bluuebunny/crossref_metadata_2025 huggingface dataset:
Decline in Sepsis-associated Neonatal and Infant Deaths in the United States, 1979 Through 1994
Authors: Stoll Barbara J. , Holman Robert C. , Schuchat Anne
Published: August 2004

Background. Infant mortality in the United States has continued to decline in recent years, but changes in sepsis-associated deaths among infants have not been evaluated previously.

Methods. Data from US death records were analyzed for the period 1979 through 1994 to assess trends in sepsis-associated deaths among newborns and older infants.

Results. Annual neonatal mortality associated with sepsis declined by 25% from 50.5 deaths per 100 000 live births in 1979 through 1981 to 38.0 deaths per 100 000 live births in 1992 through 1994. Although infant mortality associated with sepsis declined from 71.7 to 56.4 per 100 000 live births over the same period, this decline was attributable to lower sepsis-related mortality among newborns. The rates of sepsis-associated deaths declined for both preterm and term deliveries. Approximately 2260 infants (1521 of whom were newborns) died of sepsis per year in 1992 through 1994. Sepsis-associated death was more likely to occur among infants who were male, black, preterm, or born in the South. Among black infants, the racial gap in sepsis-associated mortality was greater for term than for preterm infants.

Conclusions. Despite declines in the overall sepsis-related mortality among newborns, racial and regional gaps in mortality persisted over the 16-year study period. Almost half of the sepsis-related deaths occurred among infants who were born prematurely. Disproportionate rates of prematurity among blacks and infants born in the South may have contributed to persistently high sepsis-related mortality in these groups. Future efforts to reduce the incidence of sepsis-associated deaths will depend on targeting higher risk populations and reducing prematurity.
Estimation of Outcome and Restriction of Interventions in Neonates
Authors: Haywood James L. , Morse Steven B. , Goldenberg Robert L. , Bronstein Janet , Nelson Kathleen G. , Carlo Waldemar A.
Published: August 2004

Objective. To learn whether pediatricians accurately estimate rates of survival and freedom from handicap in preterm infants and to learn whether their knowledge and attitude influence their choice of interventions that may enhance survival of extremely preterm infants.

Methods. Pediatricians practicing in Alabama were surveyed using a pretested questionnaire designed to identify pediatricians' knowledge regarding survival and handicap-free rates of infants born at gestational ages between 21 and 36 weeks. For infants born at each week of gestation, they were asked if they would provide specific therapeutic interventions. Survival and handicap-free rates were compared with published national rates. Pediatricians were divided into an optimist group and a pessimist group based on how their estimates of survival compared with national published data. The rates at which each group used therapeutic interventions were compared.

Results. The 159 (57%) responding pediatricians underestimated survival rates from 23 through 34 weeks' gestation and freedom from serious handicap from 23 through 36 weeks. Responses of the optimists approximated actual data whereas the pessimists underestimated neonatal outcome. Those pediatricians who underestimated neonatal outcome would intervene less often with invasive therapies, including mechanical ventilation, cardiopulmonary resuscitation, inotropes, and intravenous fluids, compared with those who accurately predicted outcome from 23 through 27 weeks' gestation.

Conclusion. Pediatricians often underestimate neonatal outcome of preterm infants. Appropriate neonatal practice may be affected by this underestimation of the survival potential of preterm infants.
Gambling and Other Risk Behaviors Among 8th- to 12th-Grade Students
Authors: Proimos Jenny , DuRant Robert H. , Pierce Judith Dwyer , Goodman Elizabeth
Published: August 2004

Objective. To examine the associations between a self-reported history of gambling or problems related to gambling and health risk behaviors in adolescence.

Design. An anonymous risk behavior survey was administered to 21 297 8th- through 12th-grade students in 79 public and private schools in Vermont. Gambling or problems related to gambling were the outcome variables of interest. Demographic variables and 13 target risk behaviors related to substance use, sexual activity, and violence were tested for association with gambling and problems related to gambling.

Results. Of the students, 53% reported gambling in the past 12 months, and 7% reported problems attributable to gambling. Male gender, any use of alcohol, infrequent use of cigarette smoking, any marijuana use, any inhalant use, infrequent steroid use, frequent illegal drug use, seatbelt nonuse, driving after drinking alcohol, being threatened, carrying a weapon, being involved in a fight, and years of sexual activity were all significantly associated with reported gambling in the past 12 months. Among the students who gambled, younger age, male gender, daily marijuana use, frequent use of cocaine, frequent use of inhalants, any steroid use, never wearing seatbelts, carrying a weapon for up to 3 days a month, fighting, and years of sexual activity were all significantly associated with reported problems with family and friends as a consequence of gambling. There was an increase in the absolute number of risk behaviors reported between those who had not gambled, those who had gambled, and those for whom gambling had created problems.

Conclusions. Risk behaviors are associated with gambling in adolescence. The typology of risk behaviors was different for adolescents who reported gambling compared with those for whom gambling had created problems. Both gambling and problems related to gambling were significantly associated with the absolute number of risk behaviors reported by adolescents in a graded manner. Involvement in gambling should be assessed as part of the health encounter. Assessment may provide a nonthreatening entry into the evaluation of other risk behaviors. Furthermore, it may identify youth who are at risk of developing additional risk behaviors or pathological gambling. Interventions then could be targeted toward prevention of these undesirable outcomes.
Parental Literacy Level and Understanding of Medical Information
Authors: Moon Rachel Y. , Cheng Tina L. , Patel Kantilal M. , Baumhaft Kalanit , Scheidt Peter C.
Published: August 2004

Objective. To ascertain the impact of literacy level on parents' understanding of medical information and ability to follow therapy prescribed for their children.

