bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of Vaginal Infections in Adolescent Women: Can It Be Done Without a Speculum?
Authors: Blake Diane Ruth , Duggan Anne , Quinn Thomas , Zenilman Jonathan , Joffe Alain
Published: August 2004

Objective.

Given that highly sensitive urine-based nucleic acid amplification tests may eliminate the need for speculum exam to diagnose gonorrhea and chlamydia cervicitis, we sought to determine if vaginal infections could be diagnosed without using a speculum.

Methods.

Matched pairs of vaginal specimens were collected from participants before and during speculum exam for diagnosis of trichomoniasis, bacterial vaginosis, and vulvovaginal candidiasis. Females age 12 to 22 years presenting to the Johns Hopkins adolescent primary care clinics who required a pelvic examination were eligible to participate. A convenience sample of 686 patients was recruited between July 1995 and August 1996. Paired vaginal specimens were evaluated with blinded microscopic evaluation. Analysis consisted of: 1) comparison of collection method sensitivities; and 2) assessment of proportions of infections detected by one method that were also detected by the other method.

Results.

Sensitivities of speculum and nonspeculum collection methods were 75% and 77% (difference = −2%; 95% confidence interval, −11%, 7%) for trichomoniasis, 64% and 68% (difference = −4% [−10%,3%]) for bacterial vaginosis, and 85% and 80% (difference = 5% [−12%, 22%]) for vulvovaginal candidiasis. The speculum method identified 88% (trichomoniasis), 90% (bacterial vaginosis), and 81% (vulvovaginal candidiasis) of infections detected by the nonspeculum method. The nonspeculum method identified 91% (trichomoniasis), 95% (bacterial vaginosis), and 76% (vulvovaginal candidiasis) of infections detected by the speculum method.

Conclusions.

Vaginal infections can be adequately diagnosed without a speculum. Once urine-based diagnosis of gonorrhea and chlamydia becomes well established, it may be possible to perform evaluations for uncomplicated genitourinary complaints without using a speculum.
Prenatal Cocaine Exposure and Child Behavior
Authors: Delaney-Black Virginia , Covington Chandice , Templin Thomas , Ager Joel , Martier Susan , Sokol Robert
Published: August 2004

Objective.

The aim of this study was to evaluate previous teacher reports that children exposed to cocaine prenatally have more problem behaviors.

Methods.

A historical, prospective design was used. Maternal subjects (n = 116) of 6-year-old singleton, term (≥36 weeks) children, and the children's first-grade teachers (n = 102) agreed to participate. The child's first-grade teacher, blinded to study design and exposure status, rated the child's behavior with the Conners' Teacher Rating Scales (CTRS) and an investigator-developed scale, the Problem Behavior Scale (PROBS 14), measuring behaviors reported by educators to be specific to cocaine exposure. Mothers were interviewed by telephone regarding demographic and socioeconomic factors.

Results.

Although the cocaine-exposed group had higher (more problem behaviors) for each of the CTRS subscales, the overall multivariate analysis of variance for the CTRS was not significant. Children exposed to cocaine prenatally had higher scores (more problem behaviors) for 11 of the 14 PROBS items and the overall multivariate analysis of variance relating prenatal cocaine exposure to the PROBS was significant (Wilkes' λ =.775), even after controlling for gender and prenatal exposure to alcohol and cigarettes.

Conclusions.

This pilot study supports that teachers blinded to exposure status of early elementary students did rate the cocaine-exposed group as demonstrating significantly more problem behaviors than control children. Although an important first step, postnatal factors that also may influence behavior were not evaluated; hence, causation is not addressed.
Catch-up Growth in Children Treated With Home Enteral Nutrition
Authors: Kang Anna , Zamora Samuel A. , Scott R. Brent , Parsons Howard G.
Published: August 2004

Objective.

This study was designed to determine the effect of home enteral nutrition on the outcomes of growth and the relationship between growth and entrance anthropometric criteria.

Methods.

We reviewed the medical records of 78 consecutive children (median age, 20 months) who were enrolled in the home enteral feeding program at the Alberta Children's Hospital (Calgary, Alberta, Canada) between 1993 and 1995. Weights, heights, and weight-for-heights were expressed as Z scores, using the Centers for Disease Control and Prevention anthropometric growth curve software. To evaluate growth outcome, the total group was further subdivided using anthropometric criteria into appropriate, wasted, or stunted at the time of entry to the program. In a subgroup of 36 children on whom anthropometric data was available for a median length of 5.7 months,Z scores were compared at 3 points in time: before entry, at time of entry, and last follow-up.

