bluuebunny/crossref_metadata_2025 huggingface dataset:
Zinc Supplementation in Infants Born Small for Gestational Age Reduces Mortality: A Prospective, Randomized, Controlled Trial
Authors: Sazawal Sunil , Black Robert E. , Menon Venugopal P. , Dinghra Pratibha , Caulfield Laura E. , Dhingra Usha , Bagati Adeep
Published: August 2004

Background. Low birth weight infants have been noted to have low zinc concentrations in cord blood, and zinc deficiency in childhood is associated with reduced immunocompetence and increased infectious disease morbidity. This study investigates whether zinc supplementation of infants born full term and small for gestational age affects mortality.

Methods. A randomized, double-blind, controlled trial with 2-by-2 factorial design enrolled 1154 full-term small for gestational age infants to receive in syrup 1 of the following: riboflavin; riboflavin and zinc (5 mg as sulfate); riboflavin, calcium, phosphorus, folate, and iron; or riboflavin, zinc, calcium, phosphorus, folate, and iron. A fixed dosage of 5 mL per child was given daily from 30 to 284 days of age. Household visits were made 6 days per week to provide the syrup and conduct surveillance for illness and death. When a child’s death was reported, parental reports and medical records were used to ascertain the cause. The effects of zinc and of the combination of iron, folate, calcium, and phosphorus were analyzed by intent to treat. The mortality analysis was performed using a survival analytic approach that models time until death as the dependent variable; all models had 2 terms as independent variables: 1 for the zinc effect and 1 for the vitamin and mineral (calcium and phosphorus, folate and iron) effect.

Results. Zinc supplementation was associated with significantly lower mortality, with a rate ratio of 0.32 (95% confidence interval: 0.12–0.89). Calcium, phosphorus, folate, and iron supplementation was not associated with a mortality reduction, although a statistically nonsignificant trend toward reduction was observed with a rate ratio of 0.88 (95% confidence interval: 0.36–2.15).

Conclusion. Zinc supplementation in small for gestational age infants can result in a substantial reduction in infectious disease mortality.
Impact of Early Intervention on Outcome After Mild Traumatic Brain Injury in Children
Authors: Ponsford Jennie , Willmott Catherine , Rothwell Andrew , Cameron Peter , Ayton Gary , Nelms Robyn , Curran Carolyn , Ng Kim
Published: August 2004

Objectives. The impact of mild head injury or mild traumatic brain injury (TBI) in children is variable, and determinants of outcome remain poorly understood. There have been no previous attempts to evaluate the impact of interventions to improve outcome. Results of previous intervention studies in adults have been mixed. This study aimed to evaluate the impact of providing information on outcome measured in terms of reported symptoms, cognitive performance, and psychological adjustment in children 3 months after injury.

Methods. A total of 61 children with mild TBI were assessed 1 week and 3 months after injury, and 58 children with mild TBI were assessed 3 months after injury only. They were compared with 2 control groups (N = 45 and 47) of children with minor injuries not involving the head. Participants completed measures of preinjury behavior and psychological adjustment, postconcussion symptoms, and tests of attention, speed of information processing, and memory. Children with mild TBI seen at 1 week were also given an information booklet outlining symptoms associated with mild TBI and suggested coping strategies. Those seen 3 months after injury only did not receive this booklet.

Results. Children with mild TBI reported more symptoms than controls at 1 week but demonstrated no impairment on neuropsychological measures. Initial symptoms had resolved for most children by 3 months after injury, but a small group of children who had previous head injury or a history of learning or behavioral difficulties reported ongoing problems. The group not seen at 1 week and not given the information booklet reported more symptoms overall and was more stressed 3 months after injury.

Conclusions. Providing an information booklet reduces anxiety and thereby lowers the incidence of ongoing problems.
Cardiorespiratory Events in Preterm Infants Referred for Apnea Monitoring Studies
Authors: Di Fiore Juliann M. , Arko Marina K. , Miller Martha J. , Krauss Abby , Betkerur Anupama , Zadell Arlene , Kenney Sarah R. , Martin Richard J.
Published: August 2004

Background. Episodes of apnea, desaturation, and bradycardia are common in preterm infants. Such infants who have persistent cardiorespiratory events detected by clinical bedside monitoring often are referred for overnight apnea monitoring studies.

Objective. To characterize apnea, bradycardia, and desaturation events in infants referred for an overnight apnea monitoring study and compare them with corresponding events in control infants of similar age and weight with no bedside monitor alarms.

Methods. Twelve-hour bedside apnea monitoring studies were performed on 68 preterm infants before hospital discharge. This population included 35 infants who were referred by their attending physicians because of persistent bedside monitor alarms (referral group) and 33 infants who had no documented cardiorespiratory events for at least 2 days before the study (control group). Each study monitored respiration via respiratory inductance plethysmography, oxygen saturation (Sao2), and heart rate. Events were defined as meeting 1 of the following criteria: apnea ≥20 seconds, bradycardia ≤80 beats per minute, or Sao2 ≤80%.

Results. The incidence of apnea ≥20 seconds was low, with no significant difference between infant groups. Referral infants exhibited a higher occurrence of desaturation episodes (20 ± 6 vs 6 ± 3 episodes/12-hour study) and a higher occurrence of bradycardia episodes (4.3 ± 0.8 vs 1.1 ± 0.3 episodes/12-hour study) than controls. These episodes of desaturation and bradycardia were always preceded by a respiratory pause, which was shorter in the referral infants (10.0 ± 0.4 seconds vs 12.0 ± 1.0 seconds). Baseline Sao2 was lower in referrals than controls (95 ± 1% vs 98 ± 1%), and the incidence of periodic breathing was significantly higher.