Design/Methods. A prospective cohort of parents accompanying their children for acute care. Parents were interviewed about demographic status, their child's health, and use of pediatric preventive services. The Rapid Estimate of Adult Literacy in Medicine (REALM) test was used to assess parental literacy. The same parent was interviewed 48 to 96 hours later and asked to recall the child's diagnosis, any medication prescribed, and instructions.

Results. A total of 633 patients were enrolled. Follow-up was obtained in 543 patients (85.8%). Mean parental age was 32.43 years (SD = 9.07). Mean REALM score was 57.6 (SD = 10.9), corresponding to a 7th- to 8th-grade reading level, with a mean parental educational level of 13.43 years (SD = 2.09). Low REALM score was significantly correlated with young parental age and parental education. African-American race was associated with lower REALM scores. After controlling for these variables, REALM score significantly correlated with parental perception of how sick the child was, but not with use of preventive services, comprehension of diagnosis, medication name and instructions, or ability to obtain and administer prescribed medications.

Conclusions. Parental literacy level did not correlate with use of preventive services or parental understanding of or ability to follow medical instructions for their children.
Comparative Efficacy of the Lederle/Takeda Acellular Pertussis Component DTP (DTaP) Vaccine and Lederle Whole-Cell Component DTP Vaccine in German Children After Household Exposure
Authors: Heininger Ulrich , Cherry James D. , Stehr Klemens , Schmitt-Grohé Sabina , Überall Michael , Laussucq Suzanne , Eckhardt Thomas , Meyer Martin , Gornbein Jeffrey ,   the Pertussis Vaccine Study Group
Published: August 2004

Background.

A household contact substudy was performed as part of a prospective, cohort pertussis vaccine efficacy trial in Germany.

Design.

Infants received four doses of either the Lederle/Takeda acellular pertussis component diphtheria-tetanus toxoids (DTP) vaccine (DTaP) or Lederle whole-cell component DTP vaccine at 3, 4.5, 6, and 15 to 18 months of age (Wyeth-Lederle Vaccines and Pediatrics, Pearl River, NY). An open control group received three doses of diphtheria and tetanus toxoids vaccine (DT) at 3, 4.5, and 15 to 18 months of age. Vaccine efficacy rates were calculated using a number of principal and ancillary case definitions for primary, secondary, and noncases by analyzing secondary attack rates in study infants after exposure to pertussis in the household using 7- to 28- and 7- to 42-day postexposure observation periods and the inclusion and the exclusion of noncases who received macrolide antibiotics or trimethoprim-sulfamethoxazole during the exposure period.

Results.

During a 3.5-year study period, 10 271 infants (DTP or DTaP, n = 8532; DT, n = 1739) were enrolled and actively followed along with all household members for cough illnesses. Depending on the case definition, 160 to 519 household exposures to pertussis were identified. In general, secondary attack rates in DT recipients were low and this was primarily because of the frequent use of antimicrobial prophylaxis. Using the principal case definitions and the exclusion of noncases who received macrolide antibiotics or trimethoprim-sulfamethoxazole during the exposure period and the 7- to 42-day observation period, the efficacy of DTP against cough illness of ≥7 days duration caused by Bordetella pertussis was 84% (95% confidence interval [CI] = 65–93) and that of DTaP was 58% (95% CI = 30–75). Using similar criteria, the efficacy against typical pertussis (≥21 days of cough with either paroxysms, whoop, or posttussive vomiting) was 94% (95% CI = 77–99) and 86% (95% CI = 62–95) for DTP and DTaP, respectively. The efficacy against any cough illness (with or without) laboratory confirmation was 54% (95% CI = 32–69) and 38% (95% CI = 13–56) for DTP and DTaP, respectively.

Conclusion.

This household contact substudy within our cohort study, with active investigator-generated surveillance, was a severe test of vaccine efficacy. Both vaccines (DTP and DTaP) are better at preventing typical pertussis than mild illness. When case definitions similar to those in other recent trials are used, the Lederle/Takeda vaccine has an efficacy similar to other multicomponent DTaP vaccines.
Determinants of Health and Service Use Patterns in Homeless and Low-income Housed Children
Authors: Weinreb Linda , Goldberg Robert , Bassuk Ellen , Perloff Jennifer
Published: August 2004

Objective.

Previous studies of homeless children have described more health problems and service use than in housed children, but failed to control for potential confounding factors that may differ between these children. This observational study examines the relationship of homelessness and other determinants to health status and service use patterns in 627 homeless and low-income housed children.

Methods.

Case-control study of 293 homeless and 334 low-income housed children aged 3 months to 17 years and their mothers conducted in Worcester, Massachusetts. Information was collected about mothers' housing history, income, education, emotional distress, and victimization history. Standardized instruments were administered to assess children's health. Health service use questions were adapted from national surveys. Main outcome measures included health status, acute illness morbidity, emergency department and outpatient medical visits. Multivariable regression analyses were used to examine the association of family and environmental determinants, including homelessness, with health status and service use outcomes.

Results.