Results.

Patients were classified into five main groups: 11 (14%) had pulmonary disease, 26 (33%) had a gastrointestinal disorder, 21 (27%) had congenital defects, 10 (13%) had a neurologic disorder, and the remaining 10 (13%) had a variety of other illnesses, including malignancies and metabolic disorders. Patients were on the program for a median duration of 8.9 months. It was found that during the period of support within the program, enteral feeding was successful in improving weight-for-age Z scores by 0.42 standard deviations but the effect on height-for-age Zscores and weight-for-height Z scores did not reach significance for this population. The subgroup of 36 children on whom longitudinal anthropometric data was available before entering the program was found to have had a significant drop in weightZ scores between the time before program entry (median length of time, 5.7 months) and the time of program entry, which indicates that these children were falling off the growth curve before commencing enteral feeding. To evaluate growth outcome, the total group was further subdivided using anthropometric criteria into appropriate, wasted, or stunted at the time of entry to the program. In the group of appropriate growth patients, while in the program, 50% had catch-up growth for weight (positive change in Z scores) and 33% for height. In the wasted patients, 92% improved their weight percentile and 75% their height percentile. In the stunted group, 71% had catch-up growth for weight and 74% for height.

Conclusion.

We concluded that the enteral feeding program was able to promote catch-up growth or maintain growth along percentiles in the majority of children.
Principles of Child Health Care Financing
Authors:   Committee on Child Health Financing
Published: August 2004

Child health care financing must maximize access to and ensure quality comprehensive child and maternal care. This policy statement replaces the 1993 policy statement, “Principles of Child Health Care Financing.” Changes reflect new state and federal legislation that affect child health care financing. The principles outlined in the policy statement will be used to evaluate the changing structure of health care financing.
Risk Factors for Early Childhood Malnutrition in Uganda
Authors: Kikafunda Joyce K. , Walker Ann F. , Collett David , Tumwine James K.
Published: August 2004

Objective.

To assess the dietary and environmental factors influencing stunting and other signs of poor nutritional status of children <30 months of age in a central Ugandan community, whose main dietary staples are banana (matoki) and maize.

Methods.

The study was a cross-sectional survey using stratified multistage random sampling to select households with a child <30 months of age in rural and semi-urban environments. A questionnaire was administered to mothers of 261 infants and toddlers in their home setting. Their health status was assessed by clinical examination and anthropometric measurements (mid-upper arm circumference [MUAC], weight, and supine length).

Results.

A large minority (21.5%) of the children surveyed were found in poor health after clinical examination: 3.8% being classified as suffering from kwashiorkor and 5.7% with marasmus. A high proportion of children were stunted (23.8%), underweight (24.1%), or had low MUAC (21.6%). Although rural living, poor health, the use of unprotected water supplies, lack of charcoal as fuel, lack of milk consumption, and lack of personal hygiene were shown as risk factors for marasmus and underweight, different factors were found to be associated with risk of stunting and low MUAC, despite these three parameters being significantly correlated. For stunting the risk factors were: age of the child, poor health, prolonged breastfeeding (from >18 months to <24 months), low socioeconomic status of the family, poor education of the mother of infants <12 months, lack of paraffin as fuel, consumption of food of low energy density (<350 kcal/100 g dry matter), presence of eye pathology, and consumption of small meals. Risk factors for low MUAC were poor health, lack of meat and cow's milk consumption, low intake of energy from fat, and less well educated and older mothers. Food taboos had no influence on any of the anthropometric measurements. Although 93.1% of the children had been immunized against tuberculosis, polio, diphtheria, and measles and showed better general health than children who were not immunized, there was a high prevalence of infection in the week preceding the survey interview, including diarrhea (23.0%), malaria (32.3%), or cough/influenza (72.8%).

Conclusions.

This first account of dietary and environmental risk factors involved in the etiology of early childhood malnutrition in Uganda indicates differences in risk factors for marasmus and underweight compared with stunting and low MUAC. The high prevalence of malnutrition and current infection of children in this survey suggests poor immune function as a result of inadequate nutrition.
Computer-assisted Diagnosis of Pediatric Rheumatic Diseases
Authors: Athreya Balu H. , Cheh May L. , Kingsland Lawrence C.
Published: August 2004

Objective.

