bluuebunny/crossref_metadata_2025 huggingface dataset:
Survival and Developmental Disability in Infants With Birth Weights of 501 to 800 Grams, Born Between 1979 and 1994
Authors: O'Shea T. Michael , Klinepeter Kurt L. , Goldstein Donald J. , Jackson Barbara W. , Dillard Robert G.
Published: August 2004

Objective. Because the survival rate has increased for extremely low birth weight neonates, many have raised the concern that the rate of developmental disability among survivors will also increase. To address this concern, we analyzed changes over time in survival and major neurosensory impairment in a sample of extremely low birth weight infants born between July 1, 1979, and June 30, 1994.

Methods. The study sample included 513 infants with birth weights of 501 to 800 g who were cared for in either of the two neonatal intensive care units that serve a 17-county region in northwest North Carolina and who were born to mothers residing in that region. At 1 year of age (corrected for gestation), survivors were examined by a pediatrician and were tested using the Bayley Scales of Infant Development. Major neurosensory impairment was defined as cerebral palsy, a Bayley Mental Developmental Index <68, or blindness. A total of 209/216 (97%) of survivors were examined at 1 year of age. Epoch of birth was defined as follows: epoch 1, July 1, 1979 to June 30, 1984; epoch 2, July 1, 1984 to June 30, 1989; and epoch 3, July 1, 1989 to June 30, 1994.

Results. Survival rates for epochs 1, 2, and 3 were, respectively, 24/120 (20%), 63/175 (36%), and 129/218 (59%). In contrast, the proportions with a major neurosensory impairment did not increase over time; rates for successive epochs were 6/24 (25%), 17/61 (28%), and 26/124 (21%). Rates of cerebral palsy were 3/24 (13%), 12/61 (20%), and 9/124 (7%); rates of delayed mental development were 4/24 (17%), 12/61 (20%), and 17/124 (14%); and rates of blindness were 2/24 (8%), 0/62, and 5/124 (4%), respectively.

Conclusions. This analysis suggests that the increasing survival of extremely low birth weight neonates since the late 1970s has not resulted in an increased rate of major developmental problems identifiable at 1 year of age.
Use of Alternative Therapies for Children With Cancer
Authors: Friedman Tracey , Slayton William B. , Allen Linda S. , Pollock Brad H. , Dumont-Driscoll Marilyn , Mehta Paulette , Graham-Pole John
Published: August 2004

Objective. To compare the use of alternative therapy (AT) in families of children with cancer with its use in those with routine pediatric conditions.

Background and Rationale. AT refers to healing practices such as therapeutic massage, acupuncture, and use of medicinal herbs that have become increasingly popular with the general public, but are not widely accepted by the medical profession. Although studies have investigated the use of AT in the families of both healthy children and children with cancer, no comparison of the incidence of its use between these two populations has been published. We hypothesized that AT was used more frequently among the families of children with cancer.

Methods. Using a prevalence survey design, we interviewed 81 parents of children with cancer attending a pediatric hematology/oncology clinic and 80 parents of children attending a continuity care clinic for routine check-ups and acute care. We explored the types of AT being used, the reasons for its use, and the frequency with which it was discussed with the patient's physician.

Results. 1) Overall, 65% of the cancer group were using AT, compared with 51% of the control group. This was not statistically significant. 2) Prayer, exercise, and spiritual healing were three AT practices most often used by the cancer group, and prayer, massage, and spiritual healing by the control group. 3) Discussion of AT with the physician varied according to group, with 53% of the cancer patients discussing its use; income level, with 59% of parents in the higher income group discussing its use; and ethnicity, with 47% of whites discussing its use.

Conclusion. Use of AT is not limited to the families of children with life-challenging illnesses, but is commonly used by those of children with routine pediatric problems. Pediatricians need to be aware that their patients may not tell them about AT practices they are using in addition to prescribed treatment.
Vapocoolant Spray Is Equally Effective as EMLA Cream in Reducing Immunization Pain in School-aged Children
Authors: Cohen Reis Evelyn , Holubkov Richard
Published: August 2004

Background. Untreated immunization pain causes undue distress and contributes to underimmunization through physician, and possibly parental, resistance to multiple simultaneous injections.

Objective. To compare the efficacies of two pain management methods in reducing immediate immunization injection pain and distress in school-aged children.

Design. A randomized, controlled clinical trial of eutectic mixture of local anesthetics (EMLA) cream and vapocoolant spray.

Patients. Children aged 4 to 6 years and scheduled to receive diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) during health supervision visits.

Interventions. Enrolled children were randomized to one of three treatment groups: 1) EMLA cream + distraction; 2) vapocoolant spray + distraction; or 3) distraction alone (control). The specific pharmacologic pain control interventions consisted of EMLA cream (2.5% lidocaine, 2.5% prilocaine [Astra Pharmaceutical Products, Inc, Westborough, MA] $15.00/patient; applied 60 minutes before injection) and vapocoolant spray (Fluori-Methane [Gebauer Company, Cleveland, OH] $0.50/patient; applied via spray-saturated cotton ball for 15 seconds immediately before injection).

