bluuebunny/crossref_metadata_2025 huggingface dataset:
Epidemiology of Terror-Related Versus Non-Terror-Related Traumatic Injury in Children
Authors: Aharonson-Daniel Limor , Waisman Yehezkel , Dannon Yehuda L. , Peleg Kobi ,   Members of the Israel Trauma Group
Published: August 2004

Objective. In the past 2 years hundreds of children in Israel have been injured in terrorist attacks. There is a paucity of data on the epidemiology of terror-related trauma in the pediatric population and its effect on the health care system. The objective of this study was to review the accumulated Israeli experience with medical care to young victims of terrorism and to use the knowledge obtained to contribute to the preparedness of medical personnel for future events.

Methods. Data on all patients who were younger than 18 years and were hospitalized from October 1, 2000, to December 31, 2001, for injuries sustained in a terrorist attack were obtained from the Israel National Trauma Registry. The parameters evaluated were patient age and sex, diagnosis, type, mechanism and severity of injury, interhospital transfer, stay in intensive care unit, duration of hospitalization, and need for rehabilitation. Findings were compared with the general pediatric population hospitalized for non-terror-related trauma within the same time period.

Results. During the study period, 138 children were hospitalized for a terror-related injury and 8363 for a non-terror-related injury. The study group was significantly older (mean age: 12.3 years [standard deviation: 5.1] v 6.9 years [standard deviation: 5.3]) and sustained proportionately more penetrating injuries (54% [n = 74] vs 9% [n = 725]). Differences were also noted in the proportion of internal injuries to the torso (11% in the patients with terror-related trauma vs 4% in those with non-terror-related injuries), open wounds to the head (13% vs 6%), and critical injuries (Injury Severity Score of 25+; 25% vs 3%). The study group showed greater use of intensive care unit facilities (33% vs 8% in the comparison group), longer median hospitalization time (5 days vs 2 days), and greater need for rehabilitative care (17% vs 1%).

Conclusions. Terror-related injuries are more severe than non-terror-related injuries and increase the demand for acute care in children.
Fetal Hemoglobin Synthesis Determined by γ-mRNA/γ-mRNA + β-mRNA Quantitation in Infants at Risk for Sudden Infant Death Syndrome Being Monitored at Home for Apnea
Authors: Bard Harry , Côté Aurore , Praud Jean-Paul , Infante-Rivard Claire , Gagnon Carmen
Published: August 2004

Objective. Fetal hemoglobin (HbF) levels in the hemolysates obtained from infants who died from sudden infant death syndrome (SIDS) are reported to be markedly increased compared with controls. This finding could have been explained by increased HbF synthesis caused by episodes of hypoxemia in the SIDS infants. A prospective study in a group of infants being monitored at home after an apparent life-threatening event (ALTE) and considered at increased risk for SIDS was conducted with an improved ribonuclease protection assay. The ribonuclease protection assay allowed for the quantitation of [γ/(γ+β)]-globin mRNAs, which has a highly significant correlation with the levels of HbF synthesis.

Methods. Thirty-five infants who were admitted for an ALTE were included in the study. All infants were at home under surveillance with a cardiorespiratory monitor and followed in an apnea clinic with monthly appointments. Seventy-three blood samples were obtained between 38 and 61 weeks of postconceptional age. For control purposes, a similar group of 37 normal infants (99 samples) whose HbF synthesis was previously determined were included.

Results. Mean [γ/(γ+β)]-globin mRNAs were increased in the ALTE group at 42 to 45 and 46 to 49 weeks of postconceptional age (mean: 55.2 ± 17.4% and 33.9 ± 14%) in comparison with HbF synthesis in controls (mean: 42.6 ± 13.7% and 23.6 ± 9.8%).

Conclusions. The data obtained in this report from infants who were considered at risk for SIDS show that HbF synthesis is increased between 42 and 49 weeks of postconceptional age. Determining HbF synthesis as described in this study may have value as a marker for episodes of hypoxemia for certain infants who are at risk for SIDS.
Pediatric Viral Human Immunodeficiency Virus Type 1 RNA Levels, Timing of Infection, and Disease Progression in African HIV-1-Infected Children
Authors: Rouet François , Sakarovitch Charlotte , Msellati Philippe , Elenga Narcisse , Montcho Crépin , Viho Ida , Blanche Stéphane , Rouzioux Christine , Dabis François , Leroy Valériane ,   for the Abidjan ANRS 049 Ditrame Study Group
Published: August 2004

Objective. To describe plasma human immunodeficiency virus type 1 (HIV-1) RNA levels in African HIV-1-infected children in relation to the timing of infection and disease progression.

Methods. A retrospective cohort study was conducted of 80 children who were born to HIV-1-positive mothers and clinically followed from birth to 18 months of age in the ANRS 049 Ditrame project, Abidjan, Côte d’Ivoire (West Africa). The diagnosis and timing of pediatric HIV-1 infection were determined prospectively according to HIV-1 DNA polymerase chain reaction results. A total of 364 HIV-1 RNA viral load (VL) measurements were assessed retrospectively. Kaplan-Meier analyses and proportional hazards models were used to evaluate the prognostic value of pediatric VL and covariates for HIV disease progression or death.

