bluuebunny/crossref_metadata_2025 huggingface dataset:
Retropharyngeal Abscess in Children: Clinical Presentation, Utility of Imaging, and Current Management
Authors: Craig Frances W. , Schunk Jeff E.
Published: August 2004

Objective. We sought to describe the clinical presentation of patients with retropharyngeal abscess (RPA), utility of imaging studies, and implications on management.

Methods. A retrospective chart review was performed at a tertiary-care, pediatric hospital with cases identified by a discharge diagnosis of RPA; posttraumatic RPA cases were excluded. Patients without confirmatory radiographic findings, fluoroscopy, or computed tomography (CT) were excluded.

Results. Sixty-four cases involving 64 patients were studied. The median age of the patients was 36 months; 48 (75%) of the 64 patients were younger than 5 years. The most common chief complaints were neck pain (38%), fever (17%), sore throat (17%), neck mass (16%), and respiratory distress or stridor (5%). In 29 children (45%), it was noted that there was limitation of neck extension, in 23 (36.5%) torticollis, and in 8 (12.5%) limitation of neck flexion. The physical examination revealed stridor with wheezing in only 1 patient (1.5%) and wheezing in 1 other (1.5%). Twenty-seven patients (42%) underwent surgery; 37 (58%) were treated with antibiotics only. Performance of a surgical procedure was significantly associated with CT scan findings. Ten (37%) of 27 patients with defined abscess on CT scan were treated with antibiotics alone. There were no treatment failures in either the antibiotic-only group or the antibiotics-plus-surgery group.

Conclusions. Children with RPA present with limitation of neck movement, especially difficulty extending their neck to look up. They rarely present with respiratory distress or stridor. CT scan is useful to distinguish patients with RPA from those with retropharyngeal cellulitis. Most patients with retropharyngeal cellulitis and some with RPA can be treated successfully without surgery.
Expanded Newborn Screening for Inborn Errors of Metabolism by Electrospray Ionization-Tandem Mass Spectrometry: Results, Outcome, and Implications
Authors: Schulze Andreas , Lindner Martin , Kohlmüller Dirk , Olgemöller Katharina , Mayatepek Ertan , Hoffmann Georg F.
Published: August 2004

Objective. The aims of this study were to determine the impact of expanded newborn screening using tandem mass spectrometry (MS/MS) on the overall detection rate of inborn errors of metabolism in Germany and to assess the outcome for the patients that were diagnosed.

Methods. During the period of study, 250 000 neonates in a German population were investigated for 23 inborn errors of metabolism by electrospray ionization-MS/MS. The overall value of the screening program was estimated by 1) complete ascertainment of all positive tests; 2) definite assignment of all diagnoses including reconfirmation at 12 months; and 3) clinical follow-up of all detected patients in an overall interval of 42 months. The mean observation period was 13.5 months per child.

Results. In 106 newborns, confirmed inborn errors of metabolism were found. The disorders were classified as 50 classic forms and 56 variants. A total of 825 tests (0.33%) were false-positives. Seventy of the 106 newborns with confirmed disorders were judged to require treatment. Six children developed symptoms despite treatment. Three children had died. Among 9 children who became symptomatic before report of the results of screening, in 6 the diagnosis had been made in advance of the screening report. In evaluation of the screening program, 61 of the 106 identified children (58% of true-positives, or 1 of 4100 healthy newborns) were judged to have benefited from screening and treatment, because the diagnosis had not been made before screening. None of these infants had died and none developed psychomotor retardation or metabolic crisis during the follow-up period.

Conclusions. The screening by MS/MS for up to 23 additional disorders has approximately doubled the detection rate compared with that achieved by the conventional methods used in Germany. This strategy represents valuable preventive medicine by enabling diagnosis and treatment before the onset of symptoms.
Human Metapneumovirus Infection in the United States: Clinical Manifestations Associated With a Newly Emerging Respiratory Infection in Children
Authors: Esper Frank , Boucher Derek , Weibel Carla , Martinello Richard A. , Kahn Jeffrey S.
Published: August 2004

Objective. Respiratory tract infections are a leading cause of morbidity and mortality worldwide. Recently, a newly identified human respiratory virus, human metapneumovirus (hMPV), was reported by investigators in the Netherlands. We sought to determine whether hMPV was circulating in our community and to determine the clinical features associated with hMPV infection.

Methods. Respiratory specimens from children who were younger than 5 years and had a negative result for respiratory syncytial virus, influenza A and B, parainfluenza viruses 1 to 3, and adenovirus by direct fluorescent antibody test were screened for hMPV by reverse transcriptase–polymerase chain reaction. Samples were collected from October 30, 2001, to February 28, 2002.

Results. Of the 296 patients screened, 19 (6.4%) had evidence of hMPV infection. hMPV was identified in patients with either upper or lower respiratory tract infection or both. Clinical manifestations included wheezing, hypoxia, and abnormal findings on chest radiographs (eg, focal infiltrates, peribronchial cuffing). Nosocomial infection occurred in at least 1 patient.

Conclusions. hMPV is circulating in the United States and is associated with respiratory tract disease in patients with respiratory illnesses not caused by respiratory syncytial virus, influenza, parainfluenza viruses, and adenovirus. Additional studies are required to define the epidemiology and the extent of disease in the general population caused by hMPV.
Platelet Count and Sepsis in Very Low Birth Weight Neonates: Is There an Organism-Specific Response?
Authors: Guida Jack D. , Kunig Anette M. , Leef Kathleen H. , McKenzie Steven E. , Paul David A.
Published: August 2004

Objective. Thrombocytopenia is commonly observed in very low birth weight (VLBW) neonates with sepsis. Specific platelet responses to different infectious agents have not been extensively characterized. The objectives of this study were to examine platelet counts and platelet indices in preterm neonates with culture-proven sepsis to determine if there are organism-specific platelet responses.

Study Design. We analyzed a cohort of all VLBW neonates (birthweight <1500 g) born over a 4-year period and admitted to a single level III neonatal intensive care unit (N = 943). Thrombocytopenia was defined as a platelet count <100 000/mm3. Platelet count, nadir, duration of thrombocytopenia, and mean platelet volume (MPV) were examined during episodes of culture-proven sepsis. Analysis of variance, Kruskal-Wallis, Mann-Whitney U, and χ2 tests were used to compare groups, and data are expressed as mean ± standard deviation.

Results. Sepsis was diagnosed in 154 (16%) of 943 patients in the study population. Of the sepsis episodes, 54% were associated with thrombocytopenia and 61% with an elevation in MPV. Infections were grouped by organism type: Gram-positive bacteria (117/154, 76%), Gram-negative bacteria (24/154, 16%), and fungi (13/154, 8%). When compared with patients with Gram-positive sepsis, those with Gram-negative or fungal sepsis had a significantly lower initial platelet count, a lower platelet nadir, a higher incidence of thrombocytopenia, and a greater duration of thrombocytopenia. The decrease in platelet count from baseline was also significantly less in the Gram-positive infections than in the fungal infections. Although there was an overall increase in MPV from baseline, there were no differences between groups.

Conclusions. In our population of VLBW infants, sepsis is frequently associated with thrombocytopenia and an elevation in MPV. However, fungal and Gram-negative pathogens are associated with a lower platelet count and more prolonged thrombocytopenia compared with Gram-positive pathogens. We conclude that common pathogens causing sepsis have different effects on platelet kinetics.
Midaortic Syndrome in the Fetus and Premature Newborn: A New Etiology of Nonimmune Hydrops Fetalis and Reversible Fetal Cardiomyopathy
Authors: Zeltser Ilana , Parness Ira A. , Ko Helen , Holzman Ian R. , Kamenir Steven A.
Published: August 2004

Nonimmune hydrops fetalis is the final common pathway of many conditions that ultimately result in fetal anasarca. Even after extensive evaluation, the etiology of a small percentage of cases of hydrops remains unknown. We present a case of midaortic syndrome, also known as abdominal coarctation syndrome, in a fetus with hydrops and a severe cardiomyopathy. The clinical manifestations of midaortic syndrome in this fetus and premature newborn, including malignant hypertension and reversible cardiomyopathy, are detailed. The fetal pathophysiology of midaortic syndrome remains speculative, but likely includes fetal hypertension as the cause of cardiac dysfunction. To our knowledge, this is the first report of midaortic syndrome as an etiology for nonimmune hydrops fetalis.
Transmission of Salmonella enterica Serotype Typhimurium DT104 to Infants Through Mother’s Breast Milk
Authors: Qutaishat Salah S. , Stemper Mary E. , Spencer Susan K. , Borchardt Mark A. , Opitz James C. , Monson Timothy A. , Anderson Jennifer L. , Ellingson Jay L. E.
Published: August 2004

This study documents the first reported transmission of Salmonella enterica serotype Typhimurium definitive type 104 (DT104) to premature fraternal twins via their mother’s breast milk. When premature twin neonates developed severe enteritis in the neonatal intensive care unit (NICU), stool samples and the mother’s breast milk were cultured for the presence of Salmonella. Antibacterial susceptibility patterns were determined. Semiquantitative organism abundance data were retrospectively gathered on 54 stored breast milk samples collected on 34 different days using a rapid, real-time polymerase chain reaction (PCR) methodology (LightCycler PCR). Fecal samples from other infants in the NICU at that time were also tested. Pulsed-field gel electrophoresis (PFGE) was used to assess the genetic composition of the isolated organisms. The twins’ neonatal stools and mother’s breast milk cultures revealed a resistance pattern (R-type) to ampicillin, chloramphenicol, streptomycin, sulfonamides, and tetracycline. LightCycler PCR analysis of sequential breast milk samples confirmed this to be the likely source of transmission. In the subsequent outbreak investigation, none of the NICU surveillance fecal samples proved positive for this organism. The genetic composition of organisms isolated from the maternal breast milk was indistinguishable from those isolated from neonatal specimens as determined by PFGE. Antibiotic susceptibility tests coupled with PFGE patterns suggested that these Salmonella isolates were DT104. Because the prevalence of DT104 infections is rising in the United States, neonatologists should be aware of breast milk as a potential mode of transmission.
Advanced Practice in Neonatal Nursing
Authors:   Committee on Fetus and Newborn
Published: August 2004

The advanced practice neonatal nurse’s participation in newborn care continues to be accepted and supported by the American Academy of Pediatrics. Recognized categories of advanced practice neonatal nurse are the neonatal clinical nurse specialist and the neonatal nurse practitioner. Training and credentialing requirements have been updated recently and are endorsed in this revised statement.
Radiation Disasters and Children
Authors:   Committee on Environmental Health
Published: August 2004

The special medical needs of children make it essential that pediatricians be prepared for radiation disasters, including 1) the detonation of a nuclear weapon; 2) a nuclear power plant event that unleashes a radioactive cloud; and 3) the dispersal of radionuclides by conventional explosive or the crash of a transport vehicle. Any of these events could occur unintentionally or as an act of terrorism. Nuclear facilities (eg, power plants, fuel processing centers, and food irradiation facilities) are often located in highly populated areas, and as they age, the risk of mechanical failure increases. The short- and long-term consequences of a radiation disaster are significantly greater in children for several reasons. First, children have a disproportionately higher minute ventilation, leading to greater internal exposure to radioactive gases. Children have a significantly greater risk of developing cancer even when they are exposed to radiation in utero. Finally, children and the parents of young children are more likely than are adults to develop enduring psychologic injury after a radiation disaster. The pediatrician has a critical role in planning for radiation disasters. For example, potassium iodide is of proven value for thyroid protection but must be given before or soon after exposure to radioiodines, requiring its placement in homes, schools, and child care centers. Pediatricians should work with public health authorities to ensure that children receive full consideration in local planning for a radiation disaster.
Pediatric Exposure and Potential Toxicity of Phthalate Plasticizers
Authors: Shea Katherine M. ,   Committee on Environmental Health
Published: August 2004

This Technical Report was retired January 2011.

Phthalates are plasticizers that are added to polyvinyl chloride (PVC) products to impart flexibility and durability. They are produced in high volume and generate extensive though poorly defined human exposures and unique childhood exposures. Phthalates are animal carcinogens and can cause fetal death, malformations, and reproductive toxicity in laboratory animals. Toxicity profiles and potency vary by specific phthalate. The extent of these toxicities and their applicability to humans remains incompletely characterized and controversial. Two phthalates, diethylhexyl phthalate (DEHP) and diisononyl phthalate (DINP), have received considerable attention recently because of specific concerns about pediatric exposures. Like all phthalates, DEHP and DINP are ubiquitous contaminants in food, indoor air, soils, and sediments. DEHP is used in toys and medical devices. DINP is a major plasticizer used in children’s toys.

Scientific panels, advocacy groups, and industry groups have analyzed the literature on DEHP and DINP and have come to different conclusions about their safety. The controversy exists because risk to humans must be extrapolated from animal data that demonstrate differences in toxicity by species, route of exposure, and age at exposure and because of persistent uncertainties in human exposure data. This report addresses sensitive endpoints of reproductive and developmental toxicity and the unique aspects of pediatric exposures to phthalates that generate concern. DEHP and DINP are used as specific examples to illustrate the controversy.
Response to Immunization With Measles, Tetanus, andHaemophilus influenzaeType b Vaccines in Children Who Have Human Immunodeficiency Virus Type 1 Infection and Are Treated With Highly Active Antiretroviral Therapy
Authors: Melvin Ann J. , Mohan Kathleen M.
Published: August 2004

Objective. To assess the level of immunity to measles, tetanus, and Haemophilus influenzae type b (Hib) in previously immunized children who have human immunodeficiency virus (HIV) infection and were treated with highly active antiretroviral therapy (HAART) and to determine the response to reimmunization.

Methods. Retrospective review of clinical data from children who have HIV-1 infection and were treated with HAART. Children were included in the analysis when they had a history of immunizations before treatment with HAART; had specific immunoglobulin G levels to tetanus, measles, or Hib measured after starting HAART but before the receipt of additional immunizations; were reimmunized while on HAART; and had postimmunization immunoglobulin G levels available.

Results. Nineteen children (median age: 7 years; range: 3–14 years) who were treated with 3 to 5 drug HAART regimens for a median of 20 months (range: 8–37) met the criteria for at least 1 antigen and were included in this review. Fifteen (79%) of the 19 had plasma RNA levels <50 copies/mL. The median CD4% before HAART was 26% (range: 1–41) and at the time of immunization, 35% (range: 20–54). Before reimmunization, 1 (5%) of 18 children had detectable antibody levels to measles, 6 (35%) of 17 had detectable antibody levels to tetanus, and 14 (78%) of 18 had detectable antibody levels to Hib. After immunization, 15 (83%) of 18, 10 (90%) of 11, and 3 (75%) of 4 seroconverted to measles, tetanus, and Hib, respectively. Antibody levels remained detectable after 1 year in the majority of children tested.

Conclusions. Consideration should be given to readministering childhood immunizations to children who have HIV infection and are treated successfully with combination antiretroviral therapy.
The State of Office-Based Interventions for Youth Tobacco Use
Authors: Pbert Lori , Moolchan Eric T. , Muramoto Myra , Winickoff Jonathan P. , Curry Susan , Lando Harry , Ossip-Klein Deborah , Prokhorov Alexander V. , DiFranza Joseph , Klein Jonathan D. ,   for the Tobacco Consortium, Center for Child Health Research of the American Academy of Pediatrics
Published: August 2004

Tobacco use is a serious pediatric health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Primary care settings provide tremendous opportunities for delivering tobacco treatment to young tobacco users. Although evidence-based practice guidelines for treating nicotine dependence in youths are not yet available, professional organizations and the current clinical practice guideline for adults provide recommendations based on expert opinion. This article reports on the current tobacco treatment practices of pediatric and family practice clinicians, discusses similarities and differences between adolescent and adult tobacco use, summarizes research efforts to date and current cutting-edge research that may ultimately help to inform and guide clinicians, and presents existing recommendations regarding treating tobacco use in youths. Finally, recommendations are made for the primary care clinician, professional organizations, and health care systems and policies. Pediatricians and other clinicians can and should play an important role in treating tobacco dependence in youths.
Evaluating the American Academy of Pediatrics Diagnostic Standard for Streptococcus pyogenes Pharyngitis: Backup Culture Versus Repeat Rapid Antigen Testing
Authors: Gieseker Karen E. , Roe Martha H. , MacKenzie Todd , Todd James K.
Published: August 2004

Objective. The American Academy of Pediatrics recommends that all negative rapid diagnostic tests for Streptococcus pyogenes pharyngitis be backed up by culture, which creates a dilemma for clinicians who must make treatment decisions without complete diagnostic information at the time of visit. The use of a follow-up serial rapid antigen test instead of a follow-up culture would provide a more timely result.

Methods. Two swabs were collected from children who were suspected of having S pyogenes pharyngitis. Each swab was used for a culture and an OSOM Ultra Strep A Test rapid antigen test. The gold standard of comparison was defined as the identification of S pyogenes on either of the 2 culture plates. Three diagnostic strategies were evaluated: a single rapid antigen test, a rapid antigen test with follow-up rapid antigen test (rapid-rapid), and a rapid antigen test with follow-up culture (rapid-culture).

Results. A total of 210 (23.7%) of 887 throat cultures with matched data were identified with S pyogenes. A single rapid antigen test had a sensitivity of 87.6% (95% confidence interval [CI]: 83.2%–92.1%), the sensitivity of the rapid-rapid follow-up was 91.4% (95% CI: 87.6%–95.2%), and the sensitivity of the rapid-culture follow-up was 95.7% (95% CI: 93.0%–98.5%), which was significantly higher than the others. As shown in Fig 1, when these test strategies were evaluated on a subgroup with clinical symptoms commonly associated with S pyogenes pharyngitis, the sensitivities all increased and were no longer significantly different. None of the strategies reliably exceeded a 95% sensitivity threshold.

Conclusions. The American Academy of Pediatrics strategy for S pyogenes detection in children with pharyngitis, requiring a backup culture for those with negative antigen tests, was not exceeded by any other test strategy; however, a rapid-rapid diagnostic strategy may approximate it with the use of judicious clinical selection of patients.
Neurodevelopmental Outcome of Infants Supported With Extracorporeal Membrane Oxygenation After Cardiac Surgery
Authors: Hamrick Shannon E. G. , Gremmels David B. , Keet Corinne A. , Leonard Carol H. , Connell J. Kelly , Hawgood Samuel , Piecuch Robert E.
Published: August 2004

Objectives. To evaluate the long-term neurodevelopmental outcome of infants who underwent cardiac surgery and required extracorporeal membrane oxygenation (ECMO) support, and to examine variables that predict death or disability in these patients.

Methods. We studied all infants who had congenital heart disease and were supported postoperatively with ECMO from 1990 to 2001 at our institution (n = 53). Medical records were reviewed retrospectively to obtain clinical variables. Neurologic and age-appropriate developmental examinations occurred at ages 1, 1.5, 2.5, and 4.5 years. Median age at follow-up was 55 months (9–101). Cognitive outcome was defined as suspect when scores were between 1 and 2 SD below the mean for age and abnormal when scores were >2 SD below mean for age. Neuromotor outcome was defined as suspect when the patient manifested clumsiness, tremor, or mild tone and reflex changes without functional limitations, and abnormal when there were functional limitations.

Results. In-hospital survival was 17 (32%) of 53. Of survivors, 14 (88%) of 16 are living and 1 patient was lost to follow-up. Of the 53 patients, 7 survived completely intact (13%). Seven (50%) of 14 patients had a normal cognitive outcome, 3 (21%) had a suspect cognitive outcome, and 4 (29%) were abnormal. Ten (72%) of 14 patients had a normal neuromotor outcome, 1 (7%) patient had a suspect neuromotor outcome, and 3 (21%) were abnormal. No survivor with an aortic cross-clamp time >40 minutes had a normal cognitive outcome. Nonsurvivors were more likely than survivors to have had cardiac arrest as an indication for ECMO (31% vs 6%), to have had a longer aortic cross-clamp time (mean 73 minutes vs 32 minutes), and to have required continuous arteriovenous hemofiltration (78% vs 35%). The age and weight at cannulation, gender, cardiac diagnosis, interval from surgery to ECMO, cardiopulmonary bypass time, diagnosis of sepsis or mediastinitis, and duration of ECMO were not significantly associated with survival.

Conclusions. Although mortality was 68% in infants who had congenital heart disease and were treated with ECMO postoperatively, of those who survive to hospital discharge, 75% have a normal neuromotor outcome and 50% have a normal cognitive outcome. These high rates of mortality and disability suggest that increased attention be paid to neuroprotection in these complex disorders.
Which Psychiatric Patients Board on the Medical Service?
Authors: Mansbach Jonathan M. , Wharff Elizabeth , Austin S. Bryn , Ginnis Katherine , Woods Elizabeth R.
Published: August 2004

Objectives. Patients who require psychiatric hospitalization may be admitted to a medical service only because there are no available inpatient psychiatric beds. These patients are psychiatric “boarders.” The goals of this study were to describe the extent of the boarder problem and to compare the characteristics of patients who are placed successfully into psychiatric facilities from the emergency department (ED) with those who require admission to the medical service as a boarder.

Methods. A retrospective cohort study of a large pediatric ED was conducted. Included were patients who required inpatient psychiatric admission between July 1, 1999, and June 30, 2000. Patients were excluded when they needed inpatient medical treatment before psychiatric placement. The main outcome measured was placement into a psychiatric facility or boarding on medical service.

Results. Of the 315 patients who presented to the ED and required psychiatric admission, 103 (33%) were boarded on the medical service. Multivariate logistic regression demonstrated an increased odds of boarding for age 10 to 13 years (adjusted odds ratio [AOR]: 3.5; 95% confidence interval [CI]: 1.8–6.6), black race (AOR: 2.3; 95% CI: 1.1–4.8), presenting on a weekend or holiday (AOR: 3.8; 95% CI: 1.6–8.8), and presenting from October to June (October–December 1999 [AOR: 4.7; 95% CI: 1.7–13.4], January–March 2000 [AOR: 14.5; 95% CI: 4.9–42.6], and April–June 2000 [AOR: 10.4; 95% CI: 3.5–30.2]) but a decreased odds for 1 insurance company (AOR: 0.08; 95% CI: 0.02–0.4). There was a linear increase in odds of boarding as severity of homicidal ideation increased from none to mild (AOR: 1.5; 95% CI: 1.2–1.8) to moderate (AOR: 2.3; 95% CI: 2.0–2.6) to severe (AOR: 3.5; 95% CI: 3.2–3.8). Suicidal patients also had increased risk of boarding (AOR: 2.2; 95% CI: 1.2–4.3).

Conclusions. Boarders are a problem in pediatrics, and this study identifies multiple characteristics that were associated with increasing a youth’s odds of becoming a boarder at this institution. The suicidal and homicidal symptom results suggest a reverse triage system in which sicker patients are not necessarily given priority by psychiatric facilities. These data highlight mental health practices that need to be reassessed to ensure optimal care for youths with acute mental illness.
Long-Term Safety of Fluticasone Propionate and Nedocromil Sodium on Bone in Children With Asthma
Authors: Roux Christian , Kolta Sami , Desfougères Jean-Luc , Minini Pascal , Bidat Etienne
Published: August 2004

Objective. Inhaled corticosteroids are recommended as first-line therapy for pediatric asthma. However, few controlled long-term studies have investigated their effect on bone mineral density (BMD) and growth.

Methods. Children who were aged 6 to 14 years and had persistent asthma were randomized to 24 months’ treatment with fluticasone propionate (FP) 200 μg/d or nedocromil sodium (NS) 8 mg/d (if uncontrolled, maximum doses of 400 μg/d and 16 mg/d, respectively). BMD was assessed blind and analyzed at a central facility on the basis of dual-energy x-ray absorptiometry measurements of the lumbar spine and femoral neck at months 0, 6, 12, and 24. Height was measured at months 0, 12, and 24. Efficacy parameters (lung function, asthma control, occurrence of exacerbations) were measured every 3 months.

Results. In total, 174 children were randomized to treatment (87 received FP, and 87 received NS). At month 24, the adjusted mean percentage increase in lumbar spine BMD was 11.6% in the FP group compared with 10.4% in NS-treated children (95% confidence interval for treatment difference: −0.7% to 3.1%). The corresponding increases in femoral neck BMD were 8.9% and 8.5%, respectively. There was no significant difference in growth between the 2 groups: adjusted mean growth rates were 6.1 cm/y with FP and 5.8 cm/y with NS. FP was significantly superior for every efficacy parameter investigated and was similarly well tolerated as NS.

Conclusions. The long-term effects of FP and NS on BMD accrual and growth are similar among children with asthma. The benefit:risk ratio of FP may be considered superior to that of NS.
Fluoroquinolone Safety in Pediatric Patients: A Prospective, Multicenter, Comparative Cohort Study in France
Authors: Chalumeau Martin , Tonnelier Sylvie , d’Athis Philippe , Tréluyer Jean-Marc , Gendrel Dominique , Bréart Gérard , Pons Gérard ,   the Pediatric Fluoroquinolone Safety Study Investigators
Published: August 2004

Objective. To evaluate the safety of fluoroquinolones (FQ) in comparison with other antibiotics in pediatric patients.

Methods. A multicenter, observational, comparative cohort study was conducted between 1998 and 2000 in French pediatric departments. Patients who were receiving systemic FQ were included and matched to control patients who were receiving other antibiotics. Antibiotic-associated potential adverse events (PAEs) were recorded prospectively in both groups, and their rates were compared using univariate and multivariate analyses.

Results. Patients were recruited from 73 centers: 276 patients were exposed to FQ, and 249 composed the control group. Among patients who were exposed to FQ, 23% were younger than 2 years, 33% had cystic fibrosis, and PAEs occurred in 52 patients, leading to withdrawal for 11. The odds ratio for PAE in the FQ group was 3.7 (95% confidence interval: 1.9–7.5) and was not significantly modified after adjustment for potential confounders. Musculoskeletal PAEs also occurred more frequently in the FQ group (3.8%) than in controls (0.4%); they were recorded in 10 patients who were receiving standard FQ doses and were of moderate intensity and transient.

Conclusion. The rates of PAEs and musculoskeletal PAEs were higher for the FQ group than the control group. This observation supports the American Academy of Pediatrics statement restricting off-label FQ use in pediatric patients to second-line treatment in a limited number of situations.
Rest-Activity Patterns in Children With Hypopituitarism
Authors: Rivkees Scott A.
Published: August 2004

Objectives. Physical lesions in the region of the suprachiasmatic nuclei, which are the site of a circadian clock, result in abnormal circadian rhythmicity in animals, yet the extent of biological rhythm problems in individuals with anatomic or functional lesions in the hypothalamic-pituitary region are largely unknown. To address this issue, we examined patterns of rest and activity of children with hypopituitarism.

Methods. Children who were between the ages of 2 and 18 years and had the diagnosis of panhypopituitarism were evaluated. Twenty children were studied, including children with septo-optic dysplasia (SOD), congenital hypopituitarism, brain tumors, closed head trauma, and head irradiation. For assessing patterns of activity, individuals wore Actiwatches for 3–4 weeks to measure patterns of gross motor activity.

Results. Seventeen children had normal patterns of rest and activity, with an average period length of 24.01 ± 0.01 hours. Three children, including 2 with SOD and 1 with a hypothalamic germinoma, showed abnormal activity patterns in which there was not consolidated rest at night. One patient with an optic glioma had nonentrained circadian phase.

Conclusions. A proportion of children with hypopituitarism have abnormal daily rest-activity patterns. Children with anterior hypothalamic tumors and SOD seem to be at risk for circadian system dysfunction.
Strangulation With Intravenous Tubing: A Previously Undescribed Adverse Advent in Children
Authors: Garros Daniel , King W. James , Brady-Fryer Barbara , Klassen Terry P.
Published: August 2004

Nonintentional strangulation in children is a widely recognized risk as a result of the vulnerability of their airway to occlusion by relatively low pressures. We describe 2 cases of strangulation by intravenous (IV) tubing in infants, 1 of which was fatal. This is the first documentation in the health science literature of this as a potential adverse consequence of IV therapy in young children. It is important that hospitals that care for such children recognize this potential risk and implement the appropriate strategies to minimize or eliminate it. Preventive interventions may include ongoing assessment of the need for continuous rather than intermittent IV infusions (saline or heparin locked IV sites), individualized level of supervision according to the child’s age and behavior, and engineering modifications to the IV equipment.
Diffusion-Weighted Imaging of the Brain in Preterm Infants With Focal and Diffuse White Matter Abnormality
Authors: Counsell Serena J. , Allsop Joanna M. , Harrison Michael C. , Larkman David J. , Kennea Nigel L. , Kapellou Olga , Cowan Frances M. , Hajnal Joseph V. , Edwards A. David , Rutherford Mary A.
Published: August 2004

Objective. The most common finding on magnetic resonance imaging (MRI) of the brain in preterm infants at term-equivalent age is diffuse excessive high signal intensity (DEHSI) in the white matter. It is unclear whether DEHSI represents a biological abnormality. This study used diffusion-weighted imaging (DWI) to compare apparent diffusion coefficient (ADC) values in DEHSI with infants with normal imaging and those with overt brain damage to determine whether DEHSI shows the diffusion characteristics of normal or abnormal tissue.

Methods. MRI, using conventional and diffusion-weighted imaging (DWI), was performed in 50 preterm infants at term-equivalent age using a 1.5 Tesla MR scanner. The infants were divided into 3 groups on the basis of their MRI results: 1) normal white matter, 2) DEHSI, or 3) overt white matter pathology. ADC values were measured in the frontal, central, and posterior white matter at the level of the centrum semiovale. ADC values in the 3 groups of preterm infants were compared using a 1-way analysis of variance with a Bonferroni test for multiple comparisons.

Results. ADC values were significantly higher in infants with DEHSI and infants with overt white matter pathology than in infants with normal white matter. There was no significant difference between ADC values in infants with DEHSI and those with overt white matter pathology.

Conclusions. This study provides objective evidence that DEHSI represents diffuse white matter abnormality.
A Population-Based Study of the 22q11.2 Deletion: Phenotype, Incidence, and Contribution to Major Birth Defects in the Population
Authors: Botto Lorenzo D. , May Kristin , Fernhoff Paul M. , Correa Adolfo , Coleman Karlene , Rasmussen Sonja A. , Merritt Robert K. , O’Leary Leslie A. , Wong Lee-Yang , Elixson E. Marsha , Mahle William T. , Campbell Robert M.
Published: August 2004

Objectives. Although several studies describe the 22q11.2 deletion, population-based data are scant. Such data are needed to evaluate properly the impact, distribution, and clinical presentation of the deletion in the population. Our goals were to assess the population-based birth prevalence of the 22q11.2 deletion and its associated phenotype and its impact on the occurrence of heart defects.

Methods. We evaluated data on infants who were born from 1994 through 1999 to women who resided in metropolitan Atlanta. We matched records from the Metropolitan Atlanta Congenital Defects Program (a population-based registry with active case ascertainment), the Sibley Heart Center at Children’s Healthcare of Atlanta, and the Division of Medical Genetics at Emory University. We used birth certificate data for the denominators of the rates.

Results. We identified 43 children with laboratory-confirmed 22q11.2 deletion among 255 849 births. The overall prevalence was 1 in 5950 births (95% confidence interval: 1 in 4417 to 1 in 8224 births). The prevalence was between 1 in 6000 and 1 in 6500 among whites, blacks, and Asians and 1 in 3800 among Hispanics. Most affected children (81%) had a heart defect, and many (1 in 3) had major extracardiac defects (other than velopalatal anomalies), including anomalies of the central nervous system. Overall, the deletion contributed to at least 1 of every 68 cases of major heart defects identified in the total birth cohort and, in particular, to 1 of every 2 cases diagnosed with interrupted aortic arch type B, 1 of every 5 with truncus arteriosus, and 1 of every 8 with tetralogy of Fallot.

Conclusions. The 22q11.2 deletion was common in this birth population. The clinical phenotype included a wide and variable spectrum of major cardiac and extracardiac anomalies. From these population-based data, one can estimate that at least 700 affected infants are born annually in the United States. Population-based estimates such as these should be useful to medical professionals and policy makers in planning for the optimal care of people with the 22q11.2 deletion.
Comparison of Propofol/Fentanyl Versus Ketamine/Midazolam for Brief Orthopedic Procedural Sedation in a Pediatric Emergency Department
Authors: Godambe Sandip A. , Elliot Vanessa , Matheny Dana , Pershad Jay
Published: August 2004

Purpose. To compare the effectiveness of 2 medication regimens, propofol/fentanyl (P/F) and ketamine/midazolam (K/M), for brief orthopedic emergency department procedural sedation. This study was powered to compare recovery times (RT) and procedural distress as measured by the Observational Score of Behavioral Distress-revised (OSBD-r; range: 0–23.5 with 23.5 representing maximal distress).

Methods. We conducted a prospective, partially-blinded controlled comparative trial comparing intravenous P/F with K/M in a convenience sample of 113 patients aged 3 to 18 years old undergoing orthopedic procedural sedation. All medications were administered by the intermittent intravenous bolus method. An independent sedation nurse recorded total sedation time and RT. Effectiveness was measured using 6 parameters: 1) patient distress as assessed by independent blinded observers after videotape review using the OSBD-r; 2) orthopedic satisfaction score (Likert scale 1–5); 3) sedation nurse satisfaction score (Likert 1–5); 4) parental perception of procedural pain using a 0 to 100 mm Visual Analog Scale with the upper limit being “most pain”; 5) patient recall of the procedure; and 6) 1 to 3 week follow-up.

Results. RT and total sedation time were significantly less in the P/F group than in the K/M group (33.4 minutes vs 23.2 minutes). The mean OSBD-r scores during manipulation were 0.084 and 0.278 for the K/M and P/F groups, respectively. Although this difference was statistically significant (95% confidence interval for the mean difference −0.34 to −0.048), both regimens were successful in keeping the scores low. There was no statistical difference between the groups in the other measures of effectiveness. There was a statistically significant difference between the groups in the occurrence of desaturation and late side effects.

Conclusions. RT with P/F is shorter than with K/M. P/F is comparable to K/M in reducing procedural distress associated with painful orthopedic procedures in the pediatric emergency department. Although propofol has a greater potential of respiratory depression and airway obstruction as compared with ketamine, it offers some unique advantages including a quicker offset and smoother recovery profile.
Appropriateness of Admissions and Days of Stay in Pediatric Wards of Italy
Authors: Bianco Aida , Pileggi Claudia , Trani Francesca , Angelillo Italo F.
Published: August 2004

Objective. The objective of this study was to measure inappropriateness of admission and inpatient days in pediatric hospital wards in Catanzaro, Italy, and the effect of different variables on such inappropriateness.

Design. A retrospective application was made using the Pediatric Appropriateness Evaluation Protocol list of criteria. For each patient, there were recorded data on: sociodemographic characteristics; distance from home to hospital; date, day of the week, ward, and type of admission; overall and pre-index day length of hospital stay; and location within the stay of the day reviewed.

Results. A total of 656 children were reviewed. Overall, 30% of the hospital admissions and 55.5% of days of stay were judged to be inappropriate; for about one third of those admitted inappropriately, the hospital stay was judged to be appropriate. Multiple logistic regression analysis indicated that the inappropriate admission was significantly higher if the admission occurred during the daytime. The inappropriate number of days of hospitalization was significantly higher if the patient was female, if the admission was urgent, in medical wards, for patients who were inappropriately admitted, and for those sampled close to discharge. The main reasons for inappropriate use were hospital organization and an over-cautious physician in the management of a patient.

Conclusions. The high degree of inappropriate admission or days of stay in pediatric wards and the reasons for such unnecessary hospital use suggest the need for a more vigilant interaction between hospital and community-based services to mitigate such inappropriateness and for a continuing education system to define standardized guidelines.
Comprehensive Assessments for Children Entering Foster Care: A National Perspective
Authors: Leslie Laurel K. , Hurlburt Michael S. , Landsverk John , Rolls Jennifer A. , Wood Patricia A. , Kelleher Kelly J.
Published: August 2004

Objectives. To 1) investigate the status of policies for comprehensive health assessments of children entering out-of-home care, 2) develop a profile for each primary sampling unit (PSU) regarding the comprehensiveness of its assessment policies with respect to physical, mental, and developmental health, and 3) examine the relationship between inclusiveness and the estimated percentage of children assessed, primary assessment location, and principal assessment provider type.

Method. In collaboration with the National Survey of Child and Adolescent Well-Being, a national probability sample of 92 PSUs was identified. Detailed telephone survey data, addressing policies for the assessment of physical, mental, and developmental needs of children on entry into out-of-home care, were collected from child welfare key informants. Descriptive statistics were used for analyses, and were weighted to account for the sampling strategy.

Results. Over 94% of PSUs surveyed assessed all children for physical health problems. The percentage of PSUs with inclusive policies regarding mental health and developmental assessment was much lower (47.8% and 57.8%, respectively). Only 42.6% of PSUs provided comprehensive physical, mental health, and developmental examinations inclusive of all children entering out-of-home care. Community locations and primary care providers were most often used to conduct assessments for physical and developmental problems.

Conclusions. Despite the publication of national guidelines regarding assessment, many PSUs do not have comprehensive policies or routine practices that address all children entering out-of-home care. Given the high use of primary care providers, these providers must be educated regarding the prevalence and types of problems experienced by children entering foster care.
Diagnosis and Treatment of Acute Otitis Media: An Assessment
Authors: Garbutt Jane , Jeffe Donna B. , Shackelford Penelope
Published: August 2004

Objective. To assess compliance with the Centers for Disease Control and Prevention (CDC) evidence-based guidelines for the judicious use of antimicrobials in children with acute otitis media (AOM).

Methods. Compliance with CDC’s recommended diagnostic criteria and antimicrobial treatments for management of AOM was assessed by chart review and self-report for 29 community pediatricians in St. Louis, Missouri. For each physician, a simple random sample of AOM visits was selected and reviewed by trained reviewers. In addition, each physician completed a questionnaire.

Results. Compliance with recommended diagnostic criteria was 38% (95% confidence interval: 34%–42%; n = 573) by chart audit and 41% (95% confidence interval: 24%–61%; n = 29) by self-report. Antimicrobial selection assessed by chart audit was consistent with CDC guidelines in 68% (95% confidence interval: 64%–72%) of visits for a new infection, 63% (95% confidence interval: 47%–78%) of visits for treatment failure, and 50% (95% confidence interval: 33%–67%) for recurrent disease. Self-reported compliance with treatment guidelines for new infection was 100% (95% confidence interval: 88%–100%) and 83% (95% confidence interval: 64%–94%) for treatment failure. Noncompliance was most frequently attributable to overuse of broad-spectrum antimicrobials. Most patients treated with amoxicillin received a 10-day course (98%). Subtherapeutic dosing occurred in 26% of patients treated with amoxicillin.

Conclusions. Overdiagnosis of AOM is common. Efforts to improve the judicious use of antimicrobials for AOM should focus on improving diagnostic accuracy, limiting the use of broad-spectrum antimicrobials to cases where they offer clinical benefit, and ensuring that amoxicillin dosing regimens are optimal.
Early Physical Activity Intervention Prevents Decrease of Bone Strength in Very Low Birth Weight Infants
Authors: Litmanovitz Ita , Dolfin Tzipora , Friedland Orit , Arnon Shmuel , Regev Rivka , Shainkin-Kestenbaum Ruth , Lis Monika , Eliakim Alon
Published: August 2004

Objective. To evaluate the effect of early range-of-motion intervention on bone strength and bone turnover in very low birth weight infants.

Methods. Twenty-four infants (mean birth weight: 1135 ± 247 g; mean gestational age: 28.5 ± 2.3 weeks) were matched for gestational age and birth weight and then randomly assigned into exercise (n = 12) and control (n = 12) groups. Exercise protocol started at the first week of life and involved daily extension and flexion range of motion against passive resistance of the upper and lower extremities (5 minutes per day, 5 days per week, 4 weeks). Growth parameters, bone strength, and biochemical markers of bone homeostasis were measured at enrollment and after 4 weeks. Bone strength was determined using quantitative ultrasound measurement of bone speed of sound (SOS) at the middle left tibial shaft.

Results. Bone SOS decreased significantly in the control group during the study period (from 2892 ± 30 m/sec to 2799 ± 26), whereas bone SOS of the exercise group remained stable (2825 ± 32 m/sec and 2827 ± 26 m/sec at baseline and 4 weeks, respectively). This significant difference in bone SOS was not expressed in the biochemical markers of bone homeostasis.

Conclusions. There is a significant postnatal decrease in the bone SOS of very low birth weight infants. A brief range-of-motion exercise attenuates the decrease in bone strength and may decrease the risk of osteopenia.
Fractures in Biliary Atresia Misinterpreted as Child Abuse
Authors: DeRusso Patricia A. , Spevak Melissa R. , Schwarz Kathleen B.
Published: August 2004

Bone fractures in children without a history of injury are highly suspicious for child abuse. Biliary atresia is a disorder associated with metabolic bone disease, and there are numerous reports of osteopenia, rickets, and/or fractures in this population. We report 3 cases of children with biliary atresia who had bony fractures as well as osteopenia whose caretakers were investigated for child abuse. Pediatricians should be aware of an increased incidence of fractures and overall prevalence of bone disease in this population.
Anti-β2-Glycoprotein I Antibodies and Ischemic Stroke in a 20-Month-Old Boy
Authors: Katsarou Eustathia , Attilakos Achilleas , Fessatou Smaragdi , Tsapra Heleni , Tzavara Vasiliki , Dracou Christina
Published: August 2004

Antibodies to β2-glycoprotein I (anti-β2GPI) have been associated with recurrent thrombosis and pregnancy morbidity. However, the prevalence of anti-β2GPI in children suffering from cerebral infarction is unknown. We report on a 20-month-old boy who had an ischemic stroke, secondary to antiphospholipid syndrome with high titers of immunoglobulin G anti-β2GPI (first titer: 132 U; second titer 6 weeks later: 350 U; normal range: 0–100 U). Anticardiolipin antibodies and lupus anticoagulant tests were negative. All other causes of infarction were excluded. Laboratory studies showed anti-β2GPI IgG levels of 164 U and 216 U at 6 months and 2 years, respectively, after the onset. The patient received treatment with low-dose aspirin. To our knowledge, this is the first reported case of childhood ischemic stroke with only anti-β2GPI but no antibodies detectable in standard antiphospholipid assays. This case supports the recommendation of others to search for these antibodies in the presence of strong clinical suspicion of antiphospholipid syndrome, when anticardiolipin antibodies and lupus anticoagulant tests are negative.