confidence interval [CI]: 1.05, 2.90), multiparous (AOR 2.10; 95% CI: 1.26, 3.52), not coresident with the child's grandmother (AOR 1.75; 95% CI: 1.01, 3.03), had not received adequate prenatal care (AOR 1.78; 95% CI: 1.12, 2.84), or lived in poverty (AOR 2.62; 95% CI: 1.44, 4.75) were more likely to have undervaccinated children, as were mothers who perceived less satisfaction with their child's health care (AOR 1.63; 95% CI: 1.01, 2.61), less control over their lives (AOR 2.01; 95% CI: 1.03, 3.94), or more benefit of medical care to prevent vaccine-related diseases (AOR 1.76; 95% CI: 1.25, 2.48).

Conclusions. Family environment, a mother's history of prenatal care use, and financial barriers are important factors related to vaccination receipt among socioeconomically disadvantaged children at age 2 years. These factors, however, do not fully explain the variation in vaccination status.
Safety and Immunogenicity of Heptavalent Pneumococcal Vaccine Conjugated to CRM197 in United States Infants
Authors: Rennels Margaret B. , Edwards Kathryn M. , Keyserling Harry L. , Reisinger Keith S. , Hogerman Deborah A. , Madore Dace V. , Chang Ih , Paradiso Peter R. , Malinoski Frank J. , Kimura Alan
Published: August 2004

Objective. To determine the safety and immunogenicity of heptavalent pneumococcal saccharide vaccine (serotypes 4, 6B, 9V, 14, 18C, 19F, 23F) individually conjugated to CRM197 (PNCRM7), administered at 2, 4, 6, and 12 to 15 months of age.

Design. Two hundred twelve healthy 2-month-old infants were equally randomized to receive four consecutive doses of PNCRM7 or an investigational meningococcal group C conjugate vaccine, which served as a control. Concomitantly administered routine vaccines were oral polio vaccine and combined diphtheria toxoid, tetanus toxoid, and whole cell pertussis vaccine/Haemophilus influenzae type b vaccine consisting of capsular oligosaccharides conjugated to CRM197 (DTP/HbOC) at 2, 4, and 6 months, and either measles-mumps-rubella vaccine or HbOC at 12 to 15 months. Active safety surveillance was conducted for 3 days after each dose. Antibody concentrations to each of the 7 pneumococcal serotypes were measured by enzyme-linked immunosorbent assay prevaccination, after doses two and three, prebooster, and postbooster.

Results. Significantly fewer children experienced local reactions at the PNCRM7 injection site than at the DTP/HbOC site. There was no increase in the incidence or severity of local reactions at the PNCRM7 site with increasing doses of vaccine. Mild to moderate postvaccination fever was common in both the PNCRM7 and control vaccine groups, however DTP/HbOC was administered concurrently. All 7 vaccine serotypes were immunogenic. The kinetics of the immune responses were serotype-specific. After three doses of PNCRM7, between 92% to 100% of children had ≥0.15 μg/mL of antibody, and 51% to 90% achieved a level of ≥1 μg/mL against specific serotypes. A booster dose of PNCRM7 resulted in a brisk anamnestic response to all 7 vaccine serotypes, demonstrating effective stimulation of T-cell memory by the primary series of vaccinations.

Conclusion. Primary immunization followed by a booster dose of PNCRM7 seemed to be acceptably safe and resulted in significant rises in antibody to all 7 serotypes.

Implications. Studies to assess vaccine efficacy of PNCRM7 for prevention of systemic disease, nasopharyngeal colonization, and acute otitis media are in progress. If PNCRM7 proves to be protective, there is the potential to prevent up to 85% of invasive pneumococcal disease occurring in US children.
Child Fatalities From Religion-motivated Medical Neglect
Authors: Asser Seth M. , Swan Rita
Published: August 2004

Objective. To evaluate deaths of children from families in which faith healing was practiced in lieu of medical care and to determine if such deaths were preventable.

Design. Cases of child fatality in faith-healing sects were reviewed. Probability of survival for each was then estimated based on expected survival rates for children with similar disorders who receive medical care.

Participants. One hundred seventy-two children who died between 1975 and 1995 and were identified by referral or record search. Criteria for inclusion were evidence that parents withheld medical care because of reliance on religious rituals and documentation sufficient to determine the cause of death.

