bluuebunny/crossref_metadata_2025 huggingface dataset:
Attitudes of Pediatric Residents Toward Ethical Issues Associated With Genetic Testing in Children
Authors: Rosen Ami , Wallenstein Sylvan , McGovern Margaret M.
Published: August 2004

Objective. To assess the attitudes of pediatric residents toward molecular genetic testing and some associated ethical issues that accompany its use in pediatric patients.

Methods. A questionnaire study of pediatric residents (n = 160; response rate: 40%) enrolled in training programs at 3 New York metropolitan area hospitals was designed to determine their attitudes toward genetic testing in children and adolescents. The study instrument presented 2 clinical vignettes that described scenarios where a pediatric patient was at risk for being affected with or a carrier of a genetic disorder. Residents returned the questionnaire anonymously.

Results. Most pediatric residents recognized the importance of educating family members (95%) and at-risk individuals (89%) about the inheritance pattern of the disorders they were at risk for. However, a substantial number would order predictive testing for Huntington disease in a child at the request of a parent (39% at age 10 and 52% at age 17), and more than half would order fragile X carrier studies on the cognitively normal sister of an affected male (56%).

Conclusions. An effort must be made to educate all physicians during their residency training about the ethical issues associated with genetic testing. For pediatric residents, such education must include instruction on the complexities associated with offering such testing in this age group.
Are Research Ethics Standards Satisfied in Pediatric Journal Publications?
Authors: Weil Eric , Nelson Robert M. , Ross Lainie Friedman
Published: August 2004

Background. The requirements for institutional review board (IRB) review and informed consent (IC) for research involving human subjects have existed for more than 2 decades. Although many studies document them poorly, most published research undergoes IRB review and has IC procedures. Less is known about research published in pediatric journals, and how child health research is determined to be exempt.

Method. All full-length articles published in the paper edition of 3 pediatric journals between January and December 2000 were examined. Articles were excluded if they were case studies, meta-analyses, lacked empirical data, or did not include at least 1 US researcher or US subjects. The remaining articles were examined to determine if they documented IRB review and IC mechanisms. If either or both of these features were missing, authors were asked to participate voluntarily in a survey. In addition, all exempt articles were examined to determine if the exemptions were in accordance with the federal regulations for the protection of human subjects.

Results. Three hundred seventy-nine of 575 articles met inclusion criteria. One hundred ninety-seven (52.0%) documented IRB review, 164 (43.3%) documented IC, and 131 (34.6%) properly documented the presence of both IRB review and IC. Two hundred fifty-one researchers were surveyed to clarify IRB review and/or IC mechanisms. Approximately 13.5% of the research had not undergone IRB review, and 12.4% had not had their consent methods reviewed by an IRB. We found that between 26.9% and 39.8% of exempted research did not meet federal regulations requirements.

Conclusions. We found that most research underwent IRB review and had a consent mechanism despite the lack of documentation in the articles. We also found that most research that did not undergo IRB review would have been exempt under current guidelines. However, a significant number of IRB- and researcher-exempted research were inappropriately classified. Improving research ethics standards will require additional education for researchers and IRB members, and greater adherence of researchers (and editors) to the journals’ guidelines on these issues.
Invasive Pneumococcal Disease and Hemolytic Uremic Syndrome
Authors: Brandt John , Wong Craig , Mihm Susan , Roberts Joan , Smith Jodi , Brewer Eileen , Thiagarajan Ravi , Warady Bradley
Published: August 2004

Objective. Severe pneumococcal infections have been associated with hemolytic uremic syndrome (HUS), usually with a poor clinical outcome when compared with Escherichia coli O157 gastroenteritis-associated (D+) HUS. We examined our experience with 12 cases of Streptococcus pneumoniae-associated HUS (SP-HUS) and compare it with a cohort of diarrhea-associated HUS (D+ HUS).

Methods. A retrospective case survey compared 2 unrelated groups of HUS patients. Demographic factors, clinical indices of disease severity, and outcome were used to compare the 2 groups of HUS patients.

Results. Twelve children with SP-HUS were studied. Pneumococcal pneumonia with empyema was the most common precipitating illness (67%), pneumococcal meningitis was present in 17% of children, pneumonia with bacteremia in 8%, and both pneumonia and meningitis in 8%. SP-HUS patients were younger than D+ HUS patients (22.1 vs 49 months) and had more severe renal and hematologic disease than D+ HUS patients. Compared with D+ HUS patients, SP-HUS patients were more likely to require dialysis (75% vs 59%) and had a longer duration of hospitalization (33.2 vs 16.1 days) and duration of thrombocytopenia (11.6 vs 6.8 days). SP-HUS patients were also more likely to require platelet transfusions (83% vs 47%) and needed more platelet (4.7 vs 0.5) and packed red blood cell transfusions (7.8 vs 2.0). The 2 groups did not differ significantly in the incidence of extrarenal HUS complications. There were no deaths in either group. Seven patients have been seen for long-term follow-up; 2 developed end-stage renal disease, and 5 have normal renal function.

