bluuebunny/crossref_metadata_2025 huggingface dataset:
Health Care Utilization and Health Status in High-risk Children Randomized to Receive Group or Individual Well Child Care
Authors: Taylor James A. , Davis Robert L. , Kemper Kathi J.
Published: August 2004

Objective. To determine if health care utilization and health status among high-risk children is modified by the use of group well child care (GWCC) as compared with traditional one-to-one individual well child care (IWCC).

Study Design. Randomized controlled trial.

Participants. Children less than 4 months old from families with at least one of the following maternal risk factors: poverty, single marital status, age <20 years at delivery, less than a high school education, previous substance abuse, or history of abuse as a child.

Setting. Two urban, university pediatric clinics in Seattle, Washington.

Interventions. Children were randomized to receive GWCC or IWCC at the time of enrollment. Health supervision visits with two study nurse practitioners were scheduled at 4, 5, 6, 8, 10, 12, and 15 months of age. GWCC study visits consisted of a group discussion of age-appropriate child-rearing issues, along with a physical examination, health screening, and immunizations. Health care utilization among children receiving GWCC and those randomized to IWCC was assessed using the following measures: compliance with study visits, compliance with any age-appropriate health supervision visit, emergency department utilization, and immunization rates (defined as the proportion of children in each group who had received all recommended vaccines by 1 year of age). Provider time for GWCC and IWCC study visits was also recorded. Health status was measured using Stein's Functional Status IIR, completed by the mothers of study patients when their children completed the study at 15 months of age.

Results. A total of 106 children received GWCC, whereas 104 were randomized to IWCC. Compliance with scheduled study visits was 47% for GWCC patients and 54% for IWCC recipients; overall compliance with any age-appropriate health supervision visit was 68% and 66%, respectively. Provider time was similar for GWCC and IWCC visits. By the age of 1 year, 67% of GWCC recipients and 73% of those receiving IWCC had received three DTP/DT, three OPV/IPV, three Hib, and three hepatitis B immunizations. A total of 242 emergency department visits were made by study patients during their enrollment in the project; there was no difference in the average number of visits between GWCC or IWCC children. However, children receiving IWCC were more likely to have at least one emergency department visit than GWCC recipients. At the conclusion of the project, health status, as measured by the Functional Status IIR, was similar in GWCC and IWCC patients (mean scores 92.4 ± 1.4 and 92.5 ± 1.1, respectively).

Conclusions. Health care utilization and health status was similar in high-risk children whether they received GWCC or IWCC. GWCC is a viable format for health supervision visits in this population.
A Missense Cystic Fibrosis Transmembrane Conductance Regulator Mutation With Variable Phenotype
Authors: Kerem Eitan , Nissim-Rafinia Malka , Argaman Zvi , Augarten Arie , Bentur Lea , Klar Aharon , Yahav Yaacov , Szeinberg Amir , Hiba Ornit , Branski David , Corey Mary , Kerem Batsheva
Published: August 2004

Objective. Cystic fibrosis (CF) has variable clinical presentation. Disease severity is partially associated with the type of mutation. The aim of this study was to report genotype-phenotype analysis of the G85E mutation.

Patients. The phenotype of 12 patients (8 were from the same extended family, and 5 of them were siblings from 2 families) carrying at least one copy of the G85E mutation was evaluated and compared with the phenotype of 40 patients carrying the two severe mutations, W1282X and/or ΔF508 (group 1), and with 20 patients carrying the splicing mutation, 3849+10kb C->T, which was found to be associated with milder disease (group 2).

Results. A high phenotypic variability was found among the patients carrying the G85E mutation. This high variability was found among patients carrying the same genotype and among siblings. All the studied chromosomes carrying the G85E mutation had the 7T variant in the polythymidine tract at the branch/acceptor site in intron 8. Of the G85E patients, 25% had pancreatic sufficiency and none had meconium ileus, compared with 0% and 32%, respectively, of patients from group 1, and 80% and 0%, respectively, from group 2. Two patients carrying the G85E mutation had sweat chloride levels <60 mmol/L whereas all the others had typically elevated levels >80 mmol/L. Compared with group 2, patients carrying the G85E mutation were diagnosed at an earlier age and had higher sweat chloride levels, with mean values similar to group 1 but significantly more variable. Forced expiratory volume in 1 second (FEV1) was similar in the three groups, with no differences in the slope or in age-adjusted mean values of FEV1. The levels of transcripts lacking exon 9 transcribed from the G85E allele measured in 3 patients were 55%, 49%, and 35% and their FEV1 values were 82%, 83%, and 50% predicated, respectively.

Conclusions. The G85E mutation shows variable clinical presentation in all clinical parameters. This variability could be seen among patients carrying on the other chromosome the same CFTR mutation, and also among siblings. This variability is not associated with the level of exon 9 skipping. Thus, the G85E mutation cannot be classified either as a severe or as a mild mutation.
Frequency and Necessity of Thyroid Function Tests in Neonates and Infants With Congenital Hypothyroidism
Authors: Vogiatzi Maria G. , Kirkland John L.
Published: August 2004

Objective. The American Academy of Pediatrics recommends frequent thyroid function tests in infants and children with congenital hypothyroidism (CH). Data supporting the recommended frequency are lacking. This review was conducted to assess the validity of these recommendations.

