bluuebunny/crossref_metadata_2025 huggingface dataset:
Child Disobedience and Noncompliance: A Review
Authors: Kalb Larry M. , Loeber Rolf
Published: August 2004

Child disobedience and noncompliance is a recurring problem frequently brought to the attention of pediatricians and others working with children and their parents. This article reviews empirical studies concerning childhood noncompliance. Definitions of noncompliance (also called disobedience) are presented, and observational studies that have measured noncompliance in the laboratory and at home are reviewed. Studies show considerable variability in the prevalence of noncompliance, but demonstrate that it is a frequent problem for parents. Longitudinal data from the Pittsburgh Youth Study are presented to more closely examine the onset and stability of noncompliance in childhood and adolescence. Evidence suggests that extreme childhood noncompliance is relatively stable over time, peaking slightly during early adolescence and decreasing during late adolescence. Studies indicate that for some children noncompliance predicts aggression and externalizing problems. Antecedents of noncompliance including parental discipline techniques and child characteristics are reviewed. Parent training programs designed to reduce noncompliance are described, and the effectiveness of such programs is examined.
Addressing Parents’ Concerns: Do Vaccines Cause Allergic or Autoimmune Diseases?
Authors: Offit Paul A. , Hackett Charles J.
Published: August 2004

Anecdotal case reports and uncontrolled observational studies in the medical literature claim that vaccines cause chronic diseases such as asthma, multiple sclerosis, chronic arthritis, and diabetes. Several biological mechanisms have been proposed to explain how vaccines might cause allergic or autoimmune diseases. For example, allergic diseases might be caused by prevention of early childhood infections (the “hygiene hypothesis”), causing a prolongation of immunoglobulin E-promoting T-helper cell type 2-type responses. However, vaccines do not prevent most common childhood infections, and large well-controlled epidemiologic studies do not support the hypothesis that vaccines cause allergies. Autoimmune diseases might occur after immunization because proteins on microbial pathogens are similar to human proteins (“molecular mimicry”) and could induce immune responses that damage human cells. However, wild-type viruses and bacteria are much better adapted to growth in humans than vaccines and much more likely to stimulate potentially damaging self-reactive lymphocytes. Consistent with critical differences between natural infection and immunization, well-controlled epidemiologic studies do not support the hypothesis that vaccines cause autoimmunity.

Flaws in proposed biological mechanisms that explain how vaccines might cause chronic diseases are consistent with the findings of many well-controlled large epidemiologic studies that fail to show a causal relationship.
Medical Treatment of Recurrent Intussusception Associated With Intestinal Lymphoid Hyperplasia
Authors: Shteyer Eyal , Koplewitz Benjamin Z. , Gross Eitan , Granot Esther
Published: August 2004

Intestinal lymphoid hyperplasia (ILH) is an uncommon cause of recurrent intussusception in infants and young children. Surgical treatment has been suggested in the management of this disorder.

We report 2 cases in which recurrent intussusception was associated with ILH. A short course of steroids resulted in resolution of both symptoms and hyperplasia.

We conclude that when recurrent intussusception occurs in association with ILH, and no other lead point can be identified, it is important that treatment with steroids is considered before resorting to a more radical surgical approach.
Toe Tourniquet Syndrome in Association With Maternal Hair Loss
Authors: Strahlman R. Scott
Published: August 2004

Increased hair loss a few months after delivering an infant is a common postpartum condition known as telogen effluvium. A much less common condition involving young infants is the hair-thread tourniquet syndrome, or toe tourniquet syndrome, which involves hair or thread becoming so tightly wrapped around an appendage that pain, injury, and sometimes loss of the appendage result. This case report is the first known description of the hair-thread tourniquet syndrome in association with maternal telogen effluvium. A literature review shows that accidental cases involving human hair almost always involve the toes, and usually occur at the age when mothers are experiencing excessive hair loss. This association is significant in that anticipatory guidance of new parents experiencing rapid hair loss may prevent cases of the toe tourniquet syndrome and its associated morbidity.
Physicians’ Roles in Coordinating Care of Hospitalized Children
Authors: Percelay Jack M. ,   Committee on Hospital Care
Published: August 2004

The care of hospitalized children has become increasingly complex and intense and often involves multiple physicians beyond the traditional primary care attending physician. Pediatric and adult subspecialists and surgeons, teaching attending physicians, and hospitalists may all participate in the care of hospitalized children. This report summarizes the responsibilities of the primary care physician, attending physician, and other involved physicians to ensure that children receive appropriate, coordinated, and comprehensive inpatient care that is delivered within the context of their medical home and is appropriately continued on an outpatient basis.
Stimulus-Induced Drop Episodes in Coffin-Lowry Syndrome
Authors: Nelson Gregg B. , Hahn Jin S.
Published: August 2004

Objective. Coffin-Lowry syndrome (CLS) is a rare disorder characterized by moderate to severe mental retardation, facial dysmorphism, tapering digits, and skeletal deformity. Paroxysmal drop attacks occur in patients with CLS, characterized by sudden loss of muscle tone induced by unexpected tactile or auditory stimuli. Our objective is to characterize these attacks better using neurophysiologic studies.

Methods. We report 2 teenage boys with CLS and stimulus-induced drop episodes (SIDEs). Simultaneous surface electromyogram (EMG) and video electroencephalogram were performed during SIDEs on our 2 patients.