Results. Mean initial positive VL was significantly lower among children who were infected in utero (4.94 log10/mL, n = 12) than in children who were infected later (5.6–6.1 log10/mL, n = 68). In the first 6 months after diagnosis, HIV-1 RNA levels peaked (≥6 log10/mL), regardless of timing of infection. Then, a slow decline (overall slope, −0.076 log10 copies/mL/mo) was observed until 18 months of age. A 1 log10 higher value of the pediatric peak VL (risk ratio [RR]: 1.85; 95% confidence interval [CI]: 1.0–3.44) and of the maternal VL at delivery (RR: 1.90; CI: 1.16–3.12) were independently associated with an increased risk of rapid progression to acquired immune deficiency syndrome (AIDS) or death at 18 months of life (23 AIDS diagnoses and 31 deaths). Disease progression or death was more rapid for girls than for boys (RR: 2.26; CI: 1.39–4.96).

Conclusions. In Africa, pediatric HIV-1 RNA levels are very close to those described in industrialized countries and seem to be predictive of AIDS stage or death, as in industrialized countries. With antiretroviral therapy becoming more widely available, the early identification and monitoring of pediatric HIV disease remains of paramount importance in Africa.
A Prospective Study of Bacillus Calmette-Guérin Scar Formation and Tuberculin Skin Test Reactivity in Infants in Lima, Peru
Authors: Santiago Eunice M. , Lawson Elise , Gillenwater Kari , Kalangi Sheela , Lescano Andrés G. , Du Quella Gregory , Cummings Kristin , Cabrera Lilia , Torres Cecilia , Gilman Robert H.
Published: August 2004

Objectives. To determine the sensitivity of the bacillus Calmette-Guérin (BCG) scar as an indicator of previous vaccination and to ascertain the tuberculin skin test (TST) response in infancy after vaccination in a community from an area hyperendemic for tuberculosis (TB).

Methods. In a birth cohort of healthy term infants from Lima, Peru, a single dose of BCG vaccine was administered within the first month of life. Scar formation was assessed biweekly during the first 6 months and again at 3 years after vaccination. TST response was evaluated 6 months after vaccination.

Results. Six months after vaccination, 99% (68) of the newborns exhibited a BCG scar (>2 mm). Scar size did not differ by sex, birth weight, age at vaccination, or nutritional status in the first 2 months. Eighty percent of the participants were found 3 years after vaccination, and all of them had a BCG scar. Mean TST reaction size 6 months after vaccination was 2.9 ± 0.3 mm. No association was found between sex or age at BCG vaccination and TST size. Only 3 children had a TST >10 mm, and the 3 had a TB contact at home.

Conclusions. The BCG scar was a sensitive indicator of vaccination status up to 3 years after the administration of the vaccine in the first month of life. Although nearly a quarter of the children had a TST response >5 mm 6 months after vaccination, TST reactions >10 mm did not occur in the absence of exposure to a person with tuberculosis. A cutoff of 10 mm should be used for disease control purposes in people who are born in countries where TB is endemic.
Determinants of Nonsynostotic Plagiocephaly: A Case-Control Study
Authors: Hutchison B. Lynne , Thompson John M. D. , Mitchell Ed A.
Published: August 2004

Objective. There has been a large increase in reported cases of nonsynostotic plagiocephaly in infants since the adoption of supine sleeping recommendations to prevent sudden infant death syndrome. The objective of this study was to identify and quantify the determinants of nonsynostotic plagiocephaly in infants.

Methods. One hundred infants who received a diagnosis of having nonsynostotic plagiocephaly were recruited as case patients and compared with 94 control subjects who were selected from a citywide database of infants. The infants all were aged between 2 and 12 months. Information concerning sociodemographic variables, obstetric factors, infant factors, and infant care practices was obtained by parental interview.

Results. Case patients were significantly more likely to be male (adjusted odds ratio [aOR]: 2.51; 95% confidence interval [CI]: 1.23–5.16), to be a firstborn (aOR: 2.94; 95% CI: 1.46–5.96), and to have been premature (aOR: 3.26; 95% CI: 1.02–10.47). In the first 6 weeks, they were more likely to have been sleeping in the supine position (aOR: 7.02; 95% CI: 2.98–16.53), not to have had the head position varied when put down to sleep (aOR: 7.11; 95% CI: 2.75–18.37), and to have had <5 minutes a day of tummy time (OR: 2.26; 95% CI: 1.03–5.00). Mothers of case patients were more likely to perceive their infants as less active (aOR: 3.23; 95% CI: 1.38–7.56), to have a developmental delay (aOR: 3.32; 95% CI: 1.01–10.85), and to have had a definite preferred head orientation at 6 weeks (aOR: 37.46; 95% CI: 8.44–166.32). Case mothers were more likely to have no or low educational qualifications (aOR: 5.61; 95% CI: 2.02–15.56), although they were more likely to have attended antenatal classes (aOR: 6.61; 95% CI: 1.59–27.47).

Conclusions. Early identification of a preferred head orientation, which may indicate the presence of neck muscle dysfunction, may help prevent the development or further development of nonsynostotic plagiocephaly in infants. Plagiocephaly might also be prevented by varying the head position when putting the very young infant down to sleep and by giving supervised tummy time when awake.
Newborn Screening by Tandem Mass Spectrometry for Medium-Chain Acyl-CoA Dehydrogenase Deficiency: A Cost-Effectiveness Analysis
Authors: Venditti Laura N. , Venditti Charles P. , Berry Gerard T. , Kaplan Paige B. , Kaye Edward M. , Glick Henry , Stanley Charles A.
Published: August 2004

Objective. To determine whether newborn screening by tandem mass spectrometry (MS/MS) for medium-chain acyl-CoA dehydrogenase deficiency (MCADD) is cost-effective versus not screening and to define the contributions of disease, test, and population parameters on the decision.