Methods. The thyroxine (T4) and thyroid-stimulating hormone (TSH) levels of 50 neonates diagnosed between 1988 to 1993 were reviewed to assess the length of time on a specific dose of levothyroxine.

Results. 1) Changes in the dose of levothyroxine occurred 35 times during the first year of life for the 39 children treated with .025 mg/day, five times during the first year of life for the 9 children treated with .0375 mg/day, and three times during the first year of life for the 2 children treated with .050 mg/day. 2) These dose changes occurred at varying time intervals. 3) The T4 and TSH levels obtained at visits requiring dose changes were statistically different from the T4 and TSH levels obtained at the previous two visits. The T4 and TSH levels at the two visits before the change in dosage did not differ statistically.

Conclusions. 1) An initial levothyroxine dose of .0375 mg/day requires fewer dose changes than a dose of .025 mg/day. 2) A lack of statistical change in T4 or TSH levels obtained at visits before the change-in-dose visit and the variable time span between dose changes necessitate frequent monitoring regardless of the dose of levothyroxine, the previous T4 or TSH levels, or the length of time at a specific dose. 3) These data support the recommendations of the American Academy of Pediatrics regarding the frequency of thyroid function studies during the first 2 years of life.
Hemoptysis: A 10-Year Retrospective Study
Authors: Coss-Bu Jorge A. , Sachdeva Ramesh C. , Bricker John T. , Harrison Gunyon M. , Jefferson Larry S.
Published: August 2004

Background. Hemoptysis is uncommon in pediatric practice. We reviewed 10 years of experience with hemoptysis in a tertiary pediatric hospital to identify patient characteristics and predictors of mortality.

Methods. Patients were divided into four age groups (0 to 5, 6 to 10, 11 to 20, and >20 years). Hemoptysis was defined as mild (<150 mL/day), large (150 to 400 mL/day), or massive (>400 mL/day). Fever was defined as ≥38.5°C.

Results. A total of 228 patients (115 males and 113 females) with 246 episodes of hemoptysis were identified and grouped according to primary diagnosis. There were 149 patients in the cystic fibrosis (CF) group, 37 in the congenital heart disease (CHD) group, and 42 in the Other group. Age was significantly higher in the CF group compared with the CHD and Other groups. Length of stay was significantly prolonged in the CF group compared with the Other group. The overall mortality was 13%. After initial analysis, mortality predictors were age, amount of hemoptysis, receipt of blood products, and fever. After stratification, we found: 1) in the >20-year age group, there was a difference in mortality when comparing CF patients with CHD patients; 2) for patients who received blood products, there were differences in mortality in patients with CF, CHD, and Other diagnoses; 3) for patients who received blood, there were differences in mortality only for the 0- to 5-year age group; and 4) the amount of hemoptysis was predictive for mortality only in CHD patients.

Conclusions. Hemoptysis presented in young adult CF patients and in adolescent CHD patients. Young adult CF patients with hemoptysis had a higher risk of mortality compared with young adult CHD patients. The amount of hemoptysis predicted mortality only for CHD patients. Receiving blood products was predictive of mortality for all patients.
Sexually Abused Children 5 Years After Presentation: A Case-Control Study
Authors: Swanston Heather Y. , Tebbutt Jennifer S. , O'Toole Brian I. , Oates R. Kim
Published: August 2004

Objective. A total of 68 sexually abused children and their nonoffending parents were reassessed 5 years after presentation and were compared with a cohort of children of similar age and sex who were not known to have been abused.

Method. Outcome measures were behavior, depression, self-esteem, anxiety, eating problems, drug use, suicide attempts, self-injury, running away, criminal activity, and attributional style. Recent life events, demographics, family functioning, and mothers' mental health were taken into account when examining outcome.

Results. Although the abused children had experienced more negative life events, were from lower socioeconomic groups, had more changes in parent figures, and had mothers who were more psychologically distressed, multiple regression analysis showed that after allowing for these and other demographic factors, there were still significant differences between the groups after the 5 years. The abused children displayed more disturbed behavior, had lower self-esteem, were more depressed or unhappy, and were more anxious than controls. Sexually abused children had significantly higher levels of bingeing, self-injury, and suicide attempts.

Conclusions. It is clear that many children who are sexually abused have ongoing problems. Their ongoing problems may be indicative of false beliefs about themselves and the sexual abuse experience.
Combined Effects of Sleeping Position and Prenatal Risk Factors in Sudden Infant Death Syndrome: The Nordic Epidemiological SIDS Study
Authors: Øyen Nina , Markestad Trond , PhD Rolv Skjærven , Irgens Lorentz M , Helweg-Larsen Karin , Alm Bernt , Norvenius Gunnar , Wennergren Göran
Published: August 2004

Objective. Prone sleeping is a strong risk factor for sudden infant death syndrome (SIDS). We investigated whether the combined effect of prone sleeping position and prenatal risk factors further increased the SIDS risk.

Methods. In the Nordic Epidemiological SIDS Study, parents of SIDS victims in Denmark, Norway, and Sweden completed a questionnaire on potential risk factors for SIDS. Forensic pathologists verified the SIDS diagnosis. Four controls of the same gender, age, and place of birth were selected. This matched case–control study, which included 244 SIDS cases and 869 controls from 1992 to 1995, was analyzed by conditional logistic regression.

