bluuebunny/crossref_metadata_2025 huggingface dataset:
Neonatal Sepsis Workups in Infants ≥2000 Grams at Birth: A Population-Based Study
Authors: Escobar Gabriel J. , Li De-kun , Armstrong Mary Anne , Gardner Marla N. , Folck Bruce F. , Verdi Joan E. , Xiong Blong , Bergen Randy ,   for the Neonatal Infection Study Group
Published: August 2004

Background.

Few data are available on the outcome of neonatal sepsis evaluations in an era when intrapartum antibiotic therapy is common.

Methods.

We identified all newborns weighing ≥2000 g at birth who were ever evaluated for suspected bacterial infection at 6 Kaiser Permanente hospitals between October 1995 and November 1996, reviewed their records and laboratory data, and tracked them to 1 week after discharge. We analyzed the relationship between key predictors and the presence of neonatal bacterial infection.

Results.

Among 18 299 newborns ≥2000 g without major congenital anomalies, 2785 (15.2%) were evaluated for sepsis with a complete blood count and/or blood culture. A total of 62 (2.2%) met criteria for proven, probable, or possible bacterial infection: 22 (.8%) had positive cultures and 40 (1.4%) had clinical evidence of bacterial infection. We tracked all but 10 infants (.4%) to 7 days postdischarge. There were 67 rehospitalizations (2.4%; 2 for group B streptococcus bacteremia). Among 1568 infants who did not receive intrapartum antibiotics, initial asymptomatic status was associated with decreased risk of infection (adjusted odds ratio [AOR]: .26; 95% confidence interval [CI]: .11–.63), while chorioamnionitis (AOR: 2.40; 95% CI: 1.15–5.00), low absolute neutrophil count (AOR: 2.84; 95% CI: 1.50–5.38), and meconium-stained amniotic fluid (AOR: 2.23; 95% CI: 1.18–4.21) were associated with increased risk. Results were similar among 1217 infants who were treated, except that maternal chorioamnionitis was not significantly associated with neonatal infection.

Conclusions.

The risk of bacterial infection in asymptomatic newborns is low. Evidence-based observation and treatment protocols could be defined based on a limited set of predictors: maternal fever, chorioamnionitis, initial neonatal examination, and absolute neutrophil count. Many missed opportunities for treating mothers and infants exist.
Parental Preferences for Primary and Specialty Care Collaboration in the Management of Teenagers With Congenital Heart Disease
Authors: Miller Marlene R. , Forrest Christopher B. , Kan Jean S.
Published: August 2004

Objectives.

We examined parental preferences for locus of service delivery for their teenager's congenital heart disease (CHD) and the influence of disease severity, sociodemographic factors, and insurance on these preferences.

Methods.

A consecutive sample of parents of teenagers followed in a pediatric cardiology clinic completed a mailed questionnaire. Disease severity was classified as low (≤1 cardiovascular procedure), moderate (>1 cardiovascular procedure), and high (cyanosis or single ventricle physiology).

Results.

Eighty-six of 148 parents responded (58%): 40, low severity; 36, moderate severity; and 10, high severity of illness. Parents preferred using primary care providers (PCPs) as a point of first contact for all 11 of 11 general health concerns and 5 of 7 potential cardiovascular-related concerns: chest pain (52%), syncope (73%), seeming seriously ill (79%), sports physical examination (79%), and endocarditis prophylactic antibiotics (94%). Increasing disease severity was significantly associated with preferring cardiologists for 6 of 7 cardiovascular-related concerns. Overall, 58% of parents viewed their care as a PCP–cardiologist comanagement model versus a cardiologist-dominated model. Lower family income (odds ratio [OR]: 1.5; confidence interval [CI]: 1.0–2.2) and severity of illness (OR: 2.1; CI: 1.0–4.4) were associated with a comanagement model of health care versus a cardiologist-dominated model.

Conclusions.

This study suggests that the majority of parents of teenagers with CHD prefer to use their teenager's PCP for all routine health care needs and many cardiovascular health needs. Severity of illness and family income are positively associated with greater preference for cardiologist care.
High-Versus Low-Threshold Surfactant Retreatment For Neonatal Respiratory Distress Syndrome
Authors: Kattwinkel John , Bloom Barry T. , Delmore Paula , Glick Christina , Brown David , Lopez Suzanne , Willett Lynne , Egan Edmund A. , Conaway Mark , Patrie James
Published: August 2004

Surfactant therapy has become an effective standard therapy for infants with respiratory distress syndrome (RDS). The first dose may be given either as prophylaxis immediately after delivery, or as rescue after an infant has developed RDS. Second and subsequent doses are currently recommended by the manufacturers to be administered at minimal levels of respiratory support.

Purpose. This study compared the relative efficacy of administering second and subsequent doses of Infasurf surfactant at a low threshold (Fio2 >30%, still requiring endotracheal intubation) versus a high threshold (Fio2 >40%, mean airway pressure >7 cm H2O) of respiratory support.