AI/RHEUM is a multimedia expert system developed originally to assist in the diagnosis of rheumatic diseases in adults. In the present study we evaluated the usefulness of a modified version of this diagnostic decision support system in diagnosing childhood rheumatic diseases.

Methodology.

AI/RHEUM was modified by the addition of 5 new diseases to the knowledge base of the system. Criteria tables for each of the diseases included in the knowledge base were modified to suit the needs of children. The modified system was tested on 94 consecutive children seen in a pediatric rheumatology clinic.

Results.

AI/RHEUM made the correct diagnosis in 92% of the cases when the diagnosis was available in the knowledge base of the system. It was also shown to be effective in the education of pediatric trainees through its multimedia features.

Conclusions.

AI/RHEUM is an expert system that may be helpful to the nonspecialist as a diagnostic decision support system and as an educational tool.
Neuroprotection With Prolonged Head Cooling Started Before Postischemic Seizures in Fetal Sheep
Authors: Gunn Alistair J. , Gunn Tania R. , Gunning Mark I. , Williams Christopher E. , Gluckman Peter D.
Published: August 2004

Objective.

Cerebral hypothermia has been shown to reduce damage from experimental hy-poxia-ischemia if started shortly after reperfusion. However, in the newborn infant it may not be feasible to determine prognosis so soon after exposure to asphyxia. The aim of this study was to determine whether head cooling, delayed until shortly before the onset of postasphyxial seizure activity, is neuroprotective.

Methods.

Unanesthetized near-term fetal sheep in utero were subjected to 30 minutes of cerebral ischemia. Later, at 5.5 hours, they were randomized to either cooling (n = 7) or sham cooling (n = 10) for 72 hours. Intrauterine cooling was induced by circulating cold water through a coil around the fetal head. The water temperature was titrated to reduce fetal extradural temperature from 39.1 ± 0.1°C to between 30°C and 33°C, while maintaining esophageal temperature >37°C.

Results.

Cerebral cooling suppressed the secondary rise in cortical impedance (a measure of cytotoxic edema), but did not prevent delayed seizures, 8 to 30 hours after ischemia. Transient metabolic changes including increased plasma lactate and glucose levels were seen with a moderate sustained rise in blood pressure. This severe cerebral insult resulted in depressed residual parietal electroencephalographic activity after 5 days recovery (−14.2 ± 1.5 decibels), associated with a watershed distribution of neuronal loss (eg, 94 ± 4% in parasagittal cortex and 77 ± 4% in the lateral cortex). Hypothermia was associated with better recovery of electroencephalographic activity (−8.9% ± 1.8 decibels) and substantially reduced neuronal loss in the parasagittal cortex (46 ± 13%), the lateral cortex (9 ± 4%), and other regions except the cornu ammonis sectors 1 and 2 of the hippocampus.

Conclusions.

Delayed selective head cooling begun before the onset of postischemic seizures and continued for 3 days may have potential to significantly improve the outcome of moderate to severe hypoxic-ischemic encephalopathy.
Preliminary Report: rhG-CSF May Reduce the Incidence of Neonatal Sepsis in Prolonged Preeclampsia-associated Neutropenia
Authors: Kocherlakota Prabhakar , La Gamma Edmund F.
Published: August 2004

Objectives.

To determine whether adjunctive therapy with recombinant human granulocyte colony-stimulating factor (rhG-CSF) could reverse the neutropenia and reduce the incidence of sepsis (≤28 days postnatal age) in neonates with prolonged preeclampsia-associated neutropenia compared with conventional therapy.

Study Design.

An intravenous infusion of rhG-CSF (10 μg/kg/day × 3 days for 10 neonates or 5 μg/kg/day × 3 days for 5 neonates) was administered to ventilated patients with prolonged (≥3 consecutive days in the first postnatal week) preeclampsia-associated neutropenia (absolute neutrophil count [ANC] <1500/mm3). Neutrophilic responses and the incidence of neonatal sepsis in the next 28 postnatal days were compared with 13 case-matched control neonates who also had prolonged preeclampsia-associated neutropenia. Sepsis was defined as at least one positive blood culture in a newly symptomatic neonate treated with antibiotics for ≥7 days.

Results.