Methods. A decision-analytic Markov model was designed to perform cost-effectiveness and cost-utility analyses measuring the discounted, incremental cost per life-year saved and per quality-adjusted life-year saved of newborn screening for MCADD compared with not screening. A hypothetical cohort of neonates made transitions among a set of health states that reflected clinical status, morbidity, and cost. Outcomes were estimated for time horizons of 20 and 70 years. Probabilities and costs were derived from a retrospective chart review of a 32-patient cohort treated over the past 30 years at the Children’s Hospital of Philadelphia, clinical experience with MCADD patient management, patient-family interviews, cost surveys, state sources, and published studies. In addition to older patients who came to medical attention by symptomatic presentation, our patient group included 6 individuals whose MCADD had been diagnosed by supplemental newborn screening. Estimates of the expected net changes in costs and life expectancy for MCADD screening were used to compute the incremental cost-effectiveness ratios. Sensitivity analyses were performed on key input variables, and 95% confidence intervals (CIs) were computed through second-order Monte Carlo simulations.

Results. In our base-case analysis over the first 20 years of life, the cost of newborn screening for MCADD was approximately $11 000 (2001 US dollars; 95% CI: <$0–$33 800) per life-year saved, or $5600 (95% CI: <$0–$17 100) per quality-adjusted life-year saved compared with not screening. Over a 70-year horizon, the respective ratios were approximately $300 (95% CI: <$0–$13 000) and $100 (95% CI: <$0–$6900). The results were robust when tested over plausible ranges for diagnostic test sensitivity and specificity, MCADD prevalence, asymptomatic rate, and screening cost.

Conclusions. Simulation modeling indicates that newborn screening for MCADD reduces morbidity and mortality at an incremental cost below the range for accepted health care interventions. At the 70-year horizon, the model predicts that almost all of the additional costs of screening would be offset by avoided sequelae.
Postnatal Serum Insulin-Like Growth Factor I Deficiency Is Associated With Retinopathy of Prematurity and Other Complications of Premature Birth
Authors: Hellström Ann , Engström Eva , Hård Anna-Lena , Albertsson-Wikland Kerstin , Carlsson Björn , Niklasson Aimon , Löfqvist Chatarina , Svensson Elisabeth , Holm Sture , Ewald Uwe , Holmström Gerd , Smith Lois E. H.
Published: August 2004

Objective. Insulin-like growth factor I (IGF-I) is necessary for normal development of retinal blood vessels in mice and humans. Because retinopathy of prematurity (ROP) is initiated by abnormal postnatal retinal development, we hypothesized that prolonged low IGF-I in premature infants might be a risk factor for ROP.

Design. We conducted a prospective, longitudinal study measuring serum IGF-I concentrations weekly in 84 premature infants from birth (postmenstrual ages: 24–32 weeks) until discharge from the hospital. Infants were evaluated for ROP and other morbidity of prematurity: bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC).

Results. Low serum IGF-I values correlated with later development of ROP. The mean IGF-I ± SEM level during postmenstrual ages 30–33 weeks was lowest with severe ROP (25 ± 2.41 μg/L), 29 ± 1.76 μg/L with moderate ROP, and 33 ± 1.72 μg/L with no ROP. The duration of low IGF-I also correlated strongly with the severity of ROP. The interval from birth until serum IGF-I levels reached >33 μg/L was 23 ± 2.6 days for no ROP, 44 ± 4.8 days for moderate ROP, and 52 ± 7.5 days for severe ROP. Each adjusted stepwise increase of 5 μg/L in mean IGF-I during postmenstrual ages 30 to 33 weeks decreased the risk of proliferative ROP by 45%. Other complications (NEC, BPD, IVH) were correlated with ROP and with low IGF-I levels. The relative risk for any morbidity (ROP, BPD, IVH, or NEC) was increased 2.2-fold (95% confidence interval: 1.41–3.43) if IGF-I was ≤33 μg/L at 33 weeks’ postmenstrual age.

Conclusions. These results indicate that persistent low serum concentrations of IGF-I after premature birth are associated with later development of ROP and other complications of prematurity. IGF-I is at least as strong a determinant of risk for ROP as postmenstrual age at birth and birth weight.
A Randomized, Controlled Trial Comparing Two Different Continuous Positive Airway Pressure Systems for the Successful Extubation of Extremely Low Birth Weight Infants
Authors: Stefanescu Beatrice M. , Murphy W. Paul , Hansell Brenda J. , Fuloria Mamta , Morgan Timothy M. , Aschner Judy L.
Published: August 2004

Objective. To determine whether the use of the Infant Flow continuous positive airway pressure (IF CPAP) system reduces the rate of extubation failure among extremely low birth weight (ELBW) infants (infants with birth weight <1000 g) when compared with conventional CPAP delivered with a conventional ventilator and nasal prongs.

Methods. A prospective, unmasked, randomized, controlled clinical trial was conducted in 162 eligible intubated ELBW infants who were hospitalized in 2 intensive care nurseries in Winston-Salem, North Carolina, between July 1997 and November 2000. Successful extubation was defined as no need for reintubation for any reason for at least 7 days after the first extubation attempt.

Results. The individual extubation success rates were 61.9% (52 of 84) in the conventional CPAP group and 61.5% (48 of 78) in the IF CPAP group. There were no significant differences in the extubation success rate in any birth weight subset between the 2 cohorts. The most common cause of extubation failure was apnea/bradycardia. Infants who were randomized to IF CPAP had fewer days on supplemental O2 and shorter hospital stays.