Methods. A total of 2484 neonates received a first dose of surfactant; 1267 reached conventional retreatment criteria and were randomized to be retreated according to low- or high-threshold criteria. They were then retreated at a minimum of 6-hour intervals each time they reached their assigned threshold until receiving a maximum of 4 total doses. Subjects were stratified by whether they received their first dose by prophylaxis or rescue and by whether their lung disease was considered complicated (evidence of perinatal compromise or sepsis) or uncomplicated.

Results. Among the patients randomized, 33% of prophylaxis and 23% of rescue subjects met criteria for the complicated stratum. Although infants allocated to the high-threshold strategy were receiving slightly more oxygen at 72 hours, there was no difference in the number receiving mechanical ventilation at 72 hours or in the secondary respiratory outcomes (requirement for supplemental oxygen or mechanical ventilation at 28 days, supplemental oxygen at 36 weeks' postconceptional age, inspired oxygen concentration >60% at any time). However, there was a significantly higher mortality for infants with complicated RDS who had received retreatment according to the high-threshold strategy.

Conclusions. We conclude that equal efficacy can be realized by delaying surfactant retreatment of infants with uncomplicated RDS until they have reached a higher level of respiratory support than is the current standard. We speculate that this would result in a substantial cost-saving from less utilization of drug. Conversely, we believe that infants with complicated RDS should continue to be treated by the low-threshold retreatment strategy, which is currently recommended by the manufacturers of the commercially available surfactants.
Sudden Infant Death Syndrome in Child Care Settings
Authors: Moon Rachel Y. , Patel Kantilal M. , Shaefer Sarah J. McDermott
Published: August 2004

Background.

The incidence of sudden infant death syndrome (SIDS) in the United States has decreased with decreased prone sleeping. Extrapolating from Census Bureau data, ∼7% of SIDS should occur in organized child care settings (ie, child care centers or family child care homes). However, 2 states have reported higher rates of SIDS in child care.

Objectives.

To determine the percentage of SIDS deaths occurring in child care settings, and to ascertain associated factors.

Design.

A retrospective study of SIDS deaths from January 1995 through June 1997 was conducted. Data were abstracted from SIDS databases in 11 states. Characteristics of SIDS cases occurring in child care settings, including sleep position, were compared with those occurring in the care of parents. Univariate and multiple logistic regression analyses were performed.

Results.

A total of 1916 SIDS cases were analyzed for this study. Of these deaths, 20.4% occurred in child care settings. Compared with deaths in the care of parents, those occurring in child care settings were more likely to occur on weekdays between 8:00am and 4:00 pm; infants were older; not black; and their mothers were more educated. Infants in child care were more likely to be found prone in univariate analysis, but the association was not significant in multiple logistic regression analysis. However, in multiple regression analysis, infants in child care were more likely to be last placed prone or found prone, when the usual sleep position was side or supine.

Conclusion.

A large proportion (20.4%) of SIDS cases occur in child care settings. Factors associated with SIDS in child care settings include older age, race, and highly educated parents. Previous studies have reported that unaccustomed prone sleeping puts infants at high risk for SIDS; this characteristic was found to be associated with SIDS in child care and may partly explain the high proportion of SIDS cases in child care settings. Parents must discuss sleep position with any caretakers of their infants. In addition, further efforts to educate child care providers about the importance of supine sleep for infants must be ongoing.
Pediatric Residency Education
Authors: Mulvey Holly J. , Ogle-Jewett Ethan A. B. , Cheng Tina L. , Johnson Robert L.
Published: August 2004

Objective.

On February 1, 1997, new pediatric Residency Review Committee guidelines became effective. Eighteen months later, pediatric residency program directors were queried regarding the implementation of these guidelines. Because both the challenge to implement these guidelines and the opportunities to shape pediatric graduate medical education rest with the program directors, obtaining the feedback and suggestions from this group is seen as the keystone of future planning endeavors.

Methods.

A 20-question multiple-choice/opened-ended questionnaire was sent to the 201 members of the Association of Pediatric Program Directors in 2 mailings in August and September 1998.

Results.

A final response rate of 70% was achieved. Very few program directors reported difficulties in instituting the new residency review committee requirements. The exceptions to this pattern were those requirements pertaining to limitations on time spent in intensive care experience and in the neonatal intensive care unit, wherein 34% of the respondents identified barriers. Although the majority of respondents regarded these requirements as very good or sufficient, some program directors expressed concern regarding insufficient amounts of time available for preparation in intensive care (18%), neonatal intensive care unit (22%), behavioral/developmental pediatrics (16%), and in adolescent medicine (13%). In general, programs have been more successful in defining new competencies than in developing curricula to teach them. The majority of respondents also indicated that their residents' exposure was excellent or satisfactory in all 6 of the following practice settings: private office-based practice for continuity clinic, private office-based practice for outpatient rotation, predominately managed care practice, community clinics for continuity clinic, community clinics for outpatient rotation, and hospital-based practice for continuity clinic. They also indicated that they had no serious concerns about the types of career development assistance offered to residents and the types of follow-up tracking of residents.