Results. Both patients had SIDEs stimulated by a loud noise, unexpected light touch stimulation, or visual threat that were characterized by abrupt episodes of complete or partial loss of lower extremity tone. These events were not associated with impairment of consciousness, and immediate recovery was noted. Simultaneous surface EMG and video electroencephalogram revealed no epileptiform discharges in either patient. In the first patient, after unexpected tactile or auditory stimulation, tonic EMG activity in paraspinal muscles was lost briefly, similar to that seen in cataplexy. In the second patient, at 6 years of age, sudden nonepileptic drop episodes were induced by an unexpected tactile, auditory, or visual stimulation. At 11 years of age, his episodes had changed to brief myoclonic jerk and tonic spasm that were triggered by unexpected tactile and auditory stimuli. An increase in tonic EMG activity occurred during the attacks, consistent with hyperekplexia.

Conclusions. Our data suggest that SIDEs in CLS are a heterogeneous group of nonepileptic events that may manifest features of both cataplexy and hyperekplexia, even in the same patient.
Outcomes of Infant Sleep Problems: A Longitudinal Study of Sleep, Behavior, and Maternal Well-Being
Authors: Lam Peiyoong , Hiscock Harriet , Wake Melissa
Published: August 2004

Objectives. In a community sample of children aged 3 to 4 years with previous infant sleep problems, we aimed to 1) establish proportions with recurring, persisting, and resolving sleep problems; 2) identify early predictors of later sleep problems; and 3) identify comorbidities of persistent or recurrent sleep problems at age 3 to 4 years.

Methods. A follow-up community survey was conducted of mothers of children aged 3 to 4 years who had, as 8- to 10-month-old infants with identified sleep problems, participated in a community-based, randomized, controlled trial of a brief sleep intervention from 3 middle-class local government areas in Melbourne, Australia. Infant sleep problems (standardized maternal questionnaire), maternal well-being (Edinburgh Postnatal Depression Scale), child behavior problems (Child Behavior Check List for ages 1.5 to 5 years), marital satisfaction (Dyadic Adjustment Scale), and family functioning (General Functioning Scale, McMaster Family Assessment Device) were measured.

Results. Seventy-three percent (114 of 156) of mothers responded, 36 (32%) of whom reported a current problem with their child’s sleep. Current sleep problems were similar regardless of infant sleep intervention. Twelve percent (14 of 114) reported that their child’s sleep problem had persisted, and 19% (21 of 113) reported that it had recurred. Children with current sleep problems were more likely still to be nursed to sleep by an adult and had slightly higher mean scores on Child Behavior Check List subscales for Aggressive Behavior (54 vs 52) and Somatic Problems (55 vs 53). Their mothers had higher Edinburgh Postnatal Depression Scale scores (median: 8 vs 5) and more difficulties with their partner undermining the management of their child. However, early depression did not predict current sleep problems. Families of children with sleep problems were functioning as well as those without sleep problems.

Conclusions. Persistence or recurrence of infant sleep problems in the preschool years is common and is associated with slightly higher child behavior problems and maternal depression scores. Results suggest that depressive symptoms are a result rather than cause of sleep problems. Despite this, families of children with sleep problems are functioning well.
Caregiver-Physician Medication Concordance and Undertreatment of Asthma Among Inner-City Children
Authors: Riekert Kristin A. , Butz Arlene M. , Eggleston Peyton A. , Huss Karen , Winkelstein Marilyn , Rand Cynthia S.
Published: August 2004

Objective. To assess the extent to which caregivers and their child’s physician agree about the prescribed asthma medication regimen and evaluate factors associated with medication concordance.

Methods. A cross-sectional, descriptive survey was administered to 318 caregivers of inner-city children with asthma, aged 5 to 12 years, and their caregiver-identified primary care physician at elementary schools and participants’ homes. Concordance between caregiver- and physician-reported controller medication prescription was measured.

Results. Only 42% of physicians and 32% of caregivers reported a controller medication prescription (78% agreement, κ = 0.54; 95% confidence interval: 0.45–0.63) despite that 73% of the children were rated by their caregiver as currently experiencing persistent asthma symptoms. When the physician reported a controller prescription, 38% of the caregivers denied use of a controller. Having a course of oral steroids in the past year (χ2 = 9.85) and positive caregiver beliefs toward asthma care (χ2 = 18.40) were associated with caregiver-physician concordance. Multivariate analysis found that when caregivers had high Asthma Beliefs Scale summary scores versus low scores, they were almost 10 times as likely to be concordant with the physician (odds ratio: 9.76; 95% confidence interval: 2.85–33.46).

Conclusions. Our data support previous reports of physician underprescribing of controller medication among inner-city children. However, even when prescribed by a physician, more than one third of caregivers did not report a controller prescription, and this discordance was related to caregivers’ beliefs about treatment. Efforts to improve physician adherence to asthma guidelines will not result in proper treatment unless caregiver–physician communication about asthma therapy is improved.
Maternal Gestational Diabetes, Birth Weight, and Adolescent Obesity
Authors: Gillman Matthew W. , Rifas-Shiman Sheryl , Berkey Catherine S. , Field Alison E. , Colditz Graham A.
Published: August 2004

Objective. Obesity increases risk of many adverse outcomes, but its early origins are obscure. Gestational diabetes mellitus (GDM) reflects a metabolically altered fetal environment associated with high birth weight, itself associated with later obesity. Previous studies of GDM and offspring obesity, however, have been few and conflicting. The objectives of this study were to examine associations of birth weight and GDM with adolescent body mass index (BMI) and to determine the extent to which the effect of GDM is explained by its influence on birth weight or by maternal adiposity.

