bluuebunny/crossref_metadata_2025 huggingface dataset:
Neonatal Necrotizing Fasciitis: A Report of Three Cases and Review of the Literature
Authors: Hsieh Wu-Shiun , Yang Peng-Hong , Chao Hsun-Chin , Lai Jin-Yao
Published: August 2004

Objective.

Necrotizing fasciitis (NF) is a predominantly adult disorder, with bacterial infection of the soft tissue. In children, it is relatively rare and has a fulminant course with a high mortality rate. In the neonate, most cases of NF are attributable to secondary infection of omphalitis, balanitis, mammitis, postoperative complications, and fetal monitoring. The objective of this communication is to report 3 cases of neonatal NF and provide a literature review of this disorder.

Results.

This review yielded 66 cases of neonatal NF. Only 3 cases were premature. There was no sex predilection and the condition rarely recurred. Several underlying conditions were identified that might have contributed to the development of neonatal NF. These included omphalitis in 47, mammitis in 5, balanitis in 4, fetal scalp monitoring in 2, necrotizing enterocolitis, immunodeficiency, bullous impetigo, and maternal mastitis in 1 patient each. The most common site of the initial involvement was the abdominal wall (n = 53), followed by the thorax (n = 7), back (n = 2), scalp (n = 2), and extremity (n = 2). The initial skin presentation ranged from minimal rash to erythema, edema, induration or cellulitis. The lesions subsequently spread rapidly. The overlying skin might later develop a violaceous discoloration, peau d'orange appearance, bullae, or necrosis. Crepitus was uncommon. Fever and tachycardia were frequent but not uniformly present. The leukocyte count of the peripheral blood was usually elevated with a shift to the left. Thrombocytopenia was noted in half of the cases. Hypocalcemia was rarely reported. Of the 53 wound cultures available for bacteriologic evaluation, 39 were polymicrobial, 13 were monomicrobial, and 1 was sterile. Blood culture was positive in only 20 cases (50%). Treatment modalities included the use of antibiotics, supportive care, surgical debridement, and drainage of the affected fascial planes. Two of the 6 cases who received hyperbaric oxygen therapy died. The overall mortality rate was 59% (39/66). In 12 cases, skin grafting was required because of poor granulation formation or large postoperative skin defects among the survivors.

Conclusion.

Neonatal NF is an uncommon but often fatal bacterial infection of the skin, subcutaneous fat, superficial fascia, and deep fascia. It is characterized by marked tissue edema, rapid spread of inflammation, and signs of systemic toxicity. The wound cultures are predominantly polymicrobial and the location of initial involvement depends on the underlying etiologic factor. High index of suspicion, prompt aggressive surgery, appropriate antibiotics, and supportive care are the mainstays of management in the newborn infant with NF.
Mothers With Histories of Domestic Violence in a Pediatric Emergency Department
Authors: Duffy Susan J. , McGrath Meghan E. , Becker Bruce M. , Linakis James G
Published: August 2004

Objective.

To determine the prevalence of domestic violence against mothers in a pediatric emergency department and the relationship of their children to the abusers.

Design.

Cross-sectional survey of a convenience sample of mothers seeking treatment for their children.

Setting.

An urban pediatric emergency department.

Participants.

A total of 157 mothers with children <3 years of age. Women were excluded if older children or partners were present.

Results.

A total of 52% of women reported histories of adult physical abuse, 21% reported adult sexual abuse, and 28% reported childhood sexual abuse. A total of 10% of women were in abusive relationships in the past year. Victims of adult physical abuse were more likely to report histories of adult sexual abuse (relative risk [RR]: 4.93) or childhood sexual abuse (RR: 3.13). Intimate partners perpetrated 67% of physical abuse and 55% of sexual abuse. Relatives perpetrated 66% of childhood sexual abuse. Women who revealed histories of childhood sexual abuse were more likely to report adult sexual abuse (RR: 4.93). A total of 40% of the perpetrators of adult physical abuse, 73% of the perpetrators of past year physical abuse, and 10% of the perpetrators of adult sexual abuse had regular contact with their victims' children.

Health care providers screened only 21% of the women for past violence. Victims of domestic violence were no more likely to have been screened than those without histories of physical or sexual abuse.

Conclusions.

Mothers of young patients in a pediatric emergency department are often victims of domestic violence. Perpetrators are often close relatives and thus place the victims' children at risk for abuse and for the psychological trauma of witnessing violence. Given the prevalence of domestic violence, families may benefit from routine violence screening and interventions in pediatric emergency departments.
Experience, Brain, and Behavior: The Importance of a Head Start
Authors: Eisenberg Leon
Published: August 2004

Nature and nurture stand in reciprocity, not opposition. All children inherit—along with their parents' genes—their parents, their peers, and the communities they live in. Development unfolds in an ecologic and a social setting which, just like the genes, is decisive in shaping the organism. The social niche is a crucial link between parents and offspring, an envelope of life chances. It is high time to replace the false dichotomy between nature versus nurture by a more inclusive trio: nature, niche, and nurture.

