bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Early Erythropoietin Therapy on the Transfusion Requirements of Preterm Infants Below 1250 Grams Birth Weight: A Multicenter, Randomized, Controlled Trial
Authors: Ohls Robin K. , Ehrenkranz Richard A. , Wright Linda L. , Lemons James A. , Korones Sheldon B. , Stoll Barbara J. , Stark Ann R. , Shankaran Seetha , Donovan Edward F. , Close Nicole C. , Das Abhik ,   for the National Institute of Child Health and Human Development Neonatal Research Network
Published: August 2004

Objectives.

Infants of ≤1250 g birth weight receive multiple erythrocyte transfusions during their hospitalization. We hypothesized that early erythropoietin (Epo) and iron therapy would 1) decrease the number of transfusions received (infants 401-1000 g birth weight; trial 1) and 2) decrease the percentage of infants who received any transfusions (1001–1250 g birth weight; trial 2).

Methods.

A total of 172 infants in trial 1 and 118 infants in trial 2 were randomized to treatment (Epo, 400 U/kg 3 times weekly) or placebo/control. Therapy was initiated by 4 days after birth and continued through the 35th postmenstrual week. All infants received supplemental parenteral and enteral iron. Complete blood and reticulocyte counts were measured weekly, and ferritin concentrations were measured monthly. Transfusions were administered according to protocol. Phlebotomy losses and transfusion data were recorded.

Results.

Treated and placebo/control infants in trial 1 received a similar number of transfusions (4.3 ± 3.6 vs 5.2 ± 4.2, respectively). A similar percentage of treated and control infants in trial 2 received at least 1 transfusion (37% vs 46%). Reticulocyte counts were higher in treated infants during each week of the study in both trials. Hematocrits were higher among treated infants from week 2 on in both trials. Ferritin concentrations were higher in placebo/controls than in treated infants at weeks 4 and 8 in trial 1 and at week 4 in trial 2. No adverse effects of Epo or supplemental iron occurred.

Conclusion.

The combination of early Epo and iron as administered in this study stimulated erythropoiesis in infants who were ≤1250 g at birth. However, the lack of impact on transfusion requirements fails to support routine use of early Epo.neonate, intravenous iron, donor exposure.
Respiratory Infections in Infants: Interaction of Parental Allergy, Child Care, and Siblings—The PIAMA Study
Authors: Koopman Laurens P. , Smit Henriette A. , Heijnen Marie-Louise A. , Wijga Alet , van Strien Rob T. , Kerkhof Marjan , Gerritsen Jorrit , Brunekreef Bert , de Jongste Johan C. , Neijens Herman J.
Published: August 2004

Objective.

To investigate the association between contacts with other children and the development of respiratory infections in the first year of life in children with or without genetic predisposition for allergy.

Methods.

Children (n = 4146) who participate in a prospective birth cohort study (Prevention and Incidence of Asthma and Mite Allergy study) were investigated. Questionnaires were used to obtain information on doctor-diagnosed upper respiratory tract infection (URTI) and lower respiratory tract infection (LRTI), child care attendance, having siblings, family history of allergic disease, and various potential confounders.

Results.

Child care attendance in the first year of life was associated with doctor-diagnosed URTI (adjusted odds ratio [AOR]: 2.7; 95% confidence interval [CI]: 2.1–3.4 for large child care facility vs no child care) and doctor-diagnosed LRTI (AOR: 5.6; 95% CI: 3.9–7.9). Having siblings was associated with doctor-diagnosed LRTI (AOR: 2.6; 95% CI: 2.0–3.4). In addition, children who have allergic parents and attend child care or have older siblings have a higher risk of developing doctor-diagnosed LRTI than do children who have nonallergic parents.

Conclusions.

Child care attendance or having siblings increases the risk of developing doctor-diagnosed LRTI in the first year of life to a greater extent in allergy-prone children than in children who are not allergy prone.
Randomized, Prospective Study of Low-Dose Versus High-Dose Inhaled Nitric Oxide in the Neonate With Hypoxic Respiratory Failure
Authors: Finer Neil N. , Sun Johnny W. , Rich Wade , Knodel Ellen , Barrington Keith J.
Published: August 2004

Objective.

There is little information on the response to very low doses of inhaled nitric oxide (iNO) in hypoxic near-term infants. The potential toxicities of iNO are dose related; thus, the ability to use lower doses safely and effectively may be advantageous. We hypothesized that there is no difference in the acute improvement in oxygenation between treatment with inhaled nitric oxide at 1 to 2 parts per million (ppm) or 10 to 20 ppm.

Methods.

We randomized near-term and term infants with hypoxic respiratory failure with oxygenation indices (OIs) of ≥10 and Pao2 <100 on 2 separate blood gases taken at least 30 minutes apart. Infants with congenital diaphragmatic hernia were excluded. After parental consent was obtained, patients were randomized to receive a starting nitric oxide (iNO) dose of either 1 to 2 ppm (low-dose group, n = 15) or 10 to 20 ppm (high-dose group, n = 21). The response to iNO was assessed according to the increase in arterial Pao2 and decrease in OI 30 to 60 minutes after exposure to the initial starting concentration. A response of <10% increase on Pao2 and a <10% decrease in OI resulted in a doubling of iNO within the dose range protocol (1, 2, 4, and 8 ppm for the low-dose group; 10, 20, 40, and 80 ppm for the high-dose group).

Results.