Methods. We conducted a survey of 7981 girls and 6900 boys, 9 to 14 years of age, who are participants in the Growing Up Today Study, a US nationwide study of diet, activity, and growth. In 1996, participants reported height, weight, diet, activity, and other variables by self-administered mailed questionnaire. We linked these data with information reported by their mothers, participants in the Nurses’ Health Study II, including GDM, height, current weight, and child’s birth weight. We excluded births <34 weeks’ gestation and mothers who had preexisting diabetes. We defined overweight as BMI (kg/m2) >95th percentile, and at risk for overweight as 85th to 95th percentile, for age and gender from US national data.

Results. Mean birth weight was 3.4 kg for girls and 3.6 kg for boys. Among the 465 subjects whose mothers had GDM, 17.1% were at risk for overweight and 9.7% were overweight in early adolescence. In the group without maternal diabetes, these estimates were 14.2% and 6.6%, respectively. In multiple logistic regression analysis, controlling for age, gender, and Tanner stage, the odds ratio for adolescent overweight for each 1-kg increment in birth weight was 1.4 (95% confidence interval: 1.2–1.6). Adjustment for physical activity, television watching, energy intake, breastfeeding duration, mother’s BMI, and other maternal and family variables reduced the estimate to 1.3 (1.1–1.5). For offspring of mothers with GDM versus no diabetes, the odds ratio for adolescent overweight was 1.4 (1.1–2.0), which was unchanged after controlling for energy balance and socioeconomic factors. Adjustment for birth weight slightly attenuated the estimate (1.3; 0.9–1.9); adjustment for maternal BMI reduced the odds ratio to 1.2 (0.8–1.7).

Conclusions. Higher birth weight predicted increased risk of overweight in adolescence. Having been born to a mother with GDM was also associated with increased adolescent overweight. However, the effect of GDM on offspring obesity seemed only partially explained by its influence on birth weight, and adjustment for mother’s own BMI attenuated the GDM associations. Our results only modestly support a causal role of altered maternal-fetal glucose metabolism in the genesis of obesity in the offspring. Alternatively, GDM may program risk for a postnatal insult leading to obesity, or it may merely be a risk marker, not in the causal pathway.
Pediatrician Beliefs About Spirituality and Religion in Medicine: Associations With Clinical Practice
Authors: Armbruster Christy A. , Chibnall John T. , Legett Sarah
Published: August 2004

Objectives. Identify pediatrician (faculty and resident) beliefs about spirituality and religion (SR) in medicine and the relationship of those beliefs to SR behavior and experiences in clinical practice.

Methods. A self-report questionnaire was administered to full-time pediatric faculty (N = 65) and residents (N = 56) of an urban children’s hospital affiliated with a school of medicine. The response rate was 70.8% among faculty (n = 46) and 78.6% among residents (n = 44). Respondents indicated the extent of their SR inquiry and the frequency of their SR experiences (requests by patients or families to discuss SR or pray), routinely and during health crisis, and rated 19 belief statements about SR in pediatrics.

Results. Few pediatricians routinely ask about SR issues. Faculty were more likely than residents to ask about religious affiliation, whereas residents were more likely to be asked to pray during health crises, to believe that SR has health relevance, and to perceive pediatrician-initiated prayer as appropriate. Composite scores indicated that physicians who did not expect negative patient reactions to SR inquiry and prayer, who believed more strongly that SR is relevant to pediatric outcomes, and who felt more capable with SR inquiry were more likely to engage in SR inquiry and to experience SR requests.

Conclusions. Pediatrician beliefs with respect to health relevance of SR, patient reactions to SR inquiry, and physician capabilities regarding SR in the clinic are strongly related to their clinical practice concerning SR inquiry and experiences. Correction of physician misperceptions about SR issues and incorporation of religious sensitivity into physician training may remove barriers to both patient and physician SR inquiry.
Frequency of Surgery Among Children Who Have Adenotonsillar Hypertrophy and Improve After Treatment With Nasal Beclomethasone
Authors: Criscuoli Gaetano , D’Amora Stefania , Ripa Giuseppe , Cinquegrana Giovanni , Mansi Nicola , Impagliazzo Nicola , Pisacane Alfredo
Published: August 2004

Objective. To describe the long-term outcome of a cohort of children with symptomatic adenotonsillar hypertrophy treated with aqueous nasal beclomethasone.

Methods. The children enrolled completed a 4-week single-blind, saline solution controlled crossover study of aqueous beclomethasone (total: 400 μg/d). In a 24-week open-label follow-on study, beclomethasone 200 μg/d was offered to all patients. During a 100-week follow-up, the degree of nasal obstruction and the frequency of adenotonsillectomy were assessed.

Results. Fifty-three children of the 60 enrolled completed the study. After the 4-week crossover trial, the severity of nasal obstruction of 24 children (45%) significantly decreased during the use of nasal steroids, but no child improved when saline solution was used. At 24, 52, and 100 weeks, the 24 children who had initially improved showed a significant decrease of the severity of nasal obstruction and of the frequency of adenotonsillectomy (54% vs 83%) compared with the 29 children who had not responded after the initial steroidal therapy.