Major brain pathways are specified in the genome, but the learned connections between brain and behavior are fashioned by social experience. The luxuriant overgrowth of neurons and their processes in embryonic and early life provides the substrate for environmentally induced structural change. Activity selects out the synapses that will persist; inactivity results in regression and apoptosis. Learning begins in utero and accelerates after birth. Responsive interactions between infants, their parents, and other caretakers is crucial to biological no less than psychosocial development. Comprehensive pediatric care can help provide a head start to enhance brain development and put the mind on the road to adaptive maturity.
Trampolines at Home, School, and Recreational Centers
Authors:   Committee on Injury and Poison Prevention and Committee on Sports Medicine and Fitness
Published: August 2004

This Policy Statement was revised. See https://doi.org/10.1542/peds.2012-2082.

The latest available data indicate that an estimated 83 400 trampoline-related injuries occurred in 1996 in the United States. This represents an annual rate 140% higher than was reported in 1990. Most injuries were sustained on home trampolines. In addition, 30% of trampoline-related injuries treated in an emergency department were fractures often resulting in hospitalization and surgery. These data support the American Academy of Pediatrics' reaffirmation of its recommendation that trampolines should never be used in the home environment, in routine physical education classes, or in outdoor playgrounds. Design and behavioral recommendations are made for the limited use of trampolines in supervised training programs.
Deaths Attributable to Injuries in Infants, United States, 1983–1991
Authors: Brenner Ruth A. , Overpeck Mary D. , Trumble DrPh; Ann C. , DerSimonian Rebecca , Berendes Heinz
Published: August 2004

Objective

To describe risk factors for injury death among infants in the United States by the specific external cause of death.

Methods.

Data were analyzed from the US-linked birth/infant death files for the years 1983–1991. Potential risk factors for injury death were identified from birth certificate data and included both maternal and infant factors. Injury rates were calculated by external cause of death. Characteristics of infants who died from an injury were compared with those of the entire birth cohort. The independent effect of potential risk factors was assessed in multivariate analyses using a case–control study design.

Results.

A total of 10 370 injury deaths were identified over the 9-year study period (29.72/100 000 live births). The leading causes of death were homicide, suffocation, motor vehicle crashes, and choking (inhalation of food or objects). There was no significant temporal trend in the overall rate of injury death; however, this was because significant increases in the rates of death from homicide (6.4%/year) and mechanical suffocation (3.7%/year) were offset by decreases in rates of death from fires (−4.7%/year) and choking (−4.6%/year). In adjusted analyses, infants born to mothers with no prenatal care, <12 years of education, two or more previous live births, Native American race, or <20 years of age were at twice the risk of injury death compared with the lowest risk groups (initiation of prenatal care in the first trimester, ≥16 years of education, no previous live births, white, or ≥25 years of age). When analyzed by the specific cause of death, the factors that were associated most strongly with death varied. For example, Native Americans were at greatest risk of a motor vehicle related death (compared with whites: OR: 3.6; 95% CI: 1.8–7.1), and infants with birth weights of <1500 g were at greatest risk of death attributable to inhalation of food (compared with ≥2500 g: OR: 9.6; 95% CI: 3.3–28.0) or objects (OR: 11.8; 95% CI: 4.5–30.5).

Conclusion.

A number of sociodemographic characteristics are associated with an increased risk of injury-related death in infants. The strength of associations between specific risk factors and death varies with the external cause of death, thus identifying high-risk subgroups for targeting of cause-specific interventions and simultaneously increasing our understanding of the individual and societal mechanisms underlying these tragedies. infant, injury, suffocation, motor vehicle, homicide, drowning, inhalation, fire.
Psychological Symptoms in Chronic Fatigue and Juvenile Rheumatoid Arthritis
Authors: Carter Bryan D. , Kronenberger William G. , Edwards Joseph F. , Marshall Gary S. , Schikler Kenneth N. , Causey David L.
Published: August 2004

Objective.

To determine if psychological morbidity in youth with chronic fatigue is caused by the stress of coping with a chronic illness.

Study Design.

Case–control study comparing pediatric patients with debilitating chronic fatigue and matched subjects with juvenile rheumatoid arthritis, a chronic medical illness with similar functional sequelae.

Setting.

Pediatric Infectious Diseases Clinic and Juvenile Rheumatoid Arthritis Clinic of Kosair Children's Hospital.

Participants.

Nineteen children and adolescents with debilitating chronic fatigue and 19 age- and sex-matched peers with juvenile rheumatoid arthritis.

Outcome.

Structured Interview, Kaufman Brief Intelligence Test, Child Behavior Checklist, and Youth Self-Report.

Results.

Intellectual functioning on the Kaufman Brief Intelligence Test Composite was average (103, standard score) for both groups. Pediatric patients with chronic fatigue had higher levels of internalizing psychological distress than patients suffering from juvenile rheumatoid arthritis, despite the fact that both groups had a similar pattern of decline in social and physical activities. Duration of illness did not explain the difference in psychological symptoms.

Conclusions.

Psychological factors may play a more active role in debilitating chronic fatigue in pediatric patients than can be explained by the stress of coping with a similar chronic, non–life-threatening illness.
Too Many Pediatric Trampoline Injuries
Authors: Furnival Ronald A. , Street Kellee A. , Schunk Jeff E.
Published: August 2004

Background.

Recent reports note a dramatic increase in the number of pediatric trampoline injuries (PTI) during the past several years. In 1996, the US Consumer Product Safety Commission estimates that 83 000 patients received treatment for trampoline injuries in US hospital emergency departments (EDs), and that ∼75% of these patients were <15 years of age. We sought to review our experience with PTI since our previous report (Pediatrics 1992;89:849), and to determine if the American Academy of Pediatrics' current (Pediatrics1981;67:438) safety recommendations are adequate.