Conclusions. HUS is a rare but severe complication of invasive pneumococcal infection. Although disseminated intravascular coagulation can also occur in these children, the treatment and follow-up may be different in the 2 conditions. Children with pneumococcal disease and severe hematologic or renal abnormalities should be investigated for evidence of HUS.
Crossover Trial of Analgesic Efficacy of Glucose and Pacifier in Very Preterm Neonates During Subcutaneous Injections
Authors: Carbajal Ricardo , Lenclen Richard , Gajdos Vincent , Jugie Myriam , Paupe Alain
Published: August 2004

Objective. Very preterm newborns undergo multiple invasive procedures. Nonpharmacological interventions are valuable alternatives for pain relief during minor procedures in neonates. Oral sucrose analgesia has been widely studied in term and preterm neonates during painful procedures. The analgesic effect of oral glucose in very preterm infants has not yet been reported. The objectives of this study were to assess the analgesic effect of orally administered glucose and to determine the synergetic analgesic effect of glucose and pacifiers during subcutaneous injections in very preterm neonates using a validated behavioral acute pain rating scale.

Design. Two crossover trials.

Setting. One neonatal intensive care unit in a community-based general hospital.

Methods. A prospective study was conducted in 40 very preterm neonates. Each infant received 2 treatments in a crossover manner during 2 consecutive subcutaneous injections of erythropoietin. The first trial (25 infants) was intended to compare oral 30% glucose (0.3 mL) versus placebo (0.3 mL of sterile water); the second trial (15 infants) compared oral 30% glucose (0.3 mL) versus oral 30% glucose (0.3 mL) followed by sucking a pacifier. The primary outcome measure was the evaluation of pain induced by a subcutaneous injection of erythropoietin, using Douleur Aiguë Nouveau-né scale (0 no pain, 10 maximum pain).

Results. Twenty-four infants completed the study in the first trial and 15 in the second one. Mean (95% confidence interval [CI]) gestational age, birth weight, postnatal age, and weight at inclusion for neonates in the first and second trial were, respectively, 28.1 (95% CI: 27.3–29.0) and 29.1 (95% CI: 27.8–30.4) weeks, 1036 (95% CI: 944-1128) and 995 (95% CI: 848-1141) g, 26.4 (95% CI: 22.4–30.3) and 26 (95% CI: 22.0–29.9) days, and 1234 (95% CI: 1120–1348) and 1209 (95% CI: 1059–1359) g. In the first trial, median (interquartile) pain scores for placebo and 30% glucose, respectively, were 7 (2.5–9.75) and 4.5 (1–6). In the second trial, median (interquartile) pain scores for 30% glucose and for 30% glucose plus pacifier, respectively, were 4 (2–7) and 4 (1–6).

Conclusions. A small dose of 0.3 mL of 30% oral glucose has an analgesic effect in very preterm neonates during subcutaneous injections. This effect is clinically evident because it can be detected by a behavioral pain rating scale. The synergetic analgesic effect of glucose plus sucking a pacifier is less obvious in very preterm neonates as opposed to what other studies have showed in full-term infants.
Low Compliance of Iron Supplementation in Infancy and Relation to Socioeconomic Status in Israel
Authors: Amsel Shlomo , Boaz Mona , Ballin Ami , Filk Dani , Ore Naama
Published: August 2004

Objective. To evaluate the compliance of parents in purchasing iron-containing drugs for their infants. In addition, we looked for possible socioeconomic characteristics of the parents who prevent their infants from accessing these medications.

Design. All infants (4–12 months) whose parents bought (from January to August 1999 and from January to August 2000) the iron-containing drugs as recommended by the Israeli Ministry of Health were retrieved from a database. The socioeconomic status of the citizens was determined according to the “mean real income” (INCMV) and “relative income” (INCMS). The percentage of parents who purchased the medication from each district was compared with the socioeconomic status of this population.

Results. Forty-four pediatricians’ offices in the Tel Aviv metropolitan area were included. The data of 4929 infants was summarized. Only 27% of the parents bought the drugs. Only 11.5% to 20% of parents from the 5 highest socioeconomic classes purchased the medication compared with 43.6% to 57.1% of the parents from the 5 lowest socioeconomic classes.

Conclusion. There was low compliance by parents in obtaining iron-containing medications for their infants, mainly among parents from high socioeconomic classes.
Genital Injuries in Prepubertal Girls From Inline Skating Accidents
Authors: Herrmann Bernhard , Crawford James
Published: August 2004

We report 2 cases where accidents from inline skating resulted in significant genital injury to female children. When genital trauma occurs in children, it frequently raises the concern that sexual abuse might have caused the injury. Historical information provided by the child and others must be compared with the injuries to understand whether an injury may be the result of abuse. We characterize the nature of the genital injuries of our cases as being caused by an accidental “rapid-splits” type mechanism while children were using inline skates. We conclude that the reported accidental mechanism caused the identified injuries. Distinguishing accidental from abusive causes of genital trauma is critical. We report these cases, as there are no reports in the literature regarding this accidental mechanism of injury.
Kawasaki Disease Before Kawasaki at Tokyo University Hospital
Authors: Shibuya Noriko , Shibuya Kazuhiko , Kato Hitoshi , Yanagisawa Masayoshi
Published: August 2004

Objective. Kawasaki disease (KD) was first reported by Tomisaku Kawasaki in 1967 in Japan. Large-scale nationwide epidemiologic surveys have been conducted continuously by the Japan Kawasaki Disease Research Committee; however, there were very few reports of KD before 1967. This study was performed to clarify when KD appeared in Japan.

Design. We investigated the medical charts of patients who had been hospitalized at Tokyo University Hospital between 1940 and 1965.