Conclusions. Evidence from this study suggests that 45% of children with adenoidal hypertrophy improved after 2 weeks of steroidal therapy. Among these children, an additional 24-week treatment at a lower steroid dosage was associated with a significant 52- and 100-week clinical improvement and with reduction of adenotonsillectomy compared with children (55%) who had not responded after the initial 2-week steroidal therapy.
Survey of Current Practice of Pediatric Electrophysiologists for Asymptomatic Wolff-Parkinson-White Syndrome
Authors: Campbell Robert M. , Strieper Margaret J. , Frias Patricio A. , Collins Kathryn K. , Van Hare George F. , Dubin Anne M.
Published: August 2004

Objective. To determine the approach that pediatric electrophysiologists use as they evaluate asymptomatic patients with Wolff-Parkinson-White (WPW) syndrome regarding electrophysiologic testing and radio frequency ablation.

Methods. A 21-question survey was mailed to 66 pediatric electrophysiologists who had voluntarily submitted patient data at any time to the Pediatric Radio Frequency Ablation Registry since its inception in 1990. The survey addressed issues regarding physician experience with electrophysiologic testing and radio frequency ablation, risk assessment, electrophysiology study, and factors that influence the decision to perform radio frequency ablation in asymptomatic patients.

Results. Returned surveys (43 of 66 [65%]) were analyzed blindly. The 43 physicians who responded were experienced, with 37 reporting >5 years of performing radio frequency ablation and 30 having performed >200 radio frequency ablation procedures. Thirty-six of the 43 electrophysiologists used invasive electrophysiologic study for risk stratification in asymptomatic patients with WPW. Electrophysiologic findings guided selection of patients for radio frequency ablation procedures. Expected radio frequency ablation outcome quotes to the family were consistent with recently published data from the Electrophysiology Society regarding current-era experience with radio frequency ablation.

Conclusion. The majority of responding electrophysiologists use invasive electrophysiologic study both to stratify risk for asymptomatic WPW and to select appropriate patients for radio frequency ablation. This current practice should be communicated to other pediatric cardiologists and pediatricians.
A Mutation in Mitochondrial DNA-Encoded Cytochrome c Oxidase II Gene in a Child With Alpers-Huttenlocher-Like Disease
Authors: Uusimaa Johanna , Finnilä Saara , Vainionpää Leena , Kärppä Mikko , Herva Riitta , Rantala Heikki , Hassinen Ilmo E. , Majamaa Kari
Published: August 2004

Objective. Cytochrome c oxidase (COX) deficiency has been demonstrated in some patients with Alpers-Huttenlocher disease, but no genetic background has been identified. Our objective was to determine the molecular defect underlying the mitochondrial respiratory chain deficiency in a child with Alpers-Huttenlocher-like progressive cerebrohepatic disease.

Methods. The entire coding region of mitochondrial DNA was analyzed by conformation-sensitive gel electrophoresis and sequencing. Biochemical and morphologic investigations were performed on tissue biopsy material, including oximetric and spectrophotometric analyses of oxidative phosphorylation, histochemistry, and electron microscopy.

Results. Postmortem histologic examination revealed a marked loss of neurons in the olivary nuclei and a spongy change in the calcarine cortex, fatty infiltration and micronodular cirrhosis of the liver, and atrophic ovaries. A novel heteroplasmic 7706G>A mutation was found in the COX II gene. The median degree of the mutant heteroplasmy was 90% in 5 tissues examined but was lower in the blood of asymptomatic maternal relatives. The distribution of the mutant heteroplasmy was skewed to the left in single muscle fibers of the proband and her mother. The 7706G>A mutation converts a hydrophobic alanine in a conserved transmembrane segment to hydrophilic threonine.

Conclusions. The 7706G>A mutation is pathogenic and may lead to impaired dioxygen transfer to the active site of COX. The clinical phenotype of this patient resembled that in Alpers-Huttenlocher disease, suggesting that analysis of mitochondrial DNA is worthwhile in patients with a progressive cerebrohepatic disease.
Transient Suppression of Atopy in Early Childhood Is Associated With High Vaccination Coverage
Authors: Grüber Christoph , Illi Sabina , Lau Susanne , Nickel Renate , Forster Johannes , Kamin Wolfgang , Bauer Carl-Peter , Wahn Volker , Wahn Ulrich ,   MAS-90 Study Group
Published: August 2004

Objective. To analyze prevalences of allergic sensitization and atopic disease in relation to vaccination coverage.

Methods. A German atopy risk-enhanced birth cohort of 1314 neonates who were born in 1990 in 5 German cities was studied. A total of 943 children participated in the follow-up visit at 5 years of age. Atopic symptoms and diagnoses (derived from structured interviews), total serum immunoglobulin E, and specific immunoglobulin E against 9 common allergens (CAP Radio-Allergo-Sorbent Test Fluoro-Enzyme Immunoassay) were evaluated. Children were grouped into dose percentiles according to cumulative doses of any vaccine given up to 5 years of age (<10%, 0–11 doses; 10%–50%, 12–14 doses; 51%–90%, 15–20 doses; >90%, 21–27 doses).

Results. The cumulative vaccine dose was inversely related to atopic dermatitis prevalences at 6 months (13.8%, 5.2%, 5.1%, and 4.5%), 2 years (16.9%, 10.9%, 7.4%, and 3.7%), 3 years (27.6%, 16.4%, 13.5%, and 4.5%), and 5 years (28.3%, 16.0%, 9.3%, and 11.9%). Asthma followed a similar pattern at age 3 (22.4%, 8.6%, 6.7%, and 6.3%), age 4 (20.0%, 8.6%, 8.9%, and 8.1%), and age 5 (20.8%, 12.6%, 10.3%, and 5.5%). Allergic sensitization rates were inversely related to the cumulative vaccine dose at age 2 (37.5%, 29.1%, 23.8%, and 12.9%).

Conclusion. Children with a higher vaccination coverage seemed to be transiently better protected against development of atopy in the first years of life.
Tagum Study II: Follow-up Study at Two Years of Age After Prenatal Exposure to Mercury
Authors: Ramirez Gloria B. , Pagulayan Olive , Akagi Hirokatsu , Francisco Rivera Ana , Lee Lillian V. , Berroya Anna , Vince Cruz Ma. Cristina , Casintahan Dainah
Published: August 2004

Objectives. To correlate the presence and levels of total mercury (THg) in cord blood and meconium indicating prenatal exposure with developmental milestones at 2 years and to compare these subjects with controls of comparable age using cognitive adaptive test and clinical linguistic auditory milestone scale (CAT/CLAMS).

Methods. In 48 of the original Tagum (T) subjects, cord blood and meconium Hg levels, head circumference (HC) at birth, and duration of breastfeeding were correlated with CAT/CLAMS at 2 years. At 2 years, THg levels using cold atomic vapor absorption spectrometry were determined in the hair of 46 T subjects and 88 Saranggani (S) controls; THg levels in blood were tested in 48 T subjects and 45 S controls. These levels were correlated with CAT/CLAMS. Both groups had standard physical and neurologic examinations, hearing screen using transitory evoked otoacoustic emissions, serum glutamate pyruvate transaminase, and routine urinalysis. A prevalidated Socioeconomic Means Test was given to both groups.

Results. The Hg level in cord blood was negatively correlated with CAT/CLAMS at 2 years. The HC at birth was negatively correlated with levels of Hg in hair of T subjects 2 years later. HC at birth and 2 years hence were positively correlated with CAT/CLAMS. The following were significantly higher in S controls than in T subjects: expressive language quotient 82.569 ± 2.21 versus 71.57 ± 2.61; CLAMS 87.96 ± 2.43 versus 77.67 ± 2.51; CAT 90.57 ± 2.22 versus 83.15 ± 1.43; and full-scale developmental quotient 89.31 ± 2.14 versus 80.56 ± 1.86. Fifteen percent of T subjects had global delay (full-scale developmental quotient ≤70) versus 5.48% in S controls. Hg levels in hair and blood in both T subjects and S controls at 2 years showed no correlation with CAT/CLAMS. The duration of breastfeeding in both groups likewise showed no correlations with CAT/CLAMS.

Conclusion. The study suggests that prenatal Hg exposure is correlated with lower scores in neurodevelopmental screening, but more so in the linguistic pathway. Other confounding factors cannot be eliminated.
Raynaud’s Phenomenon in Children: A Retrospective Review of 123 Patients
Authors: Nigrovic Peter A. , Fuhlbrigge Robert C. , Sundel Robert P.
Published: August 2004

Objective. To examine the clinical presentation and disease associations of Raynaud’s phenomenon (RP) in children and adolescents.

Methods. A systematic retrospective chart review was conducted of 123 cases drawn from 2 computerized databases at the Children’s Hospital of Boston. Participants aged <19 years with episodic reversible color changes in the extremities were examined. Case records were analyzed for clinical presentation, disease associations, and physical examination and laboratory findings.

Results. In contrast to the findings of smaller pediatric series reported to date, the large majority of our patients—approximately 70%—did not have a recognized underlying connective tissue disease. For both primary and secondary RP, approximately 80% of patients were female, and mean age of onset was similar in the 2 groups. Biphasic or triphasic color changes were less common than monophasic changes and were no more common in secondary than primary RP. Findings predictive of secondary RP were limited to the presence of antinuclear antibodies and abnormal nailfold capillaries. Antiphospholipid antibodies were found at some time in at least 21% of patients with both primary and secondary RP.

Conclusions. RP in children, as in adults, principally affects girls and is frequently free of association with connective tissue disease. Antinuclear antibody positivity and abnormal nailfold capillaries correlate with secondary disease. Antiphospholipid antibodies are surprisingly common, a new finding of uncertain implications.
Prioritizing Strategies for Preventing Medication Errors and Adverse Drug Events in Pediatric Inpatients
Authors: Fortescue Elizabeth B. , Kaushal Rainu , Landrigan Christopher P. , McKenna Kathryn J. , Clapp Margaret D. , Federico Frank , Goldmann Donald A. , Bates David W.
Published: August 2004

Objectives. Medication errors in pediatric inpatients occur at similar rates as in adults but have 3 times the potential to cause harm. Error prevention strategies in this setting remain largely untested. The objective of this study was to classify the major types of medication errors in pediatric inpatients and to determine which strategies might most effectively prevent them.

Methods. A prospective cohort study was conducted of 1020 patients who were admitted to 2 academic medical centers during a 6-week period in April and May 1999. Medication errors were characterized by subtype. Physician raters evaluated error prevention strategies and identified those that might be most effective in preventing errors.

Results. Of 10 778 medication orders reviewed, 616 contained errors. Of these, 120 (19.5%) were classified as potentially harmful, including 115 potential adverse drug events (18.7%) and 5 preventable adverse drug events (0.8%). Most errors occurred at the ordering stage (74%) and involved errors in dosing (28%), route (18%), or frequency (9%). Three interventions might have prevented most potentially harmful errors: 1) computerized physician order entry with clinical decision support systems (76%); 2) ward-based clinical pharmacists (81%); and 3) improved communication among physicians, nurses, and pharmacists (86%). Interrater reliability of error prevention strategy assignment was good (agreement: 0.92; κ: 0.82).

Conclusions. Of the assessed interventions, computerized physician order entry with clinical decision support systems; ward-based clinical pharmacists; and improved communication among physicians, nurses, and pharmacists had the greatest potential to reduce medication errors in pediatric inpatients. Development, implementation, and assessment of such interventions in the pediatric inpatient setting are needed.
Two National Surveys on Pediatric Training and Activities in School Health: 1991 and 2001
Authors: Nader Philip R. , Broyles Shelia L. , Brennan Jesse , Taras Howard
Published: August 2004

Objective. To determine from 2 surveys, in 1991 and 2001, 1) the proportion of pediatricians and which pediatricians report doing school health, 2) which school health activities are most commonly engaged in and whether this has changed, 3) whether training/education during residency influences doing school health later in practice, and 4) whether the amount or nature of residency training in school health (as reported by practicing pediatricians) increased over time, as recommended by various task forces.

Methods. Surveys were mailed to a 10% randomly selected group of the voting membership of the American Academy of Pediatrics.

Results. An estimated 50% to 70% of pediatricians report doing school health, and a consistent 20% report having had training in school health. The nature of school health work varies in urban, suburban, and rural areas, and pediatricians who practice in rural areas are more likely to be involved in school health. When resident education in school health is offered during residency, it is associated with a higher likelihood of pediatricians’ doing school health later in practice. Recent trainees report having more residency training in school health, yet fewer recent trainees report doing school health compared with their older colleagues.

Conclusions. The gap between those who do school health and have received education in school health during residency has continued over at least a 10-year period. Recommendations include specification of school health and community pediatrics competencies for the effective practice of pediatrics in the future.
The First 2 Years of a State Child Health Insurance Plan: Whom Are We Reaching?
Authors: Kempe Allison , Renfrew Brenda , Barrow Jennifer , Cherry Darci , Levinson Arnold , Steiner John F.
Published: August 2004

Objective. The Colorado Child Health Plan Plus is a non-Medicaid state Child Health Insurance Plan. The objective of this study was to compare early enrolling (EE) children with uninsured children in low-income families (ULI) with respect to 1) sociodemographic factors and previous insurance, 2) health status, and 3) previous health care access and utilization.

Methods. Cross-sectional telephone surveys were conducted during 1999 of 1) randomly selected EE children (n = 711) and 2) ULI children identified by random-dial survey (n = 105).

Results. Enrolling children were less likely to be Hispanic (32.7% vs 55.2%); 5.5% of EE versus 27.6% of ULI children had never been insured. Prevalence of chronic conditions was similar (16.2% of EE vs 13.5% of ULI children), but learning/behavioral difficulties (9.7% of EE vs 18.6% of ULI) and fair/poor health (5.4% of EE vs 17.2% of ULI) were higher for uninsured children. In the previous year, 88.2% of EE versus 66.1% of ULI children had a usual source of care. The mean number of preventive visits was similar (1.4 vs 1.2), but the EE group reported a higher mean number of sick visits (2.0 vs 1.1), emergency visits (0.48 vs 0.15), and hospitalizations (0.09 vs 0.02).

Conclusions. In the first 2 years of the program, Child Health Plan Plus is not yet reaching the “hard-to-reach” but, rather, disproportionately high numbers of non-Hispanic children who already have a usual source of care and recent insurance. EE children did not have higher rates of chronic conditions but did demonstrate higher utilization before enrollment, possibly reflecting patterns of enrollment into the program.
Are “Accidental” Gun Deaths as Rare as They Seem? A Comparison of Medical Examiner Manner of Death Coding With an Intent-Based Classification Approach
Authors: Schaechter Judy , Duran Isis , De Marchena Jacqueline , Lemard Glendene , Villar Maria Elena
Published: August 2004

Objectives. Unintentional firearm death is often considered a nearly negligible proportion of overall gun death. These rates are based on medical examiner (ME) and coroner death classifications, which affect derived epidemiologic data and subsequent prevention measures. The aim of this study was to compare the proportion of pediatric unintentional gun deaths in Miami-Dade County based on manner of death coding by the ME with an intent-based classification of child gun deaths.

Methods. ME and police records for all pediatric firearm fatalities in Miami-Dade County from 1994 to 1998 were reviewed. The ME’s assignment of manner of death as homicide, suicide, or accident was compared with an intent-based classification of intentional homicide, intentional suicide, and unintentional firearm death based on expressed or implied evidence of intent to harm.

Results. There were 123 pediatric firearm deaths in Miami-Dade County from 1994 to 1998. A significant difference between ME coding and the intent-based classification was found for homicide (94 vs 78) but not for suicide. A significant difference was also found between the ME’s coding for “accident” and the investigator’s classification of “unintentional” firearm death (4 vs 26).

Conclusions. The incidence of unintentional pediatric firearm deaths is significantly underreported by the Miami-Dade County ME when the classification of “accidental” firearm death is used. Reviewing the manner of death classification criteria or establishing an intent code on official death documentation is recommended. Furthermore, clinicians should be aware that the true incidence of unintentional gun death may be higher than that reported as accidental.
Influence of Iodine-131 Dose on the Outcome of Hyperthyroidism in Children
Authors: Rivkees Scott A. , Cornelius Eugene A.
Published: August 2004

Objectives. Iodine-131 is an effective treatment for Graves’ hyperthyroidism in children and adults. Yet the responses to treatment as related to iodine-131 dose in children are not well-defined. The objective of this study was to examine the relationship between the dose of iodine-131 in children with hyperthyroidism and thyroid status 1 year after treatment.

Methods. We examined the outcome of iodine-131 treatment in children and adolescents with Graves’ disease, as related to dose. Three iodine-131 doses were compared: 72 to 108 Gy (80–120 μCi/g), 180 to 225 Gy (200–250 μCi/g), and 270 to 364 Gy (300–405 μCi/g) in 31 patients ranging in age from 7 to 18 years old. Thyroid status was assessed >1 year after therapy.

Results. We found that doses of 100 Gy (110 μCi/g), 200 Gy (220 μCi/g), and 300 Gy (330 μCi/g) resulted in hypothyroidism in 50%, 70%, and 95% of treated individuals, respectively. These data show that to insure ablation of thyroid tissue doses, >270 Gy (300 μCi/g) is needed, especially when the thyroid is large.
Phase 1 Trial of Prevention of Hydrocephalus After Intraventricular Hemorrhage in Newborn Infants by Drainage, Irrigation, and Fibrinolytic Therapy
Authors: Whitelaw Andrew , Pople Ian , Cherian Shobha , Evans David , Thoresen Marianne
Published: August 2004

Objective. Treatment of posthemorrhagic ventricular dilation in premature infants is fraught with failures and complications. We have piloted a new treatment aimed at removing intraventricular blood and the cytokines associated with hydrocephalus.

Methods. Twenty-four infants were enrolled with ventricular width enlarged to 4 mm over the 97th centile after a large intraventricular hemorrhage. Sixteen had parenchymal brain lesions before treatment. Median gestation was 28 weeks, and birth weight was 1150 g. At a median postnatal age of 17 days, 2 ventricular catheters (1 right frontal, 1 left occipital) were inserted with 13 infants also having a reservoir frontally. Tissue plasminogen activator 0.5 mg/kg was given intraventricularly 8 hours before the ventricles were irrigated with artificial cerebrospinal fluid at 20 mL/h for a median of 72 hours.

Results. Seventeen of 23 survivors (74%) did not require a ventriculoperitoneal shunt. One infant (of 23 weeks’ gestation) died. Two infants developed reservoir-associated infection, and 2 infants had a second intraventricular hemorrhage. Of the 19 survivors aged >12 months postterm, 8 were normal, 7 (37%) had single disability, and 4 (21%) had multiple disabilities.

Conclusions. Shunt surgery was reduced compared with historical controls with similar treatment criteria. Mortality and single and multiple disability rates all showed downward trends. Reducing pressure, free iron, and proinflammatory and profibrotic cytokines may reduce periventricular brain damage and permanent hydrocephalus. Additional advances will require a controlled trial and better knowledge of the mechanisms of hydrocephalus.
Population-Based Analyses of Mortality in Trisomy 13 and Trisomy 18
Authors: Rasmussen Sonja A. , Wong Lee-Yang C. , Yang Quanhe , May Kristin M. , Friedman J. M.
Published: August 2004

Objective. Although trisomy 13 and trisomy 18 are generally considered to be lethal, long-term survival of patients has been reported. We sought to evaluate mortality in people with trisomy 13 or 18 using 2 population-based strategies.

Methods. In the first analysis, infants who had trisomy 13 or 18 and were born during 1968–1999 were identified using the Metropolitan Atlanta Congenital Defects Program, a population-based birth defects surveillance system. Dates of death were documented using hospital records, Georgia vital records, and the National Death Index. In the second analysis, we used the Multiple-Cause Mortality Files compiled from US death certificates from 1979 through 1997. Using these 2 analyses, we examined median survival time or median age at death, survival beyond 1 year of age, and factors associated with longer survival.

Results. Using Metropolitan Atlanta Congenital Defects Program, we identified 70 liveborn infants with trisomy 13 and 114 liveborn infants with trisomy 18. Median survival time was 7 days (95% confidence interval [CI]: 3–15) for people with trisomy 13 and 14.5 days (95% CI: 8–28) for people with trisomy 18. For each condition, 91% of infants died within the first year. Neither race nor gender affected survival for trisomy 13, but for trisomy 18, girls and infants of races other than white seemed to survive longer. The presence of a heart defect did not seem to affect survival for either condition. Using MCMF, we identified 5515 people with trisomy 13 and 8750 people with trisomy 18 listed on their death certificates. Median ages at death for people with trisomy 13 and trisomy 18 both were 10 days; 5.6% of people with trisomy 13 and 5.6% of people with trisomy 18 died at age 1 year or greater. Race and gender seemed to affect survival in both conditions, with girls and blacks showing higher median ages at death.

Conclusions. Although survival is greatly affected by trisomy 13 and trisomy 18, 5% to 10% of people with these conditions survive beyond the first year of life. These population-based data are useful to clinicians who care for patients with these trisomies or counsel families with infants or fetuses who have a diagnosis of trisomy 13 or 18.
Efficacy of Methylprednisolone and Urokinase Pulse Therapy for Severe Henoch-Schönlein Nephritis
Authors: Kawasaki Yukihiko , Suzuki Junzo , Nozawa Ruriko , Suzuki Shigeo , Suzuki Hitoshi
Published: August 2004

Objective. To evaluate the efficacy of methylprednisolone and urokinase pulse therapy (MUPT) for severe Henoch-Schönlein nephritis, we examined the clinical manifestation and prognosis of patients with MUPT on long-term observation.

Methods. We enrolled 56 patients with Henoch-schönlein nephritis who had been diagnosed with at least type IIIb from 1980 to 1998 on long-term observation and had been treated with MUPT. The clinical features, laboratory data, and pathologic findings between “pre-MUPT” and “post-MUPT,” and the prognosis of these patients on long-term observation were retrospectively investigated.

Results. The mean urinary protein excretion after 6 months of treatment had decreased significantly compared with “pre-MUPT.” Hypercoagulant state in “after the completion of urokinase pulse therapy” improved compared with “pre-MUPT.” First renal biopsies were performed in all patients and second biopsies were performed in 27 patients. The activity index decreased significantly from 4.1 ± 1.9 at first biopsy to 2.5 ± 1.7 at second biopsy, while the chronicity index did not differ between first and second biopsy. None had renal insufficiency and renal survival rate was 100% for the decade.

Conclusions. Although uncontrolled, our study suggested that MUPT is effective for those patients with the risk of progression of their nephropathy, especially if started early during the course of the disease before the crescents become fibrous.
Use of the GlucoWatch Biographer in Children With Type 1 Diabetes
Authors: Chase H. Peter , Roberts Mary D. , Wightman Clare , Klingensmith Georgeanna , Garg Satish K. , Van Wyhe Michelle , Desai Shashi , Harper Wesley , Lopatin Margarita , Bartkowiak Miroslaw , Tamada Janet , Eastman Richard C.
Published: August 2004

Objective. To determine whether use of the GlucoWatch biographer improves glucose control in children and adolescents with type 1 diabetes.

Methods. Forty children in poor glucose control (glycohemoglobin [HbA1c] >8%) were randomized to diabetes management with or without glucose monitoring using the biographer. Conventional glucose monitoring was performed 4 times daily in both groups. Those randomized to the biographer group were asked to wear the device 4 times per week for 3 months (intervention phase) and to perform blood glucose monitoring if the biographer alerted them that glucose was ≤70 mg/dL (3.9 mmol/L) or ≥300 mg/dL (16.7 mmol/L). After 3 months, all patients received biographers and were followed for 6 months (observation phase). HbA1c values were determined at baseline and after 1, 3, 6, and 9 months.

Results. The median HbA1c was 8.6% and 8.9% (control versus biographer) at baseline and was significantly lower in the biographer group after 3 months (8.4% vs 9%). More hypoglycemia was detected when subjects were wearing the biographer, especially at night. No severe hypoglycemia occurred. During the observation phase, HbA1c values at 6 months were 8.5% and 8.3% and at 9 months were 8.6% and 8.4% in the control and biographer groups, respectively. Two children dropped out of the study, 1 because of skin irritation from using the device.

Conclusions. The GlucoWatch biographer was well tolerated by children and adolescents and significantly improved glucose control compared with standard therapy. The use of the biographer with an alarm to detect nocturnal hypoglycemia has the potential to increase the safety of diabetes management in children.
Nighttime Child Care: Inadequate Sudden Infant Death Syndrome Risk Factor Knowledge, Practice, and Policies
Authors: Moon Rachel Y. , Weese-Mayer Debra E. , Silvestri Jean M.
Published: August 2004

Background. Millions of children in the US have parents who work alternative shifts. As a result, extended-hour and nighttime child care centers have increased in number to meet the needs of parents working nonstandard hours. Recognizing that 20% of sudden infant death syndrome (SIDS) occurs in child care settings and that child care providers may place infants prone, it is important to determine sleep position practices in nighttime child care centers.

Objective. To determine if nighttime child care centers 1) follow Back to Sleep recommendations; 2) are aware of the need for a safe sleep environment; and 3) have written policies directing proper SIDS risk reduction practices.

Design. A descriptive, cross-sectional survey of licensed child care centers in the US offering evening and nighttime care. All nighttime centers caring for infants <6 months old were recruited for the study.

Results. Out of 153 eligible centers, 110 centers in 27 states completed the survey. Infants were placed prone in 20% of centers, although only 1 center placed infants exclusively prone. Infants slept in cribs in 53.6% of centers, but slept in uncluttered sleep environments in only 18.2% of centers. Smoking was prohibited in 86.4% of centers. The most commonly cited reason for avoiding prone altogether was SIDS risk reduction; however, 10 centers that cited SIDS risk reduction continued to place infants prone at least some of the time, because of parental request or concerns about infant comfort. Over half (59%) of the centers had written policies; however, presence of written policy was not associated with avoidance of prone position. In over one third of centers with written policies, providers were unaware of the content of the policy.

Conclusions. Twenty percent of nighttime child care centers place infants prone at least some of the time. Most providers who place infants prone do so because of lack of awareness or misinformation about safe sleep environment. Although the Back to Sleep campaign has been effective in communicating the risks of sleeping prone, nonprone positioning is not universal among nighttime child care providers. Additional educational efforts toward child care providers remain necessary. In addition, parents as advocates for their own infants need to be proactive in assuring that safe sleep practices are implemented in child care settings.