Thirty minutes after the study gas was initiated, Pao2 increased significantly overall in the low-dose (90.7 ± 41 torr to 166.8 ± 95.6 torr) and high-dose (76.2 ± 32.7 torr to 198.7 ± 142.8 torr) groups; the maximal increase was seen in the infants who initially were treated with 10 ppm. The OI also decreased significantly overall and also was significant in the high-dose group (21.0 ± 13.7 to 11.4 ± 10.4; low-dose: 18.3 ± 7.1 to 13.2 ± 12.3). There was a nonsignificant fall of Paco2 with iNO treatment (low dose 35 ± 7.3 to 30 ± 8.5 torr vs high dose 35.2 ± 9.9 to 32.4 ± 10.7 torr). A sustained response (ie, maintaining a Pao2 and OI gain greater than 20% for the duration of the study gas administration) was greater in the high-dose group (53.3% vs 30.0%). In addition, dose increases were required more often in the low-dose group than in the high-dose group (80.0% vs 57.1%). Among patients who did not respond to the initial iNO dose, 100.0% and 83.3% responded at higher doses of iNO for the low- and high-dose groups, respectively. There were no differences for death, need for extracorporeal membrane oxygenation, or other outcomes between the groups.

Conclusions.

We did not find any significant difference in response to low- versus high-dose iNO. An initial exposure to low-dose iNO does not compromise the response to higher doses if required and may result in less toxicity.
Onset of Jaundice in Glucose-6-Phosphate Dehydrogenase–Deficient Neonates
Authors: Kaplan Michael , Algur Nurit , Hammerman Cathy
Published: August 2004

Objective.

We asked whether neonatal jaundice associated with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency commences either in utero or in the immediate postnatal period and whether this perinatal bilirubinemia is the precursor of the subsequent neonatal jaundice and hyperbilirubinemia.

Methods.

Mandatory serum total bilirubin (STB) determinations were performed within 3 hours of birth, to reflect the in utero state (first STB), and on the third day of life (second STB), with additional determinations as clinically necessary, on healthy, term male neonates at high risk for G-6-PD deficiency. G-6-PD Mediterranean mutation was determined by molecular means. G-6-PD–deficient neonates were compared with control participants. The relationship of first STB values to second STB and subsequent hyperbilirubinemia (defined as STB ≥256 μmol/L [15.0 mg/dL]) was determined.

Results.

Both first and second STB values were significantly higher in the G-6-PD–deficient neonates (n = 52) than in control participants (n = 166; 50 ± 12 μmol/L vs 44 ± 10 μmol/L [2.9 ± 0.7 mg/dL vs 2.6 ± 0.6 mg/dL] and 174 ± 52 μmol/L vs 152 ± 52 μmol/L [10.2 ± 3.1 mg/dL vs 8.9 ± 3.0 mg/dL] for the first and second STB values, respectively). The rate of rise between these 2 points was greater in the G-6-PD–deficient neonates (2.6 ± 0.9 μmol/L/h vs 2.2 ± 0.9 μmol/L/h [0.15 ± 0.05 mg/dL/h vs 0.13 ± 0.05 mg/dL/h). Sixteen (30.8%) of the G-6-PD–deficient neonates developed hyperbilirubinemia compared with 10 (6%) of control participants (relative risk: 5.11; 95% confidence interval: 2.47–10.56). In both G-6-PD–deficient and normal populations, first STB values correlated significantly with both second STB values and with those who subsequently developed hyperbilirubinemia. Significantly more G-6-PD–deficient neonates with a first STB value greater than or equal to the mean developed hyperbilirubinemia compared with those with first STB less than the mean: 13 of 28 neonates versus 3 of 24 (relative risk: 3.7; 95% confidence interval: 1.20–11.51). This difference did not reach statistical significance in the control group.

Conclusions.

Higher first STB values, an increased risk of hyperbilirubinemia in G-6-PD–deficient neonates with first STB value greater than or equal to the mean, and significant correlation between first STB values and second STB values and hyperbilirubinemia suggest that jaundice in G-6-PD–deficient neonates commences in the immediate perinatal period, most likely in utero.
Issues in Islamic Biomedical Ethics: A Primer for the Pediatrician
Authors: Hedayat Kamyar M. , Pirzadeh Roya
Published: August 2004

The United States is becoming increasingly pluralistic. Pediatricians must become familiar with the factors that affect the emotional, physical, and spiritual health of their patients that are outside the ken of the traditionally dominant value system. Although many articles have addressed the cultural and ethnic factors, very few have considered the impact of religion. Islam, as the largest and fastest-growing religion in the world, has adherents throughout the world, including the United States, with 50% of US Muslims being indigenous converts. Islam presents a complete moral, ethical, and medical framework that, while it sometimes concurs, at times diverges or even conflicts with the US secular ethical framework. This article introduces the pediatrician to the Islamic principles of ethics within the field of pediatric care and child-rearing. It demonstrates how these principles may impact outpatient and inpatient care. Special attention is also given to adolescent and end-of-life issues.
Haemophilus influenzae Type b Disease Among Amish Children in Pennsylvania: Reasons for Persistent Disease
Authors: Fry Alicia M. , Lurie Perrianne , Gidley Maribeth , Schmink Susanna , Lingappa Jairam , Fischer Marc , Rosenstein Nancy E.
Published: August 2004

Objective.