Conclusions. Extubation failure is a common problem, occurring in nearly 40% of ELBW infants who require mechanical ventilation. IF CPAP was as effective but no more effective than conventional CPAP in preventing extubation failure among ELBW infants. New strategies are needed to identify predictors of extubation success and to treat apnea/bradycardia, the most common cause of extubation failure, thereby reducing the likelihood of prolonged intubation in this high-risk cohort of premature infants.
Hearing Loss at School Age in Survivors of Bacterial Meningitis: Assessment, Incidence, and Prediction
Authors: Koomen Irene , Grobbee Diederick E. , Roord John J. , Donders Rogier , Jennekens-Schinkel Aag , van Furth A. M.
Published: August 2004

Objectives. To establish the incidence of sensorineural hearing loss in children who survived non–Haemophilus influenzae type B (Hib) bacterial meningitis, to highlight the actual percentage whose hearing was evaluated, and to develop a prediction rule to identify those who are at risk of hearing loss.

Methods. In 1999, we compiled a cohort of 628 school-aged children who were born between January 1986 and December 1994 and had survived non-Hib bacterial meningitis between January 1990 and December 1995. Presence of sensorineural hearing loss (>25 dB) was determined, based on information from questionnaires and medical records. Potential risk factors for hearing loss were obtained from medical records; independent predictors were identified using multivariate logistic regression analysis, leading to the formulation of a prediction rule.

Results. The incidence of hearing loss was 7%. The hearing of 68% of the children was evaluated as part of their routine follow-up after bacterial meningitis, resulting in the detection of 75% of the cases of hearing loss. The remaining 25% were detected after this follow-up had ended. Using a prediction rule based on 5 factors—duration of symptoms before admission >2 days, absence of petechiae, cerebrospinal fluid glucose level ≤0.6 mmol/L, Streptococcus pneumoniae, and ataxia—62% of the postmeningitic children were selected as being at risk. All cases of hearing loss were in this at-risk group.

Conclusions. Hearing loss can be predicted satisfactorily. When the hearing of children who are predicted to be at risk is tested as part of their routine follow-up, no children with hearing loss need be missed.
Home Syrup of Ipecac Use Does Not Reduce Emergency Department Use or Improve Outcome
Authors: Bond G. R.
Published: August 2004

Background. The usefulness of syrup of ipecac as a home treatment for poisoning and the need to keep it in the home has been increasingly challenged. Many poison centers do not recommend any use of syrup of ipecac.

Objective. To determine if use of syrup of ipecac in children at home is associated with reduced utilization of emergency department (ED) resources or improved outcome after unintended exposure to a pharmaceutical.

Design. Cohort comparison.

Setting. American Association of Poison Control Centers’ Toxic Exposure Surveillance System Database.

Patients. Blinded data for each of the 64 US poison centers included ED referral recommendation rate, actual rate of ED use, actual home use of syrup of ipecac, and outcome. These data were derived from cases in 2000 and 2001 involving children <6 years of age who unintentionally ingested a pharmaceutical agent and in which the call to a poison center came from home (752 602 children).

Outcome Measures. Correlation between rate of home use of syrup of ipecac and rate of recommendation for ED referral was the primary outcome sought. Rate of adverse outcome was also compared. In addition, the actual ED use and home syrup of ipecac utilization rates at 7 specific centers were identified and compared with the published rates from these same centers from 1990 data to look for the trend in practice for this subgroup.

Results. Mean rate of referral to ED was 9% (range: 3%–18%). Mean home use of syrup of ipecac was 1.8% (range: 0.2%–14%). Increased home use of syrup of ipecac was not associated with referral to ED (r = 0.18; 95% confidence interval of r = −0.06–0.41). Adverse outcome was rare: 0.6% (range: 0.2%–2.1%). There was no difference in referral rate or adverse outcome rate between 2 groups of 32 centers divided by relative syrup of ipecac use. In the 7 centers, ED use decreased from a mean of 13.5% in 1990 to a mean of 8.1% in 2000–2001. Ipecac use decreased from a mean of 9.6% to 2.1%.

Conclusions. This study suggests there is no reduction in resource utilization or improvement in patient outcome from the use of syrup of ipecac at home. Although these data cannot exclude a benefit in a very limited set of poisonings, any benefit remains to be proven.
Rheumatic Fever in Children Younger Than 5 Years: Is the Presentation Different?
Authors: Tani Lloyd Y. , Veasy L. George , Minich L. LuAnn , Shaddy Robert E.
Published: August 2004

Objective. To review our experience with children who presented with rheumatic fever (RF) before 5 years of age and to compare their presentation with that of older children.

Methods. The cardiology database was reviewed to identify patients who were younger than 5 years and had a diagnosis RF using the Jones criteria from January 1985 through March 2000. Patient age, sex, date and age at presentation, and the major Jones criteria fulfilled were noted. When carditis was present, its severity was judged to be moderate to severe when there was radiographic cardiomegaly and/or clinical congestive heart failure. The clinical presentation of patients who presented in the first 5 years of life were compared with the presentation of those whose RF was diagnosed after 5 years of age. Clinical findings at follow-up evaluation and echocardiographic findings both at presentation and at follow-up were noted for the children who were younger than 5 years at presentation.