Results. Odds ratios (ORs) for prone and side sleeping compared with supine sleeping for the last sleep were 13.9 (95% confidence interval 8.2–24) and 3.5 (2.1–5.7). Infants 13 to 24 weeks old had particularly high risk in prone and side sleeping, at 28.5 (7.9–107) and 5.9 (1.6–22). OR for prone sleeping was higher in girls, at 30.4 (11–88), than in boys, 10.3 (5.5–19). We found strong combined effects of sleeping position and prenatal risk factors (more than multiplicative). The OR for prone and side sleeping was increased for infants with birth weight <2500 g, at 83 (25–276) and 36.6 (13–107); for preterm infants, at 48.8 (19–128) and 40.5 (14–115); and for intrauterine growth retarded, at 38.8 (14–108) and 9.6 (4.3–22), compared with supine position in infants without these prenatal factors. The combined effect of nonsupine positions and intrauterine growth retarded was highest among 13- to 24-week-old infants. Effects of combined presence of nonsupine sleeping positions and each of the factors of smoking in pregnancy, young maternal age, higher parity, low level of maternal education, and single motherhood were more than additive. Attributable fractions in the population for prone and side sleeping were 18.5% and 26.0%.

Conclusions. Both prone and side sleeping increased the risk of SIDS. The risk was increased further in low birth weight infants, preterm infants, and infants at the age of 13 to 24 weeks, suggesting that SIDS may be triggered by nonsupine sleeping in infants with prenatal risk factors during a vulnerable period of postnatal development.
Factors Associated With Growth of Extremely Premature Infants During Initial Hospitalization
Authors: MDCM Margaret A. Berry , Abrahamowicz Michal , Usher Robert H.
Published: August 2004

Objective. To quantify the factors associated with growth of very small premature infants during initial hospitalization.

Population. Study patients were 109 infants who were appropriate for gestational age, weighed <1000 g at birth, and were fed intravenous hyperalimentation then calcium-supplemented 81-kcal preterm formula according to a protocol.

Analysis. Multiple regression analysis was performed for periods of 0 to 56, 0 to 14, and 15 to 56 days of age. Growth was determined as change in weight during the period. Variables assessed in the initial model were caloric intake, protein intake, respiratory support duration, patent ductus arteriosus, dexamethasone use, infection, birth weight ratio (weight divided by expected intrauterine weight for gestation), gestational age, sex, calendar time from study start, maternal betamethasone administration, and necrotizing enterocolitis. For the 0 to 14-day period, maximum oxygen requirement for respiratory distress syndrome replaced respiratory support duration, and 5-minute Apgar score was added, whereas dexamethasone and necrotizing enterocolitis were deleted.

Results. Mean change in weight was 785 g for 0 to 56 days, −16 g for 0 to 14 days, and 770 g for 15 to 56 days. Mean weight was 94% (13 SD) of mean intrauterine at birth, 73% (10 SD) at 14 days, and 73% (12 SD) at 56 days. Regression models explained 85%, 43%, and 80%, respectively, of variation in growth.

Of the initial variables assessed, the following were the independent prognostic determinants of growth. There was a positive association with caloric intake at 0 to 56 days and 15 to 56 days, and with protein intake at 0 to 14 days. Negative associations were found for birth weight ratio and gestational age at 0 to 56 and 0 to 14 days. Respiratory support duration was negatively associated at 15 to 56 days, and dexamethasone was negatively associated at 0 to 56 and 15 to 56 days. Formulas to predict growth were established from the final regression models.

Conclusion. The growth failure in appropriate-for-gestational-age, <1000-g birth weight infants can be related in part to dexamethasone use and respiratory support duration. Increasing caloric intake and early protein intake improves growth. However, for the majority of these patients, early losses are not corrected completely by 56 days using currently recommended intakes.
The Relationship Between Urinary Calcium, Sodium, and Potassium Excretion and the Role of Potassium in Treating Idiopathic Hypercalciuria
Authors: Osorio Alexies V. , Alon Uri S.
Published: August 2004

Objectives. 1) To evaluate the relationships between urinary sodium (UNa), potassium (UK), and calcium (UCa) excretion in the pediatric population; and 2) to determine the effect of increasing potassium intake in patients with idiopathic hypercalciuria and investigate whether this intervention can be offered as another mode of therapy in this patient population.

Design. Prospectively, we determined UNa, UK, UCa, and creatinine (Cr) concentrations in randomly collected urine samples from children on initial evaluation for urinary frequency, dysuria, hematuria, enuresis, or kidney stones to identify children with hypercalciuria.

Setting. The outpatient renal clinic of an academic hospital.

Participants. Twenty-three black children (13 girls and 10 boys) and 77 white children (44 girls and 33 boys) 3.92 to 16.67 years of age.

Interventions. Eleven children with hypercalciuria were given potassium supplementation or placed on a high-potassium diet for at least 2 weeks.

Outcome Measures. UNa to UK, UNa to Cr, UK to Cr, and UCa to Cr ratios were calculated from measured levels of urinary minerals. These were repeated in 11 hypercalciuric patients after 2 weeks of increased potassium intake.