No significant differences existed among the three groups in the birth weight, gestational age, sex, growth retardation, method of delivery, magnitude of respiratory support, use of surfactant, usage of intravascular catheters, or in the initial (pretreatment) ANC. The average baseline ANC (pretreatment) in the 10-μg rhG-CSF group was 815 ± 169/mm3 (mean ± SEM), in the 5 μg group it was 786 ± 165/mm3, and in the conventional group it was 965 ± 283. Eighteen of 28 (64%) neonates with preeclampsia-associated neutropenia were neutropenic at birth, the other 10 (36%) had normal neutrophil counts at birth but subsequently developed ≥3 days of neutropenia between 24 and 120 hours after birth. The ANC increased by 2-fold at 24 hours, by 4-fold at 72 hours, and 14-fold by the 7th day in the 10-μg group. In the 5-μg group, a 2-fold and 5-fold increase occurred at 72 hours and 7 days, respectively. In the conventionally-treated group, only a 4-fold increase was seen as late as 7 days after achieving entry criteria. Sepsis was observed in 13% (2/15) of the rhG-CSF-treated neonates compared with an incidence of 54% (7/13) in the conventionally-treated neonates.

Conclusions.

rhG-CSF increases the ANC significantly (at 10 μg/kg/day × 3 days) and reduces the incidence of neonatal sepsis in critically ill ventilated neonates with prolonged preeclampsia-associated neutropenia when compared with conventional therapy. A future prospective, randomized, and blinded trial is needed to validate the beneficial effects of prophylactic rhG-CSF therapy in neonates with prolonged preeclampsia-associated neutropenia.
Health Outcomes in Offspring of Mothers With Breast Implants
Authors: Kjøller Kim , McLaughlin Joseph K. , Friis Søren , Blot William J. , Mellemkjær Lene , Høgsted Charlotte , Winther Jeanette F. , Olsen Jørgen H.
Published: August 2004

Objective.

To examine the occurrence of esophageal disorders, connective tissue diseases, and congenital malformations in children of mothers with breast implants.

Methods.

Nationwide register-based follow-up study of all offspring born during 1977 to 1992 to a cohort of 1135 women with breast implants for cosmetic reasons and to a comparison cohort of 7071 women who underwent breast reduction surgery. Cause-specific hospi-talization rates among offspring, relative to those of the general population, were calculated from the Danish National Registry of Patients.

Results.

Among the 939 children of mothers with breast implants, higher rates of esophageal disorders were observed, but the excess was similar for those born before versus after the implant surgery. Higher than expected hospitalization rates for these conditions were also observed among 3906 children of women who underwent breast reduction surgery. No significant increases in connective tissue diseases or congenital malformations were observed in either the breast implant or breast reduction cohorts.

Conclusions.

This first epidemiologic cohort study provides no evidence that silicone breast implants affect risks of esophageal or other disorders in children of the implantees. Rather, the observed risk pattern suggests that a lower threshold exists among both groups of women who have undergone cosmetic breast surgery in seeking professional medical care for problems normally solved outside the hospital.
Total But Not Resting Energy Expenditure Is Increased in Infants With Ventricular Septal Defects
Authors: Ackerman Inger L. , Karn Cheryl A. , Denne Scott C. , Ensing Gregory J. , Leitch Catherine A.
Published: August 2004

Objective.

The purpose of this study was to determine the effect of left-to-right shunting on the resting energy expenditure (REE), total energy expenditure (TEE), and energy intake in a group of 3- to 5-month-old infants with moderate to large unrepaired ventricular septal defects (VSDs) compared with age-matched, healthy infants.

Methods.

Eight infants with VSDs and 10 healthy controls between 3 to 5 months of age participated in the study. Indirect calorimetry was used to measure REE and the doubly-labeled water method was used to measure TEE and energy intake. An echocardiogram and anthropometric measurements were performed on all study participants. Daily urine samples were collected at home for 7 days. Samples were analyzed by isotope ratio mass spectrometry. Data were compared using analysis of variance.

Results.

No significant differences were found in REE (VSD, 42.2 ± 8.7 kcal/kg/d; control, 43.9 ± 14.1 kcal/kg/d) or energy intake (VSD, 90.8 ± 19.9 kcal/kg/d; control, 87.1 ± 11.7 kcal/kg/d) between the groups. The percent total body water was significantly higher in the VSD infants and the percent fat mass was significantly lower. TEE was 40% higher in the VSD group (VSD, 87.6 ± 10.8 kcal/kg/d; control, 61.9 ± 10.3 kcal/kg/d). The difference between TEE and REE, reflecting the energy of activity, was 2.5 times greater in the VSD group.