Results. One hundred forty fatalities were from conditions for which survival rates with medical care would have exceeded 90%. Eighteen more had expected survival rates of >50%. All but 3 of the remainder would likely have had some benefit from clinical help.

Conclusions. When faith healing is used to the exclusion of medical treatment, the number of preventable child fatalities and the associated suffering are substantial and warrant public concern. Existing laws may be inadequate to protect children from this form of medical neglect.
Helicobacter pylori and Abdominal Symptoms: A Population-based Study Among Preschool Children in Southern Germany
Authors: Bode Günter , MD Dietrich Rothenbacher , Brenner Hermann , Adler Guido
Published: August 2004

Objective. To determine the relation of Helicobacter pylori infection with gastrointestinal symptoms in a healthy population-based sample of children.

Design. Population-based cross-sectional study of preschool children.

Setting. Screening examination for school fitness by physicians of the Public Health Service in Ulm, a city with 100 000 inhabitants in southern Germany.

Participants. One thousand two hundred one preschool children.

Main Outcome Measures. Infection status was determined by13C-urea breath test. Information on gastrointestinal symptoms was collected from children's parents by a standardized questionnaire and integrated into a symptom score.

Results. Nine hundred forty-five children participated in the study (response rate, 79%). Overall, 127 children (13.4%) were infected. H pylori infection was not positively related to specific gastrointestinal symptomatology. Infected children had even fewer symptoms when compared with uninfected children.

Conclusions. Our results indicate that H pylori infection in children is mostly asymptomatic and not associated with specific gastrointestinal symptoms.
Aggressors or Victims: Gender and Race in Music Video Violence
Authors: Rich Michael , Woods Elizabeth R. , Goodman Elizabeth , Emans S. Jean , DuRant Robert H.
Published: August 2004

Objective. To examine portrayals of violence in popular music videos for patterns of aggression and victimization by gender and race.

Design and Setting. Content analysis of 518 music videos broadcast over national music television networks, Black Entertainment Television (BET), Country Music Television (CMT), Music Television (MTV), and Video Hits-1 (VH-1) during a 4-week period at randomly selected times of high adolescent viewership.

Main Outcome Measures. Differences in the genders and races portrayed as aggressors and victims in acts of violence.

Results. Seventy-six (14.7%) of the analyzed music videos contained portrayals of individuals engaging in overt interpersonal violence, with a mean of 6.1 violent acts per violence-containing video. Among the 462 acts of violence, the music video's main character was clearly the aggressor in 80.1% and the victim in 17.7%. In 391 (84.6%) of the violence portrayals, the gender of the aggressor or victim could be determined. Male gender was significantly associated with aggression; aggressors were 78.1% male, whereas victims were 46.3% female. This relationship was influenced by race. Among whites, 72.0% of the aggressors were male and 78.3% of the victims were female. Although blacks represent 12% of the United States population, they were aggressors in 25.0% and victims in 41.0% of music video violence. Controlling for gender, racial differences were significant among males; 29.0% of aggressors and 75.0% of victims were black. A logistic regression model did not find direct effects for gender and race, but revealed a significant interaction effect, indicating that the differences between blacks and whites were not the same for both genders. Black males were more likely than all others to be portrayed as victims of violence (adjusted odds ratio = 28.16, 95% confidence interval = 8.19, 84.94).

Conclusions. Attractive role models were aggressors in more than 80% of music video violence. Males and females were victims with equivalent frequency, but males were more than three times as likely to be aggressors. Compared with United States demographics, blacks were overrepresented as aggressors and victims, whereas whites were underrepresented. White females were most frequently victims. Music videos may be reinforcing false stereotypes of aggressive black males and victimized white females. These observations raise concern for the effect of music videos on adolescents' normative expectations about conflict resolution, race, and male-female relationships.
Treatment of Symptomatic Chronic Adenotonsillar Hypertrophy With Amoxicillin/Clavulanate Potassium: Short- and Long-term Results
Authors: Sclafani Anthony P. , Ginsburg Jeffrey , Shah Mahendra K. , Dolitsky Jay N.
Published: August 2004

Objective. To evaluate the short- and long-term effects of treatment of symptomatic chronic adenotonsillar hypertrophy (CATH) with a 30-day course of amoxicillin/clavulanate potassium (AMOX/CLAV).

