bluuebunny/crossref_metadata_2025 huggingface dataset:
Does Gatekeeping Control Costs for Privately Insured Children? Findings From the 1996 Medical Expenditure Panel Survey
Authors: Pati Susmita , Shea Steven , Rabinowitz Daniel , Carrasquillo Olveen
Published: August 2004

Objective. Gatekeeping requirements were widely adopted by health insurers in an attempt to control costs in the mid-1990s, but empirical evidence demonstrating decreased health expenditures for children enrolled in such plans is lacking.

Methods. We analyzed data from 3254 children with private health insurance sampled in the 1996 Medical Expenditure Panel Survey (MEPS) to compare total per capita health expenditures among gatekeeping versus indemnity plan enrollees. This sample represents 40.4 million privately insured American children. Total expenditures were defined as payments from all sources, including third-party and out-of-pocket payments, but excluding administrative costs. MEPS data are based on information provided by patients, health care providers, and hospitals. Gatekeeping plans included all children enrolled in health maintenance organizations or other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees.

Results. Mean total per capita annual expenditures for children in gatekeeping versus indemnity plans differed by <1% ($887 vs $881, respectively). Third-party payments by gatekeeping plans on behalf of their beneficiaries were $636 versus $595 by indemnity plans. Out-of-pocket payments were on average $62 less for gatekeeping enrollees than for indemnity enrollees. After multivariate adjustment, mean per capita expenditures were approximately 4% lower for gatekeeping enrollees than for indemnity enrollees.

Conclusion. In 1996, total per capita annual health expenditures for children in gatekeeping plans were approximately $8 less than for those in indemnity plans. These data indicate that gatekeeping is not an effective cost-containment method for children.
Soluble E-Selectin, Soluble L-Selectin and Soluble ICAM-1 in Bronchopulmonary Dysplasia, and Changes With Dexamethasone
Authors: Ballabh Praveen , Kumari Jaishree , Krauss Alfred N. , Shin Junghee J. , Jain Ajey , Auld Peter A. M. , Lesser Martin L. , Cunningham-Rundles Susanna
Published: August 2004

Objective. To evaluate longitudinal change in arterial blood plasma levels of soluble adhesion molecules in infants of <30 weeks’ gestation with respiratory distress syndrome (RDS) and to look for differences in these levels in neonates who subsequently developed bronchopulmonary dysplasia (BPD) compared with those neonates who did not, and also to investigate the effect of dexamethasone treatment on levels of soluble adhesion molecules in plasma.

Methods. We measured plasma concentrations of soluble L-selectin (sL-selectin), soluble E-selectin (sE-selectin), and soluble intercellular adhesion molecule-1 on days 1, 3, 7, 14, 21, and 28 of life and before and 2 to 3 days after initiating a 6-day course of dexamethasone treatment. Infants with RDS were followed until discharge and were classified as non-BPD and either 1) BPD day 28 reflecting oxygen requirement on day 28 but not at 36 corrected weeks or 2) BPD 36 weeks reflecting oxygen requirement at 36 (corrected) weeks’ gestation. The classification of presence or absence of BPD by oxygen requirement was supported by and was consistent with radiologic findings of BPD for all infants. The difference between BPD day 28 and BPD 36 weeks was supported by more extensive radiologic effects in the latter.

Results. The arterial plasma level of sL-selectin in infants who had RDS and did not develop BPD was significantly decreased compared with term healthy infants, as was the level of sE-selectin. Compared with infants who had RDS and did not develop BPD, sL-selectin levels were even further decreased in infants who had RDS and did develop BPD both at birth and throughout the first 4 weeks of life (day 1 through day 28). Infants with BPD also showed increasing levels of sE-selectin during this period of time, whereas infants without BPD did not. Levels of soluble intercellular adhesion molecule-1 in infants without BPD were not different from infants with BPD initially but increased in infants with BPD compared with infants without BPD, significant on day 28 in both groups. Dexamethasone treatment increased concentration of sL-selectin and decreased concentration of sE-selectin.

Conclusions. Low sL-selectin may be an early indicator of enhanced risk for BPD. Low levels of sL-selectin and increasing levels of sE-selectin may be risk factors for BPD. The effects of dexamethasone treatment include significant modulation of adhesion molecules.
Pulmonary Outcome at 1 Year Corrected Age in Premature Infants Treated at Birth With Recombinant Human CuZn Superoxide Dismutase
Authors: Davis Jonathan M. , Parad Richard B. , Michele Theresa , Allred Elizabeth , Price Anita , Rosenfeld Warren ,   for the North American Recombinant Human CuZnSOD Study Group
Published: August 2004

Objective. To examine whether treatment of premature infants with intratracheal recombinant human CuZn superoxide dismutase (r-h CuZnSOD) reduces bronchopulmonary dysplasia and improves pulmonary outcome at 1 year corrected age.

Design. Three hundred two premature infants (600–1200 g birth weight) treated with exogenous surfactant at birth for respiratory distress syndrome were randomized to receive either intratracheal r-h CuZnSOD (5 mg/kg in 2 mL/kg saline) or placebo every 48 hours (as long as intubation was required) for up to 1 month of age. Short-term, as well as longer-term pulmonary outcome was assessed.

Results. There were no differences between groups in the incidence of death or the development of bronchopulmonary dysplasia (oxygen requirement with an Edwards chest radiograph score of ≥3) at 28 days of life or 36 weeks’ postmenstrual age. r-h CuZnSOD was well-tolerated and not associated with significant increases in any adverse event. At a median of 1 year corrected age, health assessments and physical examinations were performed on 209 (80%) surviving infants, with complete data available on 189 infants. Thirty-seven percent of placebo-treated infants had repeated episodes of wheezing or other respiratory illness severe enough to require treatment with asthma medications such as bronchodilators and/or corticosteroids compared with 24% of r-h CuZnSOD-treated infants, a 36% reduction. In infants <27 weeks’ gestation, 42% treated with placebo received asthma medications compared with 19% of r-h CuZnSOD-treated infants, a 55% decrease. Infants <27 weeks’ gestation who received r-h CuZnSOD also had a 55% decrease in emergency department visits and a 44% decrease in subsequent hospitalizations. Growth measurements and the results of physical examinations were comparable between groups.

Conclusions. These data indicate that treatment at birth with r-h CuZnSOD may reduce early pulmonary injury, resulting in improved clinical status when measured at 1 year corrected age. r-h CuZnSOD appears to be a safe and effective therapy that improves pulmonary outcome in high-risk premature infants.
Clinical Effects ofl-Carnitine Supplementation on Apnea and Growth in Very Low Birth Weight Infants
Authors: Whitfield Jonathan , Smith Twyala , Sollohub Heather , Sweetman Lawrence , Roe Charles R.
Published: August 2004

Objective. Systemic carnitine deficiency may present with apnea, hypotonia, and poor growth. Premature infants often manifest these symptoms and are at risk of developing carnitine deficiency because of immaturity of the biosynthetic pathway, lack of sufficient predelivery transplacental transport, and lack of sufficient exogenous supplementation. This study was undertaken to examine the effect of carnitine supplementation in premature infants.

Methods. Eighty preterm infants <1500 g were enrolled in a prospective, double-blind, placebo-controlled study of carnitine supplementation within 96 hours of delivery. Growth, length of hospital stay, and frequency and severity of apnea were the primary outcome measures.

Results. Weight gain and change in length, fronto-occipital head circumference, mid arm circumference, and triceps skinfold thickness were similar between the carnitine-supplemented and placebo groups. The amount and severity of apnea and the overall length of hospitalization were also similar between the 2 groups. The carnitine levels in the supplemented group were significantly higher than in the placebo group at 4 and 8 weeks after study entry.

Conclusion. Although preterm infants <1500 g have low carnitine levels, routine supplementation with carnitine has no demonstrable effect on growth, apnea, or length of hospitalization and thus seems to be unnecessary.
Chronic Lung Disease of Prematurity and Intrauterine Growth Retardation: A Population-Based Study
Authors: Lal Mithilesh K. , Manktelow Bradley N. , Draper Elizabeth S. , Field David J.
Published: August 2004

Objective. To determine the risk of chronic lung disease (CLD) in small for gestational age (SGA) preterm infants in comparison to appropriately grown and large for gestational age (LGA) infants.

Methods. Observational study derived from a geographically defined population (Trent Health Region, United Kingdom). All preterm infants of ≤32 completed weeks’ gestation born to Trent resident mothers admitted to neonatal units between 1995 and 1999 (inclusive) were included. Birth weight percentiles were created for the whole population, and infants were classified as SGA infants (if <10th percentile), appropriately grown (if between 25th and 75th percentiles—reference group), and LGA infants (if ≥90th centile). Both mortality and CLD rates (using both 28 days’ and 36 weeks’ postmenstrual age [PMA] definitions) were determined for these groups of infants.

Results. Four thousand fifty-one preterm infants ≤32 weeks’ gestation were identified. SGA infants showed higher mortality before 28 days’ postnatal age and 36 weeks’ PMA as compared with reference group infants (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.49–2.72; and OR: 2.00, 95% CI: 1.49–2.69), respectively.

SGA infants showed a significantly greater risk of developing CLD, both at 28 days’ and 36 weeks’ PMA as compared with the reference group infants (OR: 1.34, 95% CI: 1.03–1.74; and OR: 1.87, 95% CI: 1.39–2.51), respectively. LGA infants showed a trend toward a reduced incidence of CLD in comparison to the reference group, which was statistically significant for the 36 weeks’ definition (OR: 0.76–28 weeks, 95% CI: 0.57–1.01; and OR: 0.55–36 weeks, 95% CI: 0.37–0.81).

Conclusions. Fetal growth seems to influence mortality in general and morbidity, attributable to CLD, in particular in preterm infants. SGA preterm infants are at higher risk of death before 28 days’ and 36 weeks’ PMA and CLD by both definitions. LGA infants show reduced risk of CLD.
Prolongation of Satiety After Low Versus Moderately High Glycemic Index Meals in Obese Adolescents
Authors: Ball Shauna D. , Keller Kelly R. , Moyer-Mileur Laurie J. , Ding Yi-Wen , Donaldson David , Jackson W. Daniel
Published: August 2004

Background. One in 5 American children is overweight, despite a decrease in total fat consumption. This has sparked an interest in the carbohydrate composition of diets, including the glycemic index (GI).

Objective. To investigate whether a low-GI meal replacement (LMR) produced similar metabolic, hormonal, and satiety responses in overweight adolescents as a low-GI whole-food meal (LWM) when compared with a moderately high-GI meal replacement (HMR).

Methods. Randomized, crossover study comparing LMR, HMR, and LWM in 16 (8 male/8 female) adolescents during 3 separate 24-hour admissions. The meal replacements consisted of a shake and a nutrition bar. Identical test meals were provided at breakfast and lunch. Metabolic and hormonal indices were assessed between meals. Measures of participants’ perceived satiety included hunger scales and ad libitum food intake.

Results. The incremental areas under the curve for glucose were 46% and 43% lower after the LMR and LWM, respectively, compared with the HMR. Insulin’s incremental area under the curve was also significantly lower after both low GI test meals (LMR = 36%; LWM = 51%) compared with the HMR. Additional food was requested earlier after the HMR than the LMR (3.1 vs 3.9 hours, respectively), although voluntary energy intake did not differ.

Conclusions. Differences in insulin response between the meal replacements occurred, and prolongation of satiety after the LMR, based on time to request additional food, was observed. We speculate that the prolonged satiety associated with low GI foods may prove an effective method for reducing caloric intake and achieving long-term weight control.
Internet-Enabled Interactive Multimedia Asthma Education Program: A Randomized Trial
Authors: Krishna Santosh , Francisco Benjamin D. , Balas E. Andrew , König Peter , Graff Gavin R. , Madsen Richard W.
Published: August 2004

Objective. To determine whether health outcomes of children who have asthma can be improved through the use of an Internet-enabled interactive multimedia asthma education program.

Methods. Two hundred twenty-eight children with asthma visiting a pediatric pulmonary clinic were randomly assigned to control and intervention groups. Children and caregivers in both groups received traditional patient education based on the National Asthma Education and Prevention Program. Intervention group participants received additional self-management education through the Interactive Multimedia Program for Asthma Control and Tracking. Pediatric Asthma Care Knowledge Survey, Pediatric Asthma Caregiver’s Quality of Life Questionnaire, asthma symptom history, spirometry, and health services utilization data were collected at the initial visit and at 3 and 12 months.

Results. Interactive Multimedia Program for Asthma Control and Tracking significantly increased asthma knowledge of children and caregivers, decreased asthma symptom days (81 vs 51 per year), and decreased number of emergency department visits (1.93 vs 0.62 per year) among the intervention group participants. The intervention group children were also using a significantly lower average daily dose of inhaled corticosteroids (434 vs 754 μg [beclomethasone equivalents]) at visit 3. Asthma knowledge of all 7- to 17-year-old children correlated with fewer urgent physician visits (r = 0.37) and less frequent use of quick-relief medicines (r = 0.30).

Conclusions. Supplementing conventional asthma care with interactive multimedia education can significantly improve asthma knowledge and reduce the burden of childhood asthma.
Effects on Breastfeeding of Changes in Maternity Length-of-Stay Policy in a Large Health Maintenance Organization
Authors: Madden Jeanne M. , Soumerai Stephen B. , Lieu Tracy A. , Mandl Kenneth D. , Zhang Fang , Ross-Degnan Dennis
Published: August 2004

Objective. The purpose of this study was to evaluate the effects on breastfeeding rates of a private-sector early discharge program and a subsequent government mandate guaranteeing 48 hours of hospital coverage.

Methods. Interrupted time-series analyses were conducted on retrospective data from the automated medical records of a large health maintenance organization in eastern Massachusetts. A population of 20 366 mother-infant pairs with normal vaginal deliveries between October 1990 and March 1998 was identified. This study period spanned the 2 interventions of interest: 1) the introduction of a new health maintenance organization protocol of 1 postpartum overnight hospitalization followed by a nurse home visit for normal vaginal deliveries, then 2) Massachusetts state minimum coverage legislation. Breastfeeding initiation and breastfeeding continuation among initiators (exclusive or with supplements) into the third month of life were determined through a text search of the first 90 days of infants’ automated medical records.

Results. Both policies had dramatic impacts on length of stay (LOS); postpartum LOS <2 nights rose from 29% of pairs to 65% when the early discharge program was implemented, then fell to 15% after the state mandate. Breastfeeding initiation, however, rose gradually from 71% in the fourth quarter of 1990 to 82% in the first quarter of 1998, with no changes after the interventions. Continuation of breastfeeding among those who initiated remained constant at 73%. Younger maternal age, primiparity, low socioeconomic status, and nonwhite race all were found to be risk factors for lower rates of breastfeeding (either initiation or continuation), but there was no evidence of a decline in breastfeeding associated with shorter LOS among these vulnerable groups.

Conclusions. Early postpartum discharge with outpatient breastfeeding support and a home visitor program has no adverse effects on initiation or continuation of breastfeeding.
Early-Onset Group B Streptococcal Infection After a Combined Maternal and Neonatal Group B Streptococcal Chemoprophylaxis Strategy
Authors: Velaphi Sithembiso , Siegel Jane D. , Wendel George D. , Cushion Nancy , Eid Walid M. , Sánchez Pablo J.
Published: August 2004

Objective. In January 1995, a combined maternal and neonatal protocol for prevention of early-onset group B streptococcal (GBS) infection was implemented that consisted of a risk factor-based approach for maternal intrapartum chemoprophylaxis using ampicillin combined with a single intramuscular dose of penicillin given to all newborns within 1 hour of delivery. The objective of this study was to review the cases of early-onset GBS infections that occurred from 1995 to 1999 to identify factors associated with their continued occurrence despite implementation of a GBS chemoprophylaxis protocol.

Methods. Infants ≤72 hours of age with early-onset GBS infection born at Parkland Memorial Hospital in Dallas from January 1995 to December 1999 were identified through a prospective laboratory-based surveillance system. Maternal and infant medical records were reviewed for clinical and demographic data.

Results. There were 32 cases (0.47/1000 live births) of early-onset GBS infection for the 5-year period. This represented a 76% reduction compared with the rate from 1986 to 1994 (1.95/1000), when there was no protocol for GBS chemoprophylaxis. Thirteen cases (41%) did not have any identifiable maternal risk factor. Of the 19 cases (59%) with risk factors, maternal intrapartum fever was the most frequent (15 [79%]), followed by prematurity (6 [32%]) and prolonged rupture of membranes (6 [32%]). Among the 19 mothers with risk factors, 15 (79%) mothers received intrapartum chemoprophylaxis, and 12 (80%) of the 15 mothers had intrapartum fever. Only 33% of mothers with risk factors received ≥2 doses of intrapartum chemoprophylaxis, and among those with intrapartum fever, 25% received ≥2 doses. None of the 32 infants with early-onset GBS infection received the combination of intrapartum ampicillin and postnatal penicillin.

Conclusions. A combined obstetric and neonatal chemoprophylaxis protocol significantly reduced early-onset GBS infection. Maternal intrapartum fever was the most frequent risk factor associated with failure of chemoprophylaxis.
Functional Disability and School Activity Limitations in 41 300 School-Age Children: Relationship to Medical Impairments
Authors: Msall Michael E. , Avery Roger C. , Tremont Michelle R. , Lima Julie C. , Rogers Michelle L. , Hogan Dennis P.
Published: August 2004

Objective. Our purpose was to examine the contribution of medical impairments to functional disability and school activity limitations in 41 300 school-age children participating in the 1994–1995 National Health Interview Survey.

Methods. The 1994 and 1995 National Health Interview Survey and Disability Interview Supplement samples provide International Classification of Diseases, Ninth Revision medical impairment codes for children with functional limitations or school activity limitations in a nationally representative US sample. Functional limitations were distributed as follows: mobility 12.4/1000 (95% confidence interval [CI]: 11.1–13.6), self-care 8.8/1000 (95% CI: 7.7–9.8), communication 52.9/1000 (95% CI: 50.2–55.5), and learning 104.6/1000 (95% CI: 100.7–108.4). Functional disability status was classified as 4.1% mild, 5.9% major, and 1.9% multiple. School activity limitations included 4.1% needing or receiving special education, 0.7% unable to attend, and 0.9% limited attendance. We categorized International Classification of Diseases, Ninth Revision impairment codes reported in conjunction with medical usage as physical disorders (n = 1251; eg, leukemia, diabetes), asthma (n = 916), neurodevelopmental disorders (n = 802; eg, cerebral palsy, epilepsy, mental retardation, autism, blindness, deafness), and learning-behavior disorders (n = 806; eg, attention-deficit/hyperactivity disorder, learning disability, anxiety) for children with functional or school activity limitations. Of children with multiple functional disabilities, 29.9% had neurodevelopmental disorders, 27.1% had learning-behavior disorders, 18.1% had physical disorders, 4.2% had asthma, and 20.8% did not have an identified medical impairment because they had not received medical services in the past year. Among children requiring special education, physical disorders accounted for 9.4%, neurodevelopmental disorders for 16.7%, learning and behavior disorders for 17%, asthma for 3.4%, and 53.4% did not have an identified medical impairment because they had not received medical services in the past year.

Conclusions. Chronic health impairments, neurodevelopmental disorders, learning-behavior disorders, and functional limitations in essential activities are required to understand the complexity of disability in school-age children. A large number of children with functional disability or school activity limitations have not received ongoing medical services.
Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study
Authors: Dube Shanta R. , Felitti Vincent J. , Dong Maxia , Chapman Daniel P. , Giles Wayne H. , Anda Robert F.
Published: August 2004

Objective. Illicit drug use is identified in Healthy People 2010 as a leading health indicator because it is associated with multiple deleterious health outcomes, such as sexually transmitted diseases, human immunodeficiency virus, viral hepatitis, and numerous social problems among adolescents and adults. Improved understanding of the influence of stressful or traumatic childhood experiences on initiation and development of drug abuse is needed.

Methods. We examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age categories: ≤14 years, 15 to 18 years, or as an adult (≥19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use.

Results. Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug addiction, and parenteral drug use. Compared with people with 0 ACEs, people with ≥5 ACEs were 7- to 10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use. The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%, 64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong graded relationship to lifetime drug use.

Conclusions. The ACE score had a strong graded relationship to the risk of drug initiation from early adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to account for one half to two third of serious problems with drug use, progress in meeting the national goals for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing childhood experiences by pediatric practice.
Intravenous Bisphosphonate Therapy in Children With Osteogenesis Imperfecta
Authors: Falk Marni J. , Heeger Shauna , Lynch Katherine A. , DeCaro Kathleen R. , Bohach Deborah , Gibson Karen S. , Warman Matthew L.
Published: August 2004

Objective. Several studies have reported beneficial effects of bisphosphonates in children with osteogenesis imperfecta (OI); however, these studies have differed in the protocols they used, and none has been independently replicated. We intended to confirm the efficacy of a specific intravenous bisphosphonate protocol in children with moderate to severe OI.

Methods. We used the protocol described by Glorieux et al and performed a prospective clinical trial in 6 children who were aged 22 months to 14 years. Each patient received intravenous pamidronate therapy for a minimum of 2 years in cycles of 1 mg/kg daily over 3 consecutive days at a mean cycle interval of 3.8 months. Outcome measures included lumbar spine areal bone mineral density (BMD) and z score, fracture rate, and occupational therapy functional assessment with serial Pediatric Evaluation of Disability Inventory.

Results. While on therapy, the average annual increase in areal BMD was 48% and the average annual increase in BMD z score was 1.0. This increase in z score is statistically significant. There was no clear correlation between changes in BMD and fracture rate. All patients experienced functional improvement in mobility.

Conclusions. Our results support the findings of Glorieux et al that cyclic administration of intravenous pamidronate in children with OI has beneficial effects with respect to BMD z scores and physical disability. Long-term follow-up will be required to determine whether bisphosphonate therapy will decrease fracture rates and increase mobility in children with moderate to severe OI.
Physical and Psychosocial Health in Children Who Have Had Kawasaki Disease
Authors: Baker Annette L. , Gauvreau Kimberlee , Newburger Jane W. , Sundel Robert P. , Fulton David R. , Jenkins Kathy J.
Published: August 2004

Objective. The purpose of this study was to examine the physical and psychosocial well-being of children who have had Kawasaki disease (KD), including the influence of coronary artery status on health and health perceptions.

Methods. The Child Health Questionnaire (CHQ) measures overall physical and psychosocial well-being in children 5 to 18 years. To study the long-term impact of KD on overall health status, we mailed the CHQ to patients without a history of coronary artery abnormalities (normal group), with regressed aneurysms (regressed group), with current coronary aneurysms <8 mm (mild-moderate aneurysm group), and with giant aneurysms ≥8 mm (giant group).

Results. Of 201 questionnaires mailed, 174 were delivered and 110 (63%) were completed. Median age (range) at completion was 10.5 years (5.1–17.9 years) and at illness onset was 3.1 years (0.2–12 years). There were no significant differences in psychosocial summary scores in any of the Kawasaki groups when compared with the US population sample. Physical summary scores were also similar to the US population sample in the normal coronary, mild-moderate aneurysm, and regressed aneurysm groups. However, the giant aneurysm group had significantly lower physical summary scores compared with the US population sample. Among subscales, general health perceptions in the KD groups were lower than in the US population sample, reaching statistical significance in all but the mild to moderate aneurysm group. In addition, parents whose children have had KD reported a higher proportion of anxiety issues, allergies, and orthopedic/bone/joint issues in their children than did the general US population sample. We did not find any difference in the incidence of attentional, behavioral, or learning issues when compared with the US population sample.

Conclusions. KD patients without coronary artery aneurysms were similar to the general population in their general physical and psychosocial health. However, the parents of children in all KD groups reported lower general health perceptions than parents in the US population sample, suggesting that long-term concerns about their children’s health exist regardless of overall health status. In addition, children with giant coronary artery aneurysms had lower overall physical summary scores.
How Readable Are Child Safety Seat Installation Instructions?
Authors: Wegner Mark V. , Girasek Deborah C.
Published: August 2004

Objectives. To measure the required reading level of a sample of child safety seat (CSS) installation instructions and to compare readability levels among different prices of CSSs to determine whether the lower cost seats to which low-income parents have greater access are written to a lower level of education.

Methods. A CD-ROM containing CSS installation instructions was obtained from the National Highway Traffic Safety Administration. Pricing information was obtained for available models from an Internet-based company that provides comparative shopping information. Paper copies of the instruction sets were generated, and their readability levels were determined using the SMOG test. A second rater was used in addition to the primary investigator to assess interrater reliability of the SMOG as applied to the instruction sets.

Results. The readability of instruction sets ranged from the 7th- to 12th-grade levels, with an overall mean SMOG score of 10.34. No significant associations were found to exist between readability and seat prices; this was observed whether the data were treated as continuous or categorical.

Conclusions. CSS instruction manuals are written at a reading level that exceeds the reading skills of most American consumers. These instruction sets should be rewritten at a lower reading level to encourage the proper installation of CSSs.
Risk of Seizures in Survivors of Newborn Heart Surgery Using Deep Hypothermic Circulatory Arrest
Authors: Clancy Robert R. , McGaurn Susan A. , Wernovsky Gil , Gaynor J. William , Spray Thomas L. , Norwood William I. , Jacobs Marshall L. , Goin James E.
Published: August 2004

Objective. To identify pre- and intraoperative variables associated with postoperative acute neurologic events (ANEs), including seizures and coma, in newborn survivors of congenital heart surgery undergoing deep hypothermic circulatory arrest (DHCA), and to risk-stratify this population on the basis of preoperative risk variables for the purpose of designing future neuroprotection trials.

Methods. Survivors of newborn heart surgery who were enrolled in a neuroprotection trial provided a comprehensive database for the evaluation of pre- and intraoperative variables that influence the postoperative occurrence of ANEs (seizures or coma). Patients with hypoplastic heart syndrome were excluded. After characterization of the study population, stepwise logistic regression, combined with clinical judgment, was used to identify variables that were most likely to be associated with an increased risk of seizures in the study sample and that were most likely to be generalized to other populations.

Results. Data were available on 164 nonhypoplastic left heart syndrome survivors who underwent newborn heart surgery using DHCA. ANEs occurred in 31 (18.9%) including “seizures alone” (n = 28), “coma alone” (n = 2) or “seizures and coma” (n = 1). A preoperative risk model was constructed demonstrating that infants with a genetic condition and aortic arch obstruction had a 47.8% risk of ANEs compared with all other remaining infants, who had a 9.9% risk. It was also found that prolonged DHCA time (≥60 minutes) can be a significant risk for infants who have a preexisting genetic condition; however, infants who have genetic conditions and do not undergo prolonged DHCA time or have an aortic arch obstruction are not at increased risk of ANEs.

Conclusions. This study provides new information about the occurrence of ANEs after newborn heart surgery. Seizures or coma, which appeared in approximately 19% of all non–hypoplastic left heart syndrome survivors, were not random events but were significantly associated with specific types of congenital heart disease, the presence of genetic conditions, and prolonged DHCA time. The 3 identified variables permitted individual cases to be assigned to low-, intermediate-, or high-risk categories. Because neonatal seizures are a good surrogate marker of long-term neurologic outcome, these models provide useful information to stratify individual patients for risk of seizures in future neuroprotection trials.
Can the Initial History Predict Whether a Child With a Head Injury Has Been Abused?
Authors: Hettler Joeli , Greenes David S.
Published: August 2004

Objective. Previous studies of child abuse have used the presenting history as part of the case definition of abuse. Thus, data from these studies cannot be used to determine the diagnostic utility of historical features for identifying cases of abuse. The objective of this study was to determine the diagnostic utility of certain historical features for identifying cases of abusive head trauma.

Methods. We retrospectively studied all children, aged 0 to 3 years, who had acute traumatic intracranial injury and were admitted to a tertiary care pediatric hospital from 1993 to 2000. Cases were categorized as either “definite abuse” or “not definite abuse” on the basis of radiologic, ophthalmologic, and physical examination findings, without regard to the presenting history.

Results. Forty-nine (30%) of 163 children met the criteria for definite abuse. Having no history of trauma had a high specificity (0.97) and positive predictive value (PPV; 0.92) for abuse. Among the subgroup of patients with persistent neurologic abnormality at hospital discharge (n = 34), having a history of no or low-impact trauma had a specificity of 1.0 and a PPV of 1.0 for definite abuse. Injuries were blamed on home resuscitative efforts in 12% of definite abuse cases and 0% of not definite abuse cases. The initial history of trauma was changed in 9% of definite abuse cases, as compared with 0% of not definite abuse cases.

Conclusion. Among young children with a head injury, certain historical features have high specificity and PPV for diagnosing child abuse.
Atopic Dermatitis and Asthma: Parallels in the Evolution of Treatment
Authors: Eichenfield Lawrence F. , Hanifin Jon M. , Beck Lisa A. , Lemanske Robert F. , Sampson Hugh A. , Weiss Scott T. , Leung Donald Y.M.
Published: August 2004

Objectives. To review epidemiologic correlations between asthma and atopic dermatitis (AD), identify common features in disease pathophysiology, and review steps involved in the development of asthma therapy guidelines to assess the appropriateness of a similar process and approach for AD.

Methods. A 7-member panel representing specialists in dermatology, allergy, asthma, immunology, and pediatrics from around the United States convened to review the current literature and evolving data on AD. Participants presented reviews to the panel on the epidemiology of asthma and AD, the genetic predisposition to allergic disease, the current understanding of the immunopathophysiology of AD, interrelationships between the pathologic pathways of asthma and AD, evolving treatment concepts and options in AD, and the applicability of the asthma treatment model and how it may be adapted for guideline development for AD. Commentary and criticism were recorded for use in document preparation.

Results. There are clear epidemiologic parallels in asthma and AD. Importantly, AD frequently is the first manifestation of an atopic diathesis, which occurs in genetically predisposed individuals and also includes asthma and allergic rhinitis. Up to 80% of children with AD will eventually develop allergic rhinitis or asthma later in childhood. This classic “atopic triad” has numerous pathophysiologic elements in common, including cyclic nucleotide regulatory abnormalities, immune cell alterations, and inflammatory mediators and allergic triggers. New therapeutic options that target underlying immune mechanisms are available, and their place among treatments for AD is becoming established. Guidelines of care have been developed for asthma. The panel noted that the National Institutes of Health/National Heart, Lung, and Blood Institute guidelines for diagnosis and management of asthma, first issued in 1991, had a tremendous positive impact on many aspects of asthma treatment. It not only created a heightened awareness that asthma is a disease of chronic inflammation, but it also provided unified approaches for therapy and opened new areas of basic science and clinical research. In addition, the guidelines spurred interactions among physicians of various specialties and stimulated a great quantity of research in asthma therapy. It is anticipated that AD therapy guidelines would have similar positive outcomes.

Conclusions. The panel concluded that, on the basis of current information and evolving therapeutic options, a clear rationale exists to support AD guideline development. The many parallels between AD and asthma suggest that processes and approaches used for the asthma therapy guidelines would be appropriate for AD.
Hospital-Reported Medical Errors in Children
Authors: Slonim Anthony D. , LaFleur Bonnie J. , Ahmed Wendy , Joseph Jill G.
Published: August 2004

Context. Medical errors are an important problem for hospitalized adult inpatients. However, medical errors in children remain comparatively understudied, and published research has been relatively limited.

Objectives. To investigate the national rates of hospital-reported medical errors in pediatric inpatients over the period 1988–1997; and to determine the association of patient and hospital characteristics with the occurrence of hospital-reported medical errors in children.

Design, Setting, and Patients. A nonconcurrent cohort study of hospitalized nonnewborn pediatric patients in the United States ≤18 years of age. Data from the Healthcare Cost and Utilization Project for the years 1988, 1991, 1994, and 1997 were used for these analyses.

Main Outcome Measure. The occurrence of hospital-reported medical errors.

Results. The national rate of hospital-reported medical errors in hospitalized children ranged from 1.81 to 2.96 per 100 discharges. These medical error rates were statistically lower in 1988, with the years 1991, 1994, and 1997 not being statistically different from each other. There were no consistent differences in the rates of medical errors when stratified by gender, race, payor status, or median household income of the patient’s zip code across years. There was, however, a statistically significant relationship between higher median household income and increasing medical error rates; this trend was consistent across all 4 years. Similarly, children with special medical needs or dependence on a medical technology also had significantly higher rates of hospital-reported medical errors. Although hospital size did not seem to be related to the rate of medical errors, private for-profit hospitals consistently reported lower rates, whereas urban teaching hospitals in all years but 1997 reported higher rates of medical errors.

Conclusions. These data highlight both the strengths and limitations of administrative data in the investigation of medical errors. Substantively, they suggest fruitful areas for additional and more detailed study, notably children with special medical needs.
Effect of Position on Sleep, Heart Rate Variability, and QT Interval in Preterm Infants at 1 and 3 Months’ Corrected Age
Authors: Ariagno Ronald L. , Mirmiran Majid , Adams Marian M. , Saporito Anna G. , Dubin Anne M. , Baldwin Roger B.
Published: August 2004

Objective. Prone sleeping position has a strong link to sudden infant death syndrome (SIDS), and the “Back to Sleep” campaign has played an important role in reducing SIDS. We tested the hypothesis that the mechanism of the sleep position effect is based on changes in sleep, arousal, heart rate variability (HRV), and the QT interval of the electrocardiogram.

Study Design. We studied 16 premature infants longitudinally, at 1 and 3 months’ corrected age. Videosomnography recordings were made during the infants’ normal daytime naps. Each infant was recorded in both supine and prone positions. The recordings were analyzed in 30-second epochs, which were classified as awake, active sleep (AS), quiet sleep (QS), or indeterminate sleep. Electrocardiogram data were sampled with an accuracy of 1 millisecond. Time domain analysis of HRV was measured by standard deviation of all R-R intervals and by the square root of the mean of the sum of the squares of the differences between adjacent R-R intervals. Frequency domain analysis was done for low frequency (0.04–0.14 Hz) and high frequency (0.15–0.5 Hz) HRV. We measured QT, JT, and R-R intervals during AS and QS for each position.

Results. We found no significant differences between supine and prone position, either in total sleep time or in percentage of QS. Percentage of AS was significantly lower in the supine position, but only at 1 month corrected age. The incidence of short, spontaneous, sleep transitions was significantly higher in supine, also only at 1 month corrected age. Time domain analysis of HRV showed a significantly lower variability in prone, but only during QS. Frequency domain analysis of HRV showed no differences between the 2 sleeping positions. Both QT and JT intervals were significantly longer in prone during QS, but only at 1 month corrected age.

Conclusions. Despite the commonly held belief, prone position did not substantially increase total sleep at these ages. On the other hand, prone sleeping decreased the number of sleep transitions at 1 month corrected age, increased QT and JT intervals, and reduced HRV, thereby potentially increasing the vulnerability for SIDS. This study supports “Back to Sleep” as the position of choice not only for term but also for preterm infants after discharge home.
Use of an Electronic Medical Record Improves the Quality of Urban Pediatric Primary Care
Authors: Adams William G. , Mann Adriana M. , Bauchner Howard
Published: August 2004

Objective. To evaluate the quality of pediatric primary care, including preventive services, before and after the introduction of an electronic medical record (EMR) developed for use in an urban pediatric primary care center.

Methods. A pre-postintervention analysis was used in the study. The intervention was a pediatric EMR. Routine health care maintenance visits for children <5 years old were reviewed, and documentation during preintervention (paper-based, 1998) and postintervention visits (computer-based, 2000) was compared.

Results. A total of 235 paper-based visits and 986 computer-based visits met study criteria. Twelve clinicians (all attendings or nurse practitioners) contributed an average of 19.4 paper-based visits (range: 5–39) and 7 of these clinicians contributed an average of 141 computer-based visits each (range: 61–213). Computer-based clinicians were significantly more likely to address a variety of routine health care maintenance topics including: diet (relative risk [RR]: 1.09), sleep (RR: 1.46), at least 1 psychosocial issue (RR: 1.42), smoking in the home (RR: 15.68), lead risk assessment (RR: 106.54), exposure to domestic or community violence (RR: 35.19), guns in the home (RR: 58.11), behavioral or social developmental milestones (RR: 2.49), infant sleep position (RR: 9.29), breastfeeding (RR: 1.99), poison control (RR: 3.82), and child safety (RR: 1.29). Trends toward improved lead exposure, vision, and hearing screening were seen; however, differences were not significant. Users of the system reported that its use had improved the overall quality of care delivered, was well-accepted by families, and improved guidance quality; however, 5 of 7 users reported that eye-to-eye contact with patients was reduced, and 4 of 7 reported that use of the system increased the duration of visits (mean: 9.3 minutes longer). All users recommended continued use of the system.

Conclusion. Use of the EMR in this study was associated with improved quality of care. This experience suggests that EMRs can be successfully used in busy urban pediatric primary care centers and, as recommended by the Institute of Medicine, must play a central role in the redesign of the US health care system.
Sleep Position of Low Birth Weight Infants
Authors: Vernacchio Louis , Corwin Michael J. , Lesko Samuel M. , Vezina Richard M. , Hunt Carl E. , Hoffman Howard J. , Willinger Marian , Mitchell Allen A.
Published: August 2004

Objectives. To describe sleep positions among low birth weight infants, variations in sleep position according to birth weight, and changes in sleep position over time. To analyze risk factors and influences associated with prone sleep.

Design. Prospective cohort study.

Setting. Massachusetts and Ohio, 1995–1998.

Study Participants. Mothers of 907 low birth weight infants.

Results. At 1, 3, and 6 months after hospital discharge, the prevalence of prone sleeping was 15.5%, 26.8%, and 28.3%, respectively. The corresponding rates for supine sleeping were 23.8%, 37.9%, and 50.2% and for side sleeping were 57.3%, 32.4%, and 20.6%. Very low birth weight (VLBW) infants (<1500 g) were most likely to be placed in the prone position. From 1995 through 1998, prone sleeping 1 month after hospital discharge declined among all low birth weight infants from 19.9% to 11.4%; among VLBW infants, the decline in prone sleeping was replaced almost entirely by an increase in side sleeping, whereas in larger low birth weight infants, it was replaced primarily by supine sleeping. Among mothers who placed their infants to sleep in nonprone positions, professional medical advice was cited most frequently as the most influential reason, whereas among mothers of prone-sleeping infants, the infant’s preference was cited most frequently. However, mothers of prone-sleeping VLBW infants also frequently cited the influence of medical professionals and nursery practices as most important in the choice of sleeping position. The factors most strongly associated with prone sleeping were single marital status (odds ratio [OR]: 3.0; 95% confidence interval [CI]: 1.5–6.2), black race (OR: 2.6; 95% CI: 1.5–4.5), birth weight <1500 g (OR: 2.4; 95% CI: 1.3–4.3), and multiparity (OR: 2.1, 95% CI: 1.2–3.5).

Conclusions. Prone sleep decreased among low birth weight infants from 1995 to 1998. However, VLBW infants, who are at very high risk for sudden infant death syndrome, are more likely to sleep prone than larger low birth weight infants.