Conclusions.

REE and energy intake are virtually identical between the two groups. Despite this, infants with VSDs have substantially higher TEE than age-matched healthy infants. The large difference between TEE and REE in VSD infants suggests a substantially elevated energy cost of physical activity in these infants. These results demonstrate that, although infants with VSDs may match the energy intake of healthy infants, they are unable to meet their increased energy demands, resulting in growth retardation.
Sleep and Daytime Behavior in Children With Obstructive Sleep Apnea and Behavioral Sleep Disorders
Authors: Owens Judith , Opipari Lisa , Nobile Chantelle , Spirito Anthony
Published: August 2004

Objective.

The purpose of this study was: 1) to examine both bedtime sleep behaviors and daytime behaviors associated with daytime sleepiness in a group of children with a primary medical sleep disorder (obstructive sleep apnea syndrome [OSAS]) compared with a group of children with a primary behavioral sleep disorder (BSD) (limit setting sleep disorder or sleep onset association disorder); and 2) to investigate the impact of a comorbid BSD on sleep and daytime behavioral consequences of OSAS.

Methods.

Children referred to a pediatric sleep disorders clinic during a 3-year period with a primary diagnosis of either polysomnographically-confirmed OSAS (n = 100) or a BSD (n = 52) were compared on several parent report measures assessing the following domains: symptoms of sleep disordered breathing, other sleep behaviors (primarily parasomnias), bedtime behaviors, and externalizing daytime behavior problems. The OSAS sample was then divided into a pure OSAS group (n = 78) and an OSAS plus a behavioral sleep diagnosis group (n = 22) based on the presence or absence of delayed sleep onset and/or prolonged nightwakings and compared on the parent-report symptom domains.

Results.

Almost one-quarter of the OSAS group had clinically significant behavioral sleep problems, primarily bedtime resistance, in addition to OSAS. Bedtime resistance was associated with a significantly shortened sleep duration in both the BSD and OSAS-BSD groups. Although the OSAS-BSD group had less severe disease, as defined by polysomnographic variables, than the pure OSAS group, they were rated by their parents as having more daytime externalizing behavior problems associated with daytime sleepiness.

Conclusions.

The results of this study suggest that evaluation for comorbid BSD should be done in all children presenting with symptoms of OSAS. The coexistence of such BSDs may contribute significantly to sleep deprivation, and thus to behavioral manifestations of daytime sleepiness in these children.
Prevention of Respiratory Syncytial Virus Infections: Indications for the Use of Palivizumab and Update on the Use of RSV-IGIV
Authors:   Committee on Infectious Diseases and Committee on Fetus and Newborn
Published: August 2004

The Food and Drug Administration recently approved the use of palivizumab (palē-vizhū-mäb), an intramuscularly administered monoclonal antibody preparation. Recommendations for its use are based on a large, randomized study demonstrating a 55% reduction in the risk of hospitalization attributable to respiratory syncytial virus (RSV) infections in high-risk pediatric patients. Infants and children with chronic lung disease (CLD), formerly designated bronchopulmonary dysplasia, as well as prematurely born infants without CLD experienced a reduced number of hospitalizations while receiving palivizumab compared with a placebo. Both palivizumab and respiratory syncytial virus immune globulin intravenous (RSV-IGIV) are available for protecting high-risk children against serious complications from RSV infections. Palivizumab is preferred for most high-risk children because of ease of administration (intramuscular), lack of interference with measles–mumps–rubella vaccine and varicella vaccine, and lack of complications associated with intravenous administration of human immune globulin products. RSV-IGIV, however, provides additional protection against other respiratory viral illnesses and may be preferred for selected high-risk children including those receiving replacement intravenous immune globulin because of underlying immune deficiency or human immuno-deficiency virus infection. For premature infants about to be discharged from hospitals during the RSV season, physicians could consider administering RSV-IGIV for the first month of prophylaxis.