Patients. Children 2 to 16 years of age with obstructive symptoms attributable to CATH, who did not have a history of recurrent adenotonsillitis.

Design. A prospective, randomized, double-blinded, placebo-controlled trial.

Setting. Ambulatory clinic of a tertiary care hospital.

Intervention. Patients were randomly treated with 30-day courses of either placebo (PLAC) or AMOX/CLAV (40 mg/kg in 3 divided doses daily).

Outcome Measures. Patients' signs and symptoms were assessed by physical examination and by both physician and parental forced-choice questionnaires 1, 3, and 24 months after treatment. The decision to proceed to surgery or to continue expectant management was made for all patients by the same physician, based on reported symptoms and physical findings.

Results. Treatment with a 30-day course of AMOX/CLAV significantly reduced the need for surgery in the short term compared with PLAC (37.5% vs 62.7%) at 1-month follow-up). The reduced need for surgery in the AMOX/CLAV-treated group persisted at 3 months (AMOX/CLAV 54.5% vs PLAC 85.7%) and 24 months (AMOX/CLAV 83.3% vs PLAC 98.0%).

Conclusions. A 30-day course of AMOX/CLAV significantly reduces the need for surgery in children with obstructive adenotonsillar hypertrophy at 1-month follow-up. This relative reduction persists at 3 and 24 months posttreatment, although the absolute percentages of patients requiring surgery increased in both groups as time after treatment increased. The reduction in symptoms in AMOX/CLAV-treated patients is modest but significant even in long-term follow-up. The precise role of this treatment for CATH is yet to be determined; however, our results suggest that a 30-day course of AMOX/CLAV can be used in situations when a temporary relief in symptoms is desirable or surgery would incur unacceptable risk.
Recent Declines in New York City Infant Mortality Rates
Authors: Racine Andrew D. , Joyce Theodore J. , Li Wenhui , Chiasson Mary Ann
Published: August 2004

Background. Although infant mortality rates have declined gradually in New York City for many years, the rate of that decline began to accelerate dramatically at the end of the 1980s.

Objective. To analyze the recent accelerated decline in infant mortality for three race/ethnicity designations in New York City and to investigate whether shifts in birth weight distribution or changes in birth weight-specific death rates were more important in determining these declines between 1988 to 1989 and 1992 to 1993.

Methods. Two complete cohorts of linked birth–death certificate files consisting of all live births in New York City in 1988 to 1989 and 1992 to 1993 were examined. For each cohort, separate multinomial logistic regressions were estimated by race/ethnicity to analyze the probability of a neonatal or postneonatal death relative to survival as a function of a spectrum of covariates. The coefficients from these regressions were used to construct direct and indirect standardization exercises to predict changes in infant mortality holding characteristics of the cohort, including birth weight distribution, constant over time, or holding the influence of determinants, including birth weight-specific death rates, constant over time.

Results. For whites, Hispanics, and blacks, infant mortality rates declined by 27.4%, 24.8%, and 22.7%, respectively, between 1988 to 1989 and 1992 to 1993. For whites and blacks, the largest decreases occurred for neonatal mortality rates, whereas for Hispanics, postneonatal rates fell the greatest. Although infant mortality rates among very low birth weight infants (<1500 g) fell by 27.8%, 19.3%, and 16.6% for whites, Hispanics, and blacks, the greatest decreases in rates were seen among normal birth weight infants (>2500 g). Infant mortality rate declines for this category of infants reached 31%, 31.7%, and 31.3%, respectively, for whites, Hispanics, and blacks. Direct and indirect standardization exercises indicated that the most important factor in determining these declines were decreases in birth weight-specific death rates, not improvements in the birth weight distribution over time.

Conclusions. We conclude that the large decreases in infant mortality rates witnessed in New York City between 1988 to 1989 and 1992 to 1993 were attributable not to improvements in birth weight distribution of the population but to declines in birth weight-specific death rates and that normal birth weight infants showed the greatest improvement.
Congenital Myotonic Dystrophy Requiring Prolonged Endotracheal and Noninvasive Assisted Ventilation: Not a Uniformly Fatal Condition
Authors: Keller Charles , Reynolds Ann , Lee Brendan , Garcia-Prats Joseph
Published: August 2004