Conclusion.

The findings from this survey have reaffirmed the merit of the current system of pediatric residency education. They have also revealed the commitment of program directors to address the complex issues generated by the evolution of health care delivery, and thereby contribute to the optimal provision of pediatric health care now and in the future.
Use of Inhaled Nitric Oxide
Authors:   Committee on Fetus and Newborn
Published: August 2004

Approval of inhaled nitric oxide by the US Food and Drug Administration for hypoxic respiratory failure of the term and near-term newborn provides an important new therapy for this serious condition. This statement addresses the conditions under which inhaled nitric oxide should be administered to the neonate with hypoxic respiratory failure.
Palliative Care for Children
Authors:   Committee on Bioethics and Committee on Hospital Care
Published: August 2004

This statement presents an integrated model for providing palliative care for children living with a life-threatening or terminal condition. Advice on the development of a palliative care plan and on working with parents and children is also provided. Barriers to the provision of effective pediatric palliative care and potential solutions are identified. The American Academy of Pediatrics recommends the development and broad availability of pediatric palliative care services based on child-specific guidelines and standards. Such services will require widely distributed and effective palliative care education of pediatric health care professionals. The Academy offers guidance on responding to requests for hastening death, but does not support the practice of physician-assisted suicide or euthanasia for children.
The Value of First-Day Bilirubin Measurement in Predicting the Development of Significant Hyperbilirubinemia in Healthy Term Newborns
Authors: Alpay Faruk , Sarici S. Ümit , Tosuncuk H. Deniz , Serdar Muhittin A. , Inanç Neriman , Gökçay Erdal
Published: August 2004

Objective.

The recognition, follow-up, and early treatment of neonatal jaundice has become more difficult, since the earlier discharge of newborns from hospitals has become common practice. This prospective study was undertaken to identify the newborns at risk for developing significant hyperbilirubinemia later during the first days of life by measuring the serum bilirubin levels of the first 5 days of life to determine the critical predictive serum bilirubin value on the first day of life.

Methodology.

A total of 498 healthy term newborns were followed with daily serum total bilirubin measurements for the first 5 days of life, and cases with serum bilirubin levels of ≥17 mg/dL after 24 hours of life were defined to have significant hyperbilirubinemia.

Results.

No newborns had a serum total bilirubin level of ≥17 mg/dL in the first 72 hours of life. Sixty of 498 cases (12.05%) had significant hyperbilirubinemia after 72 hours of life, and these cases had significantly higher bilirubin levels than those who did not develop significant hyperbilirubinemia on each of the first 5 days' measurements. Of the 206 newborns who had a serum bilirubin level of ≥6 mg/dL in the first 24 hours, 54 (26.21%) developed significant hyperbilirubinemia, whereas only 6 of the 292 newborns (2.05%) who had a serum bilirubin level of <6 mg/dL on the first day developed significant hyperbilirubinemia. A mean serum bilirubin level of ≥6 mg/dL on the first day had the highest sensitivity (90%). At this critical serum bilirubin value, the negative predictive value was very high (97.9%) and the positive predictive value was fairly low (26.2%). Furthermore, because no cases with a serum bilirubin level of <6 mg/dL in the first 24 hours of life required a subsequent phototherapy treatment and because all of those infants requiring a phototherapy treatment with serum bilirubin levels of ≥20 mg/dL were just among the cases whose first-day bilirubin levels were ≥6 mg/dL, the critical bilirubin level of 6 mg/dL on the first day made it possible, with the highest (100%) sensitivity and negative predictive value, to definitely predict all of the infants who would have a bilirubin level of >20 mg/dL, requiring a phototherapy treatment later during the first days of life.

Conclusions.

A serum bilirubin measurement and the use of the critical bilirubin level of 6 mg/dL in the first 24 hours of life will predict nearly all of the term newborns who will have significant hyperbilirubinemia and will determine all those who will require a phototherapy treatment later during the first days of life.
Depressive Symptoms and Cigarette Smoking Predict Development and Persistence of Sleep Problems in US Adolescents
Authors: Patten Christi A. , Choi Won S. , Gillin J. Christian , Pierce John P.
Published: August 2004

Objective.

To evaluate factors related to the development and persistence of adolescent sleep problems.

Methods.