Most of the guidelines from the American Academy of Pediatrics for the selection of infants and children to receive RSV-prophylaxis remain unchanged. Palivizumab has been shown to provide benefit for infants who were 32 to 35 weeks of gestation at birth. RSV-IGIV is contraindicated and palivizumab is not recommended for children with cyanotic congenital heart disease. The number of patients with adverse events judged to be related to palivizumab was similar to that of the placebo group (11% vs 10%, respectively); discontinuation of injections for adverse events related to palivizumab was rare.
Learning Disabilities, Dyslexia, and Vision: A Subject Review
Authors:   Committee on Children With Disabilities American Academy of Pediatrics (AAP) and American Academy of Ophthalmology (AAO) American Association for Pediatric Ophthalmology and Strabismus (AAPOS)
Published: August 2004

Learning disabilities are common conditions in pediatric patients. The etiology of these difficulties is multifactorial, reflecting genetic influences and abnormalities of brain structure and function. Early recognition and referral to qualified educational professionals is critical for the best possible outcome. Visual problems are rarely responsible for learning difficulties. No scientific evidence exists for the efficacy of eye exercises (“vision therapy”) or the use of special tinted lenses in the remediation of these complex pediatric developmental and neurologic conditions.
Television and Music Video Exposure and Risk of Adolescent Alcohol Use
Authors: Robinson Thomas N. , Chen Helen L. , Killen Joel D.
Published: August 2004

Objective.

Alcohol use is frequently portrayed in television programming and advertising. Exposure to media portrayals of alcohol use may lead to increased drinking. To address this issue, we examined prospectively the associations between media exposure and alcohol use in adolescents.

Design.

Prospective cohort study.

Setting.

Six public high schools in San Jose, California.

Participants.

Ninth-grade students (N = 1533; mean age = 14.6 years).

Outcome Measures.

Students reported hours of television, music video, and videotape viewing; computer and video game use; and lifetime and past 30 days' alcohol use at baseline and 18 months later. Associations between baseline media exposure and subsequent alcohol use were examined with multiple logistic regression.

Results.

During the 18-month follow-up, 36.2% of baseline nondrinkers began drinking and 50.7% of baseline drinkers continued to drink. Onset of drinking was significantly associated with baseline hours of television viewing (odds ratio [OR] = 1.09; 95% confidence interval [95% CI] = 1.01–1.18), music video viewing (OR = 1.31; 95% CI = 1.17–1.47), and videotape viewing (OR = 0.89; 95% CI = 0.79–0.99), controlling for age, sex, ethnicity, and other media use. Computer and video game use was not significantly associated with the subsequent onset of drinking. Among baseline drinkers, there were no significant associations between baseline media use and maintenance of drinking.

Conclusions.

Increased television and music video viewing are risk factors for the onset of alcohol use in adolescents. Attempts to prevent adolescent alcohol use should address the adverse influences of alcohol use in the media.
Telemedicine in Pediatric Transport: A Feasibility Study
Authors: Kofos Danny , Pitetti Raymond , Orr Richard , Thompson Ann
Published: August 2004

Objective.

Investigate the hypothesis that telemedicine, in the form of real-time audiovisual transmission, would permit accurate assessment of illness severity and allow improved triage for transport.

Methods.

A prospective study comparing assessments of patients examined conventionally (in person) and remotely by a telemedicine link. Fifteen patients (3 months to 14 years of age) admitted to our emergency department were evaluated as if for transport. Patients were evaluated simultaneously by a physically present pediatric emergency room physician and by a pediatric critical care physician linked to the examining room by a broadband audiovisual link. Each physician completed a patient assessment questionnaire independently. The sensitivity and specificity of the patient assessment by the audiovisually linked physician were calculated.

Results.

Sensitivity, ie, the ability of the remote, audiovisually connected telemedicine physician to detect abnormal findings, is 87.5%. Specificity, the ability of the remote physician to detect normal findings, is 93%. It is likely that sensitivity would be markedly improved with addition of an electronic stethoscope.

Conclusion.

This study demonstrates that pediatric patients may be assessed accurately with a broadcast-quality real-time audiovisual system. Such a system may have dramatic implications for providing pediatric specialty and subspecialty care in underserved areas.
Formula Supplementation With Long-chain Polyunsaturated Fatty Acids: Are There Developmental Benefits?
Authors: Scott David T. , Janowsky Jeri S. , Carroll Robin E. , Taylor James A. , Auestad Nancy , Montalto Michael B.
Published: August 2004

Objective.

To evaluate the developmental outcomes of children who participated in an augmented randomized clinical trial of supplementing a standard infant formula with long-chain polyunsaturated fatty acids.

Design.