Main Outcome Measures. The blinded investigator (BI) measured (by edited videotape) cry duration and the number of pain behaviors using the Observational Scale of Behavioral Distress. Pain visual analog scales (linear and faces scales) were completed by the child, parent, nurse, and the BI.

Results. Sixty-two children, aged 4.5 ± 0.4 years (mean ± SD) were randomized. The three treatment groups had similar subject characteristics. All pain measures and cry duration were similar for EMLA and vapocoolant spray. Both EMLA and spray were significantly better than control. Results for spray vs control: cry duration (seconds): 8.5 ± 21.0 vs 38.6 ± 50.5; number of pain behaviors: 1.2 ± 1.9 vs. 3.1 ± 2.1; child-scored faces scale: 2.0 ± 2.4 vs. 4.1 ± 2.3; parent-scored faces scale: 1.6 ± 1.6 vs. 3.0 ± 1.7; nurse-scored faces scale: 1.6 ± 1.2 vs. 3.1 ± 1.4; and BI-scored faces scale: 1.0 ± 1.5 vs. 2.4 ± 1.4.

Conclusions. When combined with distraction, vapocoolant spray significantly reduces immediate injection pain compared with distraction alone, and is equally effective as, less expensive, and faster-acting than EMLA cream. As an effective, inexpensive, and convenient pain control method, vapocoolant spray may help overcome physician and parent resistance to multiple injections that leads to missed opportunities to immunize.
Methylphenidate Versus Dexamphetamine in Children With Attention Deficit Hyperactivity Disorder: A Double-blind, Crossover Trial
Authors: Efron Daryl , Jarman Frederick , Barker Melinda
Published: August 2004

Objective. To compare methylphenidate (MPH) and dexamphetamine (DEX) in a sample of children with attention deficit hyperactivity disorder (ADHD).

Method. A total of 125 children with ADHD received both MPH (0.3 mg/kg twice daily) and DEX (0.15 mg/kg twice daily) for 2 weeks a double-blind, crossover study. Outcome measures were Conners' Parent Rating Scale–Revised, Conners' Teacher Rating Scale–Revised, a Parent Global Perceptions questionnaire, the Continuous Performance Test, and the Barkley Side Effects Rating Scale.

Results. There were significant group mean improvements from baseline score on all measures for both stimulants. On the Conners' Teacher Rating Scale–Revised, response was greater on MPH than DEX on the conduct problems and hyperactivity factors, as well as on the hyperactivity index. On the Conners' Parent Rating Scale–Revised, anxiety was the only factor to differ significantly, in favor of MPH. Parents rated 73% of subjects as globally improved on MPH and 69% improved on DEX, compared with baseline. Overall, 46% of parents chose MPH as the preferred drug, compared with 37% who chose DEX. On the Continuous Performance Test, there was no difference in the number of correct responses or errors between the two drugs.

Conclusions. Most children with ADHD improve significantly on both MPH and DEX. There was a slight advantage to MPH on most measures.
Gonorrhea in Prepubertal Children
Authors:   Committee on Child Abuse and Neglect
Published: August 2004

This Policy Statement was retired January 2005.

This statement updates a 1983 statement on this topic and reminds physicians that sexual abuse should be strongly considered when a gonorrheal infection is diagnosed in a child after the newborn period and before the onset of puberty.
When Should a Child Be in the Hospital?: A. Frederick North, Jr, MD, Revisited
Authors: Dougherty Geoffrey
Published: August 2004

Objectives. My objective was to revisit the issues and approaches raised in a seminal article published in Pediatrics in 1976 by A. Frederick North, Jr, entitled “When Should a Child Be in the Hospital?” Dr North proposed a set of nine criteria to guide the evaluation of appropriateness of admission to hospital. These were based on a core assertion that, “The need to hospitalize a child is dependent on the special services which the child requires rather than upon the diagnosis.” This original work antedated more recent activities and publications in the area of appropriateness evaluation as applied to pediatrics (such as the Pediatric Appropriateness Evaluation Protocol), but is more context-specific than later works in the field.

Methods. A review of the literature concerning temporal trends in hospital use for children in North America was undertaken. This was done to place some of the subsequent observations in a macrocontext of overall trends in hospital use. A review of the English language literature focusing on alternatives to hospitalization and contextual evolution affecting patterns of hospital care for children is presented. Factors influencing each of the nine admission criteria proposed by North are reviewed and discussed in turn.

Results. Overall rates of hospitalization declined by 46% and 41% in the United States and Canada, respectively, during the 1971 to 1993 interval. The relative composition by diagnostic category in two specific pediatric hospital settings also evolved substantially during the 2 decades. Many of North's specific criteria required extensive revision or updating to match the contextual realities of the 1990s.