In this longitudinal, population-based study, the Teenage Attitudes and Practices Survey was administered by telephone to 7960 adolescents (3921 girls and 4039 boys) 12 to 18 years old in 1989 and at follow-up in 1993. Sleep problems at both time points were assessed using a single item on the Teenage Attitudes and Practices Survey. Those who responded that they “often or sometimes” had trouble going to sleep or staying asleep during the past 12 months were categorized as reporting sleep problems, whereas those who responded “often” were categorized as having frequent sleep problems. Multiple logistic regression analyses were used to identify baseline characteristics predictive of the development and persistence of sleep problems or frequent sleep problems, respectively, from baseline to follow-up.

Results.

Of the 4866 adolescents without sleep problems at baseline, 28% developed sleep problems by 1993, and 9% developed frequent sleep problems. Of the 3094 adolescents who reported sleep problems at baseline, 52% reported sleep problems in 1993, and 21% reported frequent sleep problems. Female sex and notable depressive symptoms were associated with the development and persistence of sleep problems and frequent sleep problems at follow-up. Cigarette smoking status showed a dose–response relationship with development of sleep problems and frequent sleep problems, and with persistence of frequent sleep problems at follow-up.

Conclusion.

The reduction of depressive symptoms and cigarette smoking among adolescents are important factors to consider in prevention and treatment efforts focused on adolescent sleep problems.
Chickenpox Attributable to a Vaccine Virus Contracted From a Vaccinee With Zoster
Authors: Brunell Philip Alfred , Argaw Takele
Published: August 2004

Five months after 2 siblings were immunized with varicella vaccine, 1 developed zoster. Two weeks later the second sibling got a mild case of chicken pox. Virus isolated from the latter was found to be vaccine type. Thus, the vaccine strain was transmitted from the vaccinee with zoster to his sibling. Vaccinees who later develop zoster must be considered contagious. varicella-zoster, zoster, vaccine, transmission, rash, PstI.
Immunization Entry at the Point of Service Improves Quality, Saves Time, and Is Well-Accepted
Authors: Adams William G. , Conners William P. , Mann Adriana M. , Palfrey Sean
Published: August 2004

Objective.

Computer-based immunization tracking is a routine part of many pediatric practices; however, data quality is inconsistent and entry often relies on dedicated data entry personnel and is time-consuming, expensive, or difficult. The purpose of this study was to evaluate data quality, nursing satisfaction, and reduction in documentation burden after the introduction of a point-of-service immunization entry system in an inner-city pediatric primary care center.

Design.

Prospective preintervention and postintervention study.

Methods.

Visit records from all pediatric nonurgent care visits for patients <5 years old were collected during a 2-week period before (preintervention) and after (postintervention) the introduction of a computer-based immunization entry system. Nurses used software designed to allow rapid entry during immunization preparation followed by printing 2 adhesive labels for documentation. Satisfaction was evaluated using an 8-question survey administered 3 months after the intervention.

Results.

One hundred forty-seven (63.6%) of 231 preintervention and 132 (51.4%) of 257 postintervention children received at least 1 immunization (immunized) during the study visit. Gender and mean age were similar for immunized children in the 2 groups. In the preintervention group, 56 (37.9%) of 147 immunized children had at least 1 dose missing (a total of 128 of 343 doses administered) from the immunization tracking database compared with none in the postintervention group. Medical record review showed that 92.6% of preintervention and 91.4% of postintervention children were on-schedule after the study visit. However, missing data lead to the misclassification of preintervention children—only 68.4% were reported by the database to be on-schedule. All 9 nurses reported using the program all the time to enter immunizations, 89% said that the program required somewhat or a lot less time, and 100% strongly recommended continued use of the program. All 9 nurses also reported that they would be somewhat or very unenthusiastic about the system if labels were not available. During the 12 months after introduction of the system, 8273 forms containing immunization information were printed, preventing nurses from having to write >101 000 dates.

Conclusions.

Immunization entry by nurses at the time of immunization preparation improves the quality of tracking data, reduces misclassification of immunization needs, saves time, and can be well-accepted. It is likely that poor data quality in some tracking systems has led to falsely low immunization coverage estimates. Systems such as the one in this study can improve quality and should be integrated into routine clinical practice.
Stimulant Treatment in Maryland Public Schools
Authors: Safer Daniel J. , Malever Michael
Published: August 2004

Objective.

A statewide school survey was performed to provide naturalistic data on the prevalence of medication administered to Maryland public school students for the treatment of attention deficit hyperactivity disorder (ADHD) to clarify the concern of some state legislators about stimulant treatment for youths.

Methods.

In April 1998, school nurses supervised a survey of all Maryland public school students medicated during school hours for ADHD. The data collected on these students included: type of medication administered, gender, school level, race/ethnicity, special education and Section 504 status, and the specialist of the prescriber.

Results.

Of the 816 465 students surveyed, 20 050 (2.46%) received methylphenidate and 3721 (0.46%) received other medications for ADHD. Other major findings were: 1) methylphenidate constituted 84% of all the medication administered for ADHD; 2) the male:female ratio of the medication's recipients was 3.5:1 and 4.3:1 in elementary and secondary school, respectively; 3) black and Hispanic students received methylphenidate at approximately half the rate of their white counterparts; 4) 45% of all students receiving methylphenidate had special education status and an additional 8% had Section 504 status; and 5) nurse practitioners were the prescribers of 3% of the methylphenidate prescribed to Maryland students.