Methods.

Retrospective medical record review of all PTI patients presenting to the pediatric ED from November 1990 through November 1997.

Results.

A total of 727 PTI patients were included; medical records were unavailable for 3 patients. The annual number of PTI nearly tripled during the study period, from 51 in 1991 to a peak of 148 in 1996. PTI patients were 53% female, with a median age of 7 years; 37% were <6 years of age. Privately owned trampolines accounted for 99% of PTI. Most injuries (66%) occurred on the trampoline, 28% resulted from falls off, and 4% from imaginative mechanisms. One hundred eleven patients (15%) suffered severe injury (1990 Abbreviated Injury Scale value ≥3), usually of an extremity (89 out of 111). Fractures occurred in 324 patients (45%). Spinal injuries were common (12%), including 7 patients with cervical or thoracic fractures, and 1 with C7 paraplegia. Fractures were more frequently associated with falls off the trampoline, whereas spinal injuries more frequently occurred on the trampoline. Eighty patients (11%) required prehospital medical transport to our ED, 584 (80%) had ED radiographs, and 382 (53%) required pediatric surgical subspecialty involvement. Seventeen percent of PTI patients (125 out of 727) were admitted to the hospital, including 9 to the pediatric intensive care unit; 99 (14%) required one or more operations. Mean hospital stay was 2 days (range, 1–63 days); 24 stays (19%) were for ≥3 days. We estimate that the hospital charges for the acute medical care of PTI study patients at our institution totaled ∼$700 000.

Conclusions.

PTI are dramatically increasing in number, and result in considerable childhood morbidity. Most PTI occur on privately owned trampolines. Few, if any, safety recommendations for the trampoline are followed. We support recommendations for a ban on the recreational, school, and competitive pediatric use of trampolines.
Monkeybar Injuries: Complications of Play
Authors: Waltzman Mark L. , Shannon Michael , Bowen Anne P. , Bailey Mary Christine
Published: August 2004

Background.

Playground equipment resulted in >200 000 injuries from 1990 to 1994, according to the Consumer Product Safety Commission; 88% were attributable to climbers (monkeybars/jungle gyms [MB/JGs]), swings, and slides. Equipment-specific injury requiring emergency department (ED) evaluation has not been reported previously.

Objective.

To describe the spectrum of significant MB/JG-related injuries.

Methods.

A 2-year retrospective chart review was performed using the computerized charting system at a large urban Children's Hospital/Regional Pediatric Trauma Center with 50 000 ED visits per year. A telephone survey also was conducted after the chart review to obtain additional information concerning the injury location, the surface type below the equipment, and the presence of adult supervision.

Results.

A total of 204 patients were identified. Mean age was 6.2 years (range, 20 months to 12 years); 114 (56%) were male. A seasonal variation was noted with June to August accounting for 43% of visits. Injuries included fractures in 124 (61%), contusions in 20 (10%), neck and back strains in 17 (8%), lacerations in 16 (8%), closed head injuries in 10 (5%), abdominal trauma in 5 (3%), genitourinary injuries in 5 (3%), and miscellaneous injuries in the remainder. Among fractures, 90% were fractures of the upper extremity; 48 (40%) were supracondylar fractures. One child sustained a C7 compression fracture. Abdominal injuries included 1 child who sustained a splenic laceration. All genitourinary injuries (2 vaginal hematomas, 1 vaginal contusion, 1 penile laceration, and 1 urethral injury) were from straddle-type injuries. Fifty-one (25%) patients were admitted to the hospital. Of these, 47 (92%) required an operative procedure (orthopedic reduction or vaginal examination under anesthesia).

Analysis of the telephone data revealed that the surface did not influence the injury type. Of the 79 fractures, 30 occurred on “soft surfaces.” Injury type was associated significantly with chronologic age. Younger children (1 to 4 years of age) sustained more long-bone fractures than did older children. The presence of adult (at least 18 years of age) supervision, did not influence the occurrence of fractures.

Conclusions.

These data suggest that 1) a significant proportion (25%) of MB/JG-related injuries that are evaluated in the ED require hospitalization; 2) most of the injuries resulting in admission will require operative intervention (92%); 3) the surface below the equipment has no influence on the type or severity of the injury; 4) younger children are more likely to sustain long-bone fractures than are older children; and 5) adult supervision does not influence the injury pattern. These data identify the need for additional investigation of means of making MB/JGs safer for child use.
Safety and Immunogenicity of an Acellular Pertussis Vaccine in Premature Infants
Authors: Schloesser Rolf L. , Fischer Doris , Otto Walter , Rettwitz-Volk Werner , Herden Peter , Zielen Stefan
Published: August 2004

Objectives.

To evaluate the safety and immunogenicity of a two-component acellular pertussis vaccine in preterm infants.

Study Design.

Fifty preterm infants (25–35 weeks of gestation; mean, 30.8 weeks) and 50 term infants as a control group received a two-component acellular pertussis vaccine irrespective of their biological age and actual weight. Adverse reactions were registered by parents on a diary card and reviewed on each visit. Antibodies against pertussis toxoid (PT) and filamentous hemagglutinin (FHA) were determined with an enzyme-linked immunosorbent assay before the first and after the third vaccination.