Conclusions. Infants referred for apnea monitoring studies because of persistent bedside monitor alarms have very infrequent prolonged apnea but a higher frequency of desaturation and bradycardia in response to short respiratory pauses than infants without persistent bedside monitor alarms. Referral infants also exhibit a lower baseline Sao2. These abnormalities in oxygenation and cardiorespiratory control may be markers for subtle residual lung disease or functional central nervous system abnormalities.
Intrauterine Growth of Full-Term Infants: Impact of Prenatal Cocaine Exposure
Authors: Bandstra Emmalee S. , Morrow Connie E. , Anthony James C. , Churchill Shervin S. , Chitwood Dale C. , Steele Bernard W. , Ofir Audrey Y. , Xue Lihua
Published: August 2004

Objective. The objectives of this study were to estimate the effect of prenatal cocaine exposure on fetal growth and gestational age after controlling for exposure to alcohol, tobacco, and marijuana and other covariates; to evaluate whether prenatal cocaine exposure has a disproportionate adverse effect on head circumference compared with overall somatic growth; and to assess whether the effect of prenatal cocaine exposure on fetal growth is mediated by cocaine’s suspected effect on gestational age.

Methods. The study population includes 476 neonates participating in the Miami Prenatal Cocaine Study, a longitudinal follow-up of in utero cocaine exposure. The sample, restricted to full-term neonates born to African-American inner-city mothers, included 253 infants exposed prenatally to cocaine (with or without alcohol, tobacco, or marijuana exposure) and 223 non–cocaine-exposed infants, of whom 147 were drug-free and 76 were exposed to varying combinations of alcohol, tobacco, or marijuana.

Results. Evidence based on structural equations and multiple regression models supports a hypothesis of cocaine-associated fetal growth deficits (0.63 standard deviation) and an independent mild effect on gestational age (0.33 standard deviation). There was no evidence of a disproportionate adverse effect on birth head circumference once the impact on overall growth was estimated. There was evidence that some but not all of the cocaine effect on fetal growth was direct and some was indirect, acting via an intermediate influence of cocaine on gestational age.

Conclusions. Cocaine-associated growth deficits, symmetrical and partially mediated by gestational age, were observed in this sample of inner-city African-American full-term infants prospectively enrolled at birth. Long-term implications will be the subject of future reports from this longitudinal investigation.
Functional Limitations in Young Children With Congenital Heart Defects After Cardiac Surgery
Authors: Limperopoulos Catherine , Majnemer Annette , Shevell Michael I. , Rosenblatt Bernard , Rohlicek Charles , Tchervenkov Christo , Darwish H.Z.
Published: August 2004

With the recent dramatic decline in mortality rates of infants undergoing open-heart surgery (OHS), there is growing concern regarding neurodevelopmental sequelae. Outcome studies have primarily focused on delineating developmental impairments; however, the impact on function and family burden has not been investigated. The objective of this study was to determine the prevalence of functional limitations and burden of care of young children with congenital heart defects (CHD) after OHS.

Study Design. One hundred thirty-one eligible infants with CHD undergoing their first OHS were recruited prospectively. Patients were assessed pre- and postoperatively, and again 12 to 18 months after surgery. Functional assessments included the WeeFIM (Functional Independence Measure) and the Vineland Adaptive Behavior Scale.

Results. For the WeeFIM, mean quotients were 84.3 ± 23.8 (self-care), 77.2 ± 30.0 (mobility), and 92.4 ± 27.8 (cognition), with an overall quotient of 83.8 ± 23.4. Only 21% of the cohort was functioning within their expected age range. Moderate disability was noted in 37%, while only 6% demonstrated a severe disability. For the Vineland scale, mean score for daily living skills was 84.4 ± 17.6, and 80.3 ± 15.9 for socialization. Functional difficulties in daily living skills were documented in 40%, whereas >1/2 had poor socialization skills. Factors enhancing risk for functional disabilities included perioperative neurodevelopmental status, microcephaly, length of deep hypothermic circulatory arrest, length of stay in the intensive care unit, age at surgery, and maternal education.

Conclusions. The high prevalence of functional limitations and dependence in activities of daily living is currently underappreciated in the clinical setting, and deserves additional attention by pediatricians and developmental specialists.
Neurobehavioral Deficits in Premature Graduates of Intensive Care—Potential Medical and Neonatal Environmental Risk Factors
Authors: Perlman Jeffrey M.
Published: August 2004

There is growing evidence that a large number of very low birth weight infants are exhibiting neurobehavioral problems in the absence of cerebral palsy at follow-up that has extended into school age and adolescence. Many clinical factors (ie, chronic lung disease, recurrent apnea and bradycardia, transient hypothyroxemia of prematurity, hyperbilirubinemia, nutritional deficiencies, glucocorticoid exposure), as well as stressful environmental conditions, including infant-provider interaction, constant noise, and bright light, may act in combination to impact on the developing brain, even in the absence of overt hemorrhage and/or ischemia. Any potential intervention strategy designed to prevent cognitive and behavioral problems has to account for the numerous biological and clinical conditions and/or interventions, as well as postdischarge social and environmental influences.
Fatty Acids, Alpha-Fetoprotein, and Cystic Fibrosis
Authors: Mizejewski Gerald J. , Pass Kenneth A.
Published: August 2004