Mothers of homeless children were more likely to report their children as being in fair or poor health compared with their housed counterparts. Homeless children were reported to experience a higher number of acute illness symptoms, including fever, ear infection, diarrhea, and asthma. Emergency department and outpatient medical visits were higher among the homeless group. After controlling for potential explanatory factors, homeless children remained more likely to experience fair or poor health status (adjusted odds ratio [OR] = 2.83; 95% confidence interval [CI], 1.16, 4.87), and a higher frequency of outpatient (OR = 1.71; 95% CI, 1.18, 2.48) and emergency department visits (OR = 1.21; 95% CI, 0.83, 1.74). Mothers' emotional distress was independently associated with acute illness symptoms and frequent use of outpatient and emergency department settings.

Conclusions.

Homelessness is an independent predictor of poor health status and high service use among children. The present findings highlight the importance of preventive interventions and efforts to increase access to primary care among homeless children.
Trial on Timing of Introduction to Solids and Food Type on Infant Growth
Authors: Mehta Ketan C. , Specker Bonny L. , Bartholmey Sandra , Giddens Jacqueline , Ho Mona L.
Published: August 2004

Objective.

The optimal time and choice of solid foods to introduce to an infant's diet is unknown. The aim of this randomized trial was to determine whether early versus late introduction of solid foods and commercially prepared versus parent's choice of solid foods affects growth or body composition in the first year.

Methods.

White infants (n = 165) were recruited before 3 months of age and were randomized to receive: 1) commercially prepared solid foods (commercial) from 3 to 12 months, 2) commercially prepared solid foods from 6 to 12 months, 3) parent's choice of solid foods (choice) from 3 to 12 months, or 4) parent's choice of solid foods from 6 to 12 months. Anthropometrics and body composition, using dual energy x-ray absorptiometry, were determined at 3, 6, and 12 months. Three-day diet diaries were completed at 3, 6, 9, and 12 months.

Results.

There were no differences in growth or body composition between infants in early versus late introduction groups or commercial versus choice groups at any age. The total energy intake was not different among infants in the early compared with the late group at any age. Infants in the commercial group consumed less protein calories at 9 months (80 ± 3 kcal/d vs 88 ± 3 kcal/d) and 12 months (101 ± 5 kcal/d vs 148 ± 5 kcal/d), less fat calories at 12 months (263 ± 10 kcal/d vs 343 ± 10 kcal/d), and less total calories at 12 months (884 ± 24 kcal/d vs 1022 ± 25 kcal/d) compared with the choice group.

Conclusion.

The early introduction of solid foods to an infant's diet does not alter growth or body composition during the first year of life and results in a displacement of energy intake from formula. Infants consuming commercially prepared foods have a decreased caloric intake from protein and fat; however, despite this difference, there is no effect on growth or body composition.
High-expenditure Children With Supplemental Security Income
Authors: Kuhlthau Karen , Perrin James M. , Ettner Susan L. , McLaughlin Thomas J. , Gortmaker Steven L.
Published: August 2004

Objective.

To examine the clinical characteristics and health service use of children with high Medicaid expenditures.

Methodology.

We examined 1992 Medicaid claims and eligibility files from four states (California, Georgia, Michigan, Tennessee) for children with at least $10 000 billed to Medicaid who obtained Medicaid through the Supplemental Security Income (SSI) Program and a comparison group (matched by age group and gender) of children receiving Medicaid for other reasons. We compared mean expenditures, examined expenses by category, and examined diagnoses associated with at least $10 000 in expenses.

Results.

In 1992, Medicaid paid on average ∼$1000 for children with non-SSI Medicaid enrollment. Expenditures for children with SSI were 2.9 to 9.4 times higher, but once the ∼10% of children with high expenditures were excluded, SSI average expenditures were only 1.5 to 2.7 times higher than the non-SSI average. Children with high expenditures are likely to use hospitals and long-term care, and these services account for more than half of the average expenditures. Children with high expenditures and SSI are more likely to have chronic medical conditions than are their peers enrolled in Medicaid but not through SSI.

Conclusions.

A small proportion of children, even on SSI, account for very large proportions of Medicaid expenditures. Most children with SSI, despite having relatively severe mental health, physical, or developmental disabilities, have relatively modest Medicaid expenditures.
Sleep-Disordered Breathing and School Performance in Children
Authors: Gozal David
Published: August 2004

Objective.

To assess the impact of sleep-associated gas exchange abnormalities (SAGEA) on school academic performance in children.

Design.

Prospective study.

Setting.

Urban public elementary schools.

Participants.

Two hundred ninety-seven first-grade children whose school performance was in the lowest 10th percentile of their class ranking.

Methods.

Children were screened for obstructive sleep apnea syndrome at home using a detailed parental questionnaire and a single night recording of pulse oximetry and transcutaneous partial pressure of carbon dioxide. If SAGEA was diagnosed, parents were encouraged to seek medical intervention for SAGEA. School grades of all participating children for the school year preceding and after the overnight study were obtained.

Results.

SAGEA was identified in 54 children (18.1%). Of these, 24 underwent surgical tonsillectomy and adenoidectomy (TR), whereas in the remaining 30 children, parents elected not to seek any therapeutic intervention (NT). Overall mean grades during the second grade increased from 2.43 ± 0.17 (SEM) to 2.87 ± 0.19 in TR, although no significant changes occurred in NT (2.44 ± 0.13 to 2.46 ± 0.15). Similarly, no academic improvements occurred in children without SAGEA.