Results. A total of 100 urine samples were analyzed. The UCa/Cr ratio in blacks 0.04 ± 0.06 (mean ± standard deviation) was significantly lower than in whites 0.16 ± 0.12. There were 21 hypercalciuric white children versus only 1 black child. Linear regression analysis revealed a positive direct correlation between UNa/Cr and UCa/Cr in all 100 subjects and in whites alone but not in blacks. An inverse relationship existed between UK/Cr and UCa/Cr in all subjects and in whites and showed a strong trend in blacks. A marked direct relationship was found between UNa/K and UCa/Cr in all subjects (r2 = .43) as well as in whites (r2 = .59) and blacks (r2 = .49). One black child and 10 white hypercalciuric children were treated with “extra” K for at least 2 weeks. The UNa/K decreased from 4.73 ± 2.28 to 1.98 ± 1.09, and the UCa/Cr decreased from 0.31 ± 0.10 to 0.14 ± 0.07, with resolution or improvement of the patients' symptoms.

Conclusions. In our patient population with urinary symptoms, the UCa/Cr ratio in black children is lower and hypercalciuria less common than in white children. In both white and black populations, the UNa/K ratio had the strongest association with the UCa/Cr ratio, indicating an opposing role of UNa and UK on the UCa/Cr ratio. Increased potassium intake was found to be beneficial for hypercalciuric children by decreasing the UNa/K ratio and, consequently, the UCa/Cr ratio.
Students' Acquisition and Use of School Condoms in a High School Condom Availability Program
Authors: Schuster Mark A. , Bell Robert M. , Berry Sandra H. , Kanouse David E.
Published: August 2004

Objectives. To determine what students know about a condom availability program in their high school, how they react to the program, whether they obtain condoms from it, and what they do with these condoms.

Design. Self-administered anonymous survey conducted 1 year after the program began.

Setting. An urban California school district.

Participants. A total of 1112 students, 9th through 12th grade, 59% of eligible students present on the survey day.

Main Outcome Measures. History of obtaining condoms from the program, use of these condoms, knowledge about the program, and attitudes toward the program.

Results. Forty-eight percent of students had personally taken school condoms, and another 5% had gotten them from someone else, for a total of 53% who had obtained school condoms. Seventy percent of nonvirgins and 38% of virgins obtained condoms. Males were more likely than females to have obtained condoms (60% vs 45%). Fifty-four percent of students who had obtained school condoms had used them for sexual activity: 52% had used them for vaginal intercourse, 7% for anal intercourse, and 4% for fellatio. Students also explored school condoms without having sex, eg, removing them from the packet, putting them on fingers, or putting them on their penis or a partner's penis. Thirty-four percent of students who had used a condom for vaginal intercourse during the previous year had obtained the condom they last used from school, with more males than females reporting the school as their source (41% vs 26%).

Eighty-eight percent of students knew that all students were allowed to obtain condoms, and 74% knew that parental permission was not required. Students generally supported the condom program: 88% thought the school should give out condoms, and 79% thought that if the school were to require parental permission for students to get condoms, students would get them less often than with the present system (which does not require permission). Thirteen percent agreed and 71% disagreed that “having condoms available at school makes it harder for someone who doesn't want to have sex to say no.”

Conclusions. Providing high school students with direct access to condoms leads to widespread use of school condoms, both for sexual activity and for exploratory activities that familiarize students with condoms. Condoms are of interest to both students who have and students who have not engaged in sexual activities for which condoms are recommended.
Cardiac Transplantation for Kawasaki Disease
Authors: Checchia Paul A. , Pahl Elfriede , Shaddy Robert E. , Shulman Stanford T.
Published: August 2004

Objective. Severe cardiac sequelae from Kawasaki disease include coronary ischemia and have been treated with a variety of coronary artery bypass procedures. There is only one published report of a child who underwent cardiac transplantation for severe Kawasaki disease-related cardiac complications. The purpose of this study was to gather the worldwide experience with cardiac transplantation for Kawasaki disease.

Methods. Data were obtained from the United Network for Organ Sharing Registry, the European transplant experience, and a phone survey of many Kawasaki disease investigators. Diagnostic and surgical reports as well as clinical records were reviewed.

Results. We identified 13 Kawasaki disease patients who underwent cardiac transplantation and obtained data on 10. In these 10 patients, the timing of transplantation was within 6 months after diagnosis of Kawasaki disease (4 patients), 1 to 5 years after diagnosis (3 patients), and 9 to 12 years after diagnosis (3 patients). Indications for transplantation included severe myocardial dysfunction, severe ventricular arrhythmias including cardiac arrest, and severe distal multivessel occlusive coronary artery disease. Nine of the 10 patients remain alive and healthy, with up to 6 years' posttransplant follow-up. One patient died 10 months posttransplant after severe refractory rejection. In addition, 1 patient required retransplantation at 4 years for severe rejection.

Conclusions. Cardiac transplantation for severe ischemic heart disease as a sequela of Kawasaki disease is feasible and can benefit the small subgroup of patients who are not candidates for revascularization because of distal coronary stenosis or aneurysms and/or those with severe irreversible myocardial dysfunction.
Noise: A Hazard for the Fetus and Newborn
Authors:   Committee on Environmental Health
Published: August 2004

Noise is ubiquitous in our environment. High intensities of noise have been associated with numerous health effects in adults, including noise-induced hearing loss and high blood pressure. The intent of this statement is to provide pediatricians and others with information on the potential health effects of noise on the fetus and newborn. The information presented here supports a number of recommendations for both pediatric practice and government policy.
The Role of Bathtub Seats and Rings in Infant Drowning Deaths
Authors: Rauchschwalbe Renae , Brenner Ruth A. , Smith Gordon S.
Published: August 2004

Objective. To describe deaths due to drowning that involve the use of an infant bathtub seat or ring.