Results. We identified 10 patients whose clinical signs fulfilled the criteria for KD. The ages of the patients ranged from 8 months to 5 years, and their final diagnoses were Stevens-Johnson syndrome, allergic toxic erythema, Izumi fever, scarlet fever, and cervical lymphadenitis. These 10 patients presented between 1950 and 1964, and no confirmed cases were seen between 1940 and 1949.

Conclusions. Our findings suggested that KD patients were rare before 1950 in Japan.
Acute Disseminated Encephalomyelitis in Children
Authors: Murthy S. N. Krishna , Faden Howard S. , Cohen Michael E. , Bakshi Rohit
Published: August 2004

Objective. To describe the epidemiologic, clinical, neuroimaging, and laboratory features; treatment; and outcome in a cohort of children with acute disseminated encephalomyelitis (ADEM).

Methods. A 6-year retrospective chart review of children with the diagnosis of ADEM was conducted.

Results. Eighteen cases were identified. Sixteen patients (88%) presented in either winter or spring. Thirteen children (72%) had a recent upper respiratory tract illness. Patients presented most often with motor deficits (77%) and secondly with altered consciousness (45%). Spinal fluid abnormalities occurred in 70%. Despite rigorous microbiologic testing, a definite microbiologic diagnosis was established only in 1 child with Epstein-Barr virus disease and probable or possible diagnoses in 3 children with Bartonella henselae, Mycoplasma pneumoniae, or rotavirus disease. Brain magnetic resonance imaging identified lesions in the cerebral cortex in 80%, in subcortical white matter in 93%, in periventricular white matter in 60%, in deep gray matter in 47%, and in brainstem in 47% of patients. Eleven patients (61%) were treated with corticosteroids, and 2 were treated with intravenous immunoglobulins. All patients survived. Three patients (17%) had long-term neurologic sequelae.

Conclusions. Epidemiologic evidence from this study suggests an infectious cause for ADEM. The agent is most likely a difficult-to-diagnose winter/spring respiratory virus. Magnetic resonance imaging was the neuroimaging study of choice for establishing the diagnosis and for following the course of the disease. Prognosis for survival and outcome was excellent. Recurrent episodes of ADEM must be differentiated from multiple sclerosis.
Weight Criticism During Physical Activity, Coping Skills, and Reported Physical Activity in Children
Authors: Faith Myles S. , Leone Mary Ann , Ayers Tim S. , Heo Moonseong , Pietrobelli Angelo
Published: August 2004

Objective. National health guidelines advocate increased physical activity in children and adolescents, but specific goals are not being achieved. Data are needed on variables that influence children’s decision to be active or sedentary.

Methods. We tested the association of weight criticism during physical activity (WCA) with attitudes toward physical activity and reported physical activity levels in children. We also tested whether these associations were moderated by children’s ability to cope with weight criticism. Subjects were 576 fifth- through eighth-graders who completed a questionnaire on physical activity patterns, weight criticism history, and coping skills.

Results. WCA was more common among girls than boys and among heavier children. In multiple regression analyses, WCA was associated with reduced sports enjoyment, perceived activity compared with peers, and mild-intensity leisure activity. These associations, however, were moderated by problem-focused coping skills such that the relationships were attenuated in children who were better able to cope with weight criticism. Avoidant coping skills also moderated the relationship between WCA and sports enjoyment.

Conclusions. Children who are the targets of weight criticism by family and peers have negative attitudes toward sports and report reduced physical activity levels, although these relationships may be buffered by certain coping skills. Assessing WCA and related coping skills may be clinically useful for identifying barriers to physical activity in certain children (eg, the obese) and may be a potential target for interventions.
Survival, Disease Manifestations, and Early Predictors of Disease Progression Among Children With Perinatal Human Immunodeficiency Virus Infection in Thailand
Authors: Chearskul Sanay , Chotpitayasunondh Tawee , Simonds R. J. , Wanprapar Nirun , Waranawat Naris , Punpanich Warunee , Chokephaibulkit Kulkanya , Mock Philip A. , Neeyapun Kanchana , Jetsawang Bongkoch , Teeraratkul Achara , Supapol Wendy , Mastro Timothy D. , Shaffer Nathan ,   Bangkok Collaborative Perinatal HIV Transmission Study Group
Published: August 2004

Objective. To describe survival and signs of human immunodeficiency virus (HIV) infection in perinatally infected children in Thailand.

Methods. At 2 large Bangkok hospitals, 295 infants born to HIV-infected mothers were enrolled at birth from November 1992 through September 1994 and followed up with clinical and laboratory evaluations every 1 to 3 months for 18 months. Infected children remained in follow-up thereafter. For the infected children, we used data collected through October 2000 to estimate survival times and compare characteristics among those whose disease progressed at rapid (died within 1 year), intermediate (died at 1–5 years), and slow (survived at least 5 years) rates.

Results. None of the 213 uninfected children died during the follow-up period. Of the 68 infected children, 31 (46%) died; median survival was 60 months (95% confidence interval: 31–89 months). The most common cause of death was pneumonia (52% of deaths). Thirty-two children (47%) started antiretroviral therapy. Six children died in their first year before developing specific signs of HIV infection; all others developed signs of HIV infection between 1 and 42 months old (median: 4 months). Severe clinical (Centers for Disease Control and Prevention Class C) conditions were diagnosed in 23 children at a median age of 12 months, 15 (65%) of whom died a median of 3 months later. Compared with children whose disease progressed slowly, those whose disease progressed rapidly gained less weight by 4 months old (median 1.7 vs 2.6 kg), and their mothers had higher viral loads (median 5.1 vs 4.5 log10 copies/mL) and lower CD4+ counts (median 350 vs 470 cells/μL) at delivery.

