bluuebunny/crossref_metadata_2025 huggingface dataset:
Cost-Effectiveness of Treatment for Threshold Retinopathy of Prematurity
Authors: Brown Gary C. , Brown Melissa M. , Sharma Sanjay , Tasman William , Brown Heidi C.
Published: August 2004

Objective.

Retinopathy of prematurity (ROP) is a leading cause of adverse visual outcomes in premature infants. Both laser photocoagulation and cryotherapy have been demonstrated in clinical trials to be efficacious in reducing the incidence of visual loss occurring secondary to threshold ROP. Visual data recently have become available concerning the long-term clinical efficacy of both treatments, as have data concerning the utility value of visual states in general. Accordingly, we undertook an analysis to ascertain the cost-effectiveness of laser photocoagulation and cryotherapy in the treatment of threshold ROP.

Design.

A computer simulation economic model is presented to evaluate the cost-effectiveness of cryotherapy and laser photocoagulation therapy, compared with the natural course of the disease, for treating premature infants with threshold ROP. The model applies long-term visual data from previous clinical trials, utility analysis, decision analysis, and economic principles, such as present value analysis, to account for the time value of money to arrive at a cost per quality-adjusted life-year (QALY) gained.

Outcome Measures.

Cost per QALY gained from laser therapy and cryotherapy.

Results.

Laser photocoagulation therapy for threshold ROP costs $678 1998 US dollars (at a 3% discount rate to account for the time value of money) for each QALY gained from treatment. Cryotherapy for the same disease costs $1801 per QALY at a similar discount rate.

Conclusions.

From the point of view of cost-effectiveness, laser therapy seems to have an advantage over cryotherapy for the treatment of threshold ROP.
Firearms in the Home: Parental Perceptions
Authors: Farah Mirna M. , Simon Harold K. , Kellermann Arthur L.
Published: August 2004

Background.

Each year, thousands of children are injured or killed from unintentional gunshot wounds. Discovering a gun while playing in the home places children at risk of being injured by the firearm.

Objectives.

To determine parental firearm storage practices and parental perceptions of the behavior of their children around guns.

Methods.

Cross-sectional survey of parents of children from 4 to 12 years of age. A sample of 424 parents, bringing their children to one of five pediatric ambulatory care centers, were asked to complete a 20-point self-administered questionnaire at the time of their visit.

Results.

A total of 400 parents (94%) completed the questionnaire; 113 parents (28%) reported keeping a firearm (most often a handgun) in the home. Firearm owners were predominantly male, 30 years of age or older, white, and married. Of the gun owners, 52% stored their firearms loaded or unlocked, and 13% kept one or more guns loaded and unlocked. Three fourths of gun-owning parents believed that their 4- to 12-year-old child could tell the difference between a toy gun and a real gun, and 23% believed that their child could be trusted with a loaded gun. Although the majority of gun-owning parents (53%) endorsed safe storage as the best firearm injury prevention strategy, 61% of parents who do not own firearms endorse not owning guns as the best way to prevent pediatric firearm injuries.

Conclusion.

A majority of gun-owning parents store their firearms loaded or unlocked, substantially underestimating the risk of injury to their children. Many firearm-owning parents trust their child with a loaded gun and believe that their young child can tell the difference between a toy gun and a real gun.
Randomized, Controlled Trial of Low-dose Inhaled Nitric Oxide in the Treatment of Term and Near-term Infants With Respiratory Failure and Pulmonary Hypertension
Authors: Cornfield David N. , Maynard Roy C. , deRegnier Raye-Ann O. , Guiang Sixto F. , Barbato Joel E. , Milla Carlos E.
Published: August 2004

Recent reports indicate that inhaled nitric oxide (iNO) causes selective pulmonary vasodilation, increases arterial oxygen tension, and may decrease the use of extracorporeal membrane oxygenation (ECMO) in infants with persistent pulmonary hypertension of the newborn (PPHN). Despite these reports, the optimal dose and timing of iNO administration in PPHN remains unclear.

Objectives. To test the hypotheses that in PPHN 1) iNO at 2 parts per million (ppm) is effective at acutely increasing oxygenation as measured by oxygenation index (OI); 2) early use of 2 ppm of iNO is more effective than control (0 ppm) in preventing clinical deterioration and need for iNO at 20 ppm; and 3) for those infants who fail the initial treatment protocol (0 or 2 ppm) iNO at 20 ppm is effective at acutely decreasing OI.

Study Design. A randomized, controlled trial of iNO in 3 nurseries in a single metropolitan area. Thirty-eight children, average gestational age of 37.3 weeks and average age <1 day were enrolled. Thirty-five of 38 infants had echocardiographic evidence of pulmonary hypertension. On enrollment, median OI in the control group, iNO at 0 ppm, (n = 23) was 33.1, compared with 36.9 in the 2-ppm iNO group (n = 15).

Results. Initial treatment with iNO at 2 ppm for an average of 1 hour was not associated with a significant decrease in OI. Twenty of 23 (87%) control patients and 14 of 15 (92%) of the low-dose iNO group demonstrated clinical deterioration and were treated with iNO at 20 ppm. In the control group, treatment with iNO at 20 ppm decreased the median OI from 42.6 to 23.8, whereas in the 2-ppm iNO group with a change in iNO from 2 to 20 ppm, the median OI did not change (42.6 to 42.0). Five of 15 patients in the low-dose nitric oxide group required ECMO and 2 died, compared with 7 of 23 requiring ECMO and 5 deaths in the control group.