Results. Of 541 cases of RF seen from January 1985 through March 20000, 27 (5%) were in children who were younger than 5 years (median: 4.0 years; range: 1.9–4.9 years). Major Jones criteria at presentation were arthritis in 17, carditis in 14, chorea in 3, and erythema marginatum in 3. The carditis was mild in 4 and moderate to severe in 10 patients. Compared with older children, younger children were more likely to present with moderate to severe carditis, arthritis without carditis or chorea, or the rash of erythema marginatum and were less likely to have chorea. The incidence of carditis was similar in the 2 groups as was the ratio of boys to girls. At follow-up (9.6 ± 5.6 years), 69% of younger children who presented with carditis have clinical rheumatic heart disease. Subclinical, echocardiographically detected valvular abnormalities were detected both at presentation (33% of all children with RF before 5 years of age) and at follow-up (55% of those who initially had carditis).

Conclusions. Approximately 5% of children with RF were younger than 5 years at diagnosis. Compared with older patients, children who presented before 5 years of age were more likely to have moderate to severe carditis and to present with arthritis or the rash of erythema marginatum and were less likely to have chorea. Chronic rheumatic heart disease was common in young children who presented with carditis. Long-term follow-up is necessary to determine the outcome for young children with subclinical echocardiographic evidence of valvular disease.
Adoption of Reminder and Recall Messages for Immunizations by Pediatricians and Public Health Clinics
Authors: Tierney Cheryl D. , Yusuf Hussain , McMahon Shawn R. , Rusinak Donna , O’ Brien Megan A. , Massoudi Mehran S. , Lieu Tracy A.
Published: August 2004

Objective. Strong scientific evidence and national recommendations support the use of reminder and recall messages to improve immunization coverage rates, yet reports have suggested that only a minority of pediatric practices use such messages. Our aims were to 1) determine the proportions of pediatric practices and public clinics that currently use practice-based reminder or recall messages and routinely undergo immunization assessment efforts, 2) evaluate barriers and supports to implementing these practices, and 3) identify predictors of either current use or plans for future adoption of these practices.

Methods. This study combined qualitative and quantitative methods in sequential phases. In the qualitative phase, we conducted semistructured, open-ended interviews with a convenience sample of 18 clinician-administrators representing adopters and nonadopters of these messages in both private practices and public health clinics. In the subsequent quantitative phase, we mailed a structured, closed-ended survey to national samples of randomly selected pediatricians (n = 600) and public clinics (n = 600).

Results. Response rates were 75% for pediatricians and 77% for public clinics. Among pediatricians, 38% were conducting regular assessments of immunization coverage but only 16% were currently using routine reminder or recall messages. Among public clinics, 85% were conducting regular assessments and 51% were using reminder or recall messages. Among pediatricians’ practices, the most commonly reported barriers to the adoption of reminder or recall messages were lack of time and funding and the inability to identify children at specified ages. For pediatricians’ practices, the strongest predictors of current use of reminder or recall messages were having a champion who led efforts to improve immunization delivery (odds ratio: 1.85; 95% confidence interval: 1.08–3.18) and current use of regular immunization assessments (odds ratio: 2.30; 95% confidence interval: 1.33–3.84). Likewise, for public health clinics, having a champion to lead immunization improvement efforts and believing that their current system needed improvement was associated with current use of reminder or recall messages.

Conclusions. Reminder and recall messages remain underused by both pediatricians and public health clinics. Promising strategies to promote adoption of these approaches in both the private and the public sectors include identifying and training champions to promote immunization delivery improvement efforts and helping practices develop methods to identify children at specific ages.
Use of a Telephone Nursing Line in a Pediatric Neurology Clinic: One Approach to the Shortage of Subspecialists
Authors: Letourneau Megan A. , MacGregor Daune L. , Dick Paul T. , McCabe E. J. , Allen Anita J. , Chan Valerie W. , MacMillan Lynn J. , Golomb Meredith R.
Published: August 2004

Objective. There are not enough pediatric neurologists to meet the many needs of pediatric neurology patients. The Hospital for Sick Children has responded by expanding the nursing role in the pediatric neurology outpatient clinic. The objective of this study was to examine the use of a telephone nursing line in this hospital-based pediatric neurology clinic.

Methods. A cross-sectional study was performed on all telephone call records collected during a 2-week study period. Each initial incoming call concerning a patient was counted as an index call. Associations between clinic type or diagnosis and length of telephone calls were assessed using the χ2 test.

Results. A total of 208 index calls were received, generating a total of 597 incoming and outgoing calls. The most common clinic types were Epilepsy clinic (35.6%) and General Neurology clinic (32.7%), and the most common patient diagnoses were epilepsy (63.5%) and developmental delay (45.2%). Most patients were between the ages of 1 and <7 years (33.9%) and 12 and <18 years (32.8%) and male (55.2%). Most calls were made by mothers (57.2%) to ask about medical administrative issues (28.4%) and/or symptoms (27.9%). Physicians were notified for 47.1% of calls; nurses were twice as likely to notify physicians for calls concerning new symptoms (relative risk: 2.1; 95% confidence interval: 1.6–2.7). Most calls required between 1 and 5 minutes (49.0%). Long telephone calls (>10 minutes) were strongly associated with a diagnosis of epilepsy.

Conclusions. There is a high demand for the neurology nursing line in our clinic. Most telephone calls and most long telephone calls concerned patients with epilepsy. Nurses managed more than half of all telephone calls without physician assistance. Use of a nursing line can aid in the provision of care to complicated subspecialty patients. Additional strategies are needed to optimize delivery of care to high-need medical populations.
Effectiveness of School-Based Telehealth Care in Urban and Rural Elementary Schools
Authors: Young Thomas L. , Ireson Carol
Published: August 2004

Objective. This study evaluated the quality and cost effectiveness of health care provided in urban and rural elementary school-based telehealth centers, using plain old telephone system (POTS) technology.