To identify reservoirs ofHaemophilus influenzae type b (Hib) pharyngeal carriage and assess barriers to vaccination among 2 Amish communities in Pennsylvania.

Methods.

We investigated recent cases, performed community surveys for Hib vaccination coverage and pharyngeal carriage, and administered a questionnaire assessing vaccination knowledge and attitudes to 298 members of 2 Amish communities (A and B) in Pennsylvania and, as a comparison group, 136 non-Amish family members who participated in state immunization clinics. From December 1999 to February 2000, 8 cases of invasive Hib disease occurred among children who were 5 years of age or younger in Pennsylvania. Six of the case-patients were from Amish communities. None of the children had been vaccinated.

Results.

Among children who were 5 years of age or younger, Hib vaccine coverage was low in the 2 Amish communities: A (9 [28%] of 32) and B (3 [7%] of 41) compared with the non-Amish group (19 [95%] of 20). Hib carriage prevalence was higher in both Amish communities than in the non-Amish group (A: 3%; B: 8%; non-Amish: 0%). More households in community B had 1 or more Hib carriers than in community A (8 [28%] of 29 vs 3 [9%] of 32). Among Amish parents who did not vaccinate their children, only 25% (13 of 51) identified either religious or philosophical objections as a factor; 51% (26 of 51) reported that vaccinating was not a priority compared with other activities of daily life. Seventy-three percent (36 of 49) would vaccinate their children if vaccination were offered locally.

Conclusions.

Undervaccinated communities in the United States still exist and allow circulation of Hib strains, resulting in disease among susceptible children. Identification of undervaccinated populations, such as the Amish, and targeted education and vaccination campaigns are essential to achieving elimination of Hib disease.
Sex Differences in the Secular Changes in Pubertal Maturation
Authors: Papadimitriou Anastasios
Published: August 2004

Objective.

It is a common experience among pediatricians in the industrialized countries that many girls—but many fewer boys—present with secondary sex characteristics at a younger age than normal. This study examines whether there are sex differences in the secular changes toward earlier pubertal maturation.

Methods.

The author collected the growth data from various studies performed in Greece in the 20th century (from 1928 to 1995) and estimated the age at peak annual height increment in each study by calculating mean increase in height in each successive year.

Results.

In all studies, boys presented peak mean annual height increment at 13 to 14 years of age. Girls did not present a discernible peak height increment until the late 1960s; however, thereafter they presented a peak height increment at 11 to 12 years of age.

Conclusions.

The data suggest sex differences in the secular changes in pubertal maturation, girls being affected more intensely than boys.
Parallel Incidences of Sudden Infant Death Syndrome and Infantile Hypertrophic Pyloric Stenosis: A Common Cause?
Authors: Persson Sofia , Ekbom Anders , Granath Fredrik , Nordenskjöld Agneta
Published: August 2004

Objective.

To determine whether there was a correlation between the incidence of infantile hypertrophic pyloric stenosis (IHPS) and the incidence of sudden infant death syndrome (SIDS) during the period 1970 to 1997 and to discuss different causative factors that could be influencing the changing trend in incidence.

Methods.

We compared the incidence of IHPS in the Stockholm Health Care Region with the incidence of SIDS in Sweden each year between 1970 and 1997. First, the relation was assessed by calculation of a correlation coefficient; second, the relative linear decrease was estimated for the time period 1990 to 1997.

Results.

The incidence of IHPS increased steadily during the 1970s, from 0.5 per 1000 live births in 1970 to 2.7 in 1979. During the 1980s, the average incidence was 2.8. During the 1990s, there was a significant decrease in the number of IHPS cases in Stockholm. The incidence rate of IHPS parallels the incidence of SIDS during the study period (r = 0.58). The incidence of SIDS dropped after the risk-reduction campaign in the beginning of the 1990s, which recommended that infants sleep on their back. We could not identify any other changes of behavioral risk factors in early exposures that could explain the temporal trends.

Conclusions.

The statistical findings suggest that IHPS and SIDS have causative factors in common. We suggest that prone sleeping is one of those factors.
Antipyretic Efficacy of an Initial 30-mg/kg Loading Dose of Acetaminophen Versus a 15-mg/kg Maintenance Dose
Authors: Tréluyer Jean Marc , Tonnelier Sylvie , d'Athis Philippe , Leclerc Beatrice , Jolivet-Landreau Isabelle , Pons Gérard
Published: August 2004

Objective.

To compare the antipyretic efficacy of an initial 30-mg/kg acetaminophen loading dose versus a 15-mg/kg maintenance dose.

Methods.

A double-blind, parallel-group, randomized clinical trial was conducted. A total of 121 febrile (rectal temperature between 39°C and 40°C) but otherwise healthy outpatients who were 4 months to 9 years of age and weighed 4 to 26 kg were assigned randomly to 1 of the dose groups: 15 mg/kg (n = 62) and 30 mg/kg (n = 59).

Results.

In an “intention to treat” analysis, the time to obtain a temperature lower than 38.5°C was significantly shorter in the 30-mg/kg than in the 15-mg/kg group (110 ± 94 minutes vs 139 ± 113 minutes). The maximum temperature decrease was significantly higher in the 30-mg/kg than in the 15-mg/kg group (2.3 ± 0.7°C vs 1.7 ± 0.6°C). Duration of rectal temperature below 38.5°C was significantly longer in the 30-mg/kg than in the 15-mg/kg group (250 ± 92 minutes vs 185 ± 121 minutes, respectively). Adverse events were reported in 6 children in the 30-mg/kg group compared with 5 in the 15-mg/kg group (hyperthermia, hypothermia, vomiting). The difference was not statistically significant.