Conclusions. Among HIV-infected Thai children, survival times are longer than among children in many African countries, but shorter than among children in the United States and Europe. Signs of HIV develop early in most children. Growth failure and advanced maternal disease can predict rapid HIV disease progression and may be useful markers for treatment decisions.
Trimethoprim-Induced Aseptic Meningitis in an Adolescent Male
Authors: Redman Richard C. , Miller John Bernard , Hood Margaret , DeMaio James
Published: August 2004

Drug-induced aseptic meningitis attributable to trimethoprim alone has only rarely been documented in the literature. A previously healthy adolescent male presented to our hospital with recurrent headaches, photophobia, and meningismus after serially starting and stopping trimethoprim. Cerebrospinal fluid studies revealed elevated white blood cell counts with a polymorphonuclear predominance. This case is the second documented report of trimethoprim-induced aseptic meningitis in a pediatric patient.
Insulin-Dependent Diabetes Mellitus in 2 Male African American Children After Kawasaki Disease
Authors: Bhowmick Samar K. , Estrada Benjamin , Rettig Kenneth R.
Published: August 2004

Two children with insulin-dependent diabetes mellitus (IDDM) presented with diabetic ketoacidosis within 4 months of being diagnosed with Kawasaki disease (KD). Both patients were African American males younger than 4 years of age. Immune markers associated with the autoimmune cause of diabetes were not detectable in these patients at the time of diagnosis with IDDM. In 1 patient, the immune markers were repeated 6 months after diagnosis but remained negative. Both patients currently require ∼1 unit of insulin/kg/d. Occurrence of IDDM after KD is rare; we could find no such reports in the English literature. The cause of diabetes in these 2 patients remains elusive, as does the cause of KD.
Rate, Risk Factors, and Outcomes of Nosocomial Primary Bloodstream Infection in Pediatric Intensive Care Unit Patients
Authors: Yogaraj Jeya S. , Elward Alexis M. , Fraser Victoria J.
Published: August 2004

Objective. The objective of this study was to determine the rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit (PICU) patients.

Design. Prospective cohort study.

Settings. This study was performed at St Louis Children’s Hospital, a 235-bed academic tertiary care center with a combined 22-bed medical and surgical PICU.

Patients. Subjects for this study were patients admitted to the PICU between September 1, 1999, and May 31, 2000.

Interventions. None.

Outcome Measures. Patients were monitored for the development of nosocomial bloodstream infections from the day of PICU admission until 48 hours after PICU discharge.

Results. Of 911 patients, 526 (58%) were male and 674 (74%) were white. Congenital heart disease (29%), lung disease (25%), and genetic syndrome (18%) were common. There were 65 episodes of primary bloodstream infection in 57 patients; 5 were polymicrobial and 7 patients had multiple bloodstream infections. Coagulase-negative Staphylococcus was the leading cause of bloodstream infection (n = 28), followed by Enterobacter cloacae (n = 8). The rate of bloodstream infection was 13.8 per 1000 central venous catheter days. In multiple logistic regression analysis, patients with bloodstream infection were more likely to have multiple central venous catheters (adjusted odds ratio [aOR]: 5.7; 95% confidence interval [CI]: 2.9–10.9), arterial catheters (aOR: 5.5; 95% CI: 1.8–16.3), invasive procedures performed in the PICU (aOR: 4.0; 95%CI: 2.0–7.8), and be transported out of the PICU (aOR: 3.4; 95% CI: 1.8–6.7) to the radiology or operating room suites. Severity of illness as measured by admission Pediatric Risk of Mortality score, underlying illnesses, and medications were not associated with increased risk of nosocomial bloodstream infection.

Conclusions This study identified a high rate of bloodstream infection among St Louis Children’s Hospital PICU patients. Risk factors for bloodstream infection were related more to process of care than to severity of illness. Additional research is needed to develop interventions to reduce nosocomial bloodstream infections in children.
A Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity
Authors: Goodman Elizabeth , Whitaker Robert C.
Published: August 2004

Background. Adolescent obesity is a strong predictor of adult obesity, and adult obesity has been associated with depression, especially in women. Studies have also suggested an association between depression in adolescence and higher body mass index (BMI) in adulthood. Whether depression leads to obesity or obesity causes depression is unclear.

Objective. To determine in longitudinal analyses whether depressed mood predicts the development and persistence of obesity in adolescents.

Methods. A prospective cohort study of 9374 adolescents in grades 7 through 12 who completed in-home interviews for the National Longitudinal Study of Adolescent Health. Assessments were made at baseline (1995) and at follow-up 1 year later. Depressed mood was assessed with the Center for Epidemiologic Studies Depression Scale. BMI (kg/m2) was calculated from self-reported height and weight. BMI percentiles and z scores were computed using the 2000 Centers for Disease Control and Prevention growth charts. Obesity was defined as BMI ≥95th percentile, overweight as BMI ≥85th percentile and <95th percentile, and normal weight as BMI <85th percentile. A parental respondent gave information on household income, parental education, and parental obesity.