Results.

The infants of both groups showed an increase in geometric mean titers (GMT) against PT and FHA after vaccination (3 doses). There was a significant difference of antibody concentration between the preterm and the control group. The GMT for PT antibody of the preterm infants was 64.16 U/L, and for the term infants it was 98.96 U/L. The GMT for FHA was 50.92 U/L in preterm versus 86.02 U/L in the control group. Efficacy of the immunization (more than a fourfold increase of antibody concentration in each infant) was 93.5% in the preterm group with respect to PT and 82.6% with respect to FHA. The incidence of adverse reactions was low and comparable in both study groups.

Conclusion.

Immunization with an acellular pertussis vaccine is safe for preterm infants. The immune response is significantly lower compared with a control group of term infants, but efficacy is high.
Combination Therapy With Stavudine (d4T) Plus Didanosine (ddI) in Children With Human Immunodeficiency Virus Infection
Authors: Kline Mark W. , Van Dyke Russell B. , Lindsey Jane C. , Gwynne Margaret , Culnane Mary , Diaz Clemente , Yogev Ram , McKinney Ross E. , Abrams Elaine J. , Mofenson Lynne M. ,   the Pediatric AIDS Clinical Trials Group 327 Team
Published: August 2004

Objectives.

To evaluate the safety, tolerance, and antiviral activity of combination therapy with stavudine (d4T) plus didanosine (ddI) in symptomatic human immunodeficiency virus (HIV)-infected children.

Methods.

The study enrolled HIV-infected children who successfully completed Pediatric AIDS Clinical Trials Group (PACTG) protocol 240 (d4T versus zidovudine [ZDV] monotherapy) without disease progression or who had received ZDV monotherapy by prescription for at least the preceding 6 months. Children who had received d4T monotherapy in PACTG 240 were assigned to treatment with d4T plus ddI (arm 1). Children who had received ZDV monotherapy in PACTG 240 or by prescription were randomized in a double-blind manner to treatment with either d4T alone (arm 2) or d4T plus ddI (arm 3). Patients were followed for 48 weeks each.

Results.

A total of 108 children were enrolled. The mean age was 5.0 years (range, 1.6 to 11.5 years), with mean baseline plasma HIV RNA concentration and CD4+ lymphocyte count of 4.6 log10 copies/mL (range, 2.6 to 5.9 log10copies/mL) and 819 cells/μL (range, 8 to 3431 cells/μL), respectively. Both d4T monotherapy and d4T plus ddI combination therapy were well-tolerated, with 96 (89%) patients completing 48 weeks of study treatment. Plasma HIV RNA concentrations showed larger average declines in arm 3 compared with arm 2 at study week 12 (0.49 vs 0.18 log10 copies/mL, respectively); these average declines were maintained through week 48 (0.51 vs 0.17 log10 copies/mL, respectively). Fewer than 8% of the patients in any of the treatment arms had plasma HIV RNA concentrations below the limit of quantification (200 copies/mL) at any time point.

Conclusions.

Combination therapy with d4T plus ddI is safe and well-tolerated in HIV-infected children, producing durable, but incomplete, suppression of virus replication. This combination of nucleoside antiretroviral agents may provide a valuable backbone to protease inhibitor-containing treatment regimens for HIV-infected children.
Age-Within-School-Class and Adolescent Gun-carrying
Authors: Hayes D. Neil , Hemenway David
Published: August 2004

Background.

Intentional injuries (suicide and homicide) are a leading causes of morbidity and mortality in the United States. Firearms cause ∼70% of these fatal intentional injuries. Risk factors associated with gun-carrying in adolescent populations include male gender, smoking, alcohol use, drug use, and number of sexual partners. Current knowledge of these and other risk factors has provided limited benefit because many are no more obvious to the clinician a priori than is the tendency to carry guns. Increasing relative age of a student within school class is an easily measured parameter that has been associated with behavioral problems, absenteeism, negative self-image, and high dropout rates.

Objective.

To characterize the association between relative student age-within-class and tendency to carry firearms.

Design.

The Massachusetts Youth Risk Behavior Survey, which collects data on demographic characteristics, risk behaviors, and health outcomes.

Participants.

A randomly selected group of 3153 Massachusetts students in grades 9 through 11.

Primary Outcome Measure.

The odds of firearms-carrying comparing older to average-age and younger students.

Results.

Using multivariate logistic regression, seven risk factors predicted gun-carrying with statistically significant results: older age-within-class (OR: 2.12; 95% CI: 1.09–4.12), male gender (OR: 4.95; 95% CI: 3.01–8.15), black race (OR: 2.49; 95% CI: 1.20–5.14), gang membership (OR: 7.22; 95% CI: 4.51–11.56), missing school out of concern for safety (OR: 2.50; 95% CI: 1.30–4.80), seeking medical treatment after a fight (OR: 4.47; 95% CI: 2.56–7.78), and fighting without seeking medical treatment (OR: 5.73; 95% CI: 3.09–10.60).

Conclusion.

Older 9th-, 10th-, and 11th-grade students are more likely than their classmates to carry firearms. This information may prove helpful in identifying high-risk students and targeting prevention strategies.
Plasma Insulin-like Growth Factor-1, Type 1 Procollagen, and Serum Tumor Necrosis Factor α in Children Recovering FromTrichuris Dysentery Syndrome
Authors: Duff E. Marilyn Watson , BScN Nutr), MSc (Nutr), , Anderson Norma McFarlane , Cooper Edward S.
Published: August 2004

Objectives.