Conclusion.

An initial 30-mg/kg acetaminophen loading dose seemed to be more effective in reducing fever than a 15-mg/kg maintenance dose. No difference was observed regarding clinical tolerance. These data suggest that acetaminophen treatment of fever may be more efficient in an initial loading dose.
Development and Impact of a Computerized Pediatric Antiinfective Decision Support Program
Authors: Mullett Charles J. , Evans R. Scott , Christenson John C. , Dean J. Michael
Published: August 2004

Objective.

Computerized medical decision support tools have been shown to improve the quality of care and have been cited by the Institute of Medicine as one method to reduce pharmaceutical errors. We evaluated the impact of an antiinfective decision support tool in a pediatric intensive care unit (PICU).

Methods.

We enhanced an existing adult antiinfective management tool by adding and changing medical logic to make it appropriate for pediatric patients. Process and outcomes measures were monitored prospectively during a 6-month control and a 6-month intervention period. Mandatory use of the decision support tool was initiated for all antiinfective orders in a 26-bed PICU during the intervention period. Clinician opinions of the decision support tool were surveyed via questionnaire.

Results.

The rate of pharmacy interventions for erroneous drug doses declined by 59%. The rate of anti-infective subtherapeutic patient days decreased by 36%, and the rate of excessive-dose days declined by 28%. The number of orders placed per antiinfective course decreased 11.5%, and the robust estimate of the antiinfective costs per patient decreased 9%. The type of anti-infectives ordered and the number of antiinfective doses per patient remained similar, as did the rates of adverse drug events and antibiotic-bacterial susceptibility mismatches. The surveyed clinicians reported that use of the program improved their antiinfective agent choices as well as their awareness of impairments in renal function and reduced the likelihood of adverse drug events.

Conclusions.

Use of the pediatric antiinfective decision support tool in a PICU was considered beneficial to patient care by the clinicians and reduced the rates of erroneous drug orders, improved therapeutic dosage targets, and was associated with a decreased robust estimate of antiinfective costs per patient. antiinfective agents, decision support systems, drug therapy, medication errors, child, infant.
Infantile Scurvy: A Historical Perspective
Authors: Rajakumar Kumaravel
Published: August 2004

Scurvy, a disease of dietary deficiency of vitamin C, is uncommon today. Among diseases, scurvy has a rich history and an ancient past. The Renaissance (14th to 16th centuries) witnessed several epidemics of scurvy among sea voyagers. In 1747, James Lind, a British Naval surgeon, performed a carefully designed clinical trial and concluded that oranges and lemons had the most antiscorbutic effect. Eventually, with the provision of lemon juice to the sea voyagers, scurvy became rare at sea. Infantile scurvy appeared almost as a new disease toward the end of the 19th century. The increased incidence of infantile scurvy during that period was attributed to the usage of heated milk and proprietary foods. Thomas Barlow described the classic clinical and pathologic features of infantile scurvy in 1883. Between 1907 and 1912, Holst and Frolich induced and cured scurvy in guinea pigs by dietary modification. In 1914, Alfred Hess established that pasteurization reduced the antiscorbutic value of milk and recommended supplementation of fresh fruit and vegetable juices to prevent scurvy. Such pioneering efforts led to the eradication of infantile scurvy in the United States. A brief history of infantile scurvy is provided.
Childhood Methanol Ingestion Treated With Fomepizole and Hemodialysis
Authors: Brown Mandy J. , Shannon Michael W. , Woolf Alan , Boyer Edward W.
Published: August 2004

Fomepizole (4-methylpyrazole; Antizol) is used increasingly in the treatment of methanol toxicity in adults. Little experience exists with this drug in the pediatric population, however. We present a case of methanol poisoning in a child in whom the use of fomepizole averted intravenous ethanol infusion and the attendant side effects of this therapy.
Changes in Stillbirth and Infant Mortality Associated With Increases in Preterm Birth Among Twins
Authors: Joseph K. S. , Marcoux Sylvie , Ohlsson Arne , Liu Shiliang , Allen Alexander C. , Kramer Michael S. , Wen Shi Wu ,   for the Fetal and Infant Heath Study Group of the Canadian Perinatal Surveillance System
Published: August 2004

Objective.

To examine whether the recent substantial increase in preterm birth among twins has been associated with changes in fetal and infant mortality.

Design.

Cohort study based on information in the linked live birth, stillbirth, and mortality databases of Statistics Canada.

Setting.

Ten of 12 provinces and territories in Canada.

Participants.

All twin live births and stillbirths between 1985 and 1996, along with information on deaths during infancy (1985–1997).

Main Outcome Measure.

Fetal and infant mortality rates.

Results.

The rate of preterm birth among twin live births increased significantly by 17% (95% confidence interval: 14%–20%) from 42.5% between 1985 and 1987 to 49.6% between 1994 and 1996. Overall, stillbirth rates among twins declined from 22.4 per 1000 total births in 1985 to 1987 to 18.8 per 1000 total births in 1994 to 1996. Among twin fetuses ≥34 weeks' gestation, stillbirth rates decreased from 9.5 per 1000 in 1985 to 1987 to 5.4 per 1000 fetuses at risk in 1994 to 1996. Infant mortality rates among twin live births declined substantially in all categories of gestational age above 24 weeks except for live births at 32 to 33 and 34 to 36 weeks' gestation.