Conclusions. Although important overall shifts have occurred in the absolute levels and relative composition of pediatric hospitalization, Dr North's core assertion, relating to the need for specific services driving the need for hospitalization, has largely stood the test of time.
Moyamoya Syndrome Associated With Congenital Heart Disease
Authors: Lutterman Joel , Scott Michael , Nass Ruth , Geva Tal
Published: August 2004

Objective. To describe the association between moyamoya syndrome and congenital heart disease and to discuss its clinical implications.

Study Design. Retrospective analysis of a case series from two institutions.

Results. Five patients with moyamoya syndrome and structural congenital heart disease were identified. Coarctation of the aorta was present in 3 patients, in association with a ventricular septal defect (1 patient), aortic and mitral valve stenoses (1 patient), and tetralogy of Fallot (1 patient). Tetralogy of Fallot and a large paramembranous ventricular septal defect were found in the other 2 patients. Four patients underwent surgical repair of their congenital heart disease during the first year of life and 1 patient had balloon dilation of aortic coarctation at 5 years of age. In all patients, moyamoya syndrome was diagnosed after surgical intervention for congenital heart disease—at 6 months of age in 1 patient, at 2 years of age in 3 patients, and at 6 years in 1 patient. Strokes were the most common presenting sign (3 patients) followed by seizures (2 patients). By the age of 33 months, 4 of 5 patients had undergone cerebral revascularization surgery to halt the clinical progression of moyamoya syndrome.

Conclusions. Moyamoya syndrome should be considered in the differential diagnosis of seizures and stroke in patients with structural congenital heart disease. Prompt diagnosis and surgical management of the occlusive cerebral angiopathy should lead to improved neurological outcome in these patients.
Antistreptolysin O and Anti-Deoxyribonuclease B Titers: Normal Values for Children Ages 2 to 12 in the United States
Authors: Kaplan Edward L. , Rothermel Constance D. , Johnson Dwight R.
Published: August 2004

Background. Measurement of antibodies to the extracellular antigens produced by group A streptococci, antistreptolysin O (ASO) and anti-deoxyribonuclease B (anti-DNase B), is often necessary to confirm a clinical diagnosis of a previous group A streptococcal infection, especially in patients suspected of having a nonsuppurative sequel to this infection. Age is among several factors that may influence antibody levels in children. Thus, in contrast to adults, what is considered a normal titer for one age group (infants) is not appropriate for another (older children). Age-related “normal” values for ASO and anti-DNase B are provided in the package inserts of commercially available kits; however, there are no recent comprehensive data to validate such values.

Objective. Using sera from 1131 children (from 23 states) ages 2 to 12 years, we determined age-specific geometric mean titers (GMT) and upper limits of normal (ULN) of ASO and anti-DNase B.

Methods. ASO and anti-DNase B titers were measured by conventional laboratory methods.

Results. Children 7 years of age comprised the largest proportion (14%) of the study population. Approximately two-thirds of the sera were collected during winter and early spring months. For both ASO and anti-DNase B, both GMT values and ULN increased with age. The GMTs for ASO and anti-DNase B for the entire group of subjects were 89 and 112, respectively. The ULN for the entire group for ASO and anti-DNase B were 240 and 640, respectively.

Conclusion. The age-specific values for GMT and ULN for this group of children from 23 states were slightly higher than previously reported. These values are likely representative of the pediatric population in the United States and should be of clinical value to physicians, epidemiologists, and clinical laboratory personnel.
Eight-Year Outcome of Universal Screening and Intrapartum Antibiotics for Maternal Group B Streptococcal Carriers
Authors: Jeffery Heather E. , Moses Lahra Monica
Published: August 2004

Objectives. To report the outcome of intervention to reduce early-onset group B streptococcal disease (EOGBSD) at a tertiary maternity hospital in Sydney and to review all cases of EOGBSD since intervention to improve outcomes further.

Methodology. A prospective study was made of all cases of EOGBSD in the 16 months before and 8 years after an intervention that comprised universal screening and intrapartum ampicillin for all maternal carriers of group B streptococcus. Carriers were detected by screening all women at 28 weeks, or 24 weeks with known risk factors for preterm birth, by low vaginal swab, cultured onto blood agar and treated with intravenous ampicillin in labor, 1 g every 6 hours until delivery. Women with a routine midstream urine test positive for group B streptococcus, a previous neonate with EOGBSD, or preterm labor with an unknown carrier status were also treated. EOGBSD was detected by screening all neonates with maternal and/or neonatal risk factors for sepsis.

Results. The incidence of blood culture-positive EOGBSD for all live births before intervention was 1.4 per 1000 compared with a rate after intervention of 0.2 per 1000 live births. The incidence, if there were clinical signs of infection and the urine tested positive for streptococcal antigen, decreased from 3.5 per 1000 before intervention to 0.6 per 1000 live births. There was a statistically significant reduction in neonatal morbidity outcomes after intervention, including requirement for admission and treatment in a neonatal unit and the need for ventilation. An audit indicated that by the 8th year, 90% of all pregnant women were screened by a low vaginal swab at 28 weeks and 10.5% were carriers. After intervention, of the 28 neonates with EOGBSD, 64% were associated with departure from the protocol.