Results. At baseline, 12.9% were overweight, 9.7% were obese, and 8.8% had depressed mood. Baseline depression was not significantly correlated with baseline obesity. Among the 9.7% who were obese at follow-up, 79.6% were obese at baseline, 18.6% were overweight at baseline, and 1.8% were normal weight at baseline. Having depressed mood at baseline independently predicted obesity at follow-up (odds ratio: 2.05; 95% confidence interval: 1.18, 3.56) after controlling for BMI z score at baseline, age, race, gender, parental obesity, number of parents in the home, and family socioeconomic status. This finding persisted after controlling further for the adolescents’ report of smoking, self-esteem, delinquent behavior (conduct disorder), and physical activity. After controlling for all these same factors, depressed mood at baseline also predicted obesity at follow-up among those not obese at baseline (odds ratio: 2.05; 95% confidence interval: 1.04, 4.06) and follow-up BMI z score among those obese at baseline (β = 0.11; standard error β = 0.05). In contrast, baseline obesity did not predict follow-up depression.

Conclusions. Depressed adolescents are at increased risk for the development and persistence of obesity during adolescence. Understanding the shared biological and social determinants linking depressed mood and obesity may inform the prevention and treatment of both disorders.
Television Viewing and Initiation of Smoking Among Youth
Authors: Gidwani Pradeep P. , Sobol Arthur , DeJong William , Perrin James M. , Gortmaker Steven L.
Published: August 2004

Background. Smoking is the leading preventable cause of death in the United States, and the risk of disease increases the earlier in life smoking begins. The prevalence of smoking among US adolescents has increased since 1991. Despite bans on television tobacco advertising, smoking on television remains widespread.

Objective. To determine whether youth with greater exposure to television viewing exhibit higher rates of smoking initiation.

Methods. We used the National Longitudinal Survey of Youth, Child Cohort to examine longitudinally the association of television viewing in 1990 among youth ages 10 to 15 years with smoking initiation from 1990–1992. Television viewing was based on the average of youth and parent reports. We used multiple logistic regression, taking into account sampling weights, and controlled for ethnicity; maternal education, IQ, and work; household structure; number of children; household poverty; child gender; and child aptitude test scores.

Results. Among these youth, smoking increased from 4.8% in 1990 to 12.3% in 1992. Controlling for baseline characteristics, youth who watched 5 or more hours of TV per day were 5.99 times more likely to initiate smoking behaviors (95% confidence interval: 1.39–25.71) than those youth who watched <2 hours. Similarly, youth who watched >4 to 5 hours per day were 5.24 times more likely to initiate smoking than youth who watched <2 hours (95% confidence interval: 1.19–23.10).

Conclusions. Television viewing is associated in a dose-response relationship with the initiation of youth smoking. Television viewing should be included in adolescent risk behavior research. Interventions to reduce television viewing may also reduce youth smoking initiation.
Early Introduction of Oral Feeding in Preterm Infants
Authors: Simpson Chanda , Schanler Richard J. , Lau Chantal
Published: August 2004

Objective. To determine whether transition from tube to all oral feeding can be accelerated by the early introduction of oral feeding in preterm infants. It is hypothesized that this shortened transition time will lead to earlier attainment of all oral feeding.

Design. Twenty-nine infants (<30 weeks’ gestation) were randomized to an intervention or control group. The intervention group (n = 13) was initiated to oral feeding 48 hours after achieving full tube feeding (120 kcal/kg/d), and the feeding progression followed a structured protocol. The oral feeding management of the control infants (n = 16) was left to the discretion of their attending physicians. Oral feeding progress was monitored for achievement of selected feeding milestones: achievement of first and all successful oral feedings. Feeding performance was assessed by overall transfer (percent volume transferred during a feeding/total volume offered) and rate of milk transfer (mL/min), which were measured from introduction of oral feeding to first successful oral feeding.

Results. Infants in the experimental group, when compared with their control counterparts, were introduced to oral feeding significantly earlier (31.1 ± 1.3 vs 33.7 ± 0.9 weeks’ postmenstrual age, respectively) and attained all oral feeding significantly earlier as well (34.5 ± 1.6 vs 36.0 ± 1.5 weeks’ postmenstrual age, respectively). The transition time from full tube feeding to all oral feeding was 26.8 ± 12.3 days for the experimental group and 38.4 ± 14.0 days for the control group. Both groups of infants demonstrated similar increase in overall transfer and rate of milk transfer from introduction of oral feeding until achievement of first successful oral feeding.

Conclusions. Early introduction of oral feeding accelerates the transition time from tube to all oral feeding. This not only allows earlier attainment of all oral feeding, but it also provides practice opportunities that enhance the oral motor skills necessary for safe and successful feeding.
Routine Sucrose Analgesia During the First Week of Life in Neonates Younger Than 31 Weeks’ Postconceptional Age
Authors: Johnston C. Celeste , Filion Francoise , Snider Laurie , Majnemer Annette , Limperopoulos Catherine , Walker Claire-Dominique , Veilleux Annie , Pelausa Ermelinda , Cake Heather , Stone Sharon , Sherrard Adam , Boyer Kristina
Published: August 2004

Objective. To determine the efficacy of sucrose analgesia for procedural pain during the first week of life in preterm neonates in neonatal intensive care units on enhancing later clinical outcomes.