In this report we present two infants with congenital myotonic dystrophy (CMD) who were successfully weaned from prolonged ventilatory support using nasal continuous positive airway pressure (N-CPAP). The first infant received 127 days of endotracheal mechanical ventilation as part of 141 days of total ventilatory support, including N-CPAP; the second infant received 27 days of endotracheal mechanical ventilation as part of 84 days of total ventilatory support. Noninvasive N-CPAP facilitated weaning these two infants from ventilatory support, thereby minimizing the morbidity associated with prolonged intubation. The developmental outcomes of our two infants were comparable to infants not requiring prolonged endotracheal mechanical ventilation. We suggest that this noninvasive modality of ventilatory support may be advantageous in the management and beneficial to the outcome of infants with CMD who are respirator-dependent for >30 days.
Toxic Effects of Indoor Molds
Authors:   Committee on Environmental Health
Published: August 2004

This statement describes molds, their toxic properties, and their potential for causing toxic respiratory problems in infants. Guidelines for pediatricians are given to help reduce exposures to mold in homes of infants. This is a rapidly evolving area and more research is ongoing.
Effectiveness and Cost-effectiveness of Letters, Automated Telephone Messages, or Both for Underimmunized Children in a Health Maintenance Organization
Authors: Lieu Tracy A. , Capra Angela M. , Makol James , Black Steven B. , Shinefield Henry R. ,   for the Immunization Message Study Group
Published: August 2004

Background. Immunization rates have improved in the United States, but are still far from the national 90% goal for the year 2000. There is scant evidence about the effectiveness and costs of automated telephone messages to improve immunization rates among privately insured children.

Objective. To evaluate the effectiveness and cost-effectiveness of sending letters, automated telephone messages, or both to families of underimmunized 20-month-olds in a health maintenance organization (HMO).

Methods. In this randomized trial, underimmunized 20-month-olds identified by the HMO's computerized immunization tracking system were assigned to one of four interventions: 1) an automated telephone message alone; 2) a letter alone; 3) an automated telephone message followed by a letter 1 week later; and 4) a letter followed by an automated telephone message 1 week later. The primary outcome was receipt of any needed immunization by 24 months of age. Decision analysis was used to evaluate the projected cost-effectiveness of the alternative strategies.

Results. A total of 648 children were randomized. A letter followed by a telephone message (58% immunized) was significantly better than either a letter alone (44% immunized) or a telephone message alone (44% immunized). A telephone message followed by a letter (53% immunized) also was more effective than either alone, although the differences were not statistically significant. Among a similar comparison group that received no systematic intervention, 36% were immunized. The estimated cost per child immunized was $7.00 using letters followed by automated telephone messages, $9.80 using automated telephone messages alone, and $10.50 using letters alone. Under alternative cost assumptions for automated telephone messages and mailed messages, the cost per child immunized ranged from $2.20 to $6.50.

Conclusions. For underimmunized 20-month-olds in this HMO setting, letters followed by automated telephone messages were more effective and cost-effective than either message alone. The cost-effectiveness of automated telephone messages and letters may vary widely depending on the setting, and choices among strategies should be tailored to the populations being served.
Analgesia for Neonatal Circumcision: A Randomized Controlled Trial of EMLA Cream Versus Dorsal Penile Nerve Block
Authors: Butler-O'Hara Meggan , LeMoine Christine , Guillet Ronnie
Published: August 2004

Objective. To compare the efficacy of the dorsal penile nerve block (DPNB) with a less invasive form of local anesthesia, eutectic mixture of local anesthetic (EMLA) cream, for reduction of pain during neonatal circumcision.

Design. Prospective, blinded, randomized, controlled trial.

Setting. Tertiary referral, neonatal intensive care nursery in a university teaching hospital.

Patients. Fifty infants ≥34½ weeks postmenstrual age and stable for discharge at time of circumcision; gestational age at birth 25 to 41 weeks; birth weight 600 to 4390 g; age at study 3 to 105 days. An additional cohort of term newborns (n = 20), who were not randomized, were circumcised without anesthesia.

Interventions. Administration of either EMLA cream (0.5 g topically 1 hour before circumcision) or 1% lidocaine (0.7–1.0 mL subcutaneously 3 minutes before circumcision).

Outcome Measures. Primary: Neonatal Infant Pain Scale (NIPS) score; secondary: heart rate, respiratory rate. All outcome measures were assessed by an individual who was blinded to the group assignment and did not perform the circumcision.