Methods. A telehealth school-based model was developed that used a full-time school nurse, half-time mental-health consultant, linked pediatric practice, and linked child psychiatrist via POTS with an electronic stethoscope; ears, nose, and throat endoscope; and otoscope. One rural and 1 urban center were evaluated. Providers, nurses, children, and parents completed satisfaction questionnaires. Providers and nurses also evaluated how well telemedicine supported their clinical decision making. Parents were asked how use of the center affected them financially and at work.

Results. Of the combined 3461 visits to school nurses at both centers, 4.3% resulted in 150 telehealth consultations referrals; 142 (95%) were completed during the 2-year project. The most common teleconsult diagnoses were otitis media, pharyngitis, dermatitis, and upper respiratory infections. Provider, nurse, child, and parent satisfaction all were high. Providers’ and nurses’ decision confidence scores ranged from a low of 4 to a high of 4.8 on a 5-point scale. Average family savings per encounter were 3.4 hours of work time ($43) and $177 in emergency department or $54 in physician costs. Including travel, savings for families ranged from $101 to $224 per encounter. Thirteen children received telepsychiatric evaluations resulting in diagnoses of depression and attention-deficit/hyperactivity, anxiety, and conduct disorders.

Conclusions. Telehealth technology was effective in delivering pediatric acute care to children in these schools. Pediatric providers, nurses, parents, and children reported primary care school-based telehealth as an acceptable alternative to traditional health care delivery systems. The POTS-based technology helps to make this telehealth service a cost-effective alternative for improving access to primary and psychiatric health care for underserved children.
Streptococcus pneumoniaeInfections in the Neonate
Authors: Hoffman Jill A. , Mason Edward O. , Schutze Gordon E. , Tan Tina Q. , Barson William J. , Givner Laurence B. , Wald Ellen R. , Bradley John S. , Yogev Ram , Kaplan Sheldon L.
Published: August 2004

Objective. Streptococcus pneumoniae infections in the neonate (SPIN) are relatively unusual events (1%–11% of neonatal sepsis) but are associated with substantial morbidity and mortality. Previous reports suggest that invasive SPIN is associated with prolonged rupture of membranes, maternal colonization/illness, prematurity, early-onset pneumonia presentation (<72 hours), and high mortality (50%). The aim of this study was to review the current epidemiology and clinical course of SPIN.

Methods. The US Pediatric Multicenter Pneumococcal Surveillance Group has been prospectively monitoring S pneumoniae infections since 1993 in 8 children’s hospitals. For this report, data were gathered retrospectively from the charts of neonates who were 30 days of age and younger and had SPIN from September 1993 to February 2001. All pneumococcal isolates were sent to a central laboratory for serogrouping/typing and susceptibility testing.

Results. Twenty-nine cases of SPIN were identified from a total of 4428 episodes of S pneumoniae infection in children. Sixty-six percent were male, and 55% were white; the mean age was 18.1 day (±8.2). Ninety percent of infants were ≥38 weeks’ gestation. Two mothers had bacterial infections at delivery; 1 had S pneumoniae isolated from both blood and cervix, and 1 had clinical amnionitis. The primary diagnoses in the neonates were bacteremia (8), meningitis (8), bacteremic pneumonia (4), septic arthritis/osteomyelitis (1), and otitis media (8). Thirty percent of infants with invasive SPIN presented with leukopenia/neutropenia, but this did not predict poor outcome. The infecting pneumococcal serogroups were 19 (32%); 9 (18%); 3 and 18 (11% each); 1, 6, and 14 (7% each); and 5 and 12 (3.5% each). Twenty-six percent of invasive neonatal infections were caused by serogroups 1, 3, 5, and 12, which are not contained in the heptavalent pneumococcal vaccine. In contrast, 6% of invasive nonneonatal disease was caused by these same nonvaccine serogroups. Susceptibility testing demonstrated that 21.4% of isolates were penicillin nonsusceptible and 3.6% were ceftriaxone nonsusceptible. Three (14.3%) neonates with invasive SPIN died; all deaths occurred within 36 hours of presentation. Deaths did not appear to be related to pneumococcal serogroup or susceptibilities.

Conclusions. Compared with previous studies of neonates with pneumococcal infection, this series showed that infants with SPIN were usually 2 to 3 weeks of age at presentation; likely to be full term; and ill with pneumonia, meningitis, and otitis media. This late-onset presentation was associated with an overall mortality rate of 10.3% (14.3% for invasive disease).
Cytokine and Cellular Inflammatory Sequence in Enteroviral Meningitis
Authors: Sato Masatoki , Hosoya Mitsuaki , Honzumi Ken , Watanabe Mikako , Ninomiya Norio , Shigeta Shiro , Suzuki Hitoshi
Published: August 2004

Objective. To clarify the sequence of cytokines and inflammatory cells in enteroviral meningitis.

Methods. Cerebrospinal fluid (CSF) was collected from 86 patients who received a diagnosis of enteroviral meningitis after detection of the enteroviral genome in the CSF using polymerase chain reaction. Twenty-one of 86 patients had repeated lumbar punctures. Cytokine concentrations were measured acutely and in 32 samples collected during recovery.