Conclusion. The intervention has coincided with a significant decrease in the incidence of blood culture-positive EOGBSD to 0.2 and urine streptococcal antigen-positive disease to 0.6 per 1000 live births. The 84% reduction in EOGBSD has been obtained by treating 244 neonates in labor to prevent disease in one neonate. Additional reduction seems possible by improving the compliance by staff with the protocol. By contrast, before intervention and in maternity units throughout Australia with no intervention, the rates for EOGBSD remain largely unchanged at ∼2 per 1000 live births.
Does the Supine Sleeping Position Have Any Adverse Effects on the Child? II. Development in the First 18 Months
Authors: Dewey Claire , Fleming Peter , Golding Jean ,   the ALSPAC Study Team
Published: August 2004

Objective. To assess whether the recommendations that infants sleep supine could have adverse consequences on their motor and mental development.

Design. A prospective study of infants, delivered before, during, and after the Back to Sleep Campaign in the United Kingdom, followed to 18 months of age.

Subjects. The children were participants of the Avon Longitudinal Study of Pregnancy and Childhood born to mothers resident in the three former Bristol-based health districts of Avon, with expected date of delivery from April 1, 1991 to December 31, 1992. Questionnaires were completed on sleeping position at 4 to 6 weeks of age and sets of standardized questions on development at 6 and 18 months.

Main Outcome Measures. Social, communication, fine and gross motor, and total developmental scales based on the Denver Developmental Screening Test at 6 and 18 months.

Results. After adjustment for 27 factors using multiple regression, 3 of the 10 scales and subscales significantly distinguished between front and back sleeping position. At 6 months of age, infants put to sleep on their front had a mean score 0.38 SD (95% confidence interval [CI]: 0.28, 0.49) higher on the gross motor scale, 0.11 SD (95% CI: 0.00, 0.23) higher in the social skills scale, and a total development score 0.20 SD (95% CI: 0.10, 0.30) higher than those on their backs. These differences were no longer apparent at 18 months.

Conclusions. There is some evidence that putting infants to sleep in the supine position results in a reduced developmental score at 6 months of age, but this disadvantage appears to be transient. Weighing this against the adverse health effects demonstrated with the prone sleeping position, these results should not change the message of the Back to Sleep Campaign.
Is the Incidence of Appendicitis Reduced in Patients With Sickle Cell Disease?
Authors: Antal Peter , Gauderer Michael , Koshy Mable , Berman Brian
Published: August 2004

Background. Patients with sickle cell disease (SCD) often present with abdominal pain, usually attributable to vasoocclusion. Experience at a single institution suggested that appendicitis was a rare cause of abdominal symptoms in this population.

Objective. We sought to determine whether the incidence of appendicitis was significantly lower in patients with SCD than in the population at large.

Methods. A 17-year retrospective chart review was performed at Rainbow Babies and Children's Hospital, Cleveland, OH, to determine the approximate incidence of acute appendicitis (AA) in patients with SCD. In addition, we performed a statistical analysis comparing the incidence of AA among SCD patients enrolled in the Cooperative Study of Sickle Cell Disease with that in the general population.

Results. Only two patients with SCD with pathologically confirmed AA were identified among ∼200 patients followed at our institution during a 17-year period (∼3500 patient-years), yielding an incidence rate of 5.7 cases per 10 000 patient-years. Among 3765 patients with SCD enrolled in the Cooperative Study of Sickle Cell Disease followed for a mean of 5.3 years (19 886 patient-years), a maximum of 9 cases of AA were identified, yielding an incidence rate of 4.5 cases per 10 000 patient-years. Based on data from the National Hospital Discharge Survey of 1978 to 1981, the incidence rate of AA in the general population (0 to 44 years of age) is ∼16 per 10 000 patient-years. Paired t test analysis demonstrated a highly significant difference (P < .001) when comparing the incidence of AA among patients enrolled in the Cooperative Study of Sickle Cell Disease and the population at large.

Conclusion. AA is an unusual event in patients with SCD. The likelihood of developing appendicitis in SCD patients is less than one third of that for the population at large. Conservative therapy is warranted in the large majority of patients with SCD who present with acute abdominal pain. Surgical exploration is best limited to patients with clear evidence of potential surgical pathology or progressive findings during a period of observation. The biologic basis of our findings remains unknown.
Reasons For First Teen Pregnancies Predict the Rate of Subsequent Teen Conceptions
Authors: Stevens-Simon Catherine , Kelly Lisa , Singer Dena , Nelligan Donna
Published: August 2004

Objective. To identify reasons for inconsistent contraceptive use that antedate conception and continue to predispose participants in adolescent-oriented maternity programs to unsafe sexual practices after delivery. We hypothesized that teens who attributed their failure to use contraceptives before their first conception exclusively to concerns about their side effects and/or their own lack of motivation to prevent conception would report less consistent contraceptive use and more repeat conceptions than would teens who attributed their previous failure to use contraceptives to their lack of capacity to do so.