Conclusion. In infants with PPHN, iNO 1): at 2 ppm does not acutely improve oxygenation or prevent clinical deterioration, but does attenuate the rate of clinical deterioration; and 2) at 20 ppm acutely improves oxygenation in infants initially treated with 0 ppm, but not in infants previously treated with iNO at 2 ppm. Initial treatment with a subtherapeutic dose of iNO may diminish the clinical response to 20 ppm of iNO and have adverse clinical sequelae.
Calcium Requirements of Infants, Children, and Adolescents
Authors:   Committee on Nutrition
Published: August 2004

This statement is intended to provide pediatric caregivers with advice about the nutritional needs of calcium of infants, children, and adolescents. It will review the physiology of calcium metabolism and provide a review of the data about the relationship between calcium intake and bone growth and metabolism. In particular, it will focus on the large number of recent studies that have identified a relationship between childhood calcium intake and bone mineralization and the potential relationship of these data to fractures in adolescents and the development of osteoporosis in adulthood. The specific needs of children and adolescents with eating disorders are not considered.
Screening Tests for Urinary Tract Infection in Children: A Meta-analysis
Authors: Gorelick Marc H. , Shaw Kathy N.
Published: August 2004

Objective.

To review systematically and to summarize the existing literature regarding performance of rapid diagnostic tests for urinary tract infection (UTI) in children.

Design.

Systematic review and meta-analysis.

Methods.

Published articles reporting the performance of urine dipstick tests (leukocyte esterase [LE] and/or nitrite), Gram stain, or microscopic analysis of spun or unspun urine in the diagnosis of UTI in children ≤12 years of age. Articles were identified through a comprehensive MEDLINE search, and those articles meeting a priori inclusion criteria were selected. Eligibility criteria included the use of urine culture as the reference standard, independent comparison of urine culture with the results of one of the screening tests, definition of positive screening test results provided, only pediatric patients included or evaluable separately, and both gold standard and screening test performed on all patients. For each test, heterogeneity of reported sensitivity and specificity of all studies was determined. The subgroups of studies with similar definitions of UTI and age of study subjects were analyzed separately to account for some of the differences in reported results. When significant unexplained heterogeneity among studies precluded simple combining of results, a summary receiver–operator characteristic curve was fitted for each screening test, from which pooled estimates of true-positive rate (TPR; ie, sensitivity) and false-positive rate (FPR; 1-specificity) were calculated.

Primary Results.

A total of 1489 titles were identified by the MEDLINE search; 26 articles met all criteria for inclusion. There was significant heterogeneity among studies for nearly all tests for both TPR and FPR, which was explained only partially by the stringency of the definition of UTI or age of subjects studied. Based on the pooled estimates, the presence of any bacteria on Gram stain on an uncentrifuged urine specimen had the best combination of sensitivity (0.93) and FPR (0.05). Urine dipstick tests performed nearly as well, with a sensitivity of 0.88 for the the presence of either LE or nitrite and an FPR of 0.04 for the presence of both LE and nitrite. Pyuria had lower TPR and higher FPR: for presence of >5 white blood cells/high-power field in a centrifuged urine sample, the TPR was 0.67 and the FPR was 0.21, whereas for >10 white blood cells per mm3 in uncentrifuged urine, the TPR was 0.77 and the FPR was 0.11.

Conclusions.

Both Gram stain and dipstick analysis for nitrite and LE perform similarly in detecting UTI in children and are superior to microscopic analysis for pyuria.
Analysis of Gastrointestinal Sounds in Infants With Pyloric Stenosis Before and After Pyloromyotomy
Authors: Tomomasa Takeshi , Takahashi Atsushi , Nako Yasushi , Kaneko Hiroaki , Tabata Masahiko , Tsuchida Yoshiaki , Morikawa Akihiro
Published: August 2004

Background.

Although recent advances in computer technology enable us to analyze gastrointestinal sounds data objectively with ease, this clinical application has been investigated in only a few disorders. To investigate one potential role of this approach in pediatric practice, we recorded and analyzed gastrointestinal sounds in infants with hypertrophic pyloric stenosis (HPS), a motility-related disorder that is common in children.

Methods.

In 15 infants with pyloric stenosis, gastrointestinal sounds were collected with a microphone placed 3 cm below the umbilicus for 60 minutes before pyloromyotomy and at 9 to 12 hours, 20 to 24 hours, 40 to 48 hours, and 112 to 120 hours after the operation. Data were entered into a computer to sum the amplitude of sound signals as a sound index (SI; mV per minute). In 12 infants, gastric emptying was measured immediately before each sound recording, using a marker dilution-double sampling method.

Results.

Before surgery, the mean SI was 4.6 ± 1.0 mV per minute, significantly less than in healthy controls (31.7 ± 8.4 mV per minute). The SI remained in a similar range until 12 hours after operation, after which it began increasing to reach the normal range by 48 hours after operation (30.0 ± 9.4 mV per minute). Gastric emptying, also low in HPS before pyloromyotomy, increased by 4 to 5 times after surgery. There was a significant positive correlation between SI and gastric emptying. The incidence of postoperative symptoms (such as vomiting) were correlated significantly with SI at 24 hours after surgery.