Docosahexaenoic acid, found lacking in animal models of cystic fibrosis, has been proposed as a dietary supplement therapy for this genetic disorder. Alpha-fetoprotein, which binds and transports docosahexaenoic acid, may be a useful marker to improve the management and follow-up in newborn screening programs for cystic fibrosis, because only 20% of such infants are diagnosed at birth.
Newborns With Suspected Occult Spinal Dysraphism: A Cost-Effectiveness Analysis of Diagnostic Strategies
Authors: Medina L. Santiago , Crone Kerry , Kuntz Karen M.
Published: August 2004

Objective. To assess the clinical and economic consequences of different diagnostic strategies in newborns with suspected occult spinal dysraphism.

Methods. A decision-analytic model was constructed to project the cost and health outcomes of magnetic resonance imaging (MRI), ultrasound (US), plain radiographs, and no imaging in newborns with suspected occult spinal dysraphism. Morbidity and mortality rates of early versus late diagnosis of dysraphism and the sensitivity and specificity of MRI, US, and plain radiographs were obtained from the literature. Cost estimates were obtained from a hospital cost accounting database and from the Medicaid fee schedule.

Results. We found that the choice of imaging strategy depends on the underlying risk of occult spinal dysraphism. In low-risk children with intergluteal dimple or newborns of diabetic mothers (pretest probability: 0.3%–0.34%), US was the most effective strategy with an incremental cost-effectiveness ratio of $55 100 per quality-adjusted life year gained. For children with lumbosacral dimples, who have a higher pretest probability of 3.8%, US was less costly and more effective than the other 3 strategies considered. In intermediate-risk newborns with low anorectal malformation (pretest probability: 27%), US was more effective and less costly than radiographs and no imaging. However, MRI was more effective than US at an incremental cost-effectiveness of $1000 per quality-adjusted life year gained. In the high-risk group that included high anorectal malformation, cloacal malformation, and exstrophy (pretest probability: 44%–46%), MRI was actually cost-saving when compared with the other diagnostic strategies. For the intermediate-risk group, we found our analysis to be sensitive to the costs and diagnostic performances (sensitivity and specificity) of MRI and US. Lower MRI cost or greater MRI diagnostic performance improved the cost-effectiveness of the MRI strategy, whereas lower US cost or greater US diagnostic performance worsened the cost-effectiveness of the MRI strategy. Therefore, individual or institutional expertise with a specific diagnostic modality (MRI versus US) may influence the optimal diagnostic strategy.

Conclusion. In newborns with suspected occult dysraphism, appropriate selection of patients and diagnostic strategy may increase quality-adjusted life expectancy and decrease cost of medical work-up.
Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae Infection in Pediatric Private Practice
Authors: Best Dana , Ford Carol A. , Miller William C.
Published: August 2004

Background. Universal screening of sexually active adolescents for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) has been recommended in settings in which prevalence is 2% or greater. Although believed to be above 2%, the prevalence of CT and GC infection in private practice settings has not been clearly established and may affect screening practices.

Objectives. To determine CT and GC infection prevalence in 2 pediatric private practices.

Design. Cross-sectional study.

Setting. Two pediatric private practices in suburban North Carolina.

Patients. Convenience sample of patients aged 15 to 24 years who were seen from August 1998 through June 1999.

Main Outcome Measures. Prevalence of CT and GC infection.

Results. Of 1114 eligible patients, 803 (72%) completed questionnaires and provided urine specimens tested for CT and GC infection using ligase chain reaction assays. Mean age was 17.1 years (standard deviation: 1.8). Most participants were female (63%), white (87%), and from highly educated families (64% of their mothers graduated from college). Sexual activity was reported by 41%. Prevalence of CT infection in all participants was 0.9% (confidence interval [CI]: 0.4%–1.8%); in sexually active participants, 2.1% (CI: 0.9%–4.3%); in sexually active females, 2.7% (CI: 1.0%–5.7%); and in sexually active males, 0.9% (CI: 0.0%–5.1%). One case of GC infection was found.

Conclusions. The prevalence of CT and GC infection in this private practice population was much lower than reported in other settings. Screening recommendations may need to be reassessed if other low prevalence populations are found.
Analysis of the Musculoskeletal System in Children and Adolescents Receiving Anticonvulsant Monotherapy With Valproic Acid or Carbamazepine
Authors: Rieger-Wettengl Gabriele , Tutlewski Bärbel , Stabrey Angelika , Rauch Frank , Herkenrath Peter , Schauseil-Zipf Ulrike , Schoenau Eckhard
Published: August 2004

Objective. To examine bone development in children and adolescents who have uncomplicated idiopathic epilepsy and had received monotherapy with carbamazepine or valproic acid for at least 1 year.

Methods. Thirty-nine patients from 6 to 19 years of age (18 girls) were studied. Total bone mineral content (BMC) and trabecular volumetric bone mineral density were measured at the distal radius using peripheral quantitative computed tomography. Maximum isometric grip force was determined with a standard dynamometer. Alkaline phosphatase activity and deoxypyridinoline (a marker of bone resorption) were assessed in serum and urine, respectively.