Randomized clinical trial, augmented with a nonrandomized human milk comparison group. There were three randomized formula groups: standard formula, standard formula containing docosahexaenoic acid (DHA), and standard formula containing DHA and arachidonic acid.

Setting.

Three clinical sites serving diverse populations: Kansas City, MO; Portland, OR; and Seattle, WA.

Participants.

A total of 274 healthy full-term infants were enrolled in the infant-feeding protocol; of these, 197 (72%) participated in assessments of developmental outcome.

Formula Supplements.

In the randomized trial, one group received a standard formula, another group received a formula that had been supplemented with DHA from fish oil, and a third group received a formula supplemented with both DHA and arachidonic acid from an egg phospholipid.

Outcome Measures.

Mental and Motor Scales of the Bayley Scales of Infant Development at 12 months of age; vocabulary and gesture communication scores from the MacArthur Communicative Development Inventories at 14 months of age.

Results.

There were no statistically significant differences for either the Bayley Mental Scale or the Bayley Motor Scale, neither when the analysis was restricted to the three randomized formula groups nor when the analysis included all four groups. However, the DHA formula group had significantly lower scores on two of the MacArthur scales: the DHA group scored lower than the nonrandomized human milk comparison group on the Vocabulary Comprehension Scale, and the DHA group scored lower than the randomized control formula group on the Vocabulary Production Scale. Moreover, additional analyses both in the formula groups and in the human milk comparison group found significant negative correlations between DHA levels and vocabulary outcomes.

Conclusion.

We believe that additional research should be undertaken before the introduction of these supplements into standard infant formulas.
Pediatric Research in Office Settings (PROS): A National Practice-Based Research Network to Improve Children's Health Care
Authors: Wasserman Richard C. , Slora Eric J. , Bocian Alison B. , Fleming Gretchen V. , Baker Alison E. , Pedlow Steven E. , Kessel Woodie
Published: August 2004

Objectives.

To describe the establishment of a national pediatric primary care research network to improve children's health care—Pediatric Research in Office Settings (PROS), and to evaluate the network's progress toward achieving its objectives.

Setting.

Pediatric practices in all 50 states and Puerto Rico.

Participants.

Approximately 1400 pediatric practitioners from more than 470 practices.

Results.

Beginning in 1986, a core of volunteer pediatrician coordinators from participating American Academy of Pediatrics chapters were identified to oversee local PROS efforts, represent practitioners, and inform the development of proposed research studies. PROS subsequently recruited practitioners from around the country, building a research infrastructure and a system of collaboration between the practitioners, research staff at the AAP, and investigative teams at academic institutions. This PROS collaboration has developed and conducted 10 primary care research studies that have added to the knowledge base of pediatric primary care.

Conclusions.

PROS has accomplished two of its initial objectives—development of a structure and process for pediatric practice-based research and provision of research experience to practitioners. Successful and consistent achievement of a third objective—meaningful dissemination of study results to relevant audiences—will depend on meeting several challenges. primary care, health services research, child health, ambulatory care.
The Effect of Handling and Immobilization on the Response to Acute Pain in Newborn Infants
Authors: Porter Fran Lang , Wolf Cynthia M. , Miller J. Philip
Published: August 2004

Background.

Previous reports have suggested that healthy, full-term newborn infants who are in more aroused behavioral states tend to respond more robustly to painful events. Others have shown that acutely ill premature and full-term infants who undergo significant handling and immobilization as part of required nursery procedures respond less robustly to concurrent painful events.

Purpose.

To investigate, using an experimental manipulation, the effect of arousal associated with handling and immobilization on response to acute pain in generally healthy, premature and full-term newborn infants.

Methods.

Infants were randomly assigned to a group that underwent a series of handling and immobilization procedures before a heelstick or to a group that underwent the heelstick without previous handling and immobilization. Heart rate, behavioral state, and facial activity were compared between the handled (n = 21) and nonhandled (n = 27) infants during an undisturbed baseline, a preparatory, and a standard heelstick procedure.

Results.

In the handled group, heart rate increased over baseline levels in response to the handling but promptly returned to prehandling levels. There were no significant differences between handled and nonhandled groups in mean heart rate, behavioral state, or facial activity during the baseline or preparatory periods before the heelstick. However, in response to the heelstick, handled infants had a higher mean heart rate, greater behavioral arousal, and displayed more facial activity as compared with nonhandled infants.

Conclusions.