Conclusion.

This study found decreased gastrointestinal sounds to be among physical findings suggestive of HPS and a useful indicator of gastric emptying and bowel motility after pyloromyotomy. Computer-assisted analysis of gastrointestinal sounds might be helpful in clinical practice for pediatric patients with some gastrointestinal disorders.
Sleep Disturbances in Children With Human Immunodeficiency Virus Infection
Authors: Franck Linda Sturla , Johnson Lora Margherita , Lee Kathryn , Hepner Christine , Lambert Lael , Passeri Mary , Manio Estrella , Dorenbaum Alejandro , Wara Diane
Published: August 2004

Objective.

To describe the sleep patterns and level of fatigue in children and adolescents (6–18 years of age) with HIV infection, compared with ethnic-, gender-, and age-matched healthy children in the home setting.

Design.

Descriptive, comparative.

Setting.

Conducted in each child's home environment.

Study Participants.

Eighteen HIV-infected and 15 noninfected children completed the study. The Centers for Disease Control and Prevention HIV classifications for the 18 HIV-infected children were: A (n = 7), B (n= 6), and C (n = 5).

Methods.

A symptom diary was developed using a previously validated fatigue assessment scale, modified for use with children. Content validity of the diary was established with a panel of 5 experts in child development and pediatric HIV disease. Children were asked to complete the diary each morning and evening for 3 days. Each child wore a wrist actigraph during the same period.

Results.

The HIV-infected children had significantly more wake time after sleep onset, compared with noninfected children (13.55% vs 7.47%). The HIV-infected children had more awakenings (25.33 vs 16.71) and were awake for longer periods (3.01 vs 1.01 minutes), compared with noninfected children. By parent report, 7 HIV-infected children napped and 2 noninfected children napped, indicating greater daytime fatigue in the HIV-infected children. HIV-infected children also reported a greater level of evening tiredness (2.47 vs 1.8).

Conclusions.

The findings from this study suggest that sleep disturbances occur in HIV-infected children, similar to findings previously described in HIV-infected adults. Additional research is necessary to characterize the nature and patterns of sleep disturbance and fatigue related to pediatric HIV-infection, to assess the impact these may have on daily activities, and to develop strategies to improve sleep for these children.
Parental Stress and Parent-rated Child Behavior in Relation to Otitis Media in the First Three Years of Life
Authors: Paradise Jack L. , Feldman Heidi M. , Colborn D. Kathleen , Campbell Thomas F. , Dollaghan Christine A. , Rockette Howard E. , Janosky Janine E. , Kurs-Lasky Marcia , Bernard Beverly S. , Smith Clyde G.
Published: August 2004

Objective.

As part of a long-term study of possible effects of early-life otitis media on speech, language, cognitive, and psychosocial development, we tested relationships between parents' ratings of parent-child stress at ages 1, 2, and 3 years, and of their children's behavior problems at ages 2 and 3 years, and the children's cumulative duration of middle-ear effusion (MEE) in their first 3 years of life.

Methods.

We enrolled healthy infants by age 2 months who presented for primary care at 1 of 2 urban hospitals or 1 of 2 small-town/rural and 4 suburban private pediatric practices. We obtained standardized baseline measures of parental stress; we intensively monitored the children's middle-ear status by pneumatic otoscopy, supplemented by tympanometry, throughout their first 3 years of life; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated children for otitis media according to specified guidelines. We obtained parent ratings of parental stress using the Parenting Stress Index/Short Form when the children reached ages 1, 2, and 3 years, and parent ratings of children's behavior using the Child Behavior Checklist when the children reached ages 2 and 3 years.

Results.

In 2278 children we found no substantial relationships between parents' ratings of parent-child stress when the children reached ages 1, 2, and 3 years, or of their children's behavior problems at ages 2 and 3 years, and the cumulative duration of the children's MEE during antecedent periods. On the other hand, ratings both of parent-child stress and of behavior problems were consistently highest among the most socioeconomically disadvantaged children and lowest among the most socioeconomically advantaged children. Ratings also tended to be highest among children whose parents' baseline stress scores were highest.

Conclusions.

Parent-child stress and children's behavior problems in the first 3 years of life, as rated by parents, bear little or no relationship to the children's previous cumulative duration of MEE.
The Relationship Between Psychosocial Factors and Asthma Morbidity in Inner-City Children With Asthma
Authors: Weil Constance M. , Wade Shari L. , Bauman Laurie J. , Lynn Henry , Mitchell Herman , Lavigne John
Published: August 2004

Objective.

Children living in the inner city are affected disproportionately by asthma morbidity and mortality. Previous research has shown that behavioral and psychosocial factors affect asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated the factors that contribute to asthma morbidity among inner-city children. This article examines the relationship between psychosocial factors and asthma morbidity in this population.

Methods.