To explore: 1) the relationship between plasma insulin-like growth factor-1 (IGF-1) and other markers of growth; and 2) the effect of serum concentrations of tumor necrosis factor α (TNF) on growth variables in children (2–10 years) stunted by Trichuris dysentery syndrome (TDS), recovering cases, and their matched controls.

Method.

Fourteen patients with TDS were admitted to the Tropical Metabolism Research Unit, treated with albendazole and iron, and then followed with matched controls (n = 28) for 1 year. Anthropometric and biochemical measurements were done on admission and then every 3 months for the year. Plasma IGF-1, the carboxyterminal propeptide of type 1 procollagen, serum TNF, total serum protein, serum albumin, and complete blood count were determined.

Results.

Low admission plasma levels of IGF-1 in TDS cases were accompanied by high serum levels of TNF, and total serum protein, normal serum albumin, low hemoglobin, reduced collagen synthesis (low plasma carboxyterminal propeptide of type 1 procollagen), and growth failure. These variables improved significantly after treatment. Plasma levels of IGF-1 were significantly related to theZ-scores for height-for-age (r = 0.60, 0.73, 0.68) and weight-for-age (r = 0.69, 0.80, 0.69) of cases and controls, height-for-age (r = 0.51, 0.52, 0.54) and weight-for-age (r = 0.51, 0.52, 0.54) at each measurement throughout the year. Serum levels of TNF were not related to any of the growth variables.

Conclusion.

These findings may contribute to the understanding of growth failure in children affected by other forms of chronic inflammatory bowel disease.
Breastfeeding Effects on Intelligence Quotient in 4- and 11-Year-Old Children
Authors: Jacobson Sandra W. , Chiodo Lisa M. , Jacobson Joseph L.
Published: August 2004

Objective

A study of preterm children found an IQ advantage among those who were breastfed as infants after controlling for maternal social class and educational status. However, this advantage needs to be examined in light of other maternal characteristics, such as maternal IQ and parenting skills, which were not measured in that study and which have been found to be related to breastfeeding.

Methodology.

IQ was assessed in 323 children at 4 years of age on the McCarthy Scales of Children's Abilities and the Peabody Picture Vocabulary Test-Revised and in 280 children on the Wechsler Intelligence Test for Children-Revised at 11 years of age.

Results.

Children who were breastfed in infancy had significantly higher scores on IQ tests at both ages, even after adjusting for social class and education, confirming the earlier findings and extending them to a predominantly full-term sample. However, the effect of breastfeeding was no longer significant after adjusting for maternal IQ assessed on the Peabody Picture Vocabulary Test-Revised and for parenting skills assessed on the Home Observation for Measurement of the Environment. Significant relations between breastfeeding and Woodcock Reading Achievement scores at 11 years were also reduced to nonsignificant levels after the inclusion of maternal IQ and the Home Observation for Measurement of the Environment.

Conclusions.

These findings suggest that the observed advantage of breastfeeding on IQ is related to genetic and socioenvironmental factors rather than to the nutritional benefits of breastfeeding on neurodevelopment. They should not be interpreted as detracting from the medical benefits associated with breastfeeding.
Antiangiogenic Therapy of a Recurrent Giant Cell Tumor of the Mandible With Interferon Alfa-2a
Authors: Kaban Leonard B. , Mulliken John B. , Ezekowitz R. Alan , Phil D , Ebb David , Smith Peter S. , Folkman Judah
Published: August 2004

We report a 5-year-old girl with a large rapidly growing giant cell tumor of the mandible that recurred 2 months after the first surgical excision and 3 months after a second resection. An angiogenic protein, (bFGF), was abnormally elevated in her urine. The patient was treated with interferon alfa-2a for 1 year because this agent inhibits angiogenesis by suppressing bFGF overexpression in infantile hemangiomas and in other human tumors. During this time the bone tumor regressed and disappeared, the urinary bFGF fell to normal levels, and the mandible regenerated. She has remained tumor-free and has been off therapy for 3 years at this writing.

This first successful use of interferon alfa-2a to treat a mandibular tumor in a child demonstrates: 1) low grade tumors that overexpress bFGF may respond to interferon alfa-2a, in a manner similar to life-threatening infantile hemangiomas; 2) antiangiogenic therapy, given without interruption for 1 year, was safe and effective in this patient; and 3) treatment may be continued for 1 year without the development of drug resistance.
Epidemiology of Otitis Media Onset by Six Months of Age
Authors: Daly Kathleen A. , Brown Judith E. , Lindgren Bruce R. , Meland Mary H. , Le Chap T. , Giebink G. Scott
Published: August 2004

Objective.

Although early otitis media (OM) onset predicts later recurrent and chronic OM, little research has been directed at illuminating the role of prenatal exposures in early OM. This prospective study examined prenatal, innate, and early environmental exposures associated with acute otitis media (AOM) onset and recurrent OM (ROM) by age 6 months.

Design and Methods.