Results. The proinflammatory cytokines (interleukin [IL]-6, IL-8, and interferon-γ) were detected at significantly higher concentrations during the acute phase when enteroviral genomes were present. Proinflammatory cytokines decreased to normal levels in the recovery phase when enteroviral genomes disappeared. Anti-inflammatory concentrations (IL-10 and transforming growth factor-β1) were significantly higher in the recovery phase than in the acute phase. Of the 86 CSF samples collected in the acute phase, 11 had no pleocytosis (<10 white blood cells/mm3). In 7 of those 11 CSF samples, IL-6 and IL-8 levels were as high as those in the 75 samples with pleocytosis (≥10 white blood cells/mm3). Seven patients were considered to be in the initial stage of their illness when production of proinflammatory cytokines were high but leukocytes had not yet infiltrated the cerebrospinal cavity.

Conclusions. The inflammatory process observed in human enteroviral meningitis is comparable with that observed in animal models: 1) infection induces proinflammatory cytokine production, followed by infiltration of white blood cells into the infected area, and 2) inflammation is terminated by the anti-inflammatory cytokines that are produced when pathogens are eliminated.
Entertainment Television as a Healthy Sex Educator: The Impact of Condom-Efficacy Information in an Episode ofFriends
Authors: Collins Rebecca L. , Elliott Marc N. , Berry Sandra H. , Kanouse David E. , Hunter Sarah B.
Published: August 2004

Context. Television is often decried as a negative influence on the sexual attitudes and behavior of America’s adolescents. However, television occasionally includes messages about the risks of having sex that may have a positive effect on youth.

Objective. To assess the impact of condom-efficacy messages in an episode of Friends on teens.

Design, Setting, and Participants. A national sample of 506 adolescents 12 to 17 years old who had been regular viewers of Friends the previous year were surveyed by telephone shortly after the episode aired.

Outcome Measures. Viewership of the Friends episode, recall of the condom-efficacy message, beliefs about condoms, self-reported change in condom knowledge, and discussions of condom efficacy with parents.

Results. At least 27% of the sample saw the episode, and 65% of these viewers recalled its depiction of condom failure resulting in pregnancy. Forty percent of the viewers watched with an adult. Ten percent of viewers talked to an adult about condom efficacy as a result of the show. Compared with other viewers, youth who talked with an adult were more likely to report learning about condoms from the episode and appeared less likely to reduce their perceptions of condom efficacy after the episode.

Conclusions. Entertainment television can serve as a healthy sex educator and can work in conjunction with parents to improve adolescent sexual knowledge.
Analgesia for Children With Acute Abdominal Pain: A Survey of Pediatric Emergency Physicians and Pediatric Surgeons
Authors: Kim Michael K. , Galustyan Sergey , Sato Thomas T. , Bergholte Jo , Hennes Halim M.
Published: August 2004

Objective. To evaluate the current opinion and practice of pediatric emergency medicine physicians (PEM) and pediatric surgeons (PS) on the use of opioid analgesia in children with acute abdominal pain during their evaluation in the emergency department.

Methods. All members of the American Academy of Pediatrics in the Section of Emergency Medicine and the American Pediatric Surgeons Association were mailed a copy of the survey. Inclusion criteria were board-eligible or -certified PEM, or PS certified by American Board of Surgery or Royal College of Surgeons currently in practice whose patient population includes children. Information on primary patient population, years in practice, practice setting, willingness to provide analgesia for acute nontraumatic abdominal pain in children, and the factors influencing their decision were requested. Data were analyzed with the Student t test and χ2 analysis.

Results. Of 1441 surveys sent, 54 were returned because of incorrect addresses. Of the 1387 presumed received, 702 completed surveys were returned with a response rate of 51%. However, of those who responded, 574 (82%) respondents met our inclusion criteria, and 385 (67%) were PEM and 189 (33%) were PS. Compared with PEM, more PS had >10 years of work experience and were in private practice. More PEM were willing to provide analgesia before definitive diagnosis. However, the overall willingness to provide analgesia was low in both groups. Among the physicians with <10 years of experience, there was no statistical difference between PEM and PS in willingness to provide analgesia. However, among the physicians with >10 years of experience, 61% of PS were less likely to provide analgesia compared with 38% of the PEM (Δ = 23%; 95% confidence interval 13%, 33%). Of the 74 PEM who made optional general comments, 64 (87%) cited disapproval by the PS as the main barrier in providing analgesia.

Conclusions. The practice of providing analgesia for children with acute abdominal pain is divergent between PEM and PS. More experienced surgeons are less likely to provide analgesia for children with acute abdominal pain. The perceived disapproval of providing analgesia to children with acute abdominal pain by PS is a barrier influencing PEM practice.
Intervention With Parental Smokers in an Outpatient Pediatric Clinic Using Counseling and Nicotine Replacement
Authors: Winickoff Jonathan P. , Buckley Valerie J. , Palfrey Judith S. , Perrin James M. , Rigotti Nancy A.
Published: August 2004

Objective. To evaluate the feasibility of implementing a smoking cessation intervention for parents at the time of the pediatric visit.

Methods. A prospective cohort of smoking parents whose child was seen in an outpatient pediatric practice was offered the Stop Tobacco Outreach Program, which includes 3 brief counseling sessions, written materials, free nicotine replacement therapy (NRT), proactive referral to a free state telephone quitline, and fax referral to the parents’ primary clinician. The primary outcome was completion of all three counseling sessions. Other outcomes were quit attempts, cessation, NRT use, state quitline use, and household smoking assessed at 2-month follow-up.