Conclusions.

This large, population-based, point prevalence study of medication administered to students for ADHD adds new and updated findings on prevalence variations, rates for minority and special education/Section 504 students, and specialty prescriber rates.
Vitamin A Status and Postnatal Dexamethasone Treatment in Bronchopulmonary Dysplasia
Authors: Shenai Jayant P. , Mellen Beverly G. , Chytil Frank
Published: August 2004

Objective.

Vitamin A (retinol) plays an important role in epithelial regeneration during recovery from lung injury in bronchopulmonary dysplasia (BPD). Dexamethasone is used in the postnatal treatment of very low birth weight (VLBW) neonates with BPD. To test the hypothesis that the vitamin A status is critical for the beneficial pulmonary response to dexamethasone, we performed a prospective cohort study in which we characterized the changes in plasma concentrations of vitamin A and retinol-binding protein (RBP) in response to dexamethasone, and correlated these changes with the pulmonary outcome.

Methods.

VLBW neonates (birth weight <1350 g, gestational age <31 weeks, postnatal age >10 days), who had presumptive diagnosis of severe BPD and need for high ventilatory support (fraction of inspired oxygen ≥.6, mean airway pressure ≥7 cm H2O), were treated with a seven-day course of dexamethasone (.5 mg/kg/d × 2 days, .25 mg/kg/d × 2 days, .1 mg/kg/d × 3 days). Plasma concentrations of vitamin A and RBP were determined sequentially at baseline, and during and after dexamethasone treatment. Pulmonary response to dexamethasone was graded daily using a composite ventilation score. The changes in plasma vitamin A and RBP concentrations were compared between infants with a positive (beneficial) pulmonary response to dexamethasone and those with a negative response.

Results.

Among 23 infants studied, 13 showed a positive pulmonary response to dexamethasone, as indicated by successful weaning from supplemental oxygen and mechanical ventilation, whereas 10 showed a negative response. A significant, yet short-term, increase in plasma concentrations of both vitamin A and RBP was observed in most infants treated with dexamethasone. The plasma vitamin A and RBP responses to dexamethasone tended to be higher in infants with a positive pulmonary response than in those with a negative response. Accounting for gender, a vitamin A response with each 10.0 μg/dL increment in plasma vitamin A concentration was associated with a 60% increase in the odds favoring a positive pulmonary response to dexamethasone.

Conclusion.

Postnatal dexamethasone treatment in VLBW neonates with BPD induces a significant, yet short-term, increase in plasma concentrations of both vitamin A and RBP. This increase probably results from endogenous mobilization of vitamin A from the liver. Our data suggest that the beneficial pulmonary response to dexamethasone in infants with BPD is influenced, at least in part, by the vitamin A status, and that gender plays a role in this response.vitamin A, dexamethasone, bronchopulmonary dysplasia.
Enhanced Growth of Preterm Infants Fed a New Powdered Human Milk Fortifier: A Randomized, Controlled Trial
Authors: Reis Bridget Barrett , Hall Robert T. , Schanler Richard J. , Berseth Carol L. , Chan Gary , Ernst Judith A. , Lemons James , Adamkin David , Baggs Geraldine , O'Connor Deborah
Published: August 2004

Objective.

A prospective, double-blind, randomized, controlled trial was conducted to evaluate the growth and nutritional status of preterm infants receiving preterm human milk supplemented with a newly formulated powdered human milk fortifier (HMF), study fortifier (SF), or a powdered commercial HMF (CF).

Methods.

Infants (n = 144) with a birth weight ≤1600 g and gestational age at birth of ≤33 weeks were enrolled and randomized before 21 days of life. Study day (SDAY) 1 was defined as the day full-strength fortification (4 packets/100 mL) began and the infant reached an intake of at least 100 mL/kg/day. Growth, biochemical indices of nutritional status, enteral intake, feeding tolerance, clinical histories, and morbidity were assessed serially. The primary outcome variable was weight gain (g/kg/day) from SDAYs 1 to 29 or hospital discharge, whichever came first.

Results.