Design. Case series, cases reported to the US Consumer Product Safety Commission data systems.

Setting. United States, 1983–1995.

Main Outcome Measures. Death in which an infant bathtub seat or ring was in use at the time of death and the primary cause of death was drowning.

Results. Thirty-two drowning deaths involving bath seats/rings were identified and investigated by the Consumer Product Safety Commission over a 13-year period. The majority of deaths (84%) occurred from 1991–1995, with more than 50% occurring in the 2 most recent years. The victims' ages at the time of the incident ranged from 5 to 15 months with a mean and median age of 8 months. In more than 90% of incidents there was a reported lapse in adult supervision, with a mean reported lapse of 6 minutes and a median lapse of 4 minutes. Focus groups with parents found that while making bathing somewhat easier, bath seats/rings are useful for a relatively short time period, as the child rapidly outgrows the product. They also suggested that care givers are more likely to leave a child unattended in the tub if one of these products is in use.

Conclusion. Bath seats/rings are associated with an increasing number of reported infant drowning deaths. The use of such products may increase the risk of drowning among infants by increasing the likelihood that an infant will be left alone in the tub. However, in the absence of exposure data in a suitable comparison group it is difficult to assess the overall risk inherent in their use. Educational efforts reinforcing the need for continuous adult supervision of infants and children around all bodies of water should now also include a reminder that bath seats/rings are not safety items and are not a substitute for adult supervision. Infants and toddlers should never be left in the bathtub unsupervised, even for brief moments.
A Long-term Prospective Study of Varicella Vaccine in Healthy Children
Authors: Johnson Candice E. , Stancin Terry , Fattlar Deborah , Rome Leonard P. , Kumar Mary L.
Published: August 2004

Background. Studies in Japan and the United States have shown that varicella vaccine is both safe and efficacious. In 1984, we undertook a 10-year prospective study using a research lot of Oka/Merck varicella vaccine to assess antibody persistence and breakthrough chickenpox rates. In 1987, we began a similar prospective study with lots made in production facilities that ended after 6 years because many children were given a second dose. The purpose of this study is to report humoral antibody persistence and breakthrough chickenpox rates after 6 to 10 years of prospective follow-up.

Methods. One hundred forty-three seronegative children received a research lot (950 plaque-forming units/dose) with 97.9% seroconversion by an assay for fluorescent antibody to membrane antigen (FAMA). One hundred thirty-eight children received production lots (1145 to 3265 plaque-forming units/dose) with 93.5% seroconversion. Yearly chickenpox exposure surveys were completed by phone, and children were seen by a study nurse whenever chickenpox was suspected. A subset in each group had serum collected every 2 years and tested for FAMA antibody.

Results. In the research group there have been 25 cases of chickenpox in 137 seroconverters in a period of more than 10 years (yearly rate of 1.7%). In the production lot group there have been 22 cases of chickenpox in 129 seroconverters in a 6-year period (yearly rate of 2.8%). In the research group the median titer rose from 1:16 to 1:64 between 1 and 10 years. In the production group, the median titer did not change between 1, 2, and 4 years. Median antibody titers were compared between the research and production groups at 1, 2, and 4 years and did not differ. The rate of development of modified chickenpox has not increased with time since vaccination, and neither has the case severity. Children with FAMA titers ≤8 at 6-weeks' postvaccination were four times more likely to develop chickenpox than those with titers ≥64.

Conclusions. 1) Modified chickenpox has occurred in approximately 2% to 3% of vaccinees per year, regardless of the vaccine lot given. 2) FAMA titers have risen between 1 and 10 years in research lot recipients and remained the same in production lot recipients. 3) The likelihood of modified chickenpox developing is inversely related to the 6-week postvaccination FAMA titer.
MMR2 Immunization at 4 to 5 Years and 10 to 12 Years of Age: A Comparison of Adverse Clinical Events After Immunization in the Vaccine Safety Datalink Project
Authors: Davis Robert L. , MD Edgar Marcuse , Black Steven , Shinefield Henry , Givens Ben , Schwalbe Joan , Ray Paula , Thompson Robert S. , Chen Robert ,   the Vaccine Safety Datalink Team
Published: August 2004

Background. The Advisory Committee on Immunization Practices recommends a second dose of measles, mumps, and rubella vaccine (MMR2) at age 4 to 5 years of age, whereas the American Academy of Pediatrics suggests MMR2 immunization at age 11 to 12 years of age. Because there is little information on whether the rate of adverse reactions to MMR2 immunization varies among these two age groups, we took advantage of differing immunization policies at two large HMOs to compare the frequency of clinical events after, and possibly related to, MMR2 immunization.

Methods. Information was collected on clinical events plausibly associated to MMR immunization (seizures, pyrexia, malaise/fatigue, nervous/musculoskeletal symptoms, rash, edema, induration/ecchymoses, lymphadenopathy, thrombocytopenia, aseptic meningitis, and joint pain) in two cohorts. At three facilities at Northern California Kaiser (Oakland, CA), 8514 children received MMR2 immunization at age 4 to 6 years of age; at Group Health Cooperative (Seattle, WA) 18 036 children received MMR2 immunization at age 10 to 12 years of age. To account for age-related differences in health care use, within each HMO, clinical events in a 30-day period after immunization were compared with a 30-day period before vaccination.