A total of 1528 English- and Spanish-speaking children 4 to 9 years of age with asthma and their primary caretakers were recruited from 8 research centers in 7 metropolitan inner-city areas in the United States. Psychosocial variables were assessed at baseline and included measures of child and caretaker mental health, caretaker's problems with alcohol, life stress, social support, and parenting style. Morbidity measures were evaluated at baseline and at 3-, 6-, and 9-month follow-up intervals. These included number of hospitalizations and unscheduled visits for asthma in the past 3 months and number of days of wheeze and functional status in the previous 2-week period.

Results.

Of the psychosocial variables assessed, mental health had the strongest relationship to children's asthma morbidity. Children whose caretakers had clinically significant levels of mental health problems were hospitalized for asthma at almost twice the rate as children whose caretakers did not have significant mental health problems. Children with clinically significant behavior problems had significantly more days of wheeze and poorer functional status in the follow-up period.

Conclusion.

Psychosocial factors, particularly the mental health of children and caretakers, are significant factors in predicting asthma morbidity. They may need to be included in intervention programs aimed at decreasing asthma morbidity in inner-city children with asthma in order for these programs to be successful.
Repeated School-based Screening for Sexually Transmitted Diseases: A Feasible Strategy for Reaching Adolescents
Authors: Cohen Deborah A. , Nsuami Malanda , Martin David H. , Farley Thomas A.
Published: August 2004

Objectives.

To determine whether repeated school-based screening and treatment for chlamydia and gonorrhea will decrease the prevalence of infection among students.

Design.

At three high schools serving over 2000 students, all 9th through 12th grade students were given the opportunity to be tested during three consecutive school years for chlamydia and gonorrhea, using urine ligase chain reaction tests. Five comparable schools with 5063 students enrolled served as wait-listed controls.

Setting.

Eight urban public high schools in Louisiana.

Participants.

Annually, 52% to 65% of all enrolled students participated; among those enrolled in schools for ≥2 years, 83.4% of students were tested at least once.

Intervention.

Education of all students; counseling and treatment of infected students with oral single-dose antibiotic therapy.

Main Outcome Measure.

Prevalence of Chlamydia trachomatis and gonorrhea infection.

Results.

At first test, 286 (11.5%) of 2497 girls and 143 (6.2%) of 2308 boys were infected with chlamydia, and 48 (2.5%) of 1883 girls and 19 (1.2%) of 1628 boys had gonorrhea. Over 90% of infections were asymptomatic. With repeated testing, chlamydia prevalence among boys dropped to half the rate of comparison schools (3.2% vs 6.4%). Among girls chlamydia prevalence declined only slightly (10.3% vs 11.9% in comparison schools).

Conclusion.

There are high rates of asymptomatic sexually transmitted diseases (STDs) in the general urban school population. Repeated screening and treatment are associated with declines in chlamydia prevalence among boys. Expansion of STD screening and treatment programs to school settings is likely to be a critical component of a national strategy to control bacterial STDs.
Evaluation of an Evidence-based Guideline for Bronchiolitis
Authors: Perlstein Paul H. , Kotagal Uma R. , Bolling Christopher , Steele Robert , Schoettker Pamela J. , Atherton Harry D. , Farrell Michael K.
Published: August 2004

Objective.

To describe the effect of implementing an evidence-based clinical practice guideline for the inpatient care of infants with bronchiolitis at the Children's Hospital Medical Center in Cincinnati, Ohio.

Methodology.

A multidisciplinary team generated the guideline for infants ≤1 year old who were admitted to the hospital with a first-time episode of typical bronchiolitis. The guideline was implemented January 15, 1997, and data on all patients admitted with bronchiolitis from that date through March 27, 1997, were compared with data on similar patients admitted in the same periods in the years 1993 through 1996. Data were extracted from hospital charts and clinical and financial databases. They included LOS and use and costs of resources ancillary to bed occupancy.

Results.

After implementation of the guideline, admissions decreased 29% and mean LOS decreased 17%. Nasopharyngeal washings for respiratory syncytial virus were obtained in 52% fewer patients. Twenty percent fewer chest radiographs were ordered. There were significant reductions in the use of all respiratory therapies, with a 30% decrease in the use of at least 1 β-agonist inhalation therapy. In addition, 51% fewer repeated inhalations were administered. Mean costs for all resources ancillary to bed occupancy decreased 37%. Mean costs for respiratory care services decreased 77%.

Conclusions.

An evidence-based clinical practice guideline for managing bronchiolitis was highly successful in modifying care during its first year of implementation.guideline, bronchiolitis, evidence-based medicine, pediatrics, outcome research.
Resolution of HIV-Associated Nephrotic Syndrome With Highly Active Antiretroviral Therapy Delivered by Gastrostomy Tube
Authors: Viani Rolando M. , Dankner Wayne M. , Muelenaer Penelope A. , Spector Stephen A.
Published: August 2004

There is no consensus regarding the specific management of HIV-associated nephrotic syndrome. We report a child whose first manifestation of human immunodeficiency virus type 1 (HIV-1) infection was nephropathy and wasting syndrome associated with profound immunodeficiency. The patient had a dramatic clinical and immunologic response to triple antiretroviral therapy delivered through a gastrostomy tube, with complete resolution of nephrotic syndrome.