Infants fed human milk supplemented with SF consistently grew more rapidly from SDAYs 1 to 29 (or hospital discharge), regardless of whether the statistical analyses were performed on all subjects who were randomized into the study and reached SDAY 1 (intent-to-treat) or were limited to those able to adhere strictly to the feeding protocol of the study (subgroup). Using mean values adjusted for study site (least square [LS] means), the weight gain differences were 2.6 and 3.8 g/kg/day for the intent-to-treat and subgroup analyses, respectively. Likewise, the length-gain differences were .14 and .18 cm/week for the intent-to-treat and subgroup analyses, respectively. Infants in the SF group reached a weight of 1800 g at SDAY 18, and those in the CF group at SDAY 25. Mean alkaline phosphatase values among infants in the SF group were higher than for the CF infants (eg, LS means: 327 U/L vs 272 U/L, intent-to-treat analysis), likely reflecting the more rapid linear growth of the SF infants. Mean serum calcium values tended to be lower in the SF group in the intent-to-treat analysis and were significantly lower in the subgroup analysis (LS means: 10.3 mg/dL vs 11.2 mg/dL). Both fortifiers were generally well-tolerated, although an increased number of infants in the CF group exited the feeding protocol because of gastric residuals and abdominal distention.

Conclusion.

A new powdered HMF was shown to enhance the growth of preterm infants, compared with a commercially available powdered HMF in the United States.
Professional Liability Coverage for Residents and Fellows
Authors:   Committee on Medical Liability
Published: August 2004

The American Academy of Pediatrics first developed a policy on professional liability coverage for pediatricians-in-training in 1989 and subsequently reaffirmed its basic position with slight modification in 1993. In this latest iteration of the statement, the original positions have been strengthened to address changes in the professional liability insurance industry, the structure and settings of residency training, and mandated reporting to health provider data banks. The new policy emphasizes the need to provide pediatricians in training with adequate professional liability insurance coverage and to educate residents and fellows on the importance of adequate and uninterrupted professional liability coverage—both during and after residency.
Medical Concerns in the Female Athlete
Authors:   Committee on Sports Medicine and Fitness
Published: August 2004

This Clinical Report was revised. See https://doi.org/10.1542/peds.2016-0922.

Female children and adolescents who participate regularly in sports may develop certain medical conditions, including disordered eating, menstrual dysfunction, and decreased bone mineral density. The pediatrician can play an important role in monitoring the health of young female athletes. This revised policy statement provides updated and expanded information for pediatricians on these health concerns as well as recommendations for evaluation, treatment, and ongoing assessments of female athletes.
International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science
Authors:   Contributors and Reviewers for the Neonatal Resuscitation Guidelines
Published: August 2004

The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC.

As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for:

• Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway.

• Preventing heat loss: Hyperthermia should be avoided.

• Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO2 detection can be useful in the secondary confirmation of endotracheal intubation.

• Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse.

• Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01–0.03 mg/kg (0.1–0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available.

• Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate.
Targeted Early Rescue Surfactant in Ventilated Preterm Infants Using the Click Test
Authors: Osborn David A. , Jeffery Heather E. , Bredemeyer Sandie L. , Polverino Jan M. , Reid Shelley
Published: August 2004

Objective.

To determine whether use of the click test, a rapid bedside test of surfactant function, results in earlier and more appropriate surfactant administration in ventilated preterm infants than does usual early rescue treatment.

Study Design.

Ventilated preterm infants (n = 126) with inspired oxygen ≥25% and mean airway pressure ≥7 cm H2O were randomized in gestational strata (<28 weeks and 28–36 weeks) to have surfactant therapy determined by the click test or by usual clinical and chest radiograph criteria. The treatment group had the click test performed on a tracheal aspirate as soon as possible after intubation and, if negative or equivocal (surfactant deficient), surfactant was given. The control group had surfactant given as soon as possible based on clinical and chest radiograph diagnoses of respiratory distress syndrome.

Results.

In infants of <28 weeks' gestation, use of the click test resulted in significantly earlier surfactant therapy (median time: 50 vs 159 minutes) and a reduction in the number of infants receiving surfactant (48% vs 79%). In infants of 28 to 36 weeks' gestation, there was no difference in time to surfactant (median time: 300 vs 268 minutes) or in the number of infants receiving surfactant. Neonatal morbidity and mortality were similar in click test and control groups.

Conclusions.

Use of the click test in ventilated, extremely premature infants results in significantly earlier and more appropriately targeted administration of surfactant than does early rescue therapy based on clinical and radiograph criteria. A randomized trial of targeted early rescue surfactant therapy versus prophylactic surfactant therapy in infants of <28 weeks' gestation is warranted. The click test has the potential to improve clinical outcomes and reduce costs.
Morbid Hypocalcemia Associated With Phosphate Enema in a Six-Week-Old Infant
Authors: Walton Dawn M. , Thomas David C. , Aly Hany Z. , Short Billie L.
Published: August 2004

A 6-week-old premature infant who was born at 29 weeks of gestation presented to the emergency department with a several-hour history of stiffness and increased alarms on his apnea monitor at home. On arrival he was noted to have generalized seizures, apnea, and bradycardia. He was intubated and required cardiopulmonary resuscitation including chest compressions and medications. After stabilization he was transferred to the neonatal intensive care unit for further management. His initial laboratory tests revealed a serum calcium level of 2.4 mg/dL (normal range: 8.4–10.2 mg/dL) and a serum phosphorus level of 28.5 mg/dL (normal range: 2.4–4.5 mg/dL). During the first week of admission, the infant's mother reported that she had administered a full pediatric Fleets enema (CB Fleet Company Inc, Lynchburg, VA) to him. The infant was discharged after 12 days of hospitalization.

Anticipatory guidance on the stool patterns and behavior of infants can prevent misconceptions about constipation that are especially prevalent in new parents. Proper management of constipation, should it arise, should be addressed with all parents at early well-child visits to avoid hazardous complications of treatments. hypocalcemia, seizures, premature infants, enema.
Early Respiratory Infections and Childhood Asthma
Authors: Nafstad Per , Magnus Per , Jaakkola Jouni J. K.
Published: August 2004

Objective.

To assess the role of early respiratory infections in the development of bronchial obstruction in the first 2 years of life, and asthma by the age of 4 years in the Oslo Birth Cohort, established in 1992–1993. Having older siblings and attendance to a day care center were also considered as proxy measures of early infections.

Methods.

A total of 2531 children were followed from birth to 4 years of age. Experiences of respiratory infections were recorded in the follow-up surveys at 6 and 12 months of age, and children with symptoms and signs of bronchial obstruction during the first 2 years of life were identified and examined. The presence of current asthma was recorded when the children were 4 years old.

Results.

Children with respiratory infections during infancy had a higher risk of having bronchial obstruction during the first 2 years of life and of having asthma at 4 years of age. In logistic regression adjusting for confounders including other infections, the risk of asthma at 4 years of age was related to lower respiratory tract infection (odds ratio [OR]: 3.4; 95% confidence interval [CI]: 2.3–7.0), otitis media (OR: 1.8; 95% CI: 1.2–2.6), croup (OR: 2.1; 95% CI: 1.2–3.7) in the first year and related to the common cold (OR: 2.0; 95% CI: 1.3–3.1) in the first 6 months of life. The risk of current asthma was inversely related to older siblings after controlling for early respiratory infections.

Conclusion.

Early respiratory infections indicate increased, rather than decreased, risk of developing bronchial obstruction during the first 2 years of life and of having asthma at 4 years of age.
The EPICure Study: Outcomes to Discharge From Hospital for Infants Born at the Threshold of Viability
Authors: Costeloe Kate , Hennessy Enid , Gibson Alan T. , Marlow Neil , Wilkinson Andrew R. ,   for the EPICure Study Group
Published: August 2004

Objective.

To evaluate the outcome for all infants born before 26 weeks of gestation in the United Kingdom and the Republic of Ireland. This report is of survival and complications up until discharge from hospital.

Methodology.

A prospective observational study of all births between March 1, 1995 and December 31, 1995 from 20 to 25 weeks of gestation.

Results.

A total of 4004 births were recorded, and 811 infants were admitted for intensive care. Overall survival was 39% (n = 314). Male sex, no reported chorioamnionitis, no antenatal steroids, persistent bradycardia at 5 minutes, hypothermia, and high Clinical Risk Index for Babies (CRIB) score were all independently associated with death. Of the survivors, 17% had parenchymal cysts and/or hydrocephalus, 14% received treatment for retinopathy of prematurity (ROP), and 51% needed supplementary oxygen at the expected date of delivery. Failure to administer antenatal steroids and postnatal transfer for intensive care within 24 hours of birth were predictive of major scan abnormality; lower gestation was predictive of severe ROP, while being born to a black mother was protective. Being of lower gestation, male sex, tocolysis, low maternal age, neonatal hypothermia, a high CRIB score, and surfactant therapy were all predictive of oxygen dependency. Intensive care was provided in 137 units, only 8 of which had >5 survivors. There was no difference in survival between institutions when divided into quintiles based on their numbers of extremely preterm births or admissions.

Conclusions.

This study provides outcome data for this geographically defined cohort; survival and neonatal morbidity are consistent with previous data from the United Kingdom and facilitate comparison with other geographically based data.
Decline in Prevalence of Neural Tube Defects in a High-Risk Region of the United States
Authors: Stevenson Roger E. , Allen William P. , Pai G. Shashidhar , Best Robert , Seaver Laurie H. , Dean Jane , Thompson Shirley
Published: August 2004

Objectives.

To conduct surveillance for neural tube defects (NTDs) in a high-risk region of the United States and to prevent occurrence and recurrence of NTDs through the periconceptional use of folic acid supplements.

Design.

Active and passive methods were used for surveillance of NTD-affected pregnancies and births during a 6-year period (October 1992–September 1998). Individual genetic counseling was used to prevent NTD recurrences and a public awareness campaign was used to reduce NTD occurrences.

Setting.

State of South Carolina.

Patients.

All cases of spina bifida, anencephaly, and encephalocele identified among 278 122 live births and fetal deaths to South Carolina residents during 1992–1998 were included.