Results. NIPS scores were significantly lower in the DPNB infants (2.3 ± 1.8) compared with the EMLA infants (4.8 ± 0.7). NIPS scores in patients circumcised without anesthesia indicated severe pain. There was a significantly greater increase in heart rate over the duration of the circumcision in the EMLA group than in the DPNB group (49 vs 9 beats per minute). Adverse effects included small hematomas at the site of injection in DPNB infants (10/23), mild erythema at 1 and/or 24 hours after circumcision in the EMLA infants (3/21), and penile edema noted 5 days after circumcision requiring removal of the circumcision bell in 1 DPNB infant.

Conclusions. DPNB provides better pain reduction during neonatal circumcision than EMLA cream. EMLA cream may provide pain reduction compared with no anesthesia during neonatal circumcision.
Normative Sexual Behavior in Children: A Contemporary Sample
Authors: Friedrich William N. , Fisher Jennifer , Broughton Daniel , Houston Margaret , Shafran Constance R.
Published: August 2004

Objective. Sexual behavior in children can cause uncertainty in the clinician because of the relationship between sexual abuse and sexual behavior. Consequently, it is important to understand normative childhood sexual behavior.

Design. Sexual behavior in 1114 2- to 12-year-old children was rated by primary female caregivers. These children were screened for the absence of sexual abuse. A 38-item scale assessing a broad range of sexual behavior (Child Sexual Behavior Inventory, Third Version) was administered along with the Child Behavior Checklist and a questionnaire assessing family stress, family sexuality, social maturity of the child, maternal attitudes regarding child sexuality, and hours in day care.

Results. Sexual behavior was related to the child's age, maternal education, family sexuality, family stress, family violence, and hours/week in day care. Frequencies of sexual behaviors for 2- to 5-, 6- to 9-, and 10- to 12-year-old boys and girls are presented.

Conclusions. A broad range of sexual behaviors are exhibited by children who there is no reason to believe have been sexually abused. Their relative frequency is similar to two earlier studies, and this reinforces the validity of these results.
Management of Acute Gastroenteritis in Children in Israel
Authors: Shamir Raanan , Zahavi Ilan , Abramowich Tova , Poraz Irit , Tal Dalia , Pollak Shlomo , Dinari Gabriel
Published: August 2004

Objective. Diarrheal diseases are a major cause of morbidity and mortality worldwide. Guidelines about the use of oral rehydration solutions (ORS) and dietary management of acute gastroenteritis (GE) were recently revised and published by the American Academy of Pediatrics (AAP). Study aims were to examine Israeli pediatricians' knowledge and implementation of the revised AAP guidelines, the effect of medical school (Israeli versus foreign medical graduates) on the physicians' practice, and the effect of the type of practice (community vs hospital-based) on the management of gastroenteritis.

Methods. A multiple-choice, written questionnaire was distributed at two pediatrics annual meetings.

Results. A total of 87 pediatricians completed the questionnaire. They were aware of 73% of the current AAP guidelines and followed 60% of the guidelines. Most pediatricians (83%) use ORS for treatment of dehydration in GE, but 60% of pediatricians believe that full-strength feeds are inappropriate in the presence of GE, and 67% of them do not recommend full-strength formulas. In addition, 37% of the pediatricians stop feeding temporarily in the presence of GE, in contrast to the 1996 AAP guidelines. There were no differences in knowledge and management practices among pediatricians graduating in Israel, Europe, or the United States, and no differences between pediatricians working in an ambulatory setting or in a hospital.

Conclusions. Pediatricians in Israel, regardless of country of origin, medical school, or place of practice, are aware of the correct use of ORS but do not follow nutritional practices recommended recently by the AAP. These findings suggest that steps for implementing the guidelines are needed in Israel and most probably worldwide.
The Emergency Physician and the Office-Based Pediatrician: An EMSC Team
Authors:   Committee on Pediatric Emergency Medicine
Published: August 2004

In a quality and cost-conscious health care environment, the pediatrician and emergency physician must work as a team. This statement clarifies important issues of this relationship, including coordination of patient care, communication between clinicians, provision of continuity care, and responsibility for quality emergency care.
Counseling the Adolescent About Pregnancy Options
Authors:   Committee on Adolescence
Published: August 2004