A 5½-year-old African-American girl presented with a 2-week history of cough, chest pain, vomiting, loose stools, abdominal distention, anorexia, and fever. In addition, she had recurrent oral thrush. Her weight and height were below the 5th percentile. She was chronically ill, appearing with oropharyngeal thrush and pitting edema in lower extremities. She had scattered rhonchi and decreased breath sounds on both lung bases. Her abdomen was distended and diffusely tender. A chest radiograph showed consolidation of the right upper and left lower lobes with bilateral pleural effusion. Admission laboratories were consistent with nephrotic syndrome.Streptococcus pneumoniae grew from the blood culture and the child responded well to treatment with intravenous ceftriaxone. She was found to be HIV-infected, her CD4+ cell count was 3 cells/μL and her plasma HIV-1 RNA was >750 000 copies/mL. A percutaneous gastrostomy tube was placed for supplemental nutrition. She was treated with stavudine, lamivudine, and nelfinavir via gastrostomy tube with good clinical response.

Twenty-one months after instituting antiretroviral therapy, her weight and height had increased to the 50th and 10th percentile respectively, and she had complete resolution of her nephrotic syndrome. Her CD4+ cell count increased to 1116 cells/μL and her viral load has remained undetectable.

HIV-1 associated nephrotic syndrome has been described in children with profound immunodeficiency. The course of untreated HIV-associated nephrotic syndrome is rapid progression to renal failure in up to 40% of the children. Regardless of the presence of renal insufficiency, if untreated, it is uniformly fatal.

A modest improvement of HIV-1 associated nephrotic syndrome has been observed in patients treated with zidovudine. Steroid and cyclosporine treatment have resulted in improved renal function but long-term use of immunosuppresive therapy has raised concerns about safety. We have described, to our knowledge, the first child with HIV-associated nephrotic syndrome who had a remarkable clinical, immunologic, and virologic response to triple-drug combination therapy given by gastrostomy tube, with complete resolution of proteinuria and normalization of the serum albumin. She also had a striking improvement in weight, height, and quality-of-life. Whether the presence of a gastrostomy tube contributed to the excellent response because of improved compliance is unknown, but warrants systematic evaluation.
Development of Guidelines for Treatment of Children With Phenylketonuria: Report of a Meeting at the National Institute of Child Health and Human Development Held August 15, 1995, National Institutes of Health, Bethesda, Maryland
Authors: Seashore Margretta Reed , Wappner Rebecca , Cho Sechin , de la Cruz Felix
Published: August 2004

Objective.

To convene a small group of experts in diagnosis and management of PKU to discuss the following issues: the Subject Review of PKU management being performed by the American Academy of Pediatrics (AAP) Committee on Genetics (COG), the published British guidelines on PKU management, and the feasibility, suitability, and mechanism of developing PKU management guidelines for the United States.

Methods.

A 1-day meeting was held at the National Institutes of Health under the auspices of National Institute of Child Health and Human Development, convening experts in PKU diagnosis and management and members of the AAP/COG.

Results.

The group reviewed the published reports of outcomes of treatment of PKU and the British guidelines that were developed based on those data. It also reviewed the results of surveys of directors of clinics that manage PKU, parents of children with PKU, and young adults with PKU.

Conclusion.

The group supported the efforts of the AAP/COG to perform this review of PKU management. The group concluded that significant issues need to be resolved to provide sufficient information to establish US guidelines for PKU management. The establishment of such guidelines is an important next step in PKU management in the United States.
Immunization Outreach in an Inner-City Housing Development: Reminder–Recall on Foot
Authors: Goldstein Karen P. , Lauderdale Diane S. , Glushak Cai , Walter James , Daum Robert S.
Published: August 2004

Objective.

To determine rates of immunization coverage among children 3 to 72 months of age in a large public housing development, to develop a community-based outreach program to increase coverage, and to evaluate the effect of the program.

Design.

A door-to-door canvass of the development by specially trained emergency medical technicians to enroll families, to determine immunization status from written records, and to follow-up to encourage immunizations and well-child care. The program was evaluated, comparing rates of immunization by age with an expectation based on the immunization histories before enrollment.

Setting.

A Chicago public housing development, October 1993 through December 1996.

Outcome Variables.

Antigen-specific and series-specific coverage based on written records.

Results.

Of the caregivers, 92% were able to identify a primary care provider. At the time of enrollment, 37% of 1075 children were up-to-date, but that proportion varied by age with 27% of children 19 to 35 months of age being up-to-date. The program increased rates of immunization compared with the expectation from the preenrollment rates. At their final assessment, 50% of the children were up-to-date. For individual vaccines, there was a positive program effect. For example, before enrollment, 22% of children 15 months of age had received measles, mumps, and rubella vaccine. However, 39% of children who were enrolled in the program before they were 12 months of age had received their first immunizations by 15 months of age.

Conclusions.

Children in the housing development had very low rates of immunization before enrollment. An in-person intervention was effective in reaching families and determining immunization status. In the 3-year enrollment and observation period, rates of immunization increased.
Reliability and Validity of the Children's Health Survey for Asthma
Authors: Asmussen Linda , Olson Lynn M. , Grant Evalyn N. , Fagan Joanne , Weiss Kevin B.
Published: August 2004

Objective.

Describe the psychometric properties of the Children's Health Survey for Asthma (CHSA)— a condition-specific, self-report, functional health measure for parents of children 5 to 12 years of age with chronic asthma.

Method.