Prospective study of 596 infants from a health maintenance organization followed from birth to 6 months. Mothers completed monthly forms on prenatal exposures (diet, medications, and illnesses) and infant risk factors (eg, smoke exposure and child care) during pregnancy and until infants were 6 months old. Urine samples were collected when infants were 2 months of age and analyzed for cotinine and creatinine. Physicians and nurse practitioners examined infants at each clinic visit and completed standard ear examination forms.

Results.

Thirty-nine percent had an episode of AOM and 20% had ROM by age 6 months. Using Cox's regression models to control for confounding, respiratory tract infection (relative risk [RR] 7.5), day care (RR 1.7), >1 sibling (RR 1.4), maternal, paternal, and sibling OM history (RR 1.6, 1.5, and 1.7, respectively) were significantly related to early OM onset. ROM was related to respiratory tract infection (RR 9.5), day care (RR 1.9), conjunctivitis (RR 2.0), maternal OM history (RR 1.9), and birth in the fall (RR 2.6). Among prenatal exposures, only high prenatal dietary vitamin C intake was significantly inversely related to early AOM with univariate but not multivariate analysis.

Conclusion.

Prenatal factors were not linked to early AOM onset with multivariate analysis, but environmental and innate factors play an important role in early AOM onset. Strategies to reduce exposure to environmental variables could reduce rates of early AOM, which could potentially result in declining rates of ROM and chronic OME.
Access for Low-income Children: Is Health Insurance Enough?
Authors: Rosenbach Margo L. , Irvin Carol , Coulam Robert F.
Published: August 2004

Objective.

The Balanced Budget Act of 1997 authorizes $20 billion for states to expand health insurance coverage among uninsured low-income children. This study identifies lessons learned from the Medicaid Extension Demonstration, which was authorized by Congress to experiment with innovative approaches to providing health care coverage for low-income children. The three programs compare and contrast a variety of features that may enhance or detract from access, including a traditional Medicaid expansion, a private indemnity model, and a comprehensive managed care delivery system.

Methodology.

Two waves of telephone surveys were conducted with a sample of parents of children participating in the Medicaid Extension Demonstration, and a comparison group of parents of children who were eligible but not participating. Descriptive and multivariate analyses were conducted to determine the impact of the demonstration on access to care.

Results.

Compared with those who were uninsured, children in the managed care program were more likely to have a medical home and a physician visit and were less likely to have an emergency room visit, and had lower levels of unmet need. Outcomes across the other two demonstration programs were less favorable.

Conclusions.

This study suggests that simply providing a Medicaid card or private indemnity insurance card is not enough to ensure access to care. Future initiatives also need to consider the structure of the delivery system, especially the availability of a medical home (with adequate after-hours care), as well as the impact of discontinuous insurance coverage on access to and continuity of care.
Impact of Simple Screening Criteria on Utilization of Low-yield Bacterial Stool Cultures in a Children's Hospital
Authors: Zaidi Anita K. M. , Macone Ann , Goldmann ASCP); and Donald
Published: August 2004

Objective.

To determine diagnostic yield of stool cultures for Salmonella,Shigella, Campylobacter jejuni,Yersinia enterocolitica, and Escherichia coli O157:H7 (SSCYE) among hospitalized children and to develop guidelines for appropriate use of these tests.

Setting.

Tertiary care pediatric hospital.

Design.

Computerized records from the Microbiology Laboratory from January 1992 to December 1996 were reviewed retrospectively to collect data on the number of stool cultures performed in inpatients and outpatients, the length of hospital stay at the time cultures were sent, and diagnostic yield of cultures in hospitalized patients. A detailed review of medical records of all patients with a stool pathogen isolated after 3 days of hospitalization was also undertaken.

The results from this retrospective analysis were used to develop guidelines to reduce unwarranted stool cultures and to educate medical care providers in the appropriate use of these tests. The impact of these guidelines on reduction in the volume of stool cultures performed on hospitalized patients was measured prospectively from January 1998 to June 1998.

Results.

A total of 27 110 stool cultures for SSCYE were performed in the 5-year study period. Of the 14 125 cultures from inpatients, 174 (1.2%) were positive. Among the cultures from inpatients, 9378 (66%) were from patients hospitalized for >3 days. Only 13 (.14%) were positive. Of these 13 cultures, 4 represented nosocomial infections, whereas the remaining 9 cultures either were sent to document clearance from a patient known previously to be infected with an enteric pathogen (7), or were attributed to delayed testing in individuals admitted with a diarrheal illness (2).

Introduction of guidelines to reject all SSCYE cultures from patients hospitalized for >3 days who did not meet specified criteria was associated with an overall reduction of 689 (43%) in the volume of tests performed in the 6-month period evaluated. This included 497 fewer cultures ordered and 192 cultures that were ordered but rejected because screening criteria were not met. Only 11 (5.4%) of 203 cultures sent >3 days after admission were processed because they met clinical criteria for testing. None were positive. Estimated cost savings were $50 163/year.

Conclusions.

Stool cultures for SSCYE among hospitalized patients have very low diagnostic yield and are extremely overutilized. Simple guidelines, such as rejecting (with few exceptions) cultures from patients hospitalized for >3 days, can reduce substantially such unnecessary testing.
Cost-effective Imaging Approach to the Nonbilious Vomiting Infant
Authors: Mandell Gerald A. , Wolfson Philip J. , Adkins E. Stanton , Caro Pilar A. , Cassell Ian , Finkelstein Mark S. , Grissom Leslie E. , Gross George W. , Harcke H. Theodore , Katz Aviva L. , Murphy Steven G. , Noseworthy John , Schwartz Marshall Z.
Published: August 2004

Objective.