Conclusions.

The recent increase in preterm birth among twins was associated with a substantial reduction in stillbirth rates at and near term gestation. Infant mortality rates declined concurrently, although the absence of a significant decrease in infant mortality among twin live births at 32 to 33 and 34 to 36 weeks' gestational age needs additional scrutiny.
Botulinum Toxin Type A Neuromuscular Blockade in the Treatment of Equinus Foot Deformity in Cerebral Palsy: A Multicenter, Open-Label Clinical Trial
Authors: Koman L. Andrew , Brashear Allison , Rosenfeld Samuel , Chambers Henry , Russman Barry , Rang Mercer , Root Leon , Ferrari Eugenio , Garcia de Yebenes Prous J. , Smith Beth P. , Turkel Catherine , Walcott Jennifer M. , Molloy Patricia T.
Published: August 2004

Background.

Focal spasticity of the gastrocnemius-soleus muscles causes equinus gait in children with cerebral palsy (CP). Botulinum toxin type A (BTX-A), a neuromuscular blocking agent, reduces muscle tone/overactivity in dystonia, stroke, and CP.

Objective.

A prospective, open-label, multicenter clinical trial evaluated the long-term safety and efficacy of repeated intramuscular injections of BTX-A on equinus gait in CP children.

Methods.

Nine centers enrolled 207 children. BTX-A injections (4 U/Kg) were given approximately every 3 months (maximum dose 200 U per treatment). Outcome measures included a Physician Rating Scale of gait, ankle range of motion measurements, and the incidence and profile of adverse events.

Results.

One hundred fifty-five (75%) of 207 children completed at least 1 year with a total of 302 patient years of BTX-A treatment. The mean duration of BTX-A exposure was 1.46 years per patient. Dynamic gait pattern on the Physician Rating Scale improved in 46% of patients (86/185) at first follow-up. The response was maintained in 41% to 58% of patients for 2 years. Both gait pattern and ankle position improved at every visit. The most common treatment-related adverse events included increased stumbling, leg cramps, leg weakness, and calf atrophy in 1% to 11% of patients. No treatment-related serious adverse events were reported. Only 6% (7/117) of patients with pre- and postantibody samples had both detectable antibodies and a subsequent treatment failure.

Conclusion.

BTX-A proved both safe and effective in the chronic management of focal muscle spasticity in children with equinus gait.
Maternal Concern About Positive Test Results in Universal Newborn Hearing Screening
Authors: Weichbold Viktor , Welzl-Mueller Kunigunde
Published: August 2004

Objective.

A positive test result from universal newborn hearing screening (UNHS) has been suspected to cause maternal concern. However, findings so far are inconclusive. Against the background of a 2-stage UNHS protocol, we investigated the extent of maternal concern in 2 different situations: 1) mothers' immediate reactions after a positive result at the first-stage test and 2) maternal concern during a 1-month period while waiting for the infant's hearing assessment after the infant also failed the retest (ie, the screening). In addition, we checked whether mothers who are informed by an audiologist about the low predictive validity of positive test results in hearing screening are less concerned about a positive result than mothers who are not informed.

Methods.

A prospective study was conducted over a 1-year period, in which all mothers whose infants tested positive in the first stage or failed the screening were questioned about their level of concern attributable to the positive test result.

Results.

Of 85 mothers whose infants tested positive in the first-stage test (situation 1), 34 (40%) did not know the result. Of the remaining 51 mothers, 59% were not at all concerned and 27% were only slightly concerned about the result, whereas 14% stated that they were highly concerned. In an additional sample of 43 mothers whose infants failed the screening (situation 2), 42% reported not being worried and 37% only slightly worried, whereas 21% were highly concerned about the positive screening result. No effect of information about the low predictive validity of positive test results on the extent of maternal concern could be ascertained.

Conclusions.

The results of this study contradict the findings of some previous surveys that reported considerably higher levels of maternal concern after a positive test in UNHS. The failure to demonstrate the impact of information on maternal concern might be attributable to the fact that the number of uninformed mothers was too small to affect our results perceptibly.
Establishment of a Clinical Trials Office at a Children's Hospital
Authors: Abzug Mark J. , Esterl Elizabeth A.
Published: August 2004

Objective.

To create a clinical trials office (CTO) at a children's hospital and assess its impact.

Methods.

Meetings with faculty and clinical trials groups were undertaken to develop a conceptual plan for an exclusively pediatric CTO designed to be a 1-stop office for sponsors, contract research organizations, and investigators. Guiding principles, eg, use of the CTO would be voluntary and paid for on a fee-for-service basis, were defined, and a business plan was developed.

Results.

The CTO opened in October 1997, offering a broad menu of services. Initial marketing efforts have been followed by steadily increasing use of the CTO, measured in a number of studies and investigators who use CTO services. Commensurate growth in CTO staffing has been required. Since the CTO's opening, the number of and revenues from industry-sponsored clinical trials performed at the hospital have been significantly greater than the pre-CTO baseline and have exceeded business plan projections. In addition, the proportion of industry-sponsored clinical research at the hospital that is administered by the CTO has expanded (now >50%). The increase in hospital revenues from industry-sponsored clinical trials has exceeded the cost of running the CTO. Studies performed by the CTO have involved a mix of general pediatric clinic/private office patients, subspecialty clinic patients, and hospitalized children.

Conclusion.

A CTO dedicated to pediatric clinical research can enhance the ability of a children's hospital to participate in the growing number of pediatric clinical trials.
Snoring in 9- to 15-Year-Old Children: Risk Factors and Clinical Relevance
Authors: Corbo Giuseppe M. , Forastiere Francesco , Agabiti Nera , Pistelli Riccardo , Dell'Orco Valerio , Perucci Carlo A. , Valente Salvatore
Published: August 2004

Objective.

Our objective was to investigate the occurrence of snoring in a general population sample of children and to evaluate the association with anthropometric data and clinical findings of oropharynx and nasal airways.

Methods.

A cross-sectional study was conducted with children from primary and secondary schools in Civitavecchia and Viterbo in the Latium region in central Italy. The total sample of the survey included 2439 schoolchildren. A total of 2209 children who were ages 10 to 15 years were selected (response rate: 90.5%) according to their snoring frequency during sleep: never, only with colds, occasionally apart from with colds, often. Children in the last category were defined as habitual snorers. Data were collected by means of questionnaires and clinical examination. A blood sample was collected to determine the concentration of hemoglobin in the blood. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals.

Results.

The prevalence of habitual snorers was 5.6%. Boys who were older than 15 years and had a body mass index greater than the 90th percentile were significantly more likely to be snorers. Habitual snoring was strongly associated with decreased nasal patency (rhinitis OR: 2.13; septal deviation OR: 2.75; nasal obstruction OR: 2.20). Children who had undergone adenoidectomy or had markedly enlarged tonsils were at greater risk of being habitual snorers (OR: 4.28 and 5.07, respectively). Last, habitual snorers had a significantly higher concentration of hemoglobin in the blood compared with other children.

Conclusion.

Body weight and nasal and pharynx patency seem to be the main determinants of snoring. The finding of higher values of blood hemoglobin concentration in snorers than in nonsnorers suggests that these children could be experiencing oxyhemoglobin desaturation during sleep. Taking into consideration the relationship between these different risk factors could lead to a better clinical approach to the snoring child.
Time Course of Changes in Diffusion-Weighted Magnetic Resonance Imaging in a Case of Neonatal Encephalopathy With Defined Onset and Duration of Hypoxic-Ischemic Insult
Authors: Soul Janet S. , Robertson Richard L. , Tzika A. Aria , du Plessis Adre J. , Volpe Joseph J.
Published: August 2004

The onset and duration of hypoxic-ischemic (HI) insults rarely can be determined precisely in perinatal asphyxia. The need to establish the timing of HI insults will be critical for the successful application of evolving neuroprotective therapies that may be administered to the asphyxiated newborn. Diffusion-weighted magnetic resonance imaging has emerged as an imaging technique that can be used to identify HI brain injury before the detection of abnormalities by conventional magnetic resonance imaging. This case illustrates the early changes in diffusion-weighted and conventional magnetic resonance imaging studies and in quantitative values of the apparent diffusion coefficient in a unique case of neonatal asphyxia in which the onset and duration of the HI insult were known.hypoxia-ischemia, newborn brain, perinatal asphyxia, diffusion-weighted imaging, proton magnetic resonance spectroscopy.
Nondiscrimination in Pediatric Health Care
Authors:   Committee on Pediatric Workforce
Published: August 2004

This policy statement reaffirms and consolidates the positions of the American Academy of Pediatrics relative to nondiscrimination in pediatric health care. It addresses pediatricians who provide health care and the infants, children, adolescents, and young adults who are entitled to optimal pediatric care.
WIC Program
Authors:   Provisional Section on Breastfeeding
Published: August 2004

This policy statement highlights the important collaboration between pediatricians and local Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs to ensure that infants and children receive high-quality, cost-effective health care and nutrition services. Specific recommendations are provided for pediatricians and WIC personnel to help children and their families receive optimum services through a medical home.
The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care
Authors:   Committee on Psychosocial Aspects of Child and Family Health
Published: August 2004

In 1993, the American Academy of Pediatrics adopted the policy statement “The Pediatrician and the ‘New Morbidity.’” Since then, social difficulties, behavioral problems, and developmental difficulties have become a main part of the scope of pediatric practice, and recognition of the importance of these areas has increased. This statement reaffirms the Academy's commitment to prevention, early detection, and management of behavioral, developmental, and social problems as a focus in pediatric practice.
Abnormal Central Complex Is a Marker of Severity in the Presence of Partial Ciliary Defect
Authors: Tamalet Aline , Clement Annick , Roudot-Thoraval Francoise , Desmarquest Pascale , Roger Gilles , Boulé Michèle , Millepied Marie Claude , Baculard TA§; Armelle , Escudier Estelle
Published: August 2004

Background.

Ciliary ultrastructural defects with total lack of dynein arms (DA) cause abnormal mucociliary function leading to the chronic infections observed in primary ciliary dyskinesia. The role of partial ciliary ultrastructural defects, especially those involving the central complex, and their relationship with respiratory symptoms have been less thoroughly investigated.

Objective.

In a pediatric population with partial ciliary defects, we determined the relationship(s) between ultrastructural findings, ciliary motility, and clinical and functional features, and evaluated the outcome of this population.

Design.