Data from two cross-sectional and one longitudinal study were used to assess internal consistency reliability, test–retest reliability, and validity of the CHSA. Over 275 parents and guardians of children with asthma completed the CHSA in one of three studies. The combined samples included a heterogenous mix of respondents by child age and race/ethnicity and parental marital and socioeconomic status. Five domain scores were computed: physical health, activity (child), activity (family), emotional health (child), and emotional health (family). Raw scale scores were transformed from 0 to 100 with higher scores indicating better or more positive outcomes.

Results.

Across the three samples, mean scale scores ranged from a low of 61.5 (emotional health of the child) to a high of 86.1 (activity [family]). Internal consistency reliability for each of the scales was high (Cronbach's α = .81–.92), and test–retest reliability (correlation between forms) ranged from .62 to .86. Significant differences in mean scores for four of five scales were noted between those with low versus moderate to high recent symptom activity.

Conclusion.

In three tests, the CHSA displays strong reliability and validity. Descriptive statistics demonstrate a range of scale scores. Internal consistency is good to excellent and short-term test–retest reliability is good for each of the five scales. Construct validity is demonstrated by the ability of CHSA to distinguish levels of disease severity, defined by symptom activity.
Codeine Intoxication in the Neonate
Authors: Magnani Barbarajean , Evans Richard
Published: August 2004

Although opiates can provide patients with relief from pain and the discomfort of cough, the routine prescription of these drugs for infants demands caution and concern. Infants, particularly neonates, are not merely small adults requiring smaller dosages, but rather uniquely different patients. Neonates present with an immature physiology and biochemistry with respect to drug metabolism. We report a case of codeine intoxication in the neonate, in which the drug was prescribed for cough control during an emergency department visit.
Technical Report: Minor Head Injury in Children
Authors: Homer Charles J. , Kleinman Lawrence
Published: August 2004

Minor head trauma affecting children is a common reason for medical consultation and evaluation. In order to provide evidence on which to base a clinical practice guideline for the American Academy of Pediatrics, we undertook a systematic review of the literature on minor head trauma in children.

Methods. Medline and Health databases were searched for articles published between 1966 and 1993 on head trauma or head injury, limited to infants, children, and adolescents. Abstracts were reviewed for relevance to mild head trauma consistent with the index case defined by the AAP subcommittee. Relevant articles were identified, reviewed, and abstracted. Additional citations were identified by review of references and expert suggestions. Unpublished data were also identified through contact with authors highlighting child-specific information. Abstracted data were summarized in evidence tables. The process was repeated in 1998, updating the review for articles published between 1993 and 1997.

Results. A total of 108 articles were abstracted from 1033 abstracts and articles identified through the various search strategies. Variation in definitions precluded any pooling of data from different studies. Prevalence of intracranial injury in children with mild head trauma varied from 0% to 7%. Children with no clinical risk characteristics are at lower risk than are children with such characteristics; the magnitude of increased risk was inconsistent across studies. Computed tomography scan is most sensitive and specific for detection of intracranial abnormalities; sensitivity and specificity of skull radiographs ranged from 21% to 100% and 53% to 97%, respectively. No high quality studies tested alternative strategies for management of such children. Outcome studies are inconclusive as to the impact of minor head trauma on long-term cognitive function.

Conclusions. The literature on mild head trauma does not provide a sufficient scientific basis for evidence-based recommendations about most of the key issues in clinical management. More consistent definitions and multisite assessments are needed to clarify this field.
Delivery Room Management of the Apparently Vigorous Meconium-stained Neonate: Results of the Multicenter, International Collaborative Trial
Authors: Wiswell Thomas E. , Gannon Catherine M. , Jacob Jack , Goldsmith Leonard , Szyld Edgardo , Weiss Kerry , Schutzman David , Cleary Gerard M. , Filipov Panayot , Kurlat Isabel , Caballero Carlos L. , Abassi Soraya , Sprague Daniel , Oltorf Charles , Padula Michael
Published: August 2004

Objective. Disagreement exists concerning the appropriate delivery room management of the airway of vigorous meconium-stained infants. Some suggest a universal approach to intubation and suctioning of the airway in all such neonates, whereas others advocate a selective approach. We performed this investigation: 1) to assess whether intubation and suctioning of apparently vigorous, meconium-stained neonates would reduce the incidence of meconium aspiration syndrome (MAS); and 2) to determine the frequency of complications from delivery room intubation and suctioning of such infants.

Methods. Inclusion criteria included: 1) gestational age ≥37 weeks; 2) birth through meconium-stained amniotic fluid of any consistency; and 3) apparent vigor immediately after birth. Subjects were randomized to be intubated and suctioned (INT) or to expectant management (EXP). Primary outcome measures included: 1) the incidence of respiratory distress, including MAS, and 2) the incidence of complications from intubation.

Results. A total of 2094 neonates were enrolled from 12 participating centers (1051 INT and 1043 EXP). Meconium-stained amniotic fluid consistency was similar in both groups. Of the 149 (7.1%) infants that subsequently demonstrated respiratory distress, 62 (3.0%) had MAS and 87 (4.2%) had findings attributed to other disorders. There were no significant differences between groups in the occurrence of MAS (INT = 3.2%; EXP = 2.7%) or in the development of other respiratory disorders (INT = 3.8%; EXP = 4.5%). Of 1098 successfully intubated infants, 42 (3.8%) had a total of 51 complications of the procedure. In all cases, the complications were mild and transient in nature.