Conclusions.

SAGEA is frequently present in poorly performing first-grade students in whom it adversely affects learning performance. The data suggest that a subset of children with behavioral and learning disabilities could have SAGEA and may benefit from prospective medical evaluation and treatment.
Colovesical Fistula Resulting From a Perforated Colonic Duplication
Authors: Decter Ross M. , Kaplan Karen M. , Eggli Kathleen D. , Krummel Thomas M.
Published: August 2004

Colovesical fistulas in children are most often associated with high anorectal imperforations. Acquired enterovesical fistulas in children only rarely have been reported as a consequence of an inflammatory process. We present a case of an acquired colovesical fistula formed by the erosion of an abscess at the distal end of a colonic duplication in a child who presented with fever of unknown origin.
Selective Head Cooling in Newborn Infants After Perinatal Asphyxia: A Safety Study
Authors: Gunn Alistair J. , Gluckman Peter D. , Gunn Tania R.
Published: August 2004

Aims.

To determine the practicality and safety of head cooling with mild or minimal systemic hypothermia in term neonates with moderate to severe hypoxic-ischemic encephalopathy.

Methods.

Study group infants ≥37 weeks' gestation, who had an umbilical artery pH ≤7.09 or Apgars ≤6 at 5 minutes, plus evidence of encephalopathy. Infants with major congenital abnormalities were excluded.

Trial Design.

Infants were randomized to either no cooling (controls; rectal temperature = 37.0 ± 0.2°C,n = 10) or sequentially, either minimal systemic cooling (rectal temperature = 36.3 ± 0.2°C,n = 6) or mild systemic cooling (rectal temperature = 35.7 ± 0.2°C, n = 6). Head cooling was accomplished by circulating water at 10°C through a coil of tubing wrapped around the head for up to 72 hours. All infants were warmed by servo-controlled overhead heaters to maintain the allocated rectal temperature. The rectal, fontanelle, and nasopharyngeal temperatures were continuously monitored.

Results.

From January 1996 to October 1997, 22 term infants were randomized from 2 to 5 hours after birth. All infants showed a metabolic acidosis at delivery, with similar umbilical artery pH in the control group (mean ± standard deviation, 6.79 ± 0.25), minimal cooling group (6.98 ± 0.21), and mild cooling group (6.93 ± 0.11), and depressed Apgar scores at 5 minutes in the control group (4.5 ± 2), minimal cooling group, (4.7 ± 2) and mild cooling group (6.0 ± 1). In the mild-cooled infants, the nasopharyngeal temperature was 34.5°C during cooling, 1.2°C lower than the rectal temperature. This gradient narrowed to 0.5°C after cooling was stopped. No adverse effects because of cooling were observed. No infants developed cardiac arrhythmias, hypotension, or bradycardia during cooling. Thrombocytopenia occurred in 2 out of 10 controls, 2 out of 6 minimal cooling infants, and 1 out of 6 mild cooling infants. Hypoglycemia (glucose <2.6 mM) was seen on at least one occasion in 2 out of 10 controls, 4 out of 6 minimal cooling infants, and 1 out of 6 mild cooling infants. Acute renal failure occurred in all infants. The metabolic acidosis present in all infants at the time of enrollment into the study progressively resolved despite cooling, even in the mild hypothermia group.

Conclusions.

Mild selective head cooling combined with mild systemic hypothermia in term newborn infants after perinatal asphyxia is a safe and convenient method of quickly reducing cerebral temperature with an increased gradient between the surface of the scalp and core temperature. The safety of mild hypothermia with selective head cooling is in contrast with the historical evidence of adverse effects with greater depths of whole-body hypothermia. This safety study and the strong experimental evidence for improved cerebral outcome justify a multicenter trial of selective head cooling for neonatal encephalopathy in term infants.
Lyme Arthritis in Children: Clinical Epidemiology and Long-term Outcomes
Authors: Gerber Michael A. , Zemel Lawrence S. , Shapiro Eugene D.
Published: August 2004

Objective.

Although Lyme disease has become a relatively common cause of arthritis among children in areas of the country in which the disease is endemic, little information is available about the clinical epidemiology and long-term outcomes of children with Lyme arthritis. We conducted a long-term follow-up study to determine the clinical epidemiology of Lyme arthritis in children as well as their long-term outcomes.

Patients and Methods.

All children seen between 1982 and 1991 at the Pediatric Rheumatology Clinic at Newington Children's Hospital (Newington, CT) with an initial diagnosis of Lyme disease were identified. Medical records were reviewed and structured telephone interviews were conducted to obtain demographic, clinical, and follow-up data.

Results.