Results. One hundred fifty-eight smoking parents met eligibility criteria and 100 (63%) enrolled in the study. Of the 100 enrollees, 81% completed all three counseling sessions and 78% accepted free NRT at the time of enrollment. At 2-month follow-up, of the 100 enrollees, 56% reported making a quit attempt of ≥24 hours, 18% reported 7-day tobacco abstinence, 34% used NRT, and 42% received additional counseling from the state telephone quitline. The mean number of cigarettes smoked inside the home and car declined over 2 months (home, 5.1 vs 1.4; and car, 2.5 vs 1.4).

Conclusions. This study demonstrates the feasibility of engaging parents in a smoking cessation intervention at the time of a child’s clinic visit. This approach may be an effective way to reach smokers who otherwise are unlikely to access smoking cessation interventions. High rates of program enrollment, use of NRT, and completion of telephone counseling in this study support the hypothesis that a child’s clinic visit is a teachable moment to address parental smoking cessation.
Short-Chain Acyl-CoA Dehydrogenase Deficiency: Studies in a Large Family Adding to the Complexity of the Disorder
Authors: Bok Levinus A. , Vreken Peter , Wijburg Frits A. , Wanders Ronald J. A. , Gregersen Niels , Corydon Morten J. , Waterham Hans R. , Duran Marinus
Published: August 2004

Objective. To understand the expanding clinical and biochemical spectrum of short-chain acyl-CoA dehydrogenase (SCAD) deficiency, the impact of which is not fully understood.

Study Design. We studied a family with SCAD deficiency and determined urinary ethylmalonic acid excretion, plasma C4-carnitine, SCAD enzyme activity in fibroblasts and lymphocytes, DNA mutations in the SCAD gene, and clinical expression. The index patient was born prematurely and had otherwise unexplained cholestasis and hepatomegaly during the first year of life. His mother developed a hemolysis-elevated liver enzymes-low platelets (HELLP) syndrome while pregnant with the index patient.

Results. Two siblings had a homozygous inactivating 1138C>T mutation, whereas the father was compound heterozygous for this mutation and the common 625G>A polymorphism. There was a good correlation between the type of SCAD mutation, the residual SCAD enzyme activity, and the levels of urinary ethylmalonic acid and plasma C4-carnitine in each of the eight family members. Retrospective acylcarnitine analysis of the index patient’s Guthrie screening card confirmed the abnormal increase of C4-carnitine, suggestive of SCAD deficiency. None of the family members had hypotonia, developmental delay, or episodes of ketotic hypoglycemia.

Conclusion. Homozygosity for an inactivating SCAD mutation does not necessarily result in disease. The previously held opinion that SCAD deficiency is always a serious disorder may have been influenced by a clinical bias. Homozygosity for an inactivating 1138C>T SCAD mutation was assessed by neonatal screening of blood spot acylcarnitines. SCAD deficiency may be associated with maternal HELLP syndrome.
Effects of Early Childhood Supplementation on the Educational Achievement of Women
Authors: Li Haojie , Barnhart Huiman X. , Stein Aryeh D. , Martorell Reynaldo
Published: August 2004

Objective. Malnutrition during early childhood has been suggested to cause functional disadvantages in adults, including reduced intelligence and lower educational achievement (EA). We assessed the effects of improved nutrition in early life on the EA of women in 4 rural Guatemalan villages.

Methods. The study sample comprised 130 female singletons exposed to either Atole (53%, 91 kcal and 6.4 g protein/100 mL) or Fresco (47%, 33 kcal/100 mL, no protein) during the prenatal period and the first 2 years of life. EA was assessed at the ages of 22 to 29 years by knowledge, numeracy, and several reading tests. A summary measure of EA was computed based on 5 tests, and outcome variables were categorized into quintiles. Analysis was based on a proportional odds model. Generalized estimating equations were used to account for sibling clustering.

Results. Overall, 36.2% of women completed primary school. Women exposed to Atole had better EA than those exposed to Fresco (odds ratio [OR]: 2.8; 95% confidence interval [CI], 1.4, 5.4), with a significant treatment-by-schooling interaction. Atole was not associated with EA (OR: 1.5; 95% CI: 0.7, 3.2) among women who did not complete primary school, whereas among those who completed primary school, Atole was associated with improved EA (OR: 13.7; 95% CI: 3.7, 50.8).

Conclusions. We conclude that better nutrition during early childhood improved adult EA, but only among children who completed primary school.
Human Milk, Breastfeeding, and Transmission of Human Immunodeficiency Virus Type 1 in the United States
Authors: Read Jennifer S. ,   Committee on Pediatric AIDS
Published: August 2004

Transmission of human immunodeficiency virus type 1 (HIV-1) through breastfeeding has been conclusively demonstrated. The risk of such transmission has been quantified, the timing has been clarified, and certain risk factors for breastfeeding transmission have been identified. In areas where infant formula is accessible, affordable, safe, and sustainable, avoidance of breastfeeding has represented one of the main components of mother-to-child HIV-1 transmission prevention efforts for many years. In areas where affordable and safe alternatives to breastfeeding may not be available, interventions to prevent breastfeeding transmission are being investigated. Complete avoidance of breastfeeding by HIV-1-infected women has been recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention and remains the only means by which prevention of breastfeeding transmission of HIV-1 can be absolutely ensured. This technical report summarizes the information available regarding breastfeeding transmission of HIV-1.