When consulted by a pregnant adolescent, pediatricians should be able to make a timely diagnosis and to help the adolescent understand her options and act on her decision to continue or terminate her pregnancy. Pediatricians may not impose their values on the decision-making process and should be prepared to support the adolescent in her decision or refer her to a physician who can.
Implementation Principles and Strategies for Title XXI (State Children's Health Insurance Program)
Authors:   Committee on Child Health Financing
Published: August 2004

A major provision of the Balanced Budget Act of 1997 established the State Children's Health Insurance Program (Title XXI of the Social Security Act). This program is a historic milestone in the financing of health care for children. Not since the enactment of Medicaid has there been a greater investment in children's health care. Title XXI does not create universal coverage for all children, but this program does offer an unprecedented opportunity to expand insurance to a large portion of uninsured children. Title XXI of the Social Security Act makes >$40 billion in federal grants available to states over the next 10 years to provide health insurance coverage, including Medicaid. However, states must contribute a defined share of funds to obtain federal matching funds. The legislation gives great flexibility to states in designing and implementing their programs, and it is critical that they do this in a timely manner. If states fail to use all State Children's Health Insurance Program funds available, it is possible that future federal funding will be reduced. If this happens, a major opportunity to improve the health insurance coverage of America's children will be diminished.
Effects of Exposure to Alcohol in Mother's Milk on Infant Sleep
Authors: Mennella Julie A. , Gerrish Carolyn J.
Published: August 2004

Objective. To test the hypothesis that exposure to alcohol in breast milk affects infants' sleep and activity levels in the short term.

Methods. Thirteen lactating women and their infants were tested on 2 days, separated by an interval of 1 week. On each testing day, the mother expressed 100 mL of milk, while a small, computerized movement detector called an actigraph was placed on the infant's left leg to monitor sleep and activity patterning. After the actigraph had been in place for ∼15 minutes, the infants ingested their mother's breast milk flavored with alcohol (32 mg) on one testing day and breast milk alone on the other. The infants' behaviors were monitored for the next 3.5 hours.

Results. The infants spent significantly less time sleeping during the 3.5 hours after consuming the alcohol-flavored milk (78.2 minutes compared with 56.8 minutes after feeding alcohol in breast milk). This reduction was apparently attributable to a shortening in the longest sleeping bout (34.5 compared with 56.7 minutes for sleeping after breast milk alone) and the amount of time spent in active sleep (25.8 minutes compared with 44.2 minutes after breast milk alone); the decrease in active sleep was observed in all but 2 of the 13 infants tested.

Conclusions. Although the mechanisms underlying the reduction in sleep remain to be elucidated, this study shows that short-term exposure to small amounts of alcohol in breast milk produces distinctive changes in the infant's sleep–wake patterning.
Do Missed Opportunities Stay Missed? A 6-Month Follow-up of Missed Vaccine Opportunities in Inner City Milwaukee Children
Authors: Sabnis Svapna S. , Pomeranz Albert J. , Lye Patricia S. , Amateau Margaret M.
Published: August 2004

Objectives. To determine 1) the frequency of missed vaccine opportunities (VOs) in inner city children ≤3 years of age; 2) whether the recommended vaccine(s) were given within 6 months of the missed opportunity (MO); 3) whether these vaccinations were age-appropriate according to the guidelines of the Advisory Committee on Immunization Practices; and 4) variables associated with MOs.

Design. Retrospective chart review with a nested retrospective cohort of children with MOs.

Setting. Two inner city practice settings in Milwaukee: a community health center and an academic continuity care practice.

Patients/Selection Procedure. A consecutive sample of 710 visits of inner city children ≤3 years of age with VOs, seen between January 1 and March 31, 1995. A VO was defined as any encounter when the child was vaccine-eligible according to Advisory Committee on Immunization Practices guidelines.

Results. MOs occurred in 47% (330/710) of the VOs. Only 40% of the children with MOs received age-appropriate immunizations within 6 months; 30% received the vaccinations beyond the age-appropriate time. The remaining 30% either did not return or were not vaccinated on return. The variables significantly associated with MOs were 1) age: children with MOs were older than those without, with a mean age of 15.5 months vs 10.9 months; 2) minor febrile illness; 3) moderate/severe illness; 4) acute illness encounters; and 5) patient's being seen at the community health center. Only 15.5% of all MOs were justified by the presence of moderate/severe illness.

Conclusions. VOs are frequently missed in inner city children. Most of the MOs were not justified by the valid contraindication of moderate/severe illness. Sixty percent of the children with MOs did not receive age-appropriate immunizations within 6 months. These children are vulnerable to vaccine-preventable diseases such as measles and pertussis.
Incidence and Prevalence of Neutralizing Antibodies to the Common Adenoviruses in Children With Cystic Fibrosis: Implication for Gene Therapy With Adenovirus Vectors
Authors: Piedra Pedro A. , Poveda Gustavo A. , Ramsey Bonnie , McCoy Karen , Hiatt Peter W.
Published: August 2004

Objective. Defining the infection rate and prevalence of the common adenoviruses (Ads) in cystic fibrosis (CF) children may aid in formulation of strategies for gene therapy with Ad vectors. We undertook this study to determine the incidence and prevalence of infection with the common Ads in children with CF.

Methodology. Thirty newly diagnosed CF children mean age 1.1 years (Group 1), 48 CF children mean age 4.6 years (Group 2), and 47 mothers of CF children (Group 3) were followed for a mean of 13 months. Group 4 consisted of 33 adult volunteers seen once. Throat and stool specimens for virus culture, and blood samples were obtained every 3 months from CF children in Group 1. Blood samples from CF children (Group 2) and their mothers (Group 3) were obtained every 6 months, and once from adults in Group 4. Neutralizing antibody to Ad serotypes 1 through 7 (Ad 1 to Ad 7) was evaluated with a microneutralization assay.

Results. Five (16.7%) CF children in Group 1 were culture-positive for an Ad; 4 of these CF children developed a fourfold or greater rise in antibody titer. Ad 3 infection occurred frequently based on serology; seronegative (<3.5 log 2) CF children had a higher infection rate compared with seropositive CF children (7/11 vs 1/34). The prevalence of neutralizing antibodies in CF children in order of decreasing frequency was 91.1% to Ad 3, 37.5% to Ad 2, 27.1% to Ad 1, 26.1% to Ad 7, 16.7% to Ad 5, 8.5% to Ad 4, and 2.0% to Ad 6. The neutralizing antibody titers in seropositive CF children were comparable to those in adults except to Ad 3, which was significantly greater in mothers of CF children.

Conclusions. CF children had a normal antibody response after Ad infection, preexisting antibody may protect against reinfection and antibody prevalence was low to the common Ads.
Implications for Estimates of Disability in Children: A Comparison of Definitional Components
Authors: Westbrook Lauren E. , Silver Ellen J. , Stein Ruth E. K.
Published: August 2004

Objective. To test how prevalence estimates and characteristics of children vary by the way that disability is defined. Specifically, to determine 1) the proportions of children identified as disabled by one particular operationalization of disability based on parental reports of three types of consequences (ie, functional limitations [FL]), dependence on compensatory mechanisms (CD), and service use or need beyond routine [SU/N]), and 2) whether children identified as disabled by these three types of consequences differ by type of disorder or condition, age, socioeconomic status, or race.

Method. We analyzed a national dataset representing a random sample of 712 households with 1388 children. The Questionnaire for Identifying Children with Chronic Conditions (QuICCC) was used to identify children with disabling conditions. We divided the QuICCC items into three discrete sets, reflecting three definitional components of disability, and compared the proportions and characteristics of children fitting these components separately and in combination.

Results. Using the QuICCC definition of disability, SU/N identified the largest proportion of children (72%), followed by CD (55%) and FLs (49%). Forty-four percent of children were identified by only one component, 36% by two components in any combination, and 20% by all three components. The type of disorder or condition generally did not vary by the three definitional components, although the FL component may be more effective at identifying children with sensory impairments. Children identified by two or more components were more likely to have multiple conditions and had more pervasive disorders than those identified by only one component. The youngest children (0 to 3 years old) may be less likely to be identified as disabled than children of other ages, especially by FLs. FLs also were more likely to identify children from the poorest and least educated families.

Conclusions. Although the specific findings reported here pertain to a single definitional approach (the QuICCC), the data highlight that who will be classified as disabled (and who will not) may be dependent on how disability is defined. The implications of using different definitions and definitional components on both the prevalence and the characteristics of children with disabilities need to be considered before data can be applied responsibly and appropriately.