Method. We conducted a 2-year, prospective, longitudinal study of contraceptive use and repeat conceptions in a racially/ethnically diverse population of poor 13- to 18-year-olds. The 198 study participants were enrolled consecutively during their first pregnancies from an adolescent-oriented maternity program.

Results. The majority (84%) of the teens attributed their failure to use contraceptives before their first pregnancy partially to a lack of capacity to do so. As hypothesized, these teen mothers were significantly more likely to use hormonal contraceptives (85% vs 62%), (particularly Norplant, 47% vs 19%) and less likely to conceive again (13% vs 41%). Most teens attributed their inconsistent contraceptive use during the postpartum study period to three factors: side effects, plans to abstain from sexual intercourse, and their lack of motivation to postpone additional childbearing.

Conclusions. The reasons teen mothers give for not using contraceptives consistently before their first pregnancies predict the occurrence of subsequent conceptions during adolescence. Those who attribute their previous failure to use contraceptives consistently to side-effect concerns and their own lack of motivation to postpone childbearing are least likely to use hormonal contraceptives after delivery and most likely to conceive again. Our findings suggest that future research should focus on the development of more effective interventions for preventing repeat conceptions among adolescent mothers who had the capacity to prevent their first pregnancies.
Breastfeeding and Later Cognitive and Academic Outcomes
Authors: Horwood L. John , Fergusson David M.
Published: August 2004

Objective. This study examines the associations between duration of breastfeeding and childhood cognitive ability and academic achievement over the period from 8 to 18 years using data collected during the course of an 18-year longitudinal study of a birth cohort of >1000 New Zealand children.

Method. During the period from birth to age 1 year, information was collected on maternal breastfeeding practices. Over the period from 8 to 18 years, sample members were assessed on a range of measures of cognitive and academic outcomes including measures of child intelligence quotient; teacher ratings of school performance; standardized tests of reading comprehension, mathematics, and scholastic ability; pass rates in school leaving examinations; and leaving school without qualifications.

Results. Increasing duration of breastfeeding was associated with consistent and statistically significant increases in 1) intelligence quotient assessed at ages 8 and 9 years; 2) reading comprehension, mathematical ability, and scholastic ability assessed during the period from 10 to 13 years; 3) teacher ratings of reading and mathematics assessed at 8 and 12 years; and 4) higher levels of attainment in school leaving examinations. Children who were breastfed for ≥8 months had mean test scores that were between 0.35 and 0.59 SD units higher than children who were bottle-fed.

Mothers who elected to breastfeed tended to be older; better educated; from upper socioeconomic status families; were in a two-parent family; did not smoke during pregnancy; and experienced above average income and living standards. Additionally, rates of breastfeeding increased with increasing birth weight, and first-born children were more likely to be breastfed.

Regression adjustment for maternal and other factors associated with breastfeeding reduced the associations between breastfeeding and cognitive or educational outcomes. Nonetheless, in 10 of the 12 models, fitted duration of breastfeeding remained a significant predictor of later cognitive or educational outcomes. After adjustment for confounding factors, children who were breastfed for ≥8 months had mean test scores that were between 0.11 and 0.30 SD units higher than those not breastfed.

Conclusions. It is concluded that breastfeeding is associated with small but detectable increases in child cognitive ability and educational achievement. These effects are 1) pervasive, being reflected in a range of measures including standardized tests, teacher ratings, and academic outcomes in high school; and 2) relatively long-lived, extending throughout childhood into young adulthood.
A Randomized Comparative Trial of Stavudine (d4T) Versus Zidovudine (ZDV, AZT) in Children With Human Immunodeficiency Virus Infection
Authors: Kline Mark W. , Van Dyke Russell B. , Lindsey Jane C. , Gwynne Margaret , Culnane Mary , McKinney Ross E. , Nichols Sharon , Mitchell Wendy G. , Yogev Ram , Hutcheon Nancy ,   the AIDS Clinical Trials Group 240 Team
Published: August 2004

Objectives. To compare the safety and tolerance of stavudine (d4T) versus zidovudine (ZDV, AZT) in symptomatic human immunodeficiency virus-infected children 3 months to 6 years of age.

Methods. In an initially double-blind trial, 212 evaluable human immunodeficiency virus-infected children who had received no more than 6 weeks of previous antiretroviral therapy were randomized to receive either d4T (1 mg/kg orally every 12 hours, maximum 40 mg orally every 12 hours) or zidovudine (180 mg/m2 orally every 6 hours, maximum 200 mg orally every 6 hours). The study was unblinded after a median follow-up period of 6.3 months; median follow-up at study closure was 17.3 months. Tolerance, safety, disease progression, and immunologic responses were evaluated.

Results. The patient population was young (median age, 1.2 years; range, 0.3 to 6.4 years), with a median baseline CD4+ lymphocyte count of 965 cells/μL (range, 18 to 4238 cells/μL). Neutropenia <400/μL occurred significantly more commonly among zidovudine recipients (1-year event rates of 20% both up to the time of unblinding and throughout the entire study) than among children receiving d4T (1-year event rates of 5% up to the time of unblinding and 6% throughout the entire study). In exploratory activity analyses using all data collected until study closure, children treated with d4T showed consistently greater positive changes from baseline in weight-for-age-and-gender z scores. As expected in this population of young children, median absolute CD4+ lymphocyte counts decreased in both treatment groups. Smaller changes from baseline were noted among d4T recipients.

Conclusions. In children between the ages of 3 months and 6 years, d4T and zidovudine are largely comparable in terms of safety and tolerance. Neutropenia occurs significantly less commonly among children treated with d4T. There was evidence that weight gain and absolute CD4+ lymphocyte counts were better maintained in children receiving d4T.
Birth Outcome From a Prospective, Matched Study of Prenatal Crack/Cocaine Use: I. Interactive and Dose Effects on Health and Growth
Authors: Eyler Fonda Davis , Behnke Marylou , Conlon Michael , Woods Nanci Stewart , Wobie Kathleen
Published: August 2004

Objective. This prospective, longitudinal project was designed to determine the effects of prenatal cocaine use on the pregnancy outcomes of women from a historically understudied rural public health population.

Methodology. We interviewed over 2500 women prenatally, identified 154 cocaine users, and matched 154 controls on race, parity, socioeconomic status, and location of prenatal care (that related to level of pregnancy risk). Drug testing was required at enrollment and at delivery; detailed demographic, psychosocial, and drug histories were taken at each available trimester and follow-up visit. After birth, neonatal nurse practitioners, blinded to maternal history of drug use, examined infants to assess gestational age and take growth measurements. Medical charts were reviewed and the Hobel Risk Scale was completed.

Results. Compared with controls, the cocaine users had significantly higher Hobel Prenatal and Total Risk Scores and more preterm infants (28 vs 14), but not a significantly greater number of fetal deaths (3 vs 1).

After controlling for the effects of marijuana, alcohol, and tobacco use, the following results remained. There was no difference in gestational age, Ponderal Index, birth weight, or length between infants born to cocaine users and controls. There was a significant interaction effect such that infant head and chest circumference were smaller in cocaine users who also smoked tobacco.

Significant correlation coefficients demonstrated the effects of the amount of drug usage on fetal growth during each trimester of pregnancy. The average cocaine use per day for trimesters one and three and for the entire pregnancy was negatively related to birth length. The mean amounts used in trimesters two and three were negatively related to head circumference. Amounts of tobacco and alcohol use in pregnancy were also inversely related to fetal growth measures. When the effects of marijuana, alcohol, and tobacco were partialed out, there continued to be a negative relationship between the amount of cocaine used in the third trimester and infant length and head circumference.

Conclusions. The observed decrement in fetal growth, especially head circumference, among cocaine-exposed neonates raises concerns about later growth and development. Follow-up of these infants will reveal if these disadvantages continue. These early results also emphasize the importance of considering amount and time of drug exposure as well as the interactive effects of drug exposure and other risk variables.
Reproducibility of 24-Hour Intraesophageal pH Monitoring in Pediatric Patients
Authors: Mahajan Lori , Wyllie Robert , Oliva Luis , Balsells Francisco , Steffen Rita , Kay Marsha
Published: August 2004

Objective. Despite the widespread use of 24-hour intraesophageal pH monitoring for evaluation of gastroesophageal reflux in infants and children, there is little published information regarding the reproducibility of ambulatory pH studies in this patient population. The purpose of our study was to evaluate the reproducibility of 24-hour intraesophageal pH monitoring in pediatric patients.

Methods. We prospectively investigated 26 patients with symptoms suggestive of gastroesophageal reflux (14 females and 12 males) ranging in age from 1 month to 18 years (mean, 9.2 years). The patients underwent extended intraesophageal pH monitoring over two consecutive 24-hour periods.

Results. Data analysis revealed that the overall reproducibility of ambulatory 24-hour pH monitoring is only 69% (r = 0.32). Eight of 26 patients had conflicting results on day 1 compared with results on day 2. Of the 8 patients with conflicting results on day 1 versus day 2, 5 had normal studies on day 1, but demonstrated pathologic reflux on day 2. Thus, the false-negative rate for day 1 was 19.2%. The κ statistic calculated for the total time the pH was abnormal was 0.32, with values <0.4 representing poor correlation. Spearman correlation coefficients indicated that the percentage of time with pH <4 (r = 0.64) and the number of reflux episodes (r = 0.71) per 24-hour period are the most reproducible pH parameters.