Methods. A total of 107 preterm neonates who were born at <31 weeks’ postconceptional age (PCA) entered this double-blind, randomized, controlled trial within 48 hours of birth at 3 level III university-affiliated neonatal intensive care units in Canada, and 103 completed the study. Sucrose (0.1 mL of 24%) or sterile water was administered orally up to 3 times, 2 minutes apart, for every invasive procedure during a 7-day period. Motor development and vigor, and alertness and orientation components of the Neurobehavioral Assessment of the Preterm Infant were measured at 32, 36, and 40 weeks’ PCA; Score for Neonatal Acute Physiology was measured on the last day of intervention; and Neuro-Biological Risk Score (NBRS) was measured at 2 weeks of age and at discharge. Primary analyses of covariance were applied for each outcome to compare group differences followed by secondary analyses using standard linear regression within each group to determine predictors of outcomes.

Results. Although there were no differences between the groups on any outcomes, there were significant dose-related effects within each group. In the sucrose group only, higher number of doses of sucrose predicted lower scores on motor development and vigor, and alertness and orientation at 36 weeks’, lower motor development and vigor at 40 weeks’, and higher NBRS at 2 weeks’ postnatal age. Higher number of invasive procedures was predictive of higher NBRS both times in the water group.

Conclusions. Repeated use of sucrose analgesia in infants <31 weeks’ PCA may put infants at risk for poorer neurobehavioral development and physiologic outcomes. Additional study is needed to determine the most appropriate age and duration of sucrose analgesia in preterm infants.
Effects of Volume-Guaranteed Synchronized Intermittent Mandatory Ventilation in Preterm Infants Recovering From Respiratory Failure
Authors: Herrera Carmen M. , Gerhardt Tilo , Claure Nelson , Everett Ruth , Musante Gabriel , Thomas Carlos , Bancalari Eduardo
Published: August 2004

Objective. Volume guarantee (synchronized intermittent mandatory ventilation [SIMV]+VG) is a novel mode of SIMV for automatic adjustment of the peak inspiratory pressure to ensure a minimum set mechanical tidal volume (VT mech). The objective of this study was to compare the effects of SIMV+VG with conventional SIMV on ventilation and gas exchange in a group of very low birth weight infants recovering from acute respiratory failure.

Methods. Nine infants were initially studied during 2 consecutive 60-minute ventilatory modalities of conventional SIMV (ventilator settings by clinical team) and SIMV+VG 4.5 (VT mech set at 4.5 mL/kg) in random order. Eight additional infants were studied during the same ventilatory modalities plus 1 additional epoch consisting of SIMV+VG 3.0 (VT mech set at 3.0 mL/kg).

Results. Peak inspiratory pressure was significantly lower during SIMV+VG 3.0. Mean airway pressure, VT mech, number of large VT mech (>7 mL/kg), and mechanical minute ventilation (V′E) were reduced during SIMV+VG 4.5 compared with SIMV and were further reduced during SIMV+VG 3.0. Spontaneous V′E increased during SIMV+VG 4.5 and was even higher during SIMV+VG 3.0. The resulting total V′E was higher during both SIMV+VG modes compared with SIMV. Arterial oxygen saturation by pulse oximetry, transcutaneous carbon dioxide tension, and fraction of inspired oxygen did not differ significantly, although transcutaneous carbon dioxide tension increased slightly during SIMV+VG 3.0.

Conclusions. The short-term use of SIMV+VG resulted in automatic weaning of the mechanical support and enhancement of the spontaneous respiratory effort while maintaining gas exchange relatively unchanged in comparison to conventional SIMV.
Retinopathy of Prematurity Outcome in Infants With Prethreshold Retinopathy of Prematurity and Oxygen Saturation >94% in Room Air: The High Oxygen Percentage in Retinopathy of Prematurity Study
Authors: McGregor Mary Lou , Bremer Don L. , Cole Cynthia , McClead Richard E. , Phelps Dale L. , Fellows Rae R. , Oden Neal ,   on behalf of the HOPE-ROP Multicenter Group
Published: August 2004

Objectives. To determine the rate of progression from prethreshold to threshold retinopathy of prematurity (ROP) in infants excluded from Supplemental Therapeutic Oxygen for Prethreshold Retinopathy of Prematurity (STOP-ROP) because their median arterial oxygen saturation by pulse oximetry (Spo2) values were >94% in room air at the time of prethreshold diagnosis and to compare them with infants who were enrolled in STOP-ROP and had median Spo2 ≤94% in room air.

Methods. Fifteen of the 30 centers that participated in STOP-ROP elected to participate in the High Oxygen Percentage in Retinopathy of Prematurity study (HOPE-ROP) from January 1996 to March 1999. Infants were followed prospectively from the time prethreshold ROP was diagnosed until ROP either progressed to threshold in at least 1 study eye (adverse outcome) or resolved (favorable outcome).

Results. A total of 136 HOPE-ROP infants were compared with 229 STOP-ROP infants enrolled during the same time period from the same 15 hospitals. HOPE-ROP infants were of greater gestational age at birth (26.2 ± 1.8 vs 25.2 ± 1.4 weeks) and greater postmenstrual age at the time of prethreshold ROP diagnosis (36.7 ± 2.5 vs 35.4 ± 2.5 weeks). HOPE-ROP infants progressed to threshold ROP 25% of the time compared with 46% of STOP-ROP infants. After gestational age, race, postmenstrual age at prethreshold diagnosis, zone 1 disease, and plus disease at prethreshold diagnosis were controlled for, logistic regression analysis showed that HOPE-ROP infants progressed from prethreshold to threshold ROP less often than STOP-ROP infants (odds ratio: 0.607; 95% confidence interval: 0.359–1.026).