We analyzed the clinical presentation and pulmonary function of 43 children with chronic bronchitis and partial ultrastructural defects (from 15% to 90%) of their respiratory cilia demonstrated on bronchial biopsies. The study population was divided into 3 groups according to ciliary ultrastructure: the main ultrastructural defect concerned the central complex in 23 patients (CC group), peripheral microtubules in 8 patients (PMT group), and DA in 12 patients (DA group).

Results.

The percentage of ciliary defects was lower in the PMT group than in the CC and DA groups. Patients in the PMT group had less severe disease with frequent normal ciliary motility. Patients in the CC group had initially a higher incidence of respiratory tract infections, extensive bronchiectasis frequently requiring surgery, and arguments in favor of a congenital origin (high proportion of sibling form). Partial absence of DA, although of congenital origin, was associated with a good prognosis. In all groups, follow-up showed that the functional prognosis remained good with appropriate treatment.

Conclusions.

In children with chronic respiratory infections, presence of situs inversus, sibling form, obstructive pulmonary syndrome, or bronchiectasis required ultrastructural analysis, regardless of ciliary motility. Detection of CC abnormalities is a marker of severity and required intensive therapy and close follow-up.
Diaphragm Dimensions of the Healthy Preterm Infant
Authors: Rehan Virender K. , Laiprasert JoAnn , Wallach Michael , Rubin Lewis P. , McCool F. Dennis
Published: August 2004

Background.

The diaphragm is the major inspiratory muscle in the neonate; however, human neonatal diaphragm development has not been extensively studied. We hypothesized that diaphragm thickness (tdi) would be positively related to postmenstrual age (PMA), body weight, body length, head circumference, and nutritional intake.

Objectives.

To evaluate the evolution of diaphragm growth and motion in the healthy, preterm infant.

Methods.

We used ultrasound to measure tdi at the zone of apposition to the rib cage and diaphragm excursion (edi) during inspiration. Thirty-four stable, preterm infants (16 males and 18 females) between 26 and 37 weeks' PMA were studied during quiet sleep at weekly intervals until the time of discharge or transfer from the neonatal intensive care unit. All infants were clinically stable and not receiving ventilatory support.

Results.

We found that 1) tdi increased from 1.2 ± 0.1 to 1.7 ± 0.05 mm between 26 to 28 and 35 to 37 weeks' PMA; 2) tdi was positively correlated with PMA (r = 0.40), body weight (r = 0.52), body length (r = 0.53), and head circumference (0.49), but not with postnatal nutritional intake (r = 0.09); and 3) edi decreased with increasing PMA.

Conclusions.

Our findings suggest that diaphragm development in premature infants scales with body dimensions. We speculate that the increase in tdi with age is likely attributable to increased diaphragm muscle mass, and the reduced edi with age may be resulting from a reduction in chest wall compliance.
Maternal and Infant Factors Associated With Failure to Thrive in Children With Vertically Transmitted Human Immunodeficiency Virus-1 Infection: The Prospective, P2C2 Human Immunodeficiency Virus Multicenter Study
Authors: Miller Tracie L. , Easley Kirk A. , Zhang Weihong , Orav E. John , Bier Dennis M. , Luder Elisabeth , Ting Andrew , Shearer William T. , Vargas Jorge Humberto , Lipshultz Steven E. ,   for the Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV Infection (P2C2 HIV) Study Group,   National Heart, Lung, and Blood Institute, Bethesda, MD
Published: August 2004

Objective. Many children with human immunodeficiency virus-1 (HIV-1) have chronic problems with growth and nutrition, yet limited information is available to identify infected children at high risk for growth abnormalities. Using data from the prospective, multicenter P2C2 HIV study, we evaluated the relationships between maternal and infant clinical and laboratory factors and impaired growth in this cohort.

Methods. Children of HIV-1-infected women were enrolled prenatally or within the first 28 days of life. Failure to thrive (FTT) was defined as an age- and sex-adjusted weight z score ≤−2.0 SD. Maternal baseline covariates included age, race, illicit drug use, zidovudine use, CD4+ T-cell count, and smoking. Infant baseline predictors included sex, race, CD4+ T-cell count, Centers for Disease Control stage, HIV-1 RNA, antiretroviral therapy, pneumonia, heart rate, cytomegalovirus, and Epstein-Barr virus infection status.

Results. The study cohort included 92 HIV-1-infected and 439 uninfected children. Infected children had a lower mean gestational age, but birth weights, lengths, and head circumferences in the 2 groups were similar. Mothers of growth-delayed infants were more likely to have smoked tobacco and used illicit drugs during pregnancy. In repeated-measures analyses of weight and length or height z scores, the means of the HIV-1-infected group were significantly lower at 6 months of age (P < .001) and remained lower throughout the first 5 years of life. In a multivariable Cox regression analysis, FTT was associated with a history of pneumonia (relative risk [RR] = 8.78; 95% confidence interval [CI]: 3.59–21.44), maternal use of cocaine, crack, or heroin during pregnancy (RR = 3.17; 95% CI: 1.51–6.66), infant CD4+ T-cell count z score (RR = 2.13 per 1 SD decrease; 95% CI: 1.25–3.57), and any antiretroviral therapy by 3 months of age (RR = 2.77; 95% CI: 1.16–6.65). After adjustment for pneumonia and antiretroviral therapy, HIV-1 RNA load remained associated with FTT in the subset of children whose serum was available for viral load analysis.