Healthy premature and full-term newborn infants who undergo common nursery experiences such as handling and immobilization as part of their routine care can exhibit greater physiologic and behavioral reactivity to subsequent painful procedures. The effects of the previous handling may be undetectable, using conventional indices of reactivity, until the painful event. These findings emphasize the importance of identifying reliable markers of previous stress, particularly for newborn infants who may become clinically compromised as a result of the physiologic instability associated with response to pain.
Changes in the Epidemiologic Profile of Sudden Infant Death Syndrome as Rates Decline Among California Infants: 1990–1995
Authors: Adams Elizabeth J. , Chavez Gilberto F. , Steen Donna , Shah Rugmini , Iyasu Solomon , Krous Henry F.
Published: August 2004

Objectives.

To evaluate changes in the rates and epidemiologic patterns of sudden infant death syndrome (SIDS) after implementation of public health campaigns to promote back sleeping and reduce exposure to cigarette smoke and environmental risk factors for SIDS.

Methods.

California vital statistics data were used to evaluate changes in SIDS rates (deaths/1000 live births) and in the proportions of SIDS deaths by age and season of occurrence for California infants of black or other races from 1990 through 1995.

Results.

From 1990 through 1995, 3508 SIDS deaths occurred. SIDS rates declined from 2.69 to 2.15 for black infants and from 1.04 to 0.61 for others between 1990 and 1995. Most SIDS deaths occurred during the 2nd to 4th months of life; the proportion of SIDS deaths during this period was unchanged for blacks but decreased for others from 70% to 65%. Of all SIDS deaths, 62% occurred during the colder season (October through March); the proportion of deaths in each season did not change for either race.

Conclusion.

California SIDS rates declined 20% for blacks and 41% for others between 1990 and 1995. Declines coincided with campaigns to reduce environmental risk factors for SIDS. Blacks continue to be at increased risk for SIDS compared with others, and the SIDS rate for blacks relative to others has increased. Reductions in SIDS mortality coinciding with interventions were smaller for blacks than for others. New strategies are needed to reduce further SIDS rates and narrow the gap between blacks and others.
A New Pattern of Cerebellar Hemorrhages in Preterm Infants
Authors: Merrill Jeffrey D. , Piecuch Robert E. , Fell Sean C. , Barkovich A. James , Goldstein Ruth B.
Published: August 2004

Objective.

Posterior fossa hemorrhages may be underdiagnosed in surviving neonates, with cerebellar hemorrhage discovered in 10% to 25% of autopsy specimens from very low birth weight infants. Posterior fossa lesions have been difficult to visualize by the traditional ultrasonography approach through the anterior fontanelle. Late in 1994, routine posterior fossa imaging through the posterolateral fontanelle was instituted to improve the ultrasonographic visualization of the posterior fossa in neonates.

Methods.

Infants identified with posterior fossa hemorrhage by cranial ultrasonography between 1994 and 1996 were followed prospectively through discharge and their clinical courses reviewed. Infants diagnosed with posterior fossa hemorrhage between 1991 and 1994 were identified retrospectively from a comprehensive radiology database to use in comparison. All infants surviving to discharge were entered into neurodevelopmental follow-up using standard developmental assessments.

Results.

Approximately 525 infants underwent cranial sonography during the study period between October 1994 and September 1996, including 250 infants weighing <1500 g. Thirteen infants were identified with posterior fossa hemorrhage using the posterolateral fontanellar approach. In contrast, only 2 infants were identified with posterior fossa hemorrhage between 1991 and 1994 using traditional anterior fontanellar views. Six very low birth weight infants were identified with cerebellar hemorrhages not associated with supratentorial, intraventricular hemorrhage. Each hemorrhage had a clinically silent presentation and, in 5 infants, was not well-appreciated by anterior fontanellar images. Magnetic resonance imaging studies were performed on 5 of the 6 infants and confirmed a cerebellar lesion in the area of previous echo density on ultrasonography. No infant is exhibiting motor abnormalities on neurologic examination, although 4 infants are demonstrating cognitive, developmental delay. Follow-up, however, is limited to a corrected age of ≤48 months.

Discussion.

Cerebellar hemorrhage is an underrecognized and poorly visualized complication in preterm infants. Consistent imaging via the posterolateral fontanelle may demonstrate cerebellar hemorrhage missed by the anterior fontanellar approach. Cerebellar hemorrhage in low birth weight infants may be clinically silent and not associated with a significant supratentorