bluuebunny/crossref_metadata_2025 huggingface dataset:
Can Pediatricians Define and Apply the Concept of Brain Death?
Authors: Harrison A. Marc , Botkin Jeffrey R.
Published: August 2004

Objective.

We sought to determine pediatric residents' and attending physicians' ability to define brain death, their ability to apply this standard of death to a clinical scenario, and their knowledge regarding the legal necessity of confirmatory testing when determining death by brain criteria. We compared resident and attending self-confidence at discussing brain death with their ability to define brain death and apply this concept to a clinical scenario.

Methodology.

A questionnaire was sent to 136 residents, postgraduate years 1 through 3, at four accredited pediatric training programs in the United States. Participation was tracked by return address. One follow-up request for participation was made. A similar procedure was followed for 140 faculty pediatricians at two of the institutions.

Demographic information including level of training, subspecialty training, training program, and formal ethics training was collected. Respondents defined brain death, interpreted a clinical scenario, and stated whether confirmatory testing is legally required to determine death by brain criteria. Respondents rated their confidence at explaining brain death to a patient's family on a scale from 1 to 5.

Results.

Eighty-seven percent (118/136) of resident surveys were returned. Thirty-six percent (42/118) of the residents correctly defined brain death. Forty-three percent (51/118) of residents correctly interpreted the clinical scenario. Fifty-five percent (65/118) of the residents correctly recognized that brain death could be determined without a confirmatory test. Residents who correctly defined brain death were as confident as those who did not (2.8 ± 1 vs 1.5 ± 1). Residents who correctly interpreted the clinical scenario were as confident as those who did not (2.6 ± 1 vs 1.9 ± 0.9).

Eighty percent (112/140) of attending physician surveys were returned. Thirty-nine percent (44/112) of attending physicians correctly defined brain death. Fifty-three percent (59/112) correctly interpreted the clinical scenario. Fifty-eight percent (65/112) recognized that brain death can be diagnosed without confirmatory testing. All pediatric intensivists (n = 12) correctly answered all three questions. Their performance was significantly better than other pediatricians. Attendings who correctly defined brain death were more confident than those who did not (4.2 ± 1 vs 1.1 ± 0.9). Attendings who correctly interpreted the clinical scenario were more confident than those who did not (3.8 ± 1.2 vs 2.2 ± 1.2).

Conclusions.

Pediatric residents and attendings have difficulty defining and applying the concept of brain death. This concept is difficult to grasp and internalize for many pediatricians. To ensure that critical decisions are made by knowledgeable physicians and well-informed families, more effective educational strategies need to be identified.
Gatekeeping and Referral of Children and Adolescents to Specialty Care
Authors: Forrest Christopher B. , Glade Gordon B. , Starfield Barbara , Baker Alison E. , Kang Myungsa , Reid Robert J.
Published: August 2004

Objective.

In this study we examined how gatekeeping arrangements influence referrals to specialty care for children and adolescents in private and Medicaid insurance plans.

Design/Participants.

We conducted a prospective study of office visits (n = 27 104) made to 142 pediatricians in 94 practices distributed throughout 36 states in a national primary care practice-based research network. During 10 practice-days, physicians and patients completed questionnaires on referred patients, while office staff kept logs of all visits. Physicians used medical records to complete questionnaires for a subset of patients 3 months after their referral was made.

Results.

Gatekeeping arrangements were common among children and adolescents with private (57.8%) and Medicaid (43.3%) insurance. Patients in gatekeeping plans were more likely to be referred with private (3.16% vs 1.85% visits referred) and Medicaid (5.39% vs 3.73%) financing. Increased parental requests for specialty care among gatekeeping patients did not explain the increased referral rate. Physicians' reasons for making the referral were similar between the two groups. Physicians were less likely to schedule an appointment or communicate with the specialist for referred patients in gatekeeping plans. However, rates of physician awareness that a specialist visit occurred and specialist communication back to pediatricians did not differ between the two groups 3 months after the referrals were made.

Conclusions.

Gatekeeping arrangements are common among insured children and adolescents in the United States. Our study suggests that gatekeeping arrangements increase referrals from pediatricians' offices to specialty care and compromise some aspects of coordination.
Evidence for Independent Genetic Influences on Fat Mass and Body Mass Index in a Pediatric Twin Sample
Authors: Faith Myles S. , Pietrobelli Angelo , Nuñez Christopher , Heo Moonseong , Heymsfield Steven B. , Allison David B.
Published: August 2004

Objective.

Insight into genetic and environmental influences on fat mass, independent of body mass index (BMI; kg/m2), is expected to enhance methods for treating pediatric obesity. However, few studies have estimated the heritability of fat mass in pediatric samples, and those conducted have relied primarily on BMI measurements.

Present Study.

Using bioimpedance analysis, the present study tested a series of hypotheses predicting significant genetic and environmental influences on percent body fat (PBF) above and beyond BMI. Subjects were 66 pairs of twins, including 41 monozygotic and 25 dizygotic pairs, from 3 to 17 years of age. Structural equation modeling tested hypotheses, adjusting for demographic variables.

Results.

Analyses indicated significant genetic influences on PBF, with genes estimated to account for 75% to 80% of the phenotypic variation. The remaining variation was attributable to nonshared environmental influences. Multivariate analyses revealed sizable genetic correlations and environmental correlations between BMI and PBF (rg = .74 andre = .67, respectively), suggesting that some genes and environmental experiences influence both phenotypes. However, analyses confirmed genetic and environmental influences on PBF above and beyond BMI. For example, 62.5% of the total genetic variation in PBF was attributable to genes that influenced PBF but not BMI.

Conclusion.

There seems to be a substantial genetic contribution to fat mass distinct from BMI in a sample of children and adolescents. Studies testing putative genetic or environmental determinants of pediatric obesity might be strengthened further by including research-based body composition methods. pediatric obesity, twin design, heritability, nonshared environment, bioimpedance analysis, body mass index, body composition.
Early Initiation of Breastfeeding and the Risk of Infant Diarrhea in Rural Egypt
Authors: Clemens John , Elyazeed Remon Abu , Rao Malla , MPH MEngg, , Savarino Stephen , Morsy Badria Z. , Kim Yongdai , Wierzba Thomas , Naficy Abdollah , Lee Y. Jack
Published: August 2004

Background.

Initiation of breastfeeding shortly after delivery may enhance breastfeeding's protective effect against diarrhea because of the protective properties of human colostrum contained in early breast milk.

Objective.

To evaluate whether initiation of breastfeeding within the first 3 days of life, when breast milk contains colostrum, was associated with a lower rate of diarrhea in rural Egyptian infants during the first 6 months of life.

Methods.

Infants initially breastfed (n = 198) were monitored prospectively with twice-weekly home visits to ascertain dietary practices and diarrheal illnesses.

Results.

The burden of diarrhea during the first 6 months of life in the cohort was high: seven episodes per child-year of follow-up. Only 151 (76%) infants initiated breastfeeding during the first 3 days of life (“early initiation”). Infants in whom breastfeeding was initiated early had a 26% (95% CI: 2%,44%) lower rate of diarrhea than those initiated late. The protective association between early initiation and diarrhea was independent of the pattern of postinitiation dietary practices and was evident throughout the first 6 months of life.

Conclusions.

Early initiation of breastfeeding was associated with a marked reduction of the rate of diarrhea throughout the first 6 months of life, possibly because of the salutary effects of human colostrum. These data highlight the need for interventions to encourage early initiation of breastfeeding in less developed settings.
Immigration and Tuberculosis Among Children on the United States–Mexico Border, County of San Diego, California
Authors: Kenyon Thomas A. , Driver Cynthia , Haas Elisabeth , Valway Sarah E. , Moser Kathleen S. , Onorato Ida M.
Published: August 2004

Objective.

To identify factors contributing to a 400% increase in tuberculosis among children in San Diego County, California, from 1985 to 1993.

Design.

Review of medical records of reported cases in 1989, 1991, and 1993 and their source case.

Results.

Of 192 children with tuberculosis, the largest increase was observed in children younger than 5 years old, of whom 77.4% were born in the United States, 67.8% had a foreign-born parent, 73.1% came from a non-English-speaking household, and 46.2% were known to visit Mexico. Of 28 source cases, 82.1% were born outside the United States, primarily in Mexico (67.9%). Resistance to at least one first-line antituberculous drug was identified in 27.5% of isolates from children and in 33.3% of isolates from source cases.

Conclusions.

The increase in tuberculosis and high level of drug-resistance among children born in the United States may be attributed to transmission outside of the United States or within the United States from household contacts born in countries in which tuberculosis is highly endemic.
Has Asthma Medication Use in Children Become More Frequent, More Appropriate, or Both?
Authors: Goodman David C. , Lozano Paula , Stukel Therese A. , Chang Chiang-hua , Hecht Julia
Published: August 2004

Objective.

Despite national initiatives to improve asthma medical treatment, the appropriateness of physician prescribing for children with asthma remains unknown. This study measures trends and recent patterns in the pediatric use of medications approved for reversible obstructive airway disease (asthma medications).

Design.

Population-based longitudinal and cross-sectional analyses.

Setting.

A nonprofit staff model health maintenance organization located in the Puget Sound area of Washington state.

Participants.

Children 0 to 17 years of age enrolled continuously during any one of the years from 1984 to 1993 (N = 83 232 in 1993).

Primary Outcome Measures.

Percent of enrollees filling prescriptions for asthma medications and fill rates by medication class and estimated duration of inhaled antiinflammatory medication use.

Results.

Between 1984 and 1993, the frequency of asthma medication use increased: the percent of children filling any asthma medication prescription increased from 4.0% to 8.1%, whereas the percent filling an inhaled antiinflammatory inhaler rose from 0.4% to 2.4%. In contrast, the intensity of inhaled antiinflammatory use decreased among users; 37% of users filled more than two inhalers during the year in 1984, and 29% in 1993. In high β-agonist users (filling more than two β-agonist inhalers each quarter per year), the estimated duration of inhaled antiinflammatory use increased slightly from a mean of 4.1 months per year in 1984–1986 to 5.0 months in 1991–1993; estimated duration of use in adolescents 10 to 17 years of age was approximately half that of children 5 to 9 years of age.

Conclusions.

The proportion of children using asthma medications increased substantially during the study period, but the use of inhaled antiinflammatory medication per patient remained low even for those using large amounts of inhaled β-agonists. These findings suggest that most asthma medications were used by children with mild lower airway symptoms and that inhaled antiinflammatory medication use in children with more severe disease fell short of national guidelines.
Demyelinative Brainstem Encephalitis Responsive to Intravenous Immunoglobulin Therapy
Authors: Assa Amit , Watemberg Natan , Bujanover Yoram , Lerman-Sagie Tally
Published: August 2004

We describe 2 patients with acute demyelinating brainstem encephalitis who were treated with intravenous immunoglobulin (IVIG). Both patients improved rapidly, concomitant with the course of therapy. To the best of our knowledge, these are the first reported cases of brainstem demyelinating lesions in children treated with IVIG. Our experience suggests that IVIG should be considered as first-line treatment for similar cases.
45,X/46,XY Mosaicism: Report of 27 Cases
Authors: Telvi Louise , Lebbar Aziza , Del Pino Olivia , Barbet Jacques Patrick , Chaussain Jean Louis
Published: August 2004

Objectives.

There exist substantial differences between prenatally and postnatally diagnosed cases of 45,X/46,XY mosaicism. Ninety percent of prenatally diagnosed cases show a normal male phenotype, whereas the postnatally diagnosed cases show a wide spectrum of phenotypes. This 10% risk of an abnormal outcome in prenatally diagnosed cases requires further attention. The purpose of the present study is to provide more information on the postnatally diagnosed 45,X/46,XY mosaicism cases. To date, only a few series have been reported. An accurate diagnosis in these patients is essential not only to their follow-up, but also to providing appropriate genetic counselling and subsequent prenatal diagnosis to their parents.

Methods.

The clinical, cytogenetic, endocrinologic, histologic and molecular biological findings of 27 patients with 45,X/46,XY mosaicism are analyzed.

Results.

The reported cases showed a wide spectrum of phenotypes as Turner syndrome, mixed gonadal dysgenesis (MGD), male pseudohermaphroditism (MPH) and apparently normal male. However, Ulrich-Turner stigmata were the most common features found in this series. Patients with MGD or MPH presented with various degrees of sex reversal such as hypospadias and/or abnormal internal genitalia. No correlation between the proportion of the 45,X/46,XY cell lines in the blood or the fibroblasts and the phenotype was found. Mild mental retardation was present in 4 of the patients and 2 patients showed signs of autism.

Conclusions.

Two major points are emphasized in this series: 1) the presence in 7 histologically analyzed streak gonads of a homogeneous 45,X chromosomal complement suggests that the invasion of the primitive genital ridge by a such a cell line may induce abnormal gonadal development; 2) 3 males, apparently normal at birth, developed late onset abnormalities such as dysgenetic testes leading to infertility, Ulrich-Turner stigmata, dysmorphic features, and mild mental retardation. These data indicate the importance of an accurate clinical and histologic evaluation of any patient presenting with 45,X/46,XY mosaicism.
Sterilization of Minors With Developmental Disabilities
Authors:   Committee on Bioethics
Published: August 2004

This Policy Statement was retired October 2012.

Sterilization of persons with developmental disabilities has often been performed without appropriate regard for their decision-making capacities, abilities to care for children, feelings, or interests. In addition, sterilization sometimes has been performed with the mistaken belief that it will prevent expressions of sexuality, diminish the chances of sexual exploitation, or reduce the likelihood of acquiring sexually transmitted diseases. A decision to pursue sterilization of someone with developmental disabilities requires a careful assessment of the individual's capacity to make decisions, the consequences of reproduction for the person and any child that might be born, the alternative means available to address the consequences of sexual maturation, and the applicable local, state, and federal laws. Pediatricians can facilitate good decision-making by raising these issues at the onset of puberty.
Growth of Infants Prenatally Exposed to Cocaine/Crack: Comparison of a Prenatal Care and a No Prenatal Care Sample
Authors: Richardson Gale A. , Hamel Sara C. , Goldschmidt Lidush , Day Nancy L.
Published: August 2004

Objective.

It has not been possible to draw firm conclusions about the effects of prenatal cocaine exposure because of methodologic problems involved in the conduct of this research. This study, designed to overcome some of these methodologic problems, is a prospective, longitudinal investigation of the effects of prenatal cocaine/crack exposure on neonatal growth in two samples, one with and one without prenatal care (PC).

Methods.

Women in the PC sample (n = 295) were interviewed at the end of each trimester about their use of cocaine, crack, alcohol, tobacco, marijuana, and other drugs. Women in the no prenatal care (NPC) sample (n = 98) were interviewed at delivery about their drug use during each trimester of pregnancy. In both samples, information was also obtained about sociodemographic, lifestyle, psychologic, and social support characteristics. Both samples consisted of women who were predominantly low income, single, and high school educated. Of the women, 48% in the PC sample were black; 81% in the NPC sample were black. Infants were examined during the postpartum hospital stay by project nurses who were blind to maternal substance use status.

Results.

Women in both samples who used cocaine/crack during pregnancy were older, had lower family incomes, and used more alcohol than did women who did not use cocaine/crack during pregnancy. In addition, women in the NPC sample were more likely to be black, less educated, gained less weight during pregnancy, and used more alcohol than did women in the PC sample, regardless of cocaine use. In both samples, cocaine/crack use during early pregnancy predicted reduced gestational age, birth weight, length, and head circumference, after controlling for the significant covariates of cocaine use. In a comparison of the samples, the offspring of the NPC/cocaine group were significantly smaller than were the offspring of the PC/no cocaine group, whereas the offspring of the PC/cocaine and NPC/cocaine groups did not differ.

Conclusions.

These results indicate that exposure to cocaine/crack during early pregnancy decreases the intrauterine growth of exposed offspring in women with and without PC. Each of the growth parameters was affected indicating symmetric growth retardation. The adequacy of PC was not a significant factor in determining the difference between cocaine-exposed and nonexposed infants. These samples are being followed throughout childhood to determine whether there are long-term effects of prenatal cocaine/crack exposure on growth.
Celiac Disease Associated With Familial Chronic Urticaria and Thyroid Autoimmunity in a Child
Authors: Levine Arie , Dalal Ilan , Bujanover Yoram
Published: August 2004

An 11-year-old girl presented with chronic urticaria (CU), antithyroid antibodies, and anemia. Celiac disease was diagnosed. The family history was positive for maternally derived CU and thyroid autoimmunity in three generations. Human leukocyte antigen typing disclosed human leukocyte antigen DQA1*0501 DQB1*0201 in both mother and child. CU was unresponsive to a gluten-free diet despite clinical and laboratory resolution of celiac disease in contrast to previous reports in adults. We believe that this is the first report of this association in a child, highlighting that CU may be a part of the spectrum of autoimmune phenomenon related to celiac disease.
The Changing Pattern of Hypernatremia in Hospitalized Children
Authors: Moritz Michael L. , Ayus J. Carlos
Published: August 2004

Objectives.

Past studies have revealed that hypernatremia occurs primarily in infants with diarrheal dehydration. With improved infant feeding practices and the advent of pediatric critical care medicine, the pattern of hypernatremia in children has likely changed. The purpose of this study was to evaluate the current pattern of hypernatremia in hospitalized children.

Methods.

Medical records were reviewed for 68 patients admitted to a large urban children's hospital during a 3-year period, all with a serum sodium greater than 150 mEq/L. The etiologies, predisposing factors, and morbidity and mortality associated with hypernatremia were evaluated.

Results.

The average patient age was 3.9 years (range, 1 day to 19.7 years), and the peak serum sodium concentration was 159 mEq/L (range, 151–184 mEq/L). Hypernatremia was hospital acquired in 60% of children. The majority of children (71%) were admitted for reasons other than hypernatremia. In 76% of the patients, inadequate fluid intake was the main cause of hypernatremia. Gastroenteritis contributed to the hypernatremia in only 20% (14 out of 68) of children. Eleven of these were infants <1 year of age with hypernatremia on admission. Eighty-eight percent of patients (60 out of 68) suffered from neurologic impairment, critical illness, chronic disease, or prematurity before developing hypernatremia. The overall mortality was 16%. Patients in whom hypernatremia was not corrected had a significantly higher mortality than those in whom hypernatremia was corrected (4 out of 8 [50%] vs 7 out of 60 [12%]). Peak serum sodium was no different for survivors than nonsurvivors. No deaths were attributable to cerebral edema caused by correction of hypernatremia. Neurologic complications related to hypernatremia occurred in 15% of patients.

Conclusions.

Hypernatremia occurs in children of all ages, with the vast majority having significant underlying medical problems. Hypernatremia caused by gastroenteritis in infants has become much less common than previously reported. Hypernatremia is primarily a hospital-acquired disease, produced by the failure to administer sufficient free water to patients unable to care for themselves. Failure to correct hypernatremia may result in a high mortality rate.
Day Care Attendance in the First Year of Life and Illnesses of the Upper and Lower Respiratory Tract in Children With a Familial History of Atopy
Authors: Celedon Juan C. , Litonjua Augusto A. , Weiss Scott T. , Gold Diane R.
Published: August 2004

Objective.

To examine the relationship between day care attendance and illnesses of the upper and lower respiratory tract in the first year of life.

Study Design.

Prospective birth cohort study.

Methods.

Children (N = 498) who had at least 1 parent with a history of allergy or asthma were enrolled at birth and followed prospectively for the first year of life. A home visit at 2 to 3 months of age and bimonthly telephone questionnaires were used to obtain information on day care arrangements, home characteristics, respiratory symptoms, and physician-diagnosed illnesses of the upper and lower respiratory tract.

Results.

Day care attendance in the first year of life was associated with two or more doctor-diagnosed ear infections (OR: 2.4; 95% CI: 1.7–3.6), three or more parental reports of runny or stuffed nose (OR: 3.2; 95% CI: 1.9–5.5), a doctor's diagnosis of sinusitis (OR: 2.2; 95% CI: 1.1–4.2), and doctor-diagnosed lower respiratory illnesses (croup, bronchitis, bronchiolitis, and pneumonia; OR: 1.6; 95% CI: 1.0–2.4). For children attending day care, exposure to pets in day care, the presence of a rug or carpet in the area where the child slept in day care, and a nonresidential setting for day care all were independent predictors of two or more doctor-diagnosed ear infections.

Conclusions.

The results suggest that day care increases the risk of illnesses of the upper and lower respiratory tract in the first year of life for children with a familial history of atopy. Specific environmental exposures within day care, such as the presence of pets or having a rug or carpet in the area where children sleep, may increase the risk of recurrent ear infections in the first year of life among children with familial history of atopy who attend day care.
The Effect of Blood Transfusion Protocol on Retinopathy of Prematurity: A Prospective, Randomized Study
Authors: Brooks Steven E. , Marcus Dennis M. , Gillis Delores , Pirie Elizabeth , Johnson CRNI§; Maribeth H. , Bhatia Jatinder
Published: August 2004

Objective.

Controversy exists regarding the potential influence of anemia and blood transfusions on the rate of retinopathy of prematurity (ROP) in premature infants. A prospective, randomized, masked trial was performed to determine the influence of red blood cell transfusion protocol on ROP incidence and severity in a population of high-risk infants.

Methods.

A total of 50 infants with birth weights <1251 g were divided randomly into two groups beginning on day of life 29. Group 1 (n = 24) received red cell transfusions during the 6-week study period, only if certain symptom-based guidelines were met. Group 2 (n = 26) received red cell transfusions to maintain the hematocrit level above 40% for the entire 6 weeks. Infants were monitored for ROP, growth, and associated morbidity. Serial measurements of serum glucose, lactate, ferritin, total iron-binding capacity, and iron were performed.

Results.

ROP occurred in 83% of infants in group 1, and 73% of infants in group 2. There were no statistically significant differences in ROP severity, intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, or any of the laboratory values except hemoglobin (10.8 vs 13.2 g/dL) and hematocrit (33.9% vs 41.8%) between the groups. Combining data from both groups, there was no association between hemoglobin or hematocrit ratios and ROP incidence or severity.

Conclusions.

A transfusion policy aimed at limiting the amount of blood given to premature infants (symptom-based) during the neonatal period does not impart a significantly different risk for ROP or other associated conditions, than does a policy in which transfusions are given more liberally for replacement purposes.
Adherence to AAP Guidelines for Well-Child Care Under Managed Care
Authors: Byrd Robert S. , Hoekelman Robert A. , Auinger Peggy
Published: August 2004

Objectives.

To determine adherence to American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care in Monroe County, New York by individual patients and individual pediatricians under managed care practice and to compare adherence-to-recommendations rates for privately insured and publicly funded managed care patients.

Study Designs and Methods.

Using claims data for children 0 through 18 years of age cared for by pediatricians, we compared adherence to well-child care (WCC) visit recommendations for 130 572 children enrolled in a privately insured managed care system during 1992, 1993, and 1994 to 17 586 children insured by a publicly funded, Medicaid-managed care system during 1994 and 1995. Criteria for WCC visit adherence were based on 1991 AAP guidelines of 19 office visits from birth through 18 years of age. Adherence-to-recommendations rates by individual pediatricians also were determined.

Results.

Despite complete financial coverage of WCC visits (with no co-payment or deductible charges) by both insurance systems, strict adherence to AAP guidelines for WCC visits was low. Only 46% of privately insured and 35% of publicly funded children received all the recommended visits during the study period. During the same period, 17% of privately insured and 35% of publicly funded managed care patients received no WCC. There was little difference in the rate of full WCC visit adherence by age in either system with the rates ranging in privately insured patients from 49% in infants (<2 years of age) to 47% in adolescents (12 through 18 years of age) and ranging in publicly funded patients from 36% to 34% in these two age groups, respectively. Only 2% of privately insured infants had no record of WCC compared with 29% of adolescents. This contrasted with 12% of infants and 54% of adolescents who were publicly funded. Of pediatricians, <5% achieved 100% adherence to AAP guidelines for their patients (privately insured or publicly funded). Pediatricians completed an average of 52% of the recommended visits with their publicly funded patients and 68% of the recommended visits with their privately insured patients.

Conclusions.

WCC visits were underutilized for children in both managed care systems. Children of parents who have low incomes presumably could benefit greatest by preventive visits, but these children were less likely to receive the recommended number of WCC visits. Finding ways to increase the number of WCC visits that all children make is a major challenge, as is conducting studies that prove their worth.
Immunizations for Native American Children
Authors:   Committee on Native American Child Health and Committee on Infectious Diseases
Published: August 2004

This Policy Statement was retired October 2004.
Thimerosal in Vaccines—An Interim Report to Clinicians
Authors:   Committee on Infectious Diseases and Committee on Environmental Health
Published: August 2004

This Policy Statement was retired January 2003.
Oral Rehydration Solution for Acute Diarrhea Prevents Subsequent Unscheduled Follow-up Visits
Authors: Duggan Christopher , Lasche Jack , McCarty Martha , Mitchell Kathleen , Dershewitz Robert , Lerman Stephen J. , Higham Margaret , Radzevich Annette , Kleinman Ronald E.
Published: August 2004

Background.

Oral rehydration solutions (ORS) for the treatment of acute diarrhea remain an underutilized therapy in the United States, despite multiple clinical trials confirming their efficacy and safety. Economic barriers to their use have been identified.

Objective.

To determine whether providing ORS to patients at the time of their office visit for acute diarrhea can increase ORS utilization and reduce unscheduled follow-up visits.

Design.

Randomized, controlled clinical trial.

Setting.

Seven health centers of a large health maintenance organization.

Participants.

Children (N = 479) 0 to 60 months of age with acute diarrhea (at least three watery or loose stools in the previous 24 hours for ≤7 days).

Intervention.

Prescription for 2 quarts of ORS filled for free at on-site pharmacy plus written instructions versus written instructions alone.

Primary Outcome Measures.

Self-reported use of ORS; unscheduled follow-up visits in office, urgent care, and/or emergency department setting.

Results.

Subjects in the intervention group were significantly more likely to use ORS after the initial office visit (85% vs 71%; RR: 1.19; 95% CI: 1.08–1.32). Of the standard treatment group subjects, 40 (17.3%) sought unscheduled follow-up care for diarrhea versus 27 (10.9%) of the intervention group subjects (RR: 0.63; 95% CI: 0.40–0.99). Subjects seeking unscheduled follow-up care tended to younger (15.7 vs 19.4 months old), have more stools (7.1 vs 6.2 stools), and more vomiting episodes (4.1 vs 3.0) in the 24 hours before initial evaluation than those not seeking unscheduled follow-up care. Multivariate analysis showed that randomization to the intervention group was associated with a 25% reduction in unscheduled follow-up visits for acute diarrhea.

Conclusions.

Providing ORS to families at the time of their office visit for acute diarrhea is associated with a significant increase in ORS use and substantially reduces the need for unscheduled follow-up visits. Health maintenance organizations should consider routine provision of ORS to children presenting with acute diarrhea.
Screening for Domestic Violence in the Community Pediatric Setting
Authors: Siegel Robert M. , Hill Teresa D. , Henderson Vicki A. , Ernst Heather M. , Boat Barbara W.
Published: August 2004

Objective.

Children exposed to domestic violence (DV) can experience a variety of adverse effects such as behavior disorders, developmental delay, and child abuse. Recently, the American Academy of Pediatrics recommended that all pediatricians incorporate screening for DV as a part of anticipatory guidance. To date, however, there is little information on how likely women are to disclose DV or whether there are any benefits to screening in the pediatric office setting. The purpose of our pilot study was to gain an understanding of whether screening for DV in the pediatric office setting could be helpful to abused women and their children.

Methods.

During a 3-month period, 92% of the women who accompanied their children for a well-child visit to a hospital-based suburban pediatrician were asked about violence in the home with a six-question screening tool.

Results.

Of the 154 women screened, 47 (31%) revealed DV at some time in their lives. Twenty-five women (17%) reported DV within the past 2 years and were reported to the mandated state agency. There were 5 episodes of child abuse reported of which two had not been previously reported. Interestingly, there were 5 women injured during their most recent pregnancy and who had separated from their abusive partner, but no legal action had been taken to protect them from their partner's return. There was no significant difference in the incidence of DV reported in families with Medicaid (37%) versus private insurance (20%). Before routine DV screening in our office, only one previous DV report had been made in 4 years.

Conclusions.

Our preliminary results suggest that many women will reveal DV when screened in the pediatric office setting. Also, there is a subgroup of women, those with young children who have recently separated from their partners, who may particularly benefit from DV screening.
Neonatal Screening for Hearing Disorders in Infants at Risk: Incidence, Risk Factors, and Follow-up
Authors: Meyer Christiane , Witte Jan , Hildmann Agnes , Hennecke Karl-Heinz , Schunck Karl-Ulrich , Maul Kerstin , Franke Ute , Fahnenstich Hubert , Rabe Heike , Rossi Rainer , Hartmann Sabine , Gortner Ludwig
Published: August 2004

Objective.

To determine the incidence and risk factors for hearing disorders in a selected group of neonates and the feasibility of selective hearing screening.

Settings.

Multicenter prospective trial at five centers in Germany.

Methods.

Enrollment criteria: in addition to previously defined risk factors by the Joint Committee on Infant Hearing (family history of hearing loss, in utero infections, craniofacial anomalies, birth weight <1500 g, critical hyperbilirubinemia, ototoxic medications, bacterial meningitis, postnatal asphyxia, mechanical ventilation >5 days, stigmata, or syndromes associated with hearing loss), the impact of maternal drug abuse, birth weight <10th percentile, persistent pulmonary hypertension, and intracranial hemorrhage more than or equal to grade III or periventricular leukomalacia on infant hearing were evaluated. The screening procedure was performed by automated auditory brainstem response (A-ABR; ALGO 1-plus; Natus Med Inc, San Carlos, CA). Statistics: univariate analyses of risk factors versus A-ABR results and a multivariate regression analysis were used; additionally, the total test time was recorded.

Results.

Seven hundred seventy recordings from 777 infants enrolled consecutively constitute the basis of this analysis. Mean gestational age was 33.8 ± 4.3 weeks, birth weight 2141 ± 968 g; 431 infants being male and 339 female; 41 (5.3%) infants exhibited pathologic A-ABR results (16 bilateral and 25 unilateral). Meningitis or sepsis, craniofacial malformations, and familial hearing loss were independent significant risk factors. Median total test time was 25 minutes. Follow-up examinations in 31 infants revealed persistent hearing loss in 18 infants (13 infants sensorineural, 5 from mixed disorders), 7 requiring amplification.

Conclusion.

Hearing screening in high-risk neonates revealed a total of 5% of infants with pathologic A-ABR (bilateral 2%). Significant risk factors were familial hearing loss, bacterial infections, and craniofacial abnormalities. Other perinatal complications did not significantly influence screening results indicating improved perinatal handling in a neonatal population at risk for hearing disorders.
Potential Mechanisms for Failure to Eradicate Group A Streptococci From the Pharynx
Authors: Gerber Michael A. , Tanz Robert R. , Kabat William , Bell Gillian L. , Siddiqui BLT∥; Parveen N. , Lerer Trudy J. , Lepow Martha L. , Kaplan Edward L. , Shulman Stanford T.
Published: August 2004

Objective.

To investigate the relative efficacy of orally administered cefadroxil and penicillin V in the treatment of group A streptococcal (GABHS) pharyngitis and the mechanism(s) responsible for failure of antimicrobial therapy to eradicate GABHS from the pharynx.

Study Design.

A prospective, randomized clinical trial was conducted in four pediatric offices in which 462 patients with acute pharyngitis and positive culture for GABHS were randomly assigned to receive cefadroxil (n = 232) or penicillin V (n = 230).

Results.

Bacteriologic treatment success rates for patients in cefadroxil and penicillin groups were 94% and 86%, respectively. However, among patients classified clinically as likely to have bona fide GABHS pharyngitis, there was no difference in bacteriologic treatment success rates in cefadroxil and penicillin groups (95% and 94%, respectively). Among patients classified clinically as likely to be streptococcal carriers, bacteriologic treatment success rates in cefadroxil and penicillin groups were 92% and 73%, respectively. The presence of β-lactamase and/or bacteriocin-producing pharyngeal flora had no consistent effect on bacteriologic eradication rates among patients in either penicillin or cefadroxil treatment groups or among patients classified as having either GABHS pharyngitis or streptococcal carriage.

Conclusions.

Neither β-lactamase nor bacteriocin produced by normal pharyngeal flora are related to bacteriologic treatment failures in GABHS pharyngitis. Cefadroxil seems to be more effective than penicillin V in eradicating GABHS from patients classified as more likely to be streptococcal carriers. However, among patients we classified as more likely to have bona fide GABHS pharyngitis, the effectiveness of cefadroxil and penicillin V seems to be comparable.
Staging of Preclinical Type 1 Diabetes in Siblings of Affected Children
Authors: Mrena Samy , Savola Kaisa , Kulmala Petri , Åkerblom Hans K. , Knip Mikael ,   the Childhood Diabetes in Finland Study Group
Published: August 2004

Objectives.

To assess whether it is clinically relevant to classify siblings of children with recent-onset type 1 diabetes mellitus (T1DM) into various stages of preclinical diabetes, and to compare the risk of developing clinical disease and the time to diagnosis between these stages.

Study Design.

From a total of 801 families taking part in the Childhood Diabetes in Finland Study, 758 initially unaffected siblings were graded into four stages of preclinical T1DM based on the number of disease-associated autoantibodies detectable close to the time of diagnosis in the index case: no (no antibodies), early (one antibody specificity), advanced (two antibodies), and late prediabetes (more than three antibodies). Another classification system, used with 712 siblings, was based on a combination of the number of antibodies and the first-phase insulin response (FPIR) to intravenous glucose: no (no antibodies), early (one antibody specificity, normal FPIR), advanced (two or more antibodies, normal FPIR), and late prediabetes (one or more antibodies, reduced FPIR).

Results.

Six out of 661 siblings who initially presented no signs of prediabetes (0.9%; 95% confidence interval [CI], 0.3%–2.0%) progressed to clinical T1DM. Based on the first set of criteria, 3 out of 49 individuals (6.1%; CI, 1.3%–16.9%; odds ratio [OR], 7.1; CI, 1.7–29.4) from the early prediabetes category, 3 out of 13 with advanced prediabetes (23.1%; CI, 5.0%–53.8%; OR, 32.8; CI, 7.2–150), and 23 out of 35 with late prediabetes (65.7%; CI, 47.8%–80.9%; OR, 209; CI, 72.2–607) presented with clinical signs of T1DM. According to the second set of criteria 1 out of 15 siblings with early prediabetes (6.7%; CI, 0.2%–32.0%; OR, 7.8; CI, 0.9–69.1), 6 out of 23 with advanced prediabetes (26.1%; CI, 10.2%–48.4%; OR, 38.5; CI, 11.3–132), and 12 out of 13 with late prediabetes (92.3%; CI, 64.0%–99.8%; OR, 1310; CI, 146–11 737) presented with clinical signs of T1DM. The time to diagnosis was significantly shorter in those with late prediabetes initially than in those with no signs of prediabetes.

Conclusions.

Our observations indicate that it is possible to grade siblings of children with newly diagnosed T1DM into categories with significant differences in the subsequent risk of clinical T1DM and time to diagnosis. Such a classification will become clinically relevant as soon as effective measures are available for preventing or delaying the manifestation of overt T1DM. autoantibodies, classification, prospective, first-phase insulin response.
Reexamination of the Age Limit for Defining When Puberty Is Precocious in Girls in the United States: Implications for Evaluation and Treatment
Authors: Kaplowitz Paul B. , Oberfield Sharon E. ,   the Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric Endocrine Society
Published: August 2004