Conclusions. Compared with expectant management, intubation and suctioning of the apparently vigorous meconium-stained infant does not result in a decreased incidence of MAS or other respiratory disorders. Complications of intubation are infrequent and short-lived.
Enhancing the Racial and Ethnic Diversity of the Pediatric Workforce
Authors:   Committee on Pediatric Workforce
Published: August 2004

Purpose.

This statement seeks to increase the awareness of the importance of diversity; to encourage the incorporation of principles of cultural competence into all aspects of pediatric education, training, and practice, as exemplified by practitioners, educators, and our national leadership; and finally to identify strategies for implementing this incorporation.

Key Concepts.

The increasing cultural diversity of the population has significant implications for the pediatric workforce and for the provision of pediatric health services. Diversity within the pediatric workforce will enhance the potential for pediatricians to acquire the knowledge and practice skills needed to effectively address the health and wellness needs of children and families. Support from this diversity should be integrated into all aspects of education, including providing quality education for minority students and attracting and retaining minority faculty; and should be sought through collaboration locally, regionally, and nationally with organizations and community leaders.

Anticipated Outcomes.

The Policy Statement recommendations will be used to inform educators, administrators, practitioners, and others in the development of curricula, programs, and initiatives to enhance the diversity of the pediatric workforce and increase the cultural competence of practitioners.
Varicella Vaccine Update
Authors:   Committee on Infectious Diseases
Published: August 2004

Recommendations for routine varicella vaccination were published by the American Academy of Pediatrics in May 1995, but many eligible children remain unimmunized. This update provides additional information on the varicella disease burden before the availability of varicella vaccine, potential barriers to immunization, efforts to increase the level of coverage, new safety data, and new recommendations for use of the varicella vaccine after exposure and in children with human immunodeficiency virus infections. Pediatricians are strongly encouraged to support public health officials in the development and implementation of varicella immunization requirements for child care and school entry.
Persistent Pulmonary Hypertension of the Newborn in the Era Before Nitric Oxide: Practice Variation and Outcomes
Authors: Walsh-Sukys Michele C. , Tyson Jon E. , Wright Linda L. , Bauer Charles R. , Korones Sheldon B. , Stevenson David K. , Verter Joel , Stoll Barbara J. , Lemons James A. , Papile Lu-Ann , Shankaran Seetha , Donovan Edward F. , Oh William , Ehrenkranz Richard A. , Fanaroff Avroy A.
Published: August 2004

Objectives.

In the era before widespread use of inhaled nitric oxide, to determine the prevalence of persistent pulmonary hypertension (PPHN) in a multicenter cohort, demographic descriptors of the population, treatments used, the outcomes of those treatments, and variation in practice among centers.

Study Design.

A total of 385 neonates who received ≥50% inspired oxygen and/or mechanical ventilation and had documented evidence of PPHN (2D echocardiogram or preductal or postductal oxygen difference) were tracked from admission at 12 Level III neonatal intensive care units. Demographics, treatments, and outcomes were documented.

Results.

The prevalence of PPHN was 1.9 per 1000 live births (based on 71 558 inborns) with a wide variation observed among centers (.43–6.82 per 1000 live births). Neonates with PPHN were admitted to the Level III neonatal intensive care units at a mean of 12 hours of age (standard deviation: 19 hours). Wide variations in the use of all treatments studied were found at the centers. Hyperventilation was used in 65% overall but centers ranged from 33% to 92%, and continuous infusion of alkali was used in 75% overall, with a range of 27% to 93% of neonates. Other frequently used treatments included sedation (94%; range: 77%–100%), paralysis (73%; range: 33%–98%), and inotrope administration (84%; range: 46%–100%). Vasodilator drugs, primarily tolazoline, were used in 39% (range: 13%–81%) of neonates. Despite the wide variation in practice, there was no significant difference in mortality among centers. Mortality was 11% (range: 4%–33%). No specific therapy was clearly associated with a reduction in mortality.

To determine whether the therapies were equivalent, neonates treated with hyperventilation were compared with those treated with alkali infusion. Hyperventilation reduced the risk of extracorporeal membrane oxygenation without increasing the use of oxygen at 28 days of age. In contrast, the use of alkali infusion was associated with increased use of extracorporeal membrane oxygenation (odds ratio: 5.03, compared with those treated with hyperventilation) and an increased use of oxygen at 28 days of age.

Conclusions.

Hyperventilation and alkali infusion are not equivalent in their outcomes in neonates with PPHN. Randomized trials are needed to evaluate the role of these common therapies.
The Respective Racial and Ethnic Diversity of US Pediatricians and American Children
Authors: Stoddard Jeffrey J. , Back Mary Ruth , Brotherton Sarah E.
Published: August 2004

Background.

Much effort has been directed toward increasing the training of physicians from underrepresented minority groups, yet few direct comparisons have examined the diversity of the racial/ethnic backgrounds of the physicians relative to the patient populations they serve, either currently or into the future. This has been particularly true in the case of pediatrics, in which little information has emerged regarding the racial/ethnic backgrounds of pediatricians, yet evidence points to ever-growing diversity in the US child population.