A total of 90 children (63% boys) with a mean age of 8.3 years (range, 1.8–16 years) at the time of diagnosis of Lyme arthritis were evaluated. Lyme arthritis was preceded by early Lyme disease in 23 (26%) of the children; however, only 8 (35%) of these children had been treated with appropriate antimicrobial therapy at that early stage. Ninety percent of the children had arthritis of at least one knee, while small joints were rarely involved. For the 31 children who underwent arthrocentesis, the mean white blood cell count in the synovial fluid was 38 000 cells/mm3 (range, 7000–99 000 cells/mm3) with predominantly neutrophils. For the 79 children for whom an erythrocyte sedimentation rate was determined, the highest level for 61 (77%) was >20 mm/h and for 36 (46%) was >50 mm/h. Antimicrobial therapy was initiated 2 days to 5.5 years (median, 2 months) after the onset of symptoms. However, 5 of the children were never treated with antimicrobials. Fifty-one percent of the patients had a single episode of arthritis, while 49% reported recurrent episodes of arthritis over a period of 1 week to 8 years (median, 6 months). Two children (2%) developed chronic arthritis and underwent arthroscopic synovectomy. At the time of the telephone follow-up evaluation, performed 2 to 12 years (median, 7 years) after the onset of the Lyme arthritis, 4 children had ongoing musculoskeletal complaints that resulted in mild to moderate impairment of school or sports activities, but none of the children had evidence of active arthritis.

Conclusion.

The results of this investigation suggest that the prognosis for children with Lyme arthritis who are treated with appropriate antimicrobial therapy is excellent.
Early Clinical Markers for the Development of Bronchopulmonary Dysplasia: Soluble E-Selectin and ICAM-1
Authors: Ramsay Patricia L. , O'Brian Smith E. , Hegemier Suzanne , Welty Stephen E.
Published: August 2004

Objective.

To test the hypothesis that in infants born at ≤29 weeks' gestation soluble adhesion molecule concentrations would be higher in the first week of life in infants that subsequently develop bronchopulmonary dysplasia than in infants that do not.

Design and Methods.

In cord blood and on days of life 1, 3, and 7, we measured serum concentrations of soluble P-Selectin, E-Selectin, and intercellular adhesion molecule-1 in samples obtained from infants ≤29 weeks' gestational age. At 1 month of age we assessed the infants' clinical courses to determine whether the infants met the criteria for the diagnosis of bronchopulmonary dysplasia (BPD) and evaluated the infants' radiographic studies to stage the level of BPD. On discharge, the duration of oxygen therapy, the requirement for home oxygen therapy, and length of hospital stay were determined.

Results.

Concentrations of soluble P-Selectin were greatest in cord blood samples obtained from all infants and were markedly reduced on day of life 1, regardless of the subsequent development of BPD. In serum samples obtained from cord blood and on days of life 1 and 3, soluble E-Selectin levels were higher in infants that developed BPD than in infants that did not develop BPD. In addition, the highest concentrations of soluble E-Selectin in serum samples from cord blood and on day of life 1 were associated with the development of stage 3 or 4 BPD. Soluble intercellular adhesion molecule-1 concentrations were higher on days of life 3 and 7 in the infants that went on to develop BPD than in those that did not.

Conclusions.

Because neutrophil attachment to endothelial cell adhesion molecules is a key event in the initiation of an inflammatory response, the association of higher early concentrations of soluble E-Selectin with the development of BPD suggests that E-Selectin may play a key role in the pathogenesis of lung inflammation and the development of BPD. This association also suggests that inflammatory events or effects leading to inflammatory responses occurring in the prenatal and/or very early perinatal periods contribute significantly to the pathogenesis of BPD.
Bisphosphonates for Treatment of Childhood Hypercalcemia
Authors: Lteif Aida N. , Zimmerman Donald
Published: August 2004

Most clinicians only have a limited experience in treating childhood hypercalcemia with bisphosphonates. We report our experience in the use of intravenous and oral bisphosphonates in a 5-year-old with hypercalcemia secondary to acute lymphocytic leukemia, a 16-year-old with immobilization hypercalcemia, and a 14-year-old with chronic hypercalcemia of unknown cause. Single infusions of 0.5 mg/kg and 1 mg/kg of intravenous pamidronate were administered over 4 hours. No adverse reactions were observed except for hypocalcemia. A dose between 10 and 20 mg of oral alendronate was successfully used to maintain normocalcemia in the patient with chronic hypercalcemia. In our experience, the administration of bisphosphonates has enabled us to achieve normocalcemia in all cases, and in all cases there were no significant side effects. Long-term potential side effects from their use in children during the active phase of growth remain unknown.
Issues in the Application of the Resource-Based Relative Value Scale System to Pediatrics: A Subject Review
Authors:   Resource-Based Relative Value Scale Project Advisory Committee
Published: August 2004

In today's rapidly changing health care environment, it is crucial to understand the genesis and concepts of the Medicare Resource-based Relative Value Scale (RBRVS) physician fee schedule. Many third-party payers, including state Medicaid programs, Blue Cross–Blue Shield agencies, and managed care organizations are using variations of the Medicare RBRVS to determine physician reimbursement and capitation rates. Because the RBRVS fee schedule was originally created for Medicare only, pediatric-specific Current Procedural Terminology codes and pediatric practice expense issues were not included. The American Academy of Pediatrics agrees with the use of the Current Procedural Terminology codes and the RBRVS physician fee schedule and continues to work to rectify the inequities of the RBRVS system as they pertain to pediatrics.
Cost-effective Treatment of Phimosis
Authors: Van Howe Robert S.
Published: August 2004

Objective.

To determine the most cost-effective treatment for phimosis.

Design.

The costs of three treatment strategies for treating phimosis were evaluated using a decision-tree analysis. Three therapeutic approaches were considered: circumcision, preputial plasty (the use of plastic surgical techniques to enlarge the preputial opening without removing tissue), and topical therapy with steroids and nonsteroidal antiinflammatories. Published failure and complication rates were used to calculate the cost per case.

Outcome Measures.