To develop a cost- and time-effective algorithm for differentiating hypertrophic pyloric stenosis (HPS) from other medical causes of emesis in infants referred from community-based pediatricians and family practitioners to the imaging department of a tertiary children's care facility.

Methods.

Eighty-nine vomiting infants (22 females, 67 males) between the ages of 11 and 120 days (mean, 43.5 days) had received nothing by mouth for at least 1 hour before the study. Each child was assessed for duration of vomiting, status of body weight, time and volume of last ingestion, and time of last emesis. A #8 French (Sherwood Medical, St Louis, MO) nasogastric feeding tube was placed in the child's stomach. The contents were aspirated and measured to determine likelihood of HPS. An aspirated volume ≥5 mL implicated gastric outlet obstruction, and ultrasonography (US) was performed. If this study was positive for HPS, the patient was referred for surgery. If US was negative, an upper gastrointestinal series (UGI) was performed. An aspirated stomach contents volume <5 mL suggested a medical cause for the emesis, and UGI was performed. Pediatric surgeons with no knowledge of the volume results palpated the abdomens of 73 of 89 infants (82%).

Results.

Twenty-three of 89 patients (25%) had HPS. The aspirate criteria for HPS had a sensitivity of 91%, a specificity of 88%, and an accuracy of 89%. Of the false-positive studies (total = 8), six were related to recent significant ingestion (within 2 hours of the study), and two were attributable to antral dysmotility. The surgeons palpated the mass in 10 of 19 patients (53%). Sensitivity and specificity were 53% and 93%, respectively. Only 6 of 89 infants (7%) required both US and UGI to determine the etiology of the nonbilious vomiting. By performing the UGI in 66 patients, it was also found that 14% had slow gastric emptying and 79% had gastroesophageal reflux. Eighty-one percent of the gastroesophageal reflux was significant.

Conclusion.

The volumetric method of determining the proper imaging study is cost- and time-effective in the evaluation of the nonbilious vomiting infant for pyloric stenosis. If US was performed initially in all patients referred for imaging, two studies would have been performed in 68 of 89 patients (76%) to define the etiology of the emesis. Because we used the volumetric method, 62 fewer imaging studies were performed, representing a savings of $4464 and 30 hours of physician time. If children are given nothing by mouth for 3 to 4 hours before gastric aspiration, the specificity of the volumetric method improves to 94%, and the accuracy improves to 96%.
Communicating Bad News: A Pediatric Department's Evaluation of a Simulated Intervention
Authors: Greenberg Larrie W. , Ochsenschlager Daniel , O'Donnell Regina , Mastruserio Jennifer , Cohen George J.
Published: August 2004

Objective.

To determine if pediatric residents and emergency department (ED) fellows could improve their ability to counsel and inform standardized patients (SPs) about bad news.

Methodology.

A crossover, self-controlled design in which trainees were their own control individuals, and SPs provided feedback after the first interview. The setting was the consultation room in the ED of a large children's hospital. The outcome measures included examining the counseling and informing skills of study participants.

Results.

Trainees improved their informing skills after being provided feedback in the broad areas of communication and follow-up and in the total number of content areas asked. Their counseling skills improved in two areas: 1) promoting more trust and 2) making parents feel less dependent. Those trainees who scored higher on counseling skills discussed more total and critical content issues with SPs in the study. Trainee feedback revealed a very high rating of the educational process, and the trainees also felt much more confident about their skills after the first and second sessions.

Conclusions.

Using SPs to teach residents and ED fellows to give bad news is an effective educational process that provides trainees with interactions that simulate real-life experience
Once-daily Gentamicin Dosing in Newborn Infants
Authors: Lundergan Faye S. , Glasscock BCNSP*‡§; Gregory F. , Kim Eun H. , Cohen Ronald S.
Published: August 2004

Objective.

We developed a simplified gentamicin dosing protocol for all neonates using a loading dose and once-daily dosing that would have an equal or lower incidence of toxicity and an equal or improved effectiveness compared with a regimen with no loading dose that included use of divided daily dosing.

Methods.

All neonatal intensive care unit patients with a postnatal age ≤7 days and started on gentamicin therapy at the discretion of the attending neonatologist were evaluated in this comparative cohort study. All peak and trough serum drug levels (SDL), pertinent demographic data, and markers of potential nephrotoxicity, ototoxicity, and cure were tracked prospectively during 132 consecutive, nonrandomized courses of therapy on a new gentamicin protocol. These were compared with data retrieved retrospectively throughout 103 consecutive, nonrandomized courses of therapy in a control group.

Results.