Results. Children 10 to 12 years of age were 50% more likely to have a clinical event after MMR2 immunization than in the period before immunization (odds ratio, 1.45; 95% confidence interval: 1.00,2.10). Children 4 to 6 years of age were less likely to have a visit for an event after immunization compared with the period before immunization (odds ratio, 0.64; 95% confidence interval: 0.40,1.01).

Conclusions. These results suggest that the risk for clinical events after MMR2 immunizations is greater in the 10- to 12-year age group.
Adolescent Childbearing Revisited: The Age of Inner-city Mothers at Delivery Is a Determinant of Their Children's Self-sufficiency at Age 27 to 33
Authors: Hardy Janet B. , Shapiro Sam , Astone Nan M. , Miller Therese L. , Brooks-Gunn Jeanne , Hilton Sterling C.
Published: August 2004

Objectives. Data from recent interviews with 1758 inner-city children, born between 1960 to 1965 and followed with their mothers in the Pathways to Adulthood Study to age 27 to 33 years, were used to address two related questions. 1) Is maternal age, across the reproductive age range, a determinant of child's adult outcome? and 2) Do covariates of maternal age at delivery reduce or eliminate the effect of maternal age on child's adult outcome?

Methods. An intergenerational life course model of development identified significant maternal and child characteristics at birth associated with the child's self-sufficient outcomes in adulthood: education (more than or equal to a high school diploma); financial independence of public support; and delay of first birth until age 20 or older. Bivariate and multiple logistic regression techniques were used to identify independent relationships between dependent and independent variables and to adjust the outcomes to compensate for the effect of possible confounding of maternal age at delivery by maternal education, parity, poverty status, and the child's race and gender.

Results. Each covariate was independently associated with maternal age at delivery. Adjustment for their effects reduced, but did not eliminate, the association between maternal age at birth and the child's outcome at age 27 to 33 years. As a group, children of the oldest mothers (≥25 years of age) had the most favorable outcomes, and those of teenage mothers (<20 years of age) had the least favorable outcomes; 22% of daughters and 6% of sons of the oldest mothers versus 38% and 18%, respectively, of the youngest mothers became teenage parents.

Conclusion. The mother's age at delivery is an independent determinant of the child's adult status.
Longitudinal Neurological Follow-up of a Group of HIV-Seropositive and HIV-Seronegative Hemophiliacs: Results From the Hemophilia Growth and Development Study
Authors: Mitchell Wendy G. , Lynn Henry , Bale James F. , Maeder Margaret A. , Donfield Sharyne M. , Garg Bhuwan , Tilton Ann H. , Willis John K. , Bohan Timothy P.
Published: August 2004

Background. Boys and young men with hemophilia treated with factor infusions before 1985 had a substantial risk of acquiring the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome. This study was designed to assess the effects of HIV and hemophilia per se on neurological function in a large cohort of subjects with hemophilia, and to investigate the relationships between neurological disease and death during follow-up.

Methods. Three hundred thirty-three boys and young men (207 HIV seropositive and 126 HIV seronegative) were evaluated longitudinally in a multicenter, multidisciplinary study. Neurological history and examination were conducted at baseline and annually for 4 years. The relationship between neurological variables, HIV serostatus, CD4+ cell counts, and vital status at the conclusion of the study was examined using logistic regression models.

Results. The risks of nonhemophilia-associated muscle atrophy, behavior change, and gait disturbance increased with time in immune compromised HIV-seropositive subjects compared with HIV seronegative or immunologically stable HIV-seropositive subjects. The risk of behavior change in immune compromised HIV-seropositive hemophiliacs, for example, rose to 60% by year 4 versus 10% to 17% for the other study groups. Forty-five subjects (13.5%), all of whom were HIV seropositive, died by year 4. Subjects who died had had increased risks of hyperreflexia, nonhemophilia-associated muscle atrophy, and behavior change.

Conclusions. These results indicate that immune compromised, HIV-seropositive hemophiliacs have high rates of neurological abnormalities over time and that neurological abnormalities were common among subjects who later died. By contrast, immunologically stable HIV-seropositive subjects did not differ from the HIV-seronegative participants. Hemophilia per se was associated with progressive abnormalities of gait, coordination, and motor function.
New Non-Cocaine-Containing Topical Anesthetics Compared With Tetracaine–Adrenaline–Cocaine During Repair of Lacerations
Authors: Smith Gary A. , Strausbaugh Steven D. , Harbeck-Weber Cynthia , Cohen Daniel M. , Shields Brenda J. , Powers Jean D.
Published: August 2004

Objective. To compare the effectiveness of three new topical anesthetics that do not contain cocaine (prilocaine–phenylephrine, tetracaine–phenylephrine [tetraphen], and tetracaine–lidocaine–phenylephrine) to that of tetracaine–adrenaline–cocaine (TAC) during laceration repair in children.

Design. Prospective, randomized, double-blind clinical trial.

Setting. The emergency department of an urban children's hospital.

Participants. Children 1 year of age or older with a laceration ≤ 5 cm in length that required suturing.

Intervention. A total of 240 children were randomly assigned to one of four treatment groups.