Cost in dollars to treat each case of phimosis.

Results.

Topical steroid therapy was the most cost-effective strategy, costing between $758 and $800 per case. Preputial plasty cost between $2515 and $2580 per case. Circumcision cost between $3009 and $3241 per case.

Conclusions.

The most cost-effective management for treating phimosis is to initiate topical therapy. Daily external application from the tip of the foreskin to the glandis corona with betamethasone 0.05% cream for 4 to 6 weeks has been demonstrated to be very effective, resulting in a 75% savings compared with circumcision. Surgical intervention should not be considered until topical therapy has been given an adequate trial. When contemplating surgery, the lower morbidity, lower costs, and tissue preservation of preputial plasty may make it preferable.
Parent Reports on Willingness to Accept Childhood Immunizations During Urgent Care Visits
Authors: Udovic Shannon L. , Lieu Tracy A. , Black Steven B. , Ray Paula M. , Ray G. Thomas , Shinefield Henry R.
Published: August 2004

Objectives.

To 1) describe whether parents would be willing to accept childhood immunizations at urgent care visits; and 2) identify predictors of parents' willingness to accept childhood immunizations at urgent care visits.

Design and Participants.

Cross-sectional telephone survey of parents of children aged 18 to 24 months who were underimmunized according to a computerized immunization tracking system and who had recently made an urgent care visit in a regional group-model health maintenance organization in Northern California. Chart review was conducted to confirm immunization status and to identify contraindications to vaccination.

Results.

Of the 424 eligible participants, 351 (83%) completed interviews. Children with contraindications to vaccination and children who were actually up-to-date at the time of the urgent care visit were excluded, leaving 263 families in the final analysis. Among these parents, 75% said they would have been willing to have their child immunized at the urgent care visit in question if the physician had suggested it. An additional 11% said they would have accepted vaccination if the physician told them that the shot would be safe and strongly encouraged them to accept it. Overall, 86% reported they theoretically would have accepted an immunization during the urgent care visit. In the multivariate analysis, the strongest predictors of stated willingness to accept shots at the urgent care visit were the parent: 1) not being aware that their child was underimmunized (odds ratio [OR] 3.5, 95% confidence interval [CI], 1.6–7.7); 2) perceiving that the child was not very sick at the visit (OR 1.8, 95% CI, 1.1–3.0); 3) being less concerned about the risk of shots (OR 1.8, 95% CI, 1.2–2.5); and 4) being of nonwhite race (OR 3.6, 95% CI, 1.6–7.7). Income and education were not significantly associated with reported willingness to accept immunization.

Conclusions.

We conclude that most parents of underimmunized toddlers report being willing to accept immunizations during urgent care visits if the clinician recommends it. More effective ways of alerting providers in urgent care settings when immunizations are due, such as indications on a chart or registration form, hold promise for improving immunization coverage rates.
Fetal Versus Maternal and Gestational Age Effects of Repetitive Antenatal Glucocorticoids
Authors: Jobe Alan H. , Newnham John , Willet Karen , Sly Peter , Ikegami Machiko
Published: August 2004

Background.

Although single courses of antenatal glucocorticoids decrease respiratory distress syndrome and mortality, repetitive courses of antenatal glucocorticoids are being given to women at risk of preterm delivery without evidence of benefit or appreciation of potential risks.

Objectives.

To evaluate the effects of single and repetitive antenatal glucocorticoid exposures on fetal growth and postnatal lung function in sheep.

Methods.

Pregnant ewes were randomized to three protocols that included one or three doses (at 7-day intervals) of 0.5 mg/kg of betamethasone (β) given to the ewe or fetus beginning at gestations ranging from 104 to 128 days' gestation with delivery at 125, 135, and 146 days' gestation. Postnatal assessments included measurements of gas exchange, compliance, ventilation efficiency, static lung volume, and lung tissue and alveolar wash saturated phosphatidylcholine.

Results.

Single or repetitive maternal β but not fetal β caused fetal growth retardation at delivery at 125, 135, and 146 days' gestation. Single-dose fetal β had no effect on postnatal lung function whereas single-dose maternal β significantly increased compliance, lung volume, and tissue and alveolar surfactant after preterm delivery. Although three-dose fetal β improved all indicators of postnatal lung function, three-dose maternal β resulted in larger responses. The added benefits of repetitive β relative to a single-dose β on postnatal lung function after preterm delivery were not as great when therapy was begun later in gestation. Postnatal lung function after delivery at 146 days' gestation (term is 150 days) was improved after repetitive maternal β at early gestational age.

Conclusions.

In sheep, single or repetitive maternal β causes growth retardation from 104 to 121 days' gestation and the growth retardation persists to term. In contrast, single or repetitive fetal β does not cause fetal growth retardation and is less potent at improving postnatal lung function and increasing surfactant pools. There are potential benefits as well as risks for the use of repetitive antenatal glucocorticoids. Randomized, controlled trials in humans are essential given the widespread use of repetitive courses of antenatal glucocorticoids in women at risk of preterm delivery. respiratory distress syndrome, maturation, prematurity, growth retardation, surfactant.
Effects of Sleep Position on Infant Motor Development
Authors: Davis Beth Ellen , Moon Rachel Y. , Sachs Hari C. , Ottolini Mary C.
Published: August 2004

Background.