Initial measured peak SDL were higher (7.8 ± 1.1 μg/mL vs 6.1 ± 1.0 μg/mL) and trough SDL were lower (0.9 ± 0.2 μg/mL vs 2.7 ± 0.6 μg/mL) in the protocol term subset, compared with the control term subset (gestational age, ≥37 weeks; weight, ≥2500 g). One hundred percent of the initial and maintenance peak SDL in term protocol neonates were 5 to 12 μg/mL; compared with 84% of the initial and 61% of maintenance peak SDL in the term control group. One hundred percent of the initial and maintenance trough SDL were in the desired range of <2 μg/mL in term protocol neonates; compared with 70% of the initial and 94% of maintenance trough SDL in the term control group. No significant differences were found in any SDL in low birth weight neonates (gestational age <37 weeks or weight <2500 g and >1500 g) in the protocol compared with the control group. The very low birth weight (weight <1500 g) protocol neonates had a significantly higher mean initial trough SDL (2.3 ± 0.7 μg/mL vs 1.5 ± 0.6 μg/mL) and a lower incidence of initial trough SDL <2.0 μg/mL (30% vs 95%) than very low birth weight neonates in the control group. No differences were seen between groups in incidence of significant rise in serum creatinine or failure of hearing screen.

Conclusion.

A loading dose followed by once-daily dosing was shown to result in SDL in the safe and therapeutic range in all term neonates in this study. In low birth weight neonates, this regimen resulted in peak and trough SDL throughout therapy that were similar to those observed in the control group. Delaying the initiation of maintenance once-daily dosing until 36 to 48 hours after the loading dose would be expected to result in a higher incidence of initial trough SDL in target range for very low birth weight neonates.
Preventing Early-onset Group B Streptococcal Sepsis: Strategy Development Using Decision Analysis
Authors: Benitz William E. , Gould Jeffrey B. , Druzin Maurice L.
Published: August 2004

Objective.

To evaluate recommended strategies for prevention of early-onset group B streptococcal infections (EOGBS) with reference to strategies optimized using decision analysis.

Methods.

The EOGBS attack rate, prevalence and odds ratios for risk factors, and expected effects of prophylaxis were estimated from published data. Population subgroups were defined by gestational age, presence or absence of intrapartum fever or prolonged rupture of membranes, and presence or absence of maternal group B streptococcus (GBS) colonization. The EOGBS prevalence in each subgroup was estimated using decision analysis. The number of EOGBS cases prevented by an intervention was estimated as the product of the expected reduction in attack rate and the number of expected cases in each group selected for treatment. For each strategy, the number of residual EOGBS cases, cost, and numbers of treated patients were calculated based on the composition of the prophylaxis group. Integrated obstetrical-neonatal strategies for EOGBS prevention were developed by targeting the subgroups expected to benefit most from intervention.

Results.

Reductions in EOGBS rates predicted by this decision analysis were smaller than those previously estimated for the strategies proposed by the American Academy of Pediatrics in 1992 (32.9% vs 90.7%), the American College of Obstetricians and Gynecologists in 1992 (53.8% vs 88.8%), and the Centers for Disease Control and Prevention in 1996 (75.1% vs 86.0%). Strategies based on screening for GBS colonization with rectovaginal cultures at 36 weeks or on use of a rapid test to screen for GBS colonization on presentation for delivery, combining intrapartum prophylaxis for selected mothers and postpartum prophylaxis for some of their infants, would require treatment of fewer patients and prevent more cases (78.4% or 80.1%, respectively) at lower cost.

Conclusions.

No strategy can prevent all EOGBS cases, but the attack rate can be reduced at a cost <$12 000 per prevented case. Supplementing intrapartum prophylaxis with postpartum ampicillin in a few infants is more effective and less costly than providing intrapartum prophylaxis for more mothers. Better intrapartum screening tests offer the greatest promise for increasing efficacy. Integrated obstetrical and neonatal regimens appropriate to the population served should be adopted by each obstetrical service. Surveillance of costs, complications, and benefits will be essential to guide continued iterative improvement of these strategies.
Antimicrobial Prevention of Early-onset Group B Streptococcal Sepsis: Estimates of Risk Reduction Based on a Critical Literature Review
Authors: Benitz William E. , Gould Jeffrey B. , Druzin Maurice L.
Published: August 2004

Objective.

To identify interventions that reduce the attack rate for early-onset group B streptococcal (GBS) sepsis in neonates.

Study Design.

Literature review and reanalysis of published data.

Results.

The rate of early-onset GBS sepsis in high-risk neonates can be reduced by administration of antibiotics. Treatment during pregnancy (antepartum prophylaxis) fails to reduce maternal GBS colonization at delivery. With the administration of intravenous ampicillin, the risk of early-onset infection in infants born to women with preterm premature rupture of membranes is reduced by 56% and the risk of GBS infection is reduced by 36%; addition of gentamicin may increase the efficacy of ampicillin. Treatment of women with chorioamnionitis with ampicillin and gentamicin during labor reduces the likelihood of neonatal sepsis by 82% and reduces the likelihood of GBS infection by 86%. Universal administration of penicillin to neonates shortly after birth (postpartum prophylaxis) reduces the early-onset GBS attack rate by 68% but is associated with a 40% increase in overall mortality and therefore is contraindicated. Intrapartum prophylaxis, alone or combined with postnatal prophylaxis for the infants, reduces the early-onset GBS attack rate by 80% or 95%, respectively.

Conclusions.

Women with chorioamnionitis or preterm premature rupture of membranes and their infants should be treated with intravenous ampicillin and gentamicin. Intrapartum antimicrobial prophylaxis may be appropriate for other women whose infants are at increased but less extreme risk, and supplemental postpartum prophylaxis may be indicated for some of their infants. Selection of appropriate candidates and prophylaxis strategies requires careful consideration of costs and benefits for each patient. group B streptococcus, neonatal sepsis, early-onset sepsis, prevention, prophylaxis.