Outcome Measures. Pain felt during suturing was scored by suture technicians, research assistants, parents, and patients ≥ 5 years of age using a visual analogue scale (VAS). Suture technicians, research assistants, and parents also scored pain using a seven-point Likert scale. In addition, suture technicians completed an anesthetic effectiveness scale.

Results. There was consistently no difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. A statistically significant difference was seen among anesthetics when comparing VAS and Likert scale scores of suture technicians and Likert scale scores of research assistants. Based on post hoc analyses, these statistically significant differences were between TAC and prilocaine–phenylephrine (suture technician VAS and Likert scale) and between TAC and tetracaine–lidocaine–phenyl-ephrine (suture technician Likert scale), but not between TAC and tetraphen. When power analyses were performed using α = 0.05 and β = 0.20, it was possible to detect a difference of 1.2 VAS units for each of the observer groups. Based on anesthetic effectiveness scale scores, the three new topical preparations collectively performed significantly better on the face and scalp than on the extremities (relative risk = 1.83; 95% confidence interval 1.20 < relative risk < 2.79).

Conclusion. This study demonstrated the effectiveness and safety of three new non-cocaine-containing topical anesthetics. Consistently, there was no statistical difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. Tetraphen offers an effective alternative to TAC during laceration repair in children.
Decrease in Birth Weight in Relation to Maternal Bone-Lead Burden
Authors: González-Cossı́o Teresa , Peterson Karen E. , Sanı́n Luz-Helena , Fishbein Eugenia , Palazuelos Eduardo , Aro Antonio , Hernández-Avila Mauricio , Hu Howard
Published: August 2004

Objectives. Birth weight predicts infant survival, growth, and development. Previous research suggests that low levels of fetal lead exposure, as estimated by umbilical cord blood-lead levels at birth, may have an adverse effect on birth weight. This report examines the relationship of lead levels in cord blood and maternal bone to birth weight.

Methods. Umbilical cord and maternal venous blood samples and anthropometric and sociodemographic data were obtained at delivery and 1-month postpartum. Blood-lead levels were analyzed by atomic absorption spectrophotometry. Maternal tibia and patella lead levels were determined at 1-month postpartum with use of a spot-source109Cd K-X-ray fluorescence instrument. The relationship between birth weight and lead burden was evaluated by multiple regression with control of known determinants of size at birth.

Results. Data on all variables of interest were obtained for 272 mother-infant pairs. After adjustment for other determinants of birth weight, tibia lead was the only lead biomarker clearly related to birth weight. The decline in birth weight associated to increments in tibia lead was nonlinear and accelerated at the highest tibia lead quartile. In the upper quartile, neonates were on average, 156 grams lighter than those in the lowest quartile. Other significant birth weight predictors included maternal nutritional status, parity, education, gestational age, and smoking during pregnancy.

Conclusions. Our results indicate that bone-lead burden is inversely related to birth weight. Taken together with other research indicating that lead can mobilize from bone into plasma without detectable changes in whole blood lead, these findings suggest that bone lead might be a better biomarker than blood lead. Because lead remains in bone for years to decades, mobilization of bone lead during pregnancy may pose a significant fetal exposure with health consequences, long after maternal external lead exposure has declined.
Pulmonary Administration of Gentamicin During Liquid Ventilation in a Newborn Lamb Lung Injury Model
Authors: Fox William W. , Weis Carla M. , Cox Cynthia , Farina Clotilde , Drott Henry , Wolfson Marla R. , Shaffer Thomas H.
Published: August 2004

Objectives. Newborns with pulmonary infection frequently present with acute lung injury leading to ventilation/perfusion abnormalities in which intravenous delivery of antibiotics to the lung can be suboptimal. Tidal liquid ventilation (TLV) has been shown to be an effective means for delivering drugs directly to the pulmonary system. The objective of this study was to compare, with lung injury, antibiotic delivery achieved by conventional techniques (gas ventilation and intravenous gentamicin) with that using pulmonary administration of drug (PAD) during TLV.

Methods. Twelve newborn lambs with an acid lung injury were randomized to receive gentamicin either intravenously during gas ventilation or via PAD during TLV using LiquiVent (Alliance Pharmaceutical Corporation, San Diego, CA, and Hoechst-Marion Roussel, Bridgewater, NJ) perfluorochemical. Gentamicin (5 mg/kg) was administered over 1 minute, and serum levels were obtained at 15-minute intervals. Arterial blood gases and pulmonary mechanics were measured. Ventilation efficiency index and arterial/alveolar oxygen ratio were calculated. Lung-tissue gentamicin levels were measured 4 hours after administration and corrected to dry weight.

Results. Serum gentamicin levels were similar in both groups. Lung gentamicin levels (μg/g) were significantly higher for TLV. Also, TLV resulted in significantly more of the total delivered dose in the lung after 4 hours. Ventilation efficiency index and arterial/alveolar oxygen ratios were significantly higher for TLV.