As a result of the American Academy of Pediatrics' recommendation that healthy infants be placed on their side or back for sleep, the percentage of infants sleeping prone has decreased dramatically. With the increase in supine sleeping, pediatricians have questioned if there are differences in the rate of acquisition of early motor milestones between prone and supine sleeping infants.

Methods.

To examine this question, we performed a prospective, practice-based study of healthy term infants. Infants were recruited before the age of 2 months. Parents were asked to record infant sleep position and awake time spent prone until 6 months of age. A developmental log was used to track milestones from birth until the infant was walking. Age of acquisition of eight motor milestones was determined, and the mean ages of milestone attainment of prone and supine sleepers were compared.

Results.

Three hundred fifty-one infants completed the study. Prone sleepers acquired motor milestones at an earlier age than supine sleepers. There was a significant difference in the age of attainment of rolling prone to supine, tripod sitting, creeping, crawling, and pulling to stand. There was no significant difference in age when infants walked.

Conclusions.

The pattern of early motor development is affected by sleep position. Prone sleepers attain several motor milestones earlier than supine sleepers. However, all infants achieved all milestones within the accepted normal age range. Pediatricians can use this information to reassure parents. This difference in milestone attainment is not a reason to abandon the American Academy of Pediatrics' sleep position recommendations.
The Decline in US Teen Pregnancy Rates, 1990–1995
Authors: Kaufmann Rachel B. , Spitz Alison M. , Strauss Lilo T. , Morris Leo , Santelli John S. , Koonin Lisa M. , Marks James S.
Published: August 2004

Objectives.

Estimate pregnancy, abortion, and birth rates for 1990 to 1995 for all teens, sexually experienced teens, and sexually active teens.

Design.

Retrospective analysis of national data on pregnancies, abortions, and births.

Participants.

US women aged 15 to 19 years.

Outcome Measures.

Annual pregnancy, abortion, and birth rates for 1990 to 1995 for women aged 15 to 19 years, with and without adjustments for sexual experience (ever had intercourse), and sexual activity (had intercourse within last 3 months).

Results.

Approximately 40% of women aged 15 to 19 years were sexually active in 1995. Teen pregnancy rates were constant from 1990 to 1991. From 1991 to 1995, the annual pregnancy rate for women aged 15 to 19 years decreased by 13% to 83.6 per 1000. The percentage of teen pregnancies that ended in induced abortions decreased yearly; thus, the abortion rate decreased more than the birth rate (21% vs 9%). From 1988 to 1995, the proportion of sexually experienced teens decreased nonsignificantly.

Conclusions.

After a 9% rise from 1985 to 1990, teen pregnancy rates reached a turning point in 1991 and are now declining. Physicians should counsel their adolescent patients about responsible sexual behavior, including abstinence and proper use of regular and emergency contraception.
Early Developmental Outcome After the Norwood Procedure for Hypoplastic Left Heart Syndrome
Authors: Kern Jeffrey H. , Hinton Veronica J. , Nereo Nancy E. , Hayes Constance J. , Gersony Welton M.
Published: August 2004

Objective.

To assess intellect and adaptive behavior in children with hypoplastic left heart syndrome (HLHS) who had undergone at least two surgical stages of the Norwood procedure.

Methods.

Fourteen children with HLHS >3 years of age participated in the study. The patients underwent intelligence quotient (IQ) testing, and their parents were interviewed regarding their children's adaptive behavior. Results were compared with those of 10 family controls. Outcomes were studied for possible correlation with perioperative variables.

Results.

Among the HLHS patients, the median scores for full scale IQ and adaptive behavior were 88 and 91, respectively (normal = 100 ± 15). One child met criteria for mental retardation. Family controls scored generally higher than did HLHS patients, but only differences in adaptive behavior were statistically significant. A negative correlation was found between stage I circulatory arrest time and full scale IQ.

Conclusions.

Children with HLHS most often function in the low-normal range of intelligence and adaptive behavior. A prolonged circulatory arrest time may result in decreased intellectual function.
Early Versus Late Surfactant Treatment in Preterm Infants of 27 to 32 Weeks' Gestational Age: A Multicenter Controlled Clinical Trial
Authors: Gortner Ludwig , Wauer Roland R. , Hammer Hannes , Stock Gerd-J. , Heitmann Friedhelm , Reiter Hans L. , Kühl Peter G. , Möller Jens C. , Friedrich Hans-J. , Reiss Irwin , Hentschel Roland , Jorch Gerhard , Hieronimi Gertrud , Kuhls Eckhard
Published: August 2004

Objective.

To investigate whether early (<1 hour after birth) surfactant administration would be superior to late treatment (2–6 hours after birth) in preterm infants.

Study Design.

Randomized controlled multicenter clinical trial.

Patients and Methods.

Prenatal randomization of all infants of 27 to 32 weeks' gestational age stratified by center after parental informed consent. Early treatment: 100 mg/kg body weight bovine surfactant (SF-RI1, Alveofact; Dr K. Thomae, Biberach, Germany) to infants requiring intubation after birth. Late treatment: identical dosage to infants requiring intubation up to 6 hours of age with the fraction of inspired oxygen >0.4 at 2 to 6 hours after birth. Primary endpoint: the time on mechanical ventilation. Main secondary endpoints: mortality, bronchopulmonary dysplasia, intraventricular hemorrhage ≥grade III, and periventricular leukomalacia. Sample size calculation: at least 280 infants to prove superiority of either approach (α = 0.05; β = 0.90).