Conclusions. The mechanisms that result in better ROP outcome for HOPE-ROP versus STOP-ROP are not fully understood. It seems that an infant’s Spo2 value at the time of prethreshold diagnosis is a prognostic indicator for which infants may progress to severe ROP. When other known prognostic indicators are factored in, the Spo2 is of borderline significance.
Sex Differences in Iron Status During Infancy
Authors: Domellöf Magnus , Lönnerdal Bo , Dewey Kathryn G. , Cohen Roberta J. , Rivera L. Landa , Hernell Olle
Published: August 2004

Background. It is commonly assumed that there is no difference in iron status between male and female infants, despite a lack of studies addressing this question.

Objective. To study sex differences in different measures of iron status in infants.

Methods. At 4 months of age, 263 term, breastfed infants (121 Swedish and 142 Honduran) were randomized to receive iron supplements or placebo until 9 months of age. Blood samples at 4, 6, and 9 months of age were analyzed for hemoglobin (Hb), mean cell volume (MCV), zinc protoporphyrin (ZPP), plasma ferritin, and transferrin receptors (TfR).

Results. At 4, 6, and 9 months, boys had significantly lower Hb, MCV, and ferritin and higher ZPP and TfR than girls. At 9 months, boys had a 10-fold higher risk of being classified as having iron deficiency anemia. The differences at 9 months in MCV (71.6 vs 75.1 fL) and ZPP (59 vs 49 μmol/mol heme) remained significant after controlling for iron supplementation, site, growth variables, and other possible confounders. For ferritin, there was a remaining sex difference at 9 months among Swedish (29 vs 53 μg/L) but not Honduran infants. For Hb and TfR, sex differences at 9 months were larger in unsupplemented infants, especially in those with a birth weight of <3500 g.

Conclusions. There are substantial sex differences in Hb and other indicators of iron status during infancy. Some of these may be genetically determined, whereas others seem to reflect an increased incidence of true iron deficiency in boys.
Prevalence of Retinal Hemorrhages and Child Abuse in Children Who Present With an Apparent Life-Threatening Event
Authors: Pitetti Raymond D. , Maffei Frank , Chang Kenneth , Hickey Robert , Berger Rachel , Pierce Mary Clyde
Published: August 2004

Objective. Child abuse (CA) can present with a spectrum of signs and symptoms. Apparent life-threatening events (ALTEs) may be a subtle presentation of CA. Retinal hemorrhages (RHs) are a well-described finding in some patients with CA. We hypothesized that screening children who present with a chief complaint of an ALTE for RH would detect an otherwise occult presentation of CA.

Methods. Children who were younger than 24 months of age and presented to the emergency department between March 1, 1997, and February 28, 1999, with signs and symptoms consistent with the National Institutes of Health’s definition of an ALTE were studied prospectively. Children were excluded when it was readily apparent on presentation that the child was a victim of CA. Demographic data, a complete blood count with differential, venous blood gas, carboxyhemoglobin level, and urine toxicological screen were collected. A pediatric ophthalmologist performed a dilated funduscopic examination; patients who were found to have RH underwent a noncontrast computerized tomographic scan of the head and skeletal survey to evaluate for occult injury. Evaluations by social services or Children, Youth and Families, the results of all diagnostic tests obtained, and the final discharge diagnosis were recorded. Medical records of all patients were reviewed at 1 year; subsequent visits, hospitalizations, and evaluations by social services or Children, Youth and Families were recorded.

Results. A total of 128 patients presented to the emergency department with an ALTE during the study period. No patients were excluded. Mean age was 2.1 months (median: 1.27; range: 0.07–16.0; standard deviation: 2.1). Fifty-seven (44.5%) were boys; 86 (67.2%) were white, and 36 (27.9%) were black. A total of 26 (20.3%) of 128 patients had a history of an ALTE, 4 (3.4%) of 117 had a family history of an ALTE, and 15 (12.8%) of 117 had a family history of sudden infant death syndrome. Dilated funduscopic examination was performed on 73 (57.0%) of 128 patients; RH was detected in 1 patient (1.4%). Four children, including the patient with RH, underwent an evaluation for suspected abuse; 3 (2.3%) of 128 were determined to have been abused.

Conclusions. RH was detected in 1 (1.4%) of 73 patients in our population of infants with ALTEs and 1 of 3 patients who were victims of CA and presented with an ALTE. CA was detected in 2.3% of patients who presented with an ALTE. The diagnosis of CA should be seriously considered in patients who present with an ALTE. The evaluation of ALTEs should include funduscopic examination as ALTEs and RHs are associated with CA.
Assessment of Adrenal Function in the Initial Phase of Meningococcal Disease
Authors: Bone Mark , Diver Michael , Selby Andrew , Sharples Andrew , Addison Michael , Clayton Peter
Published: August 2004

Objective. To determine the status of the hypothalamic-pituitary-adrenal axis in children who had meningococcal disease and were admitted to 2 regional pediatric intensive care units.

Methods. Sixty-five children (34 boys; median age: 2.5 years; range: 0.2–15 years) had cortisol and adrenocorticotropic hormone (ACTH) levels measured on admission, then at 8 am and 8 pm during the next 48 hours. At 48 hours, a low-dose short Synacthen test (LDST) (500 ng of 1–24 corticotropin/m2) was performed in 42 patients (19 boys). Normal ranges for 8 am cortisol and ACTH levels in unstressed children were 140 to 500 nmol/L and 2 to 11.3 pmol/L, respectively. Adrenal insufficiency (AI) was defined as a peak cortisol <500 nmol/L on the LDST or an 8 am cortisol value <140 nmol/L.