Conclusions. In this lung injury model, both methods achieved equivalent serum gentamicin levels with higher lung levels using PAD during TLV. This study suggests that TLV may provide an effective vehicle for gentamicin delivery in infants with severe pulmonary infection and ventilation/perfusion abnormalities.
United States Vaccine Research: A Delicate Fabric of Public and Private Collaboration
Authors: Committee National Vaccine Advisory
Published: August 2004

In the last 20 years, two thirds of all new vaccines provided worldwide have been produced by a US network of independent industrial, governmental, and academic partners engaged in vaccine research and development. Vaccines are complex products and the science of vaccinology is difficult. To achieve the full promise of modern science and technology to prevent and treat disease by immunization, the delicate fabric of America's cooperative and collaborative vaccine research relationships must be sustained and strengthened. The major partners are the federal government; four large companies—two US–headquartered (Wyeth-Lederle Biologics and Vaccines and Merck & Co), two foreign firms (SmithKline Beecham and Pasteur Mérieux Connaught); and academia. Of the $1.4 billion that fund US vaccine research and development annually, 46% comes from vaccine sales, 36% from taxpayers, and 18% from risk capital. Vaccine innovation could be strengthened by improved public and policy maker understanding of the vaccine development network; declarations of partnership; interactive dialog with federal advisory bodies; public forums for government and industry to listen to patients, providers, and researchers; sabbatical assignments between partners; mechanisms to share industries' market research with public immunization programs; continued active industry participation in the Advisory Committee on Immunization Practices and the National Vaccine Advisory Committee; increased collaboration between industry and the National Institutes of Health for clinical research; harmonization of the Advisory Committee on Immunization Practices vaccine recommendations and the Food and Drug Administration package inserts; and public policies to foster the partnership's collaboration and robustness. The optimal size and configuration of the US vaccine enterprise should be debated only in the context of a full understanding of how the current system works and its record of effectiveness. These National Vaccine Advisory Committee recommendations are directed at developing public policies to foster and sustain vaccine innovation and ensure the timely introduction and supply of new vaccines needed by this nation and the world.
Nosocomial Respiratory Syncytial Virus Infection in Canadian Pediatric Hospitals: A Pediatric Investigators Collaborative Network on Infections in Canada Study
Authors: Langley Joanne M. , LeBlanc John C. , Wang Elaine E. L. , Law Barbara J. , MacDonald Noni E. , Mitchell Ian , Stephens Derek , McDonald Jane , Boucher François D. , Dobson Simon
Published: August 2004

Objective. To determine nosocomial transmission of respiratory syncytial virus (RSV) in Canadian pediatric hospitals, outcomes associated with nosocomial disease, and infection control practices.

Design. A prospective cohort study in the 1992 to 1994 winter respiratory seasons.

Setting. Nine Canadian pediatric university-affiliated hospitals.

Participants. Hospitalized children with symptoms of lower respiratory tract infection (at least one of cough, wheezing, dyspnea, tachypnea, and apnea) and RSV antigen identified in a nasopharyngeal aspirate.

Results. Of 1516 children, 91 (6%) had nosocomial RSV (NRSV), defined as symptoms of lower respiratory tract infection and RSV antigen beginning >72 hours after admission. The nosocomial ratio (NRSV/[com-munity-acquired RSV {CARSV})] + NRSV) varied by site from 2.8% to 13%. The median length of stay attributable to RSV for community-acquired illness was 5 days, but 10 days for nosocomial illness. Four children with NRSV (4.4%) died within 2 weeks of infection, compared with 6 (0.42%) with CARSV (relative risk = 10.4, 95% confidence interval: 3.0, 36.4). All sites isolated RSV-positive patients in single rooms or cohorted them. In a multivariate model, no particular isolation policy was associated with decreased nosocomial ratio, but gowning to enter the room was associated with increased risk of RSV transmission (incidence rate ratio 2.81; confidence interval: 1.65, 4.77).

Conclusions. RSV transmission risk in Canadian pediatric hospitals is generally low. Although use of barrier methods varies, all sites cohort or isolate RSV-positive patients in single rooms. Children with risk factors for severe disease who acquire infection nosocomially have prolonged stays and excess mortality.
Twenty-Four-Hour Profile of Growth Hormone in Cyclic Nocturnal Total Parenteral Nutrition
Authors: Yokoyama Seishichi , Hirakawa Hitoshi , Soeda Jinichi , Ueno Shigeru , Mitomi Toshio
Published: August 2004

Objective. To detect the effect of the loss of alimentation rhythmicity on a circadian rhythm of human growth hormone (HGH) secretion, a 24-hour profile of HGH was studied in a growing child on cyclic nocturnal total parenteral nutrition (TPN). Twenty-four-hour profiles of substrates and metabolic hormones were also studied to evaluate the efficiency of cyclic nocturnal TPN on childhood growth.

Study Design. Periodic blood samples from a child with megacystis-microcolon-intestinal-hypoperistalsis syndrome were obtained on five occasions, at ages 6, 7, 8, 9, and 11, when she was on cyclic nocturnal TPN.

Results. Peak HGH secretion appeared with the onset of deep sleep despite the concomitant hyperglycemia and hyperinsulinemia induced by TPN at night. Smaller peaks of HGH were also observed during the noninfusion period during the day. Twenty-four-hour profiles of substrates and metabolic hormones indicated a switch from glucose use during the infusion phase to an oxidation of lipids during the noninfusion period.

Conclusion. The fact that the patient's growth curve remains within normal limits suggests that cyclic nocturnal TPN would be an efficient method of nutritional support. During cyclic nocturnal TPN, regular rhythm of HGH secretion occurs, and normal childhood growth is achieved.