Objective.

We embarked on a comparative analysis to examine trends in the racial and ethnic composition of pediatricians vis-a-vis the patient population they serve, America's infants, children, adolescents, and young adults.

Methods.

Data on US pediatricians sorted by racial/ethnic group came from Association of American Medical Colleges distribution data and is based on the cohort of pediatricians graduating from US medical schools between 1983 and 1989 extrapolated to the total number of pediatricians actively practicing in 1996. Data on the demographic diversity of the US child population came from the US Census Bureau. We derived pediatrician-to-child population ratios (PCPRs) specific to racial/ethnic groups to measure comparative diversity between and among groups.

Results.

Our results show that the black PCPR, currently less than one third of the white PCPR, will fall from 14.3 pediatricians per 100 000 children in 1996 to 12 by 2025. The Hispanic PCPR will fall from 16.9 in 1996 to 9.2 in 2025. The American Indian/Alaska Native PCPR will drop from 7.8 in 1996 to 6.5 by the year 2025. The PCPR specific to the Asian/Pacific Islander group will decline from 52.9 in 1996 to 26.1 in 2025. For whites, the PCPR will increase from 47.8 to 54.2 during this period. For 1996, each of the 5 PCPRs is significantly different from the comparison ratio. The same is true for 2025. For the time trend comparison (between 1996 and 2025), there is a significant difference for each ratio except for American Indian/Alaska Native.

Conclusion.

The racial and ethnic makeup of the US child population is currently far more diverse than that of the pediatricians who provide their health care services. If child population demographic projections hold true, and no substantial shifts transpire in the composition of the pediatric workforce, the disparities will increase substantially by the year 2025.
A Critical Appraisal of the Role of Dietary Long-Chain Polyunsaturated Fatty Acids on Neural Indices of Term Infants: A Randomized, Controlled Trial
Authors: PhD Maria Makrides , Neumann Mark A. , Simmer Karen , Gibson Robert A.
Published: August 2004

Objective.

To determine whether dietary long-chain polyunsaturated fatty acids (LCPUFA), such as docosahexaenoic acid (DHA) and arachidonic acid, affect visual evoked potential (VEP) acuity of formula-fed infants, relative to breastfed infants. A secondary objective was to assess the effect of LCPUFA on Bayley's mental developmental index (MDI) and psychomotor developmental index (PDI).

Methods.

Formula-fed infants were randomly allocated, in a double-blind manner, to either a placebo (no LCPUFA;n = 21), DHA supplemented (n = 23), or DHA+arachidonic acid supplemented formula (n = 24). Infants were fed their assigned formula from the first week of life until 1 year of age. A parallel reference group of breastfed infants was recruited and followed (n = 46). Infant VEP acuity was assessed at 16 and 34 weeks, and Bayley's MDI and PDI were assessed at 1 and 2 years of age.

Results.

There were no differences among the randomized formula groups for VEP acuity at either 16 or 34 weeks of age. Breastfed infants had better VEP acuity at 34 weeks of age, but not at 16 weeks, compared with all formula-fed infants. Bayley's MDI and PDI were similar in the 3 formula-fed groups at 1 and 2 years. Breastfed infants had higher MDI scores than formula-fed infants at 2 years of age even after adjusting for environmental variables.

Conclusions.

LCPUFA supplementation did not influence VEP acuity development in these well-nourished, formula-fed infants.
Effects of Prenatal Cocaine/Crack and Other Drug Exposure on Electroencephalographic Sleep Studies at Birth and One Year
Authors: Scher Mark S. , Richardson Gale A. , Day Nancy L.
Published: August 2004

Objective.

Little is known about the neurophysiologic effects of prenatal cocaine/crack use. The aim of this study, designed to overcome methodologic limitations of previous research, was to investigate the effects of prenatal cocaine use on electroencephalographic (EEG) sleep patterns, a marker of central nervous system development.

Methods.

In a longitudinal study of prenatal cocaine/crack exposure, women were interviewed at the end of each trimester about cocaine, crack, alcohol, tobacco, marijuana, and other drug use. Two-hour paper- and computer-generated EEG sleep recordings were obtained on a sample of the full-term infants on the second day of life and at 1 year postpartum. Eligible newborns were full-term, had received no general anesthesia, and had a 5-minute Apgar score >5. All infants whose mothers used one or more lines of cocaine during their first trimester or any crack (n = 37) were selected. A comparison group was chosen randomly from the group of women who did not use cocaine or crack during their pregnancy (n = 34).

Results.

Women who used cocaine/crack during the first trimester were older, less educated, less likely to be working, and used more tobacco, alcohol, marijuana, and other illicit drugs than women who did not use cocaine/crack during the first trimester. There were no differences in infant birth weight, length, head circumference, or gestational age between the two exposure groups. After controlling for the significant covariates, prenatal cocaine exposure was associated with less well developed spectral correlations between homologous brain regions at birth, and with lower spectral EEG power values at 1 year of age. Prenatal alcohol, marijuana, and tobacco use were found to affect state regulation and cortical activities.

Conclusions.

These results indicate that the neurotoxic effects of prenatal cocaine/crack use can be detected with quantitative EEG measures.