Results. Trabecular volumetric bone mineral density was significantly decreased in the entire group (z score mean ± standard deviation: −0.62 ± 1.04) and in the subgroup using valproic acid (−0.75 ± 1.18). In the carbamazepine subgroup, there was a similar but nonsignificant trend (−0.50 ± 0.90). Total BMC and isometric maximum grip force were normal in the entire study population (0.10 ± 1.22) and in the 2 subgroups. The relationship between BMC and grip force was similar between patients and healthy participants. Urinary levels of deoxypyridinoline were significantly elevated above normal in the whole study population (1.35 ± 2.00) and in both the valproic acid and the carbamazepine subgroups.

Conclusion. Bone turnover can be increased, but bone mass is adequate in children and adolescents who have uncomplicated idiopathic epilepsy and who receive monotherapy with carbamazepine or valproic acid.
Predictors of Influenza Virus Vaccination Status in Hospitalized Children
Authors: Poehling Katherine A. , Speroff Theodore , Dittus Robert S. , Griffin Marie R. , Hickson Gerald B. , Edwards Kathryn M.
Published: August 2004

Objective. To determine predictors of influenza virus vaccination status in children who are hospitalized during the influenza season.

Methods. A cross-sectional study was conducted among children who were hospitalized with fever between 6 months and 3 years of age or with respiratory symptoms between 6 months and 18 years of age. The 1999 to 2000 influenza vaccination status of hospitalized children and potential factors that influence decisions to vaccinate were obtained from a questionnaire administered to parents/guardians.

Results. Influenza vaccination rates for hospitalized children with and without high-risk medical conditions were 31% and 14%, respectively. For both groups of children, the vaccination status was strongly influenced by recommendations from physicians. More than 70% of children were vaccinated if a physician had recommended the influenza vaccine, whereas only 3% were vaccinated if a physician had not. Lack of awareness that children can receive the influenza vaccine was a commonly cited reason for nonvaccination.

Conclusions. A minority of hospitalized children with high-risk conditions had received the influenza vaccine. However, parents’ recalling that a clinician had recommended the vaccine had a positive impact on the vaccination status of children.
Terbinafine in the Treatment of Trichophyton Tinea Capitis: A Randomized, Double-Blind, Parallel-Group, Duration-Finding Study
Authors: Friedlander Sheila F. , Aly Raza , Krafchik Bernice , Blumer Jeffrey , Honig Paul , Stewart Daniel , Lucky Anne W. , Gupta Aditya K. , Babel Dennis E. , Abrams Bea , Gourmala Nouciba , Wraith LindaAnn , Paul Carle ,   the Tinea Capitis Study Group
Published: August 2004

Objectives. Terbinafine has been shown to be effective in tinea capitis, using different treatment durations. However, no direct comparison of treatment duration has previously been investigated. This randomized, double-blind, parallel-group, multicenter study was designed to assess the effect of terbinafine treatment duration on the outcome of Trichophyton tinea capitis in a North American population.

Methods. A total of 176 patients with a clinical diagnosis of tinea capitis were enrolled in this study and treated with oral terbinafine (3–6 mg/kg/d) for 1, 2, or 4 weeks. All patients were to be followed until week 12. A total of 159 patients had culture-confirmed tinea capitis attributable to Trichophyton species and constituted the intent-to-treat population used for efficacy analysis (50, 55, and 54 patients in the 1-, 2-, and 4-week arms, respectively).

Results. At the end of study, effective treatment, defined as negative culture and low scores on signs and symptoms, was achieved in 56%, 69%, and 65% of patients who were treated with terbinafine for 1, 2, and 4 weeks, respectively. A negative culture was achieved in 60%, 76%, and 72%, respectively. Overall, the efficacy data showed that both the 2- and 4-week treatment regimens are clinically superior to the 1-week regimen. Terbinafine was well tolerated, and the incidence of adverse events showed no relationship to the duration of therapy.

Conclusion. When efficacy, cost, and compliance are taken into consideration, 2 weeks of terbinafine therapy appears to be the optimal treatment duration for patients with Trichophyton tonsurans tinea capitis.
Trends in Mortality and Morbidity for Very Low Birth Weight Infants, 1991–1999
Authors: Horbar Jeffrey D. , Badger Gary J. , Carpenter Joseph H. , Fanaroff Avroy A. , Kilpatrick Sarah , LaCorte Meena , Phibbs Roderic , Soll Roger F. ,   for the Members of the Vermont Oxford Network
Published: August 2004

Background. Medical care for very low birth weight (VLBW) infants and their mothers has changed dramatically during the 1990s, yet it is unclear how these changes have affected mortality and morbidity.

Objective. We used the Vermont Oxford Network Database to identify trends in clinical practice and patient outcomes for VLBW infants born from 1991 to 1999.

Methods. Logistic regression was used to evaluate temporal trends in practices and outcomes while adjusting for patient characteristics and accounting for clustering of cases within hospitals.

Results. There were 118 448 infants 501 to 1500 g from 362 neonatal intensive care units enrolled in the Network Database from 1991 to 1999. Prenatal care, cesarean section, multiple births, antenatal steroids, and 1-minute Apgar scores increased during this period, as did the use of nasal continuous positive airway pressure, high-frequency ventilation, surfactant, and postnatal steroids. The proportion of white infants decreased; the proportions of Hispanic infants and those of other races increased. The crude and adjusted rates of mortality, pneumothorax, intraventricular hemorrhage (IVH), and severe IVH declined from 1991 to 1995, whereas from 1995 to 1999, the rates of mortality, IVH, and severe IVH did not change significantly, and pneumothorax increased.