Results. Five (7.7%) of the 65 children died, including 1 with primary AI. Cortisol levels were elevated on admission (median: 1122 mmol/L; range: 65–2110 nmol/L) with 81% of values more than the 8 am normal range. The median ACTH level on admission was within the 8 am normal range, but 40% of values were more than the 8 am normal range. However, 7% and 8% of cortisol and ACTH values, respectively, were less than the normal range. Both cortisol and ACTH levels fell thereafter and showed no diurnal variation during the 48-hour profile. Six (14%) of the 42 failed the LDST. These patients had significantly lower mean 8 am cortisol values than those with a normal peak value on the LDST. Five additional patients who did not have the LDST had 8 am cortisol values <140 nmol/L. In the diagnosis of AI, the sensitivity of the 8 am mean cortisol value at a cutoff of 400 nmol/L, judged against the LDST, was 83%; the specificity was 81%.

Conclusions. During the initial phase of meningococcal disease, raised cortisol and ACTH levels indicate an appropriate stress response within the hypothalamic-pituitary-adrenal axis. However, a substantial subpopulation (11 [16.9%] of 65) has evidence of adrenal dysfunction during this period. Morning cortisol values in the initial phase of meningococcal disease could be used as a potential early index of AI.
National Practices Regarding Payment to Research Subjects for Participating in Pediatric Research
Authors: Weise Kathryn L. , Smith Martin L. , Maschke Karen J. , Copeland H. Liesel
Published: August 2004

Objective. Payment to subjects for participation in research is reportedly common, but no published data documents the nature of this practice. Institutional review boards (IRBs) are responsible for ensuring both the safety and voluntary participation of research subjects, yet guidance from federal and expert pediatric sources regarding appropriate payment approaches is conflicting. Ethical issues of payment for participation of adult versus pediatric research subjects may differ. This empirical study sought to examine current payment practices for participation in pediatric research as reported by IRBs.

Design. An 18-question survey regarding payment practices for participation in pediatric research was sent to IRB chairs at member institutions of the National Association of Children’s Hospitals and Related Institutions, and to a systematic random sample of IRB chairs listed with the Office for Protection From Research Risks. Descriptive, nonparametric, and qualitative analyses were used to describe institution types, payment practices, and correlations among responses.

Results. Data from 128 institutions that conduct pediatric research revealed that payment for participation in pediatric research was allowed by 66% of responding institutions, and practices varied widely among institutions. Most responding IRBs that allowed payment required disclosure of payment before enrollment (during the consent process), following federal guidelines more closely than American Academy of Pediatrics guidelines. An IRB’s perception of potential benefits or harms of a study correlated with the amount of payment approved.

Conclusions. IRBs must balance the need to recruit pediatric research subjects against the risk of undue influence during the recruitment process. Federal guidelines and expert pediatric opinion differ in recommendations regarding payment; responding IRBs appeared to follow federal guidelines more closely than guidelines proposed by the American Academy of Pediatrics.
Adult Survivors of Pediatric Illness: The Impact on Pediatric Hospitals
Authors: Goodman Denise M. , Mendez Eduardo , Throop Cheri , Ogata Edward S.
Published: August 2004

Context. Patients now live well into adulthood surviving diseases with pediatric onset. The size and financial impact of this growing population is unknown.

Objective. To describe the demographics of adult inpatients in pediatric facilities and to assess the financial impact of providing care for these patients on freestanding children’s hospitals.

Design and Data Sources. An observational study using the Pediatric Health Information System, a proprietary database available to Child Health Corporation of America member hospitals, covering years 1994–1999. These data reflect inpatient services and exclude outpatient encounters and adult patients transitioned to adult providers. National estimates of the number of adult survivors of pediatric illness and the financial impact of care were calculated.

Hospitals with >100 discharge events for patients ≥age 21 in 1999, and having both clinical and financial data in the dataset, assured an adequate sample size to discern resource utilization. Both 18 and 21 were used as lower limits of adult age to reflect common definitions of legal majority (age 18) and common pediatric practice (age 21). We truncated the data at age 64 to exclude patients eligible for Medicare.

Results. Ten hospitals representing all geographic regions of the United States were used for an in-depth analysis of financial impact during 1999. Six of 10 had data for 1994–1999 to describe trends over time. The number of patients admitted over the 6-year period increased, as did average and total adjusted charges. In 1999, 3863 patients 18 to 64 years old incurred 5051 discharge episodes and total charges of $134.5 million. Of these, about half (1785) were ≥21 with charges of $66 million. Of the hospitals’ total discharges and financial charges, on average 2.1% and 3.1%, respectively, were from the inpatient care of patients 21 to 64 years old. Forty percent of patients receive public aid. Extrapolating from census data, up to 15 000 patients ≥21 years annually may seek inpatient care in part at children’s hospitals, with charges exceeding $500 million. The 3 most common diagnostic groups to be admitted were those with cystic fibrosis, mental retardation or cerebral palsy, and congenital heart disease.

Conclusions. We describe a subset of adults who have survived diseases of pediatric onset. We focused on the portion of that population that obtains at least some inpatient care at a children’s hospital. The data reported here can be used to set a lower boundary for the size of this population, and thereby provide valuable data for health planners as well as clinicians. If one includes estimates of expenses across the continuum of care, the financial impact of this growing population is substantial. Public policy discussions should include the medical, psychological, social, and financial needs of this population.