Conclusion. The reproducibility of 24-hour intraesophageal pH monitoring in the pediatric population is suboptimal. The investigation should be extended or repeated if the result does not correlate with the patient's clinical history.
Community Characteristics Associated With Elevated Blood Lead Levels in Children
Authors: Lanphear Bruce P. , Byrd Robert S. , Auinger Peggy , Schaffer Stanley J.
Published: August 2004

Objectives. To identify community characteristics associated with children having elevated blood lead levels (≥10 μg/dL) and examine whether these characteristics can be used to identify children with elevated blood lead levels.

Participants and Setting. A total of 20 296 children in Monroe County, New York (<6 years old) who had blood lead testing in the first 12 months after statewide mandated reporting of blood lead tests began.

Design. A logistic regression analysis was conducted to examine the association of children's blood lead levels and community characteristics by using community characteristics of 653 census block groups.

Results. The following community level variables were associated with increased risk of elevated blood lead levels in children: residence within the city [odds ratio (OR), 2.0; 95% confidence interval (CI), 1.6, 2.7]; block groups with a higher proportion of individuals of Black race (OR, 1.6; CI, 1.4, 2.0); higher screening rate (OR, 1.9; CI, 1.6, 2.4); lower housing value (OR, 1.6; CI, 1.2, 2.0); housing built before 1950 (OR, 1.5; CI, 1.3, 1.8); higher population density (OR, 1.5; CI, 1.3, 1.8); higher rates of poverty (OR, 1.4; CI, 1.2, 1.8); lower percent of high school graduates (OR, 1.3; CI, 1.1, 1.6), and lower rates of owner-occupied housing (OR, 1.2; CI, 1.0, 1.4). Community characteristics were comparable with clinic-based individual risk assessment to identify children with elevated blood lead levels.

Conclusions. These data demonstrate that community characteristics can be used to develop screening strategies to identify children who have elevated blood lead levels and shift our efforts toward identifying houses containing lead hazards before occupancy and before children are unduly exposed.
Catecholamine Neurons Alteration in the Brainstem of Sudden Infant Death Syndrome Victims
Authors: Obonai Toshimasa , Yasuhara Masahiro , Nakamura Toshihiko , Takashima Sachio
Published: August 2004

Background. Sudden infant death syndrome (SIDS) is a leading cause of postneonatal infant death. The pathogenesis of sudden death is still unknown, but an abnormality in the central nervous regulation of breathing during sleep has been suggested.

Objective. The aim of study is to confirm the brainstem disorder of SIDS victims. In order to do this, it is necessary to investigate the alterations of brain neurotransmitter systems thought to be involved in respiratory control.

Design. Neuropathologic study performed on the brainstem of SIDS victims.

Subject/Methods. The disorders of catecholaminergic systems in 22 SIDS victims were examined on the substantia nigra in the midbrain, locus coeruleus in the pons, vagal nuclei, and area reticularis superficialis ventrolateralis with the immunohistochemical method. Immunoperoxidase staining was performed with the antityrosine hydroxylase (TH) and the glial fibrillary acidic protein antibodies. Immunoreactivity was compared with 13 age-matched control infants. For statistical analysis, the χ2 test and the Student'st test were performed.

Results. The main finding was diminished TH immunoreactivity in the vagal nuclei and area reticularis superficialis ventrolateralis of SIDS victims, suggesting that adrenaline and noradrenaline neurons are altered in SIDS. In addition, this decrease in TH was closely correlated with brainstem gliosis.

Conclusion. These catecholaminergic changes may be caused by chronic hypoxia or ischemia, and also may underlie alterations in respiratory and cardiovascular control in sleep.
The Role of the Capnography Head-up Tilt Test in the Diagnosis of Syncope in Children and Adolescents
Authors: Naschitz Jochanan E. , Hardoff Daniel , Bystritzki Irena , Yeshurun Daniel , Gaitini Luis , Tamir Ada , Jaffe Michael
Published: August 2004

Objectives. To evaluate the role of the capnography head-up tilt test (CHUTT) in the diagnosis of syncope in pediatric patients.

Methods. The CHUTT is a head-up tilt test with concomitant capnometry. Hyperventilation on CHUTT was diagnosed when the patient's end-tidal carbon dioxide pressure (ETPCO2) was ≤25 mm Hg. Hyperventilation syncope was diagnosed when three criteria were met: loss of consciousness, ETPCO2 ≤25 mm Hg, and no significant drop in blood pressure. The cohort included 65 consecutive children and adolescents (mean age, 14.2 years) who were assessed for syncope by routine investigations and CHUTT.

Results. The cause of the syncope was established in 67% of cases: cardioinhibitory reaction in 17%, vasodepressor in 20%, psychogenic in 22%, and mixed neurally mediated-psychogenic in 8% of the patients. The history indicated a cause of syncope in 40%, the CHUTT in 49%, and a combination of the history and positive CHUTT in 66% of patients. Neither the patients' clinical data nor values of the blood pressure, heart rate, respiratory rate, and ETPCO2 measured during recumbency predicted which patients would manifest hyperventilation or hyperventilation syncope on tilt.