Conclusions. There have been major changes in both obstetric and neonatal care during the 1990s. These changes were associated with decreases in mortality and morbidity for VLBW infants during the first half of the decade. However, since 1995, no additional improvements in mortality or morbidity have been seen, ending a decades-long trend of improving outcomes for these infants.
Helping Children and Families Deal With Divorce and Separation
Authors: Cohen George J. ,   Committee on Psychosocial Aspects of Child and Family Health
Published: August 2004

More than 1 million children each year experience their parents’ divorce. For these children and their parents, this process can be emotionally traumatic from the beginning of parental disagreement and rancor, through the divorce, and often for many years thereafter. Pediatricians are encouraged to be aware of behavioral changes in their patients that might be signals of family dysfunction so they can help parents and children understand and deal more positively with the issue. Age-appropriate explanation and counseling is important so children realize that they are not the cause of, and cannot be the cure for, the divorce. Pediatricians can offer families guidance in dealing with their children through the troubled time as well as appropriate lists of reading material and, if indicated, can refer them to professionals with expertise in the emotional, social, and legal aspects of divorce and its aftermath.
Voluntary Anonymous Reporting of Medical Errors for Neonatal Intensive Care
Authors: Suresh Gautham , Horbar Jeffrey D. , Plsek Paul , Gray James , Edwards William H. , Shiono Patricia H. , Ursprung Robert , Nickerson Julianne , Lucey Jerold F. , Goldmann Donald ,   for the NICQ2000 and NICQ2002 investigators of the Vermont Oxford Network
Published: August 2004

Objectives. Medical errors cause significant morbidity and mortality in hospitalized patients. Specialty-based, voluntary reporting of medical errors by health care providers is an important strategy that may enhance patient safety. We developed a voluntary, anonymous, Internet-based reporting system for medical errors in neonatal intensive care, evaluated its feasibility, and identified errors that affect high-risk neonates and their families.

Methods. Health professionals (n = 739) from 54 hospitals in the Vermont Oxford Network received access to a secure Internet site for anonymous reporting of errors, near-miss errors, and adverse events. Reports used free-text entry in phase 1 (17 months) and a structured form in phase 2 (10 months). The number and types of reported events and factors that contributed to the events were measured.

Results. Of 1230 reports—522 in phase 1 (17 months) and 708 in phase 2 (10 months)—the most frequent event categories were wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products; 47%); error in administration or method of using a treatment (14%); patient misidentification (11%); other system failure (9%); error or delay in diagnosis (7%); and error in the performance of an operation, procedure, or test (4%). The most frequent contributory factors were failure to follow policy or protocol (47%), inattention (27%), communications problem (22%), error in charting or documentation (13%), distraction (12%), inexperience (10%), labeling error (10%), and poor teamwork (9%). In 24 reports, family members assisted in discovery, contributed to the cause, or themselves were victims of the error. Serious patient harm was reported in 2% and minor harm in 25% of phase 2 events.

Conclusions. Specialty-based, voluntary, anonymous Internet reporting by health care professionals identified a broad range of medical errors in neonatal intensive care and promoted multidisciplinary collaborative learning. Similar specialty-based systems have the potential to enhance patient safety in a variety of clinical settings.
Considerations Related to the Use of Recombinant Human Growth Hormone in Children
Authors:   Committee on Drugs and Committee on Bioethics
Published: August 2004

Since 1985 molecular biology techniques have made possible the synthetic synthesis of pure human growth hormone in potentially unlimited amounts. With this increased availability, its use in patients other than children with growth hormone deficiency has been associated with clinical and ethical questions. This statement presents an analysis of the current status of the use of human growth hormone in children.
The Pediatrician's Role in Disaster Preparedness
Authors:   Committee on Pediatric Emergency Medicine
Published: August 2004

This statement provides pediatricians with an overall view of disasters and disaster management and delineates the role of the pediatrician in disaster preparedness.
Comparison of Ceftriaxone and Trimethoprim-Sulfamethoxazole for Acute Otitis Media
Authors: Barnett Elizabeth D. , Teele David W. , Klein Jerome O. , Cabral Howard J. , Kharasch Sigmund J. ,   the Greater Boston Otitis Media Study Group
Published: August 2004

Objective. The purpose of this prospective, randomized, single-blind trial was to assess the clinical efficacy of a single intramuscular dose of ceftriaxone compared with 10 days of oral trimethoprim-sulfamethoxazole (TMP-SMZ) in treating acute otitis media (AOM).

Methods. Children aged 3 months through 3 years diagnosed with AOM (signs of acute illness plus evidence of middle-ear effusion) were randomized to treatment with either a single intramuscular dose of ceftriaxone (maximum dose of 50 mg/kg) or 10 days of oral trimethoprim-sulfamethoxazole (8 mg of TMP and 40 mg of SMZ/kg/day in two divided doses). Children were evaluated at scheduled visits on days 3, 14, and 28, and the parents were telephoned on day 5. Children were assessed as cured, improved, or failed on day 3, and as cured or failed on days 14 and 28. Children ill at other times during the study period were, if possible, seen and assessed by the study team.