In 1997 a study from the Pediatric Research in Office Settings network, based on pubertal staging of >17 000 girls between 3 and 12 years of age, indicated that breast and pubic hair development are occurring significantly earlier than suggested by our current guidelines, especially in African-American girls. In response to this article, the Lawson Wilkins Pediatric Endocrine Society undertook a comprehensive review of this topic. The primary conclusions of this review are:1.  The current recommendation that breast development before age 8 is precocious is based on outdated studies. Until 1997, no data were available on pubertal staging in US girls that could have documented a trend to earlier maturation.2.  The 1997 study indicates that stage 2 of breast and pubic hair development is being achieved ∼1 year earlier in white girls and 2 years earlier in African-American girls than previous studies have shown.3.  Concerns that girls with moderately precocious puberty will be significantly short adults are overstated; most have adult height within the normal range.4.  Therapy with gonadotropin-releasing hormone agonists has not been proven to have a substantial effect on adult height in most girls whose puberty starts between 6 and 8 years of age.5.  New guidelines propose that girls with either breast development or pubic hair should be evaluated if this occurs before age 7 in white girls and before age 6 in African-American girls. No changes in the current guidelines for evaluating boys (signs of puberty at younger than 9 years) can be made at this time. normal puberty, breast development, pubic hair.
Varicella Complicated by Group A Streptococcal Sepsis and Osteonecrosis
Authors: Kouwabunpat Dan , Hoffman Jill , Adler Robert
Published: August 2004

A 5-year-old boy presented with primary varicella zoster virus infection, group A streptococcal sepsis, toxic shock, and multisite osteonecrosis. An association between osteonecrosis and group A streptococcal sepsis has not been previously reported. Clinical recognition with supportive radiologic and pathologic findings are presented. Therapeutic guidelines are suggested.
Marijuana: A Continuing Concern for Pediatricians
Authors:   Committee on Substance Abuse
Published: August 2004

Marijuana, the common name for products derived from the plant Cannabis sativa, is the most common illicit drug used by children and adolescents in the United States.1 Despite growing concerns by the medical profession about the physical and psychological effects of its active ingredient, Δ-9-tetrahydrocannabinol, survey data continue to show that increasing numbers of young people are using the drug as they become less concerned about its dangers.1
A Randomized, Placebo-Controlled Trial of Erythromycin Estolate Chemoprophylaxis for Household Contacts of Children With Culture-Positive Bordetella pertussis Infection
Authors: Halperin Scott A. , Bortolussi R. , Langley Joanne M. , Eastwood Brian J. , De Serres Gaston
Published: August 2004

Context.

Household contacts of patients with pertussis are at increased risk of acquiring infection. Chemoprophylaxis has been recommended to decrease transmission, particularly to young infants who are at increased risk of severe disease. Although epidemiologic investigations of outbreaks have suggested a benefit, there have been no prospective studies evaluating the efficacy of chemoprophylaxis in preventing secondary cases of pertussis.

Objective.

To determine whether erythromycin estolate chemoprophylaxis is effective in household contacts of children with culture-positive pertussis.

Design.

Randomized, double-blind, placebo-controlled study.

Setting.

Community based.

Subjects.

All household contacts of 152 children with culture-positive pertussis who provided consent (n= 362). After withdrawals, there were 135 households with 310 contacts. Exclusions included pregnancy, age <6 months, already receiving an erythromycin-containing antibiotic, and erythromycin allergy.

Interventions.

Erythromycin estolate (40 mg/kg/day in 3 divided doses; maximum dose 1 g) or placebo for 10 days. Nasopharyngeal cultures, pertussis antibodies, and clinical symptoms were assessed before and after treatment.

Primary Outcome.

Measure efficacy of erythromycin estolate chemoprophylaxis calculated by the proportion of households in each group with a member who developed a nasopharyngeal culture positive forBordetella pertussis.

Results.

There was no difference in the development of respiratory tract symptoms compatible with a case definition of pertussis in the erythromycin- and placebo-treated groups. There were 20 households with secondary culture-positive cases of pertussis; 4 households in the erythromycin-treated group and 15 in the placebo-treated group (efficacy of erythromycin chemoprophylaxis for bacterial eradication 67.5% [95% confidence interval: 7.6–88.7]). However, medication-associated adverse reactions were reported by 34.0% of erythromycin and 15.7% of placebo recipients.

Conclusions.

Under the conditions of this study, erythromycin estolate prevented culture-positive pertussis in household contacts of patients with pertussis but did not prevent clinical pertussis.
Utility of Pupillary Dilation for Detecting Leukocoria in Patients With Retinoblastoma
Authors: Canzano John C. , Handa James T.
Published: August 2004

In the United States, 50% of all retinoblastoma cases are diagnosed after the observation of leukocoria by a family member or primary care physician. However, leukocoria produced by retinoblastoma lesions can often be missed by direct ophthalmoscopic examination through an undilated pupil. The purpose of this study is to demonstrate the utility of pupillary dilation for the detection of leukocoria in suspected cases. Seven patients (10 eyes), aged 2 days to 20 months, with retinoblastoma were examined for leukocoria using a direct ophthalmoscope with the pupils first undilated and then after pharmacologic dilation with 0.5% cyclopentolate and 2.5% phenylephrine. Leukocoria was detected by direct ophthalmoscopy on undilated examination in 3 of 10 eyes (30%). In contrast, leukocoria was observed after pupillary dilation in 10 of 10 eyes (100%). The retinoblastoma lesions, from 2 to 10 mm in diameter, were located within the posterior 45° of the retina. Pupillary dilation is a safe and effective tool that can enhance the ability of the examiner to detect leukocoria. Dilation may afford early diagnosis and treatment, and therefore should be considered on patients in whom the diagnosis of retinoblastoma is entertained.