Conclusion. Clinical and laboratory factors associated with FTT among HIV-1-infected children include history of pneumonia, maternal illicit drug use during pregnancy, lower infant CD4+ T-cell count, exposure to antiretroviral therapy by 3 months of age (non-protease inhibitor), and HIV-1 RNA viral load.
Patient Self-Management of Acute Asthma: Adherence to National Guidelines a Decade Later
Authors: Scarfone Richard J. , Zorc Joseph J. , Capraro Geoffrey A.
Published: August 2004

Background and Objectives. Children in the emergency department (ED) with acute asthma were enrolled to assess the impact of asthma on their activities of daily living and evaluate their access to care and preventive strategies, determine the proportion who adhered to the National Heart, Lung, and Blood Institute (NHLBI) guidelines for proper steps to take at home during an acute asthma exacerbation, and compare adherence rates for those with persistent and mild intermittent asthma.

Design and Methods. Children 2 to 18 years old who presented to the Children’s Hospital of Philadelphia’s ED with acute asthma exacerbations were enrolled prospectively. Parents and patients completed the 108-item Asthma Exacerbation Response Questionnaire with a focus on determining the home management steps they took both at the onset of the asthma exacerbation and just before coming to the ED.

Results. Among the 433 children studied, 76% had at least 1 doctor visit, 75% had at least 1 ED visit, and 43% had at least 1 hospitalization for asthma in the preceding 12 months. Overall, 64% had persistent asthma by NHLBI criteria, yet just 4% were cared for by an allergist or pulmonologist, 38% took daily anti-inflammatory therapy, and 18% received a daily inhaled corticosteroid. Also, 48% did not use a holding chamber with their metered-dose inhalers, and 66% did not use their peak flow meters. Regarding exacerbation response, 71% did not have a written action plan, and 89% did not maintain a symptom diary. Both at the onset of wheezing and just before coming to the ED, administration of a β2-agonist was the only step that the majority of children performed. One-third or fewer followed the other steps recommended by the NHLBI, including using a peak flow meter, beginning oral corticosteroids, calling or going to see the doctor, or going to the ED. Children with persistent asthma were not more adherent to the guidelines than those with mild intermittent disease.

Conclusions. Asthma has a significant adverse effect on the lives of these children. The NHLBI guidelines, first published a decade ago, were designed to reduce asthma’s increasing morbidity and mortality, but this study uncovered a high rate of nonadherence with many aspects of the guidelines, including preventive strategies and home management of an exacerbation.
Guiding Principles, Attributes, and Process to Review Medical Management Guidelines
Authors:   Task Force on Medical Management Guidelines
Published: August 2004

This Policy Statement was retired January 2006.

Few issues are more central to the ongoing debate about health care in the United States than concerns about cost and quality of medical care. The recent development and implementation of medical management guidelines that include recommendations for diagnostic and therapeutic interventions, hospital length of stay, intensity of service, home care, and access to specialists have often focused this debate on the potential trade-off between cost reductions and quality of care. The American Academy of Pediatrics recognizes that cost and quality are integrally related and that it is possible to reduce costs while maintaining and improving quality. The purpose of this statement is to help pediatricians and other health care providers interpret, evaluate, and improve medical management guidelines.
Economic Impact of an Infection Control Education Program in a Specialized Preschool Setting
Authors: Ackerman Stacey J. , Duff Steven B. , Dennehy Penelope H. , Mafilios Michael S. , Krilov Leonard R.
Published: August 2004

Objective. To assess the economic impact, from a societal perspective, of a multidimensional infection control education program (ICEP) in a preschool for children with Down syndrome.

Methods. Krilov et al implemented a comprehensive ICEP in a specialized preschool setting and reported a significant decrease in medical resource utilization and days absent from school. Clinical and economic data from Krilov et al and other sources were incorporated into a health-state transition (Markov) decision analysis model that estimated annual expected costs for the baseline and intervention years. Procedure and diagnosis codes were assigned to all physician office visits, emergency department visits, hospitalizations, and laboratory and diagnostic tests. Cost estimates then were derived using 1999 national reimbursement schedules and other sources. Productivity losses for parents were estimated using national wage rates. The costs of the ICEP were compared with the reduction in the costs of illness (direct medical costs plus costs associated with lost parental working time). The outcomes measured were mean annual costs of illness per child, total annual ICEP costs, and net annual costs or savings.

Results. With a comprehensive ICEP, the mean costs of illness in the baseline year was $1235 per child, of which 68% and 14% were for productivity losses and physician visits, respectively. In the intervention year, the mean costs of illness per child was $615, of which 71% and 20% were for productivity losses and physician visits, respectively. The cost of the preexisting infection control (IC) practices in place at the onset of the study (baseline year) was $716. The comprehensive ICEP cost (intervention year) was $75 627, 92% of which was spent to hire a cleaning service to decontaminate toys 3 times per week. When a secondary analysis was performed to reflect a less intensive ICEP in a nonspecialized preschool setting, the mean costs of illness in the baseline and intervention years were $962 and $614 per child, respectively, representing a total annual cost-of-illness savings of $13 224 for the 38 children who participated in the study by Krilov et al. The annual incremental cost of the less intensive ICEP was $2371; therefore, the estimated net annual savings of the less intensive ICEP in a nonspecialized preschool was $10 853.

Conclusions. This study suggests that the reduction in the costs of illness could more than offset the cost of implementing a multidimensional ICEP in a preschool setting.