Results. Of 596 children enrolled during the study period, 484 were evaluable. Characteristics of evaluable subjects did not differ significantly by drug. On day 3, 223/241 children in the ceftriaxone group (92.5%) and 231/243 (95.1%) in the TMP-SMZ group were cured or improved. On day 14, 158/197 (80.2%) in the ceftriaxone group and 174/212 (82.1%) in the TMP-SMZ group were cured. On day 28, 108/136 (79.4%) in the ceftriaxone group and 124/155 (80%) in the TMP-SMZ group were cured. Persistence of middle-ear fluid did not differ between groups at day 14 (55% in the ceftriaxone group vs 47% in the TMP-SMZ group; P = .16) or at day 28 (39% vs 43%; P = .48). Pain at the injection site persisting at day 3 occurred in 8.4% of children receiving ceftriaxone. New diarrhea was more common in the ceftriaxone group (23.6% vs 9.2%;P < .001).

Conclusion. A single intramuscular dose of ceftriaxone is comparable in clinical efficacy to 10 days of oral TMP-SMZ for treatment of AOM.
Delayed Puberty in Girls With Cystic Fibrosis Despite Good Clinical Status
Authors: Johannesson Marie , Gottlieb Claes , Hjelte Lena
Published: August 2004

Background. Previous studies have shown that puberty is delayed among patients with cystic fibrosis (CF). Malnutrition has been considered the main etiologic factor. Today with improved medical therapy and nutritional support, most CF patients obtain an almost normal nutritional status.

Objectives. To investigate whether pubertal development among female CF patients at the Stockholm CF Center was normal and, if not, what other parameters besides nutrition might influence this.

Methods. Seventeen patients were studied retrospectively regarding age at peak height velocity and menarche. Menarcheal age (MA) was compared with normal population data and related to clinical and nutritional status, genotype, oral glucose tolerance test (OGTT), and essential fatty acid levels.

Results. The mean age at peak height velocity (12.9 ± 0.8 years) and at menarche (14.9 ± 1.4 years) was significantly higher in the CF patients compared with normal controls (11.9 ± 1.0 years and 13.0 ± 1.0 years, respectively). No correlation was found between menarchal age and nutritional or clinical parameters. The patients with pathological OGTT without overt diabetes were significantly older at menarche (15.8 ± 1.7 years) compared with the patients with normal OGTT (14.3 ± 0.9 years). The patients who were homozygous for the most common mutation, deltaF508, were significantly older at menarche (15.2 ± 1.9 years) than those who were not (14.7 ± 0.9 years).

Conclusions. Pubertal delay still existed among the CF patients despite good clinical status. The patients homozygous for deltaF508 and those with pathological OGTT showed the most delayed puberty.
Pulmonary Effect of Inhaled Furosemide in Ventilated Infants With Severe Bronchopulmonary Dysplasia
Authors: Kugelman Amir , Durand Manuel , Garg Meena
Published: August 2004

Background. When administered parenterally, furosemide, a loop diuretic, results in improved lung compliance and decreased airway resistance in infants with bronchopulmonary dysplasia (BPD). However, furosemide-induced diuresis results in hypokalemia, chloride deficiency, hypercalciuria, nephrocalcinosis, and rickets. In patients with asthma, inhaled furosemide has recently been demonstrated to inhibit the bronchoconstrictive effects of exercise, cold air hyperventilation, and antigen challenge. We hypothesized that inhaled furosemide will result in improved pulmonary mechanics in ventilated infants with BPD and will prevent the systemic complications of parenteral furosemide.

Objective. To determine the efficacy and safety of a single dose of inhaled furosemide on pulmonary mechanics in infants with severe BPD who are ventilator dependent at 21 days of age.

Design and Methods. A randomized, double-blind, crossover study was performed on 9 infants with BPD, each serving as his own control. Each patient was randomized to receive an aerosol dose of furosemide (1 mg/kg in 2 mL of saline) or placebo (2 mL of saline) on the first day of the study and the other agent the following day of the study. Pulmonary mechanics were measured before and 1 and 2 hours after the inhalation using the Pulmonary Evaluation and Diagnostics System.

Results. Gestational age (mean ± SEM) was 29 ± 1 weeks; birth weight was 1.1 ± 0.1 kg; age at study was 47 ± 6 days; and weight at study was 1.8 ± 0.2 kg. There was no significant change in the pulmonary function measurements before treatment and 1 or 2 hours after treatment with either placebo or furosemide. Baseline and 2-hour values were: dynamic compliance (mL/cm H2O per kilogram): 0.46 ± .03 to 0.50 ± .03 (placebo) and 0.50 ± 0.02 to 0.51 ± 0.02 (furosemide); dynamic resistance (cm H2O/L per second): 118 ± 9 to 106 ± 7 (placebo) and 111 ± 8 to 105 ± 7 (furosemide); and tidal volume (mL/kg): 8.6 ± 0.5 to 8.9 ± 0.5 (placebo) and 8.9 ± 0.2 to 9.4 ± 0.3 (furosemide).

Conclusion. We conclude that, under the conditions of our study, a single dose of 1 mg/kg inhaled furosemide does not improve the pulmonary mechanics in ventilator-dependent infants with severe BPD.
Analgesia for Dying Infants Whose Life Support Is Withdrawn or Withheld
Authors: Partridge John Colin , Wall Stephen N.
Published: August 2004

Objective. To determine the frequency of opiate analgesia administration to infants when life support is discontinued and to determine whether infant characteristics, such as birth weight and diagnosis, or the physician's reasons for discontinuing life support influence either the decision to provide opioid agents or the dosages administered.