Main Outcome Measure.

Changes in occurrence and recurrence rates during a 6-year period.

Results.

Over the 6 years of surveillance, the prevalence rates for NTDs decreased from 1.89 to .95 cases per 1000 live births and fetal deaths. The prevalence decrease is explained primarily by a decrease in cases of spina bifida. Isolated NTDs accounted for 297/360 (82%) NTDs and 63/360 (18%) had at least 1 other structural anomaly. Females predominated among isolated NTDs but the sex distribution was equal among NTD cases with other anomalies. Prevalence rates for whites (1.48 cases per 1000 live births and fetal deaths) were higher than rates for blacks (.87 cases per 1000 live births and fetal deaths). There were no NTD recurrences in 113 subsequent pregnancies to mothers of infants with isolated NTDs who took periconceptional folic acid. The rate of periconceptional folic acid use among women of childbearing years increased from 8% to 35% during the 6-year project period.

Conclusion.

The prevalence of NTDs in a high-risk region has declined coincident with the increased periconceptional use of folic acid supplements among women of childbearing age.neural tube defects, high-risk region, birth defects, folic acid, spina bifida, anencephaly, encephalocele.
Prospective Randomized Trial of Early Versus Late Enteral Iron Supplementation in Infants With a Birth Weight of Less Than 1301 Grams
Authors: Franz Axel R. , Mihatsch Walter A. , Sander Silvia , Kron Martina , Pohlandt Frank
Published: August 2004

Objectives.

To examine whether early enteral iron supplementation (EI) would improve serum ferritin as a measure of nutritional iron status at 2 months of age and would prevent definite iron deficiency (ID) in infants with a birth weight of <1301 g.

Methods.

Infants were randomly assigned to receive enteral iron supplementation of 2 to 6 mg/kg/day as soon as enteral feedings of >100 mL/kg/day were tolerated (EI) or at 61 days of life (late enteral iron supplementation [LI]). Nutritional iron status was assessed: 1) at birth, 2) at 61 days of life, 3) when the infants reached a weight of 1.6 times birth weight, and 4) before blood was transfused at a hematocrit of <.25. ID was defined by any one of the following criteria: ferritin, <12 μg/L; transferrin saturation, <17%; or increase of absolute reticulocyte counts by >50% one week after the onset of enteral iron supplementation. Restrictive red cell transfusion guidelines were followed and all transfusions were documented. Erythropoietin was not administered. The primary outcome variables were: 1) ferritin at 61 days and 2) the number of infants with ID.

Results.

Ferritin at 61 days was not different between the groups. Infants in the LI group were more often iron-deficient (26/65 vs 10/68) and received more blood transfusions after day 14 of life. No adverse effects of EI were noted.

Conclusions.

EI is feasible and probably safe in infants with birth weight <1301 g. EI may reduce the incidence of ID and the number of late blood transfusions. ID may occur in very low birth weight infants despite early supplementation with iron and should be considered in the case of progressive anemia. preterm infant, iron supplementation, iron deficiency, blood transfusion.
Large Congenital Melanocytic Nevi and the Risk for Development of Malignant Melanoma and Neurocutaneous Melanocytosis
Authors: Bittencourt Flavia V. , Marghoob Ashfaq A. , Kopf Alfred W. , Koenig Karen L. , Bart Robert S.
Published: August 2004

Objective.

To determine the risk for developing malignant melanoma and neurocutaneous melanocytosis (NCM) in patients with large congenital melanocytic nevi.

Design.

Follow-up data suitable for calculations were available on 160 patients in the New York University Registry of Large Congenital Melanocytic Nevi who had been free of known melanomas or NCM when entered into the Registry. The cumulative 5-year life-table risks for developing melanoma and NCM were calculated. The relative risk for developing melanoma, using a control general population reference group, was determined.

Results.

The 160 patients (median age at entry: 14 months) were followed prospectively for an average of 5.5 years. Three extracutaneous melanomas developed: 2 were in the central nervous system (CNS) and 1 was retroperitoneal. The 5-year cumulative life-table risk for developing melanoma was 2.3% (95% confidence interval [CI]: .8–6.6) and the relative risk was 101 (95% CI: 21–296). No melanoma occurred within a large congenital melanocytic nevus. Four patients developed manifest NCM, 2 with CNS melanomas. The 5-year cumulative life-table risk for developing NCM was 2.5% (95% CI: .8–7.2). Ten patients were excluded from the calculations because of preexisting disease on entry into the Registry: 5 with manifest NCM and 5 with melanomas (3 in large congenital melanocytic nevi, 1 in nonnevus skin, and 1 unknown primary).

Conclusions.

Patients with large congenital melanocytic nevi are at increased risk for developing melanomas. There is also a significant increased risk for developing NCM. The high incidence of CNS involvement may influence decisions concerning treatment of the large congenital melanocytic nevi.