Conclusions. The CHUTT contributes substantially to the diagnosis of syncope in pediatric patients. The CHUTT advances the understanding of the pathophysiological mechanisms of syncope and enables the physician to reassure the patient regarding the essentially benign nature of the condition. Because it is not possible to predict which patients would develop a hyperventilation syncope on the standard tilt test, the modification of this procedure by measuring the ETPCO2 for the assessment of children with syncope should be considered.
Restricting Access to Neonatal Intensive Care: Effect on Mortality and Economic Savings
Authors: Stolz Jeffrey W. , McCormick Marie C.
Published: August 2004

Objective. Neonatal intensive care for very low birth weight (VLBW) infants is expensive, and cost-containment policies have been proposed that would restrict care according to birth weight. We examined the potential reduction in neonatal intensive care unit (NICU) VLBW charges and the impact on survivors if care were not offered to infants of extremely low birth weights or gestational ages.

Design. We reviewed hospital charges for a retrospective cohort of VLBW infants born during the 5-year period from 1988 to 1992. Local charges and survival statistics were applied to national VLBW birth statistics to estimate the national effects of a birth weight-based rationing program.

Setting. A high-risk perinatal referral center.

Patients. A consecutive sample of 1361 VLBW infants was tracked from birth to discharge home, transfer to a level II nursery, or death.

Main Outcome Measures. Hospital charges and survival.

Results. Mean charges per survivor ranged from $250 654 for infants weighing <500 g to $74 101 for those weighing 1000 to 1500 g. Policies denying care to infants born at <500, 600, or 700 g would lead to total NICU care savings of 0.8%, 3.2%, and 10.3%, respectively. Applying the local birth weight-specific survival rates, such policies applied nationally would not have offered care to 136, 575, and 2689 potential survivors annually. Birth weight-based rationing schemes also are shown to increase further the racial disparity of NICU deaths.

Conclusions. To attain significant reduction in NICU charges, policies offering care to the larger or more mature VLBW infants only will result in denying care to many infants who would otherwise survive.
Neuropsychological and Behavioral Changes in Asthmatic Children Treated With Beclomethasone Dipropionate Versus Theophylline
Authors: Bender Bruce G. , Iklé David N. , DuHamel Thomas , Tinkelman David
Published: August 2004

Objective. Results from previous investigations that examined the psychological side effects of theophylline have been inconsistent, and none have reported about inhaled corticosteroids. The objective of this study was to assess the relative psychological side effects of theophylline and beclomethasone in asthmatic children.

Methods. This was a multicenter, randomized, double-blind, parallel-groups study in which 102 asthmatic patients were assigned to one of two treatments: beclomethasone three times daily or theophylline twice daily. At baseline, 1 month, and 1 year, parents completed standardized behavioral questionnaires while the children received psychometric testing of attention and concentration, memory and learning, and problem-solving.

Results. Although power was sufficient to detect meaningful mean score changes, no consistent differential treatment effects were observed. Two significant treatment-by-period interactions were discordant, with one suggesting slightly better attention in the theophylline group, whereas the other indicated a small advantage in attention scores in the beclomethasone group. Numerous significant period effects revealed that behavior and cognitive test performance improved over the 1-year period, regardless of treatment, and confirmed a well established practice effect resulting from repeated administrations of such tests.

Conclusions. Neither theophylline nor beclomethasone should be avoided out of concern for significant psychological side effects. The possibility remains that a subset of asthmatic children may be susceptible to such medication-induced changes; investigators have suggested that preschool children may be at particular risk, although no controlled studies with this age group have been conducted. Parental perceptions of medication side effects can be influenced by temporary effects present at initiation of treatment or by erroneous attribution of the psychological effects of the chronic illness. Reports of psychological changes in response to asthma medications must be addressed respectfully but objectively, with due consideration of available evidence and an awareness of other potential explanations.
Surgical Treatment of Gastroesophageal Reflux in Children: A Combined Hospital Study of 7467 Patients
Authors: Fonkalsrud Eric W. , Ashcraft Keith W. , Coran Arnold G. , Ellis Dick G. , Grosfeld Jay L. , Tunell William P. , Weber Thomas R.
Published: August 2004

Objective. To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States.

Design. During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients.

Results. Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used.

Conclusion. The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.
Childhood Obesity: Future Directions and Research Priorities
Authors: Hill James O. , Trowbridge Frederick L.
Published: August 2004

The threat of obesity is greater than ever for US children and adolescents. All indications are that the current generation of children will grow into the most obese generation of adults in US history. Furthermore, there is every expectation that the next generation of children is likely to be fatter and less fit than the current generation. Despite the recognition of the severe health and psychosocial damage done by childhood obesity, it remains low on the public agenda of important issues facing policy makers. Perhaps this is because the most serious health effects of obesity in today's children will not be seen for several decades. Action must be taken now to stem the epidemic of childhood obesity. This action will require a prioritization of research into the etiology, treatment, and prevention of childhood obesity. It is unlikely that sufficient resources for such research will be available from public and private sources until the issue of childhood obesity is moved higher on the public agenda.