Methods. We reviewed all 165 deaths in a 3-year period at a university-based level III intensive care nursery. Of the 121 deaths attributable to withdrawal or withholding of mechanical ventilation and/or extracorporeal membrane oxygenation, we ascertained whether opioid analgesics (morphine sulfate [MS] or fentanyl) were administered either concurrent with or after life-support withdrawal and at what doses. We examined whether these end-of-life practices varied according to birth weight, diagnoses, and the reasons documented by the neonatologist for discontinuing life support.

Results. Opioid analgesia was provided to 84% of infants as their life support was either withheld or withdrawn. Infants with necrotizing enterocolitis and major anomalies or chromosomal disorders were more likely to be given opiates than infants with other diagnoses. Birth weight was not different for infants who received opiates compared with those who were not given opiates. Opioid analgesia was provided to all 18 infants for whom physicians documented the patients' suffering as a reason to discontinue life support. Sixty-four percent of infants who received opiates were given doses in the usual pharmacologic range of 0.1 to 0.2 mg/kg MS. Of the 36 infants given more than 0.2 mg/kg MS, all but 2 were receiving ongoing treatment with opioid agents.

Conclusions. In most cases of withholding or withdrawal of life support in critically ill infants, neonatologists provided opioid analgesia to these infants at the end of life, despite the potential respiratory depression of opioid agents in infants whose respiratory support is discontinued.
Reduction of Respiratory Syncytial Virus Hospitalization Among Premature Infants and Infants With Bronchopulmonary Dysplasia Using Respiratory Syncytial Virus Immune Globulin Prophylaxis
Authors:   The PREVENT Study Group
Published: August 2004

Objective. To determine the safety and efficacy of monthly prophylaxis with respiratory syncytial virus immune globulin, intravenous (RSV-IGIV) for reduction of the incidence of RSV-associated hospitalization.

Methods. A randomized, double-blind, placebo-controlled clinical trial was conducted at 54 centers in the United States during the 1994 to 1995 RSV season. A total of 510 children with bronchopulmonary dysplasia and/or a history of prematurity were randomized to receive either 750 mg/kg RSV-IGIV (n = 250) or placebo (1% albumin; n = 260) intravenously every 30 days. Randomized groups were well balanced at entry for demographics, RSV risk factors, and birth characteristics. Children were monitored for adverse events and for RSV-associated hospitalization from randomization through 30 days after the last infusion visit; serious adverse events were monitored for an additional 30 days. For children hospitalized with RSV, data were collected regarding the total days of RSV stay, total days of increased oxygen requirement, total days with a moderate or severe lower respiratory tract illness, and frequency and duration of intensive care unit stay and mechanical ventilation. Ninety-five percent of participants completed the protocol and 85% received a complete course of infusions.

Results. The incidence of RSV hospitalization was reduced by 41% in children receiving RSV-IGIV prophylaxis; 35 (13.5%) of the children in the placebo group were hospitalized for RSV, compared with 20 (8.0%) RSV-IGIV recipients. RSV-IGIV recipients had a 53% reduction in the total number of RSV hospital days per 100 children, a 60% reduction in the number of RSV days with increased oxygen requirement, and a 54% reduction in the number of RSV hospital days with a moderate or severe lower respiratory tract illness. In addition, children receiving RSV-IGIV had a 38% reduction in hospitalization for respiratory illness of any cause and a 46% reduction in total hospital days for respiratory illness per 100 children. RSV-IGIV was safe and well tolerated, with a safety profile similar to other IGIV preparations. Between 1% to 3% of children had medically significant adverse events related to RSV-IGIV administration.

Conclusions. Monthly administration of 750 mg/kg of RSV-IGIV was safe and well tolerated and was effective in reducing the incidence and total days of both RSV hospitalization and overall respiratory hospitalization in infants with a history of prematurity or bronchopulmonary dysplasia or both.
Determinants of Parental Authorization for Involvement of Newborn Infants in Clinical Trials
Authors: Zupancic John A. F. , Gillie Pat , Streiner David L. , Watts John L. , Schmidt Barbara
Published: August 2004

Objective. Parents have the right to decide on behalf of their infants whether to enroll them in controlled clinical trials. We determined the degree to which such parental decisions are influenced by risk and benefit considerations compared with other factors.

Design. Cross-sectional survey.

Participants. Parents who had recently given or declined consent to one of three controlled trials in the neonatal intensive care unit.

Intervention. Parents were asked to complete a questionnaire that consisted of 15 sociodemographic items and 13 scaled responses to statements assessing the probability and magnitude of risk and benefit as well as perceived illness severity, attitudes toward research, and the consent process.

Analysis. Responses were subjected to factor analysis to identify underlying constructs. The sample was then randomly split, and multiple regression was performed on each half.

Results. The response rate was 83% (103 of 124) for those who had consented and 86% (37 of 43) for those who had declined. Factor analysis yielded three factors: (1) illness severity, (2) perceptions of risk or benefit and attitudes to research, and (3) sociodemographic characteristics. Multiple linear regression showed a significant multiple correlation of consent decision (r = .502), but only the second factor contributed. The analyses on split halves of the sample were comparable. Thirty-two percent of all parents agreed with the statement, “I would prefer to have the doctors advise me whether my baby should be in the study, rather than asking me to decide.”