Results.

Enrollment of 317 infants, 154 randomized to early surfactant treatment, 163 to late surfactant treatment. Study infants (all following data intent-to-treat groups: early versus late surfactant) were similar with respect to: gestational age, 29.5 ± 1.6 weeks versus 29.7 ± 1.6 weeks; birth weight, 1227 ± 367 g versus 1269 ± 334 g; and the rate of prenatal corticosteroids, 79.9% versus 72.8%. Duration of mechanical ventilation: 3 days (0–8) versus 2 days (0–6) (median, interquartile); further outcome variables: death or bronchopulmonary dysplasia (day 28) 25.9% versus 23.9%, mortality 3.2% versus 1.8%, intraventricular hemorrhage ≥grade III 6.5% versus 3.7%, and periventricular leukomalacia 5.2% versus 5.5% not differing statistically.

Conclusion.

In preterm infants with a high rate of prenatal glucocorticoids, early surfactant administration was not found to be superior to late treatment in terms of relevant outcome variables.
Early Sexual Initiation: The Role of Peer Norms
Authors: Kinsman Sara B. , Romer Daniel , Furstenberg Frank F. , Schwarz Donald F.
Published: August 2004

Objective.

To elucidate which components of peer norms influence the process of sexual initiation for young adolescents.

Design.

Prospective cohort study.

Setting.

Fourteen elementary and middle schools in an urban public school district.

Participants.

The 1389 sixth-grade students who completed the questionnaire at the beginning (time 1) and at the end (time 2) of the school year comprise the study sample. Mean age at time 1 was 11.7 years.

Results.

Of students entering the sixth grade, 30% (n = 416) reported having already initiated sexual intercourse, 5% (n = 74) reported initiating sexual intercourse during the sixth-grade school year (initiated group), and 63% (n = 873) reported not having initiated sexual intercourse by the end of the sixth-grade school year (never group). Demographic comparisons revealed that students in the initiated group were significantly more likely than students in the never group to be older (11.9 years vs 11.6 years), male (58% vs 37%), African-American (70% vs 51%), attending a poorer school (87% vs 85%), and living in an area with a high proportion of single-parent families (45% vs 41%). Self-reports and reports of peers' participation in nonsexual risk behaviors were more common for students in the initiated group. Students in the initiated group were more likely than students in the never group to perceive: 1) a high prevalence of sexual initiation among peers; 2) social gains associated with early sexual intercourse; and 3) younger age of peers' sexual initiation. Students in the never group were more likely to believe that sexually-experienced 12-year-old boys would be negatively stigmatized compared with students in the initiated group. Three predictive models were developed to test the relationship between peer norms and the process of initiation. These models demonstrate that the strongest predictor of sexual initiation in sixth grade is having high intention to do so at the beginning of sixth grade. The strongest predictor of high intention is belief that most friends have already had sexual intercourse. Perceptions of social gain and stigma for sexually-experienced 12-year-old boys act independently of intention to decrease risk of early sexual initiation.

Conclusion.

Early sexual intercourse is not an unplanned experience for many teens. Decisions about initiation are strongly bound to social context with peers playing an important role in creating a sense of normative behavior. Specific components of peer norms impact the process of sexual initiation in both positive and negative ways. Interventions aimed at delaying the onset of sexual initiation need to focus on cohort norms as well as on an individual's perceptions and behaviors.
Hyperbaric Oxygen Therapy in the Pediatric Patient: The Experience of the Israel Naval Medical Institute
Authors: Waisman Dan , Shupak Avi , Weisz Giora , Melamed Yehuda
Published: August 2004

The pediatric patient is to be found in hyperbaric facilities throughout the world, receiving hyperbaric oxygen (HBO) therapy for both life-threatening and chronic diseases.

Objective. To review the experience accumulated at the Israel Naval Medical Institute in the treatment of pediatric patients.

Design. A retrospective analysis and review of all records of patients younger than age 18 years.

Results. Between 1980 and 1997, 139 pediatric patients age 2 months to 18 years (mean, 7.7 years) received HBO treatment at the Israel Naval Medical Institute. Of the children, 111 (79%) suffered from acute carbon monoxide (CO) poisoning; 13 (9.2%) were treated after crush injury, traumatic ischemia, or compartment syndrome; 4 (2.8%) had clostridial myonecrosis; 1 (0.7%) had necrotizing fasciitis; 5 (3.6%) had refractory osteomyelitis; 2 (1.4%) had suffered massive air embolism; 2 (1.4%) had purpura fulminans; and 1 (0.7%) suffered from decompression sickness. Outcome, judged by neurologic sequelae, mortality, and extent of soft tissue loss and limb amputation, was favorable in 129 patients (93%). Two patients (1.4%) died, 1 as a result of CO poisoning and the other, gas gangrene; 2 of the patients in the CO group (1.4%) remained with neurologic sequelae, and 6 patients in the acute traumatic ischemia group (4.3%) underwent limb amputation.

Conclusions. We had a favorable experience with 129 of a total 139 pediatric patients treated at our facility for the indications listed. A basic knowledge of HBO therapy is needed to refer the pediatric patient for treatment when indicated. The needs of the pediatric patient, especially the critically ill, require specific skills and equipment inside the hyperbaric chamber. Close collaboration between the pediatrician and the hyperbaric medicine physician is essential to ensure adequate care for infants and children.