Conclusions. In making consent decisions on behalf of their newborn infants, parents are influenced by risk and benefit assessments, attitudes toward research, and the integrity of the consent process. Illness severity or sociodemographic characteristics do not seem to be of similar importance. Rather than making the decision alone, a significant minority of parents would prefer to have the physicians advise them whether to volunteer their infants for a clinical trial. medical ethics, informed consent, newborn infant, clinical trial.
Anaphylaxis in Children: A 5-Year Experience
Authors: Dibs Susan D. , Baker M. Douglas
Published: August 2004

Objectives. To identify the causative agents, presenting signs and symptoms, and course of disease in children diagnosed with anaphylaxis.

Design. Five-year retrospective chart review.

Setting. Urban children’s hospital pediatric emergency department, operating suite, and inpatient units.

Participants. Fifty-five cases of anaphylaxis in 50 patients 1 to 19 years of age.

Interventions. None.

Results. The most common inciting agents in this population were latex (27%), food (25%), drugs (16%), and venoms (15%). Thirty-two cases (58%) occurred outside of the hospital, including 3 of 11 severe cases. Nineteen (35%) had histories of prior allergy to the causative agent. Most agent exposures were intravenous (38%), oral (27%), or dermal (20%). The most common systems involved were respiratory (93%), skin (93%), cardiovascular (26%), and neurologic (26%). Features distinguishing the 11 patients requiring intensive care included latex agents (45%), nonenteral route of exposure (91%), and presence of cardiovascular symptoms (45%). Of the 17 patients with known past anaphylaxis, only 5 had epinephrine self-administration devices available, and 3 had used them.

Conclusions. (1) Most patients with anaphylaxis present with skin or respiratory symptoms. (2) Severely ill children more commonly have nonenteral and/or latex exposures that occur in the hospital. (3) Most children with anaphylaxis have no stated histories of prior reaction to the causative agent. (4) Those patients who have had past episodes of anaphylaxis infrequently have epinephrine self-administration devices available for use. anaphylaxis, allergy, latex.
Comparison of Inpatient Charges Between Academic and Nonacademic Services in a Children's Hospital
Authors: Wall Terry C. , Fargason Crayton A. , Johnson Victoria A.
Published: August 2004

Objective. To compare inpatient hospital charges generated within a children's hospital by academic and nonacademic pediatric services for common medical diagnoses.

Methods. Hospital admissions to a free-standing children's hospital between 9/1/90 and 8/30/94 were selected for patients who were hospitalized 1 to 14 days, with one of six selected diagnoses, and with discharge attending of record either a private pediatrician or an academic subspecialist. Discharge diagnoses, based on ICD-9 codes, included asthma (n = 1983), bronchiolitis (n = 692), gastroenteritis (n = 733), rule out sepsis (n = 1065), urinary tract infection (n = 516), and viral meningitis (n = 288). Charges associated with patient records were dichotomized as above or below the median charge for each diagnostic category. Each category was analyzed separately using a logistic regression model where the dichotomous-dependent variable was charges above the median charge for each diagnosis. Independent variables included physician type, payor status, patient residence, ICD-9 code as primary or secondary diagnosis, patient age, and presence of complicating conditions.

Results. By univariate comparison, academic physicians cared for a higher percentage of underinsured patients, and their care was more expensive. Complicated claims were associated with higher charges than uncomplicated claims for all diagnostic categories. Academic and nonacademic physicians were equally likely to generate above-median charges for five of the six diagnostic categories when controlling for confounding factors. A linear regression model in which charge was the dependent variable generated similar results.

Conclusions. Within the same pediatric health care facility, no consistent difference was found between charges incurred on academic vs private inpatient services.
How Fetal Cocaine Exposure Increases Neonatal Hospital Costs
Authors: Behnke Marylou , Eyler Fonda Davis , Conlon Michael , Casanova Olga Quiros , Woods Nanci Stewart
Published: August 2004

Objective. Our goals were to document hospital costs associated with prenatal cocaine exposure in an understudied population—women using rural county public health units who had minimal access to drug rehabilitation and whose cocaine of choice was crack with little other illicit drug use—and to explore why increased costs occur in an effort to identify cost-reduction strategies.

Methods. We identified a sample of cocaine-exposed infants who were computer-matched to a control group with no history or evidence of cocaine exposure. Matching was performed one-to-one on the variables of maternal race, age, parity, time of entry into prenatal care, and alcohol and nicotine use. There were 327 live births, for whom 311 were correctly classified as to their prenatal cocaine use and had billing and medical records available for review (156 exposed, 155 nonexposed).

Results. Hospital charges were positively correlated with length of stay. Cocaine-exposed infants had an across-the-board increase in utilization of hospital resources as well as higher hospital charges and longer lengths of stay. Cocaine-exposed infants were significantly younger in gestational age and lower in birth weight. Significantly more cocaine-exposed infants were admitted to the neonatal intensive care unit, had more social and family problems delaying discharge, and received more septic work-ups. In addition, of those infants urine-screened for cocaine at delivery, 92% were screened secondary to a maternal history of prenatal use.

Conclusions. Cost-reduction strategies should be aimed at measures that reduce length of stay by addressing problems identified prenatally as an outpatient before delivery and by influencing objective decision-making regarding the need for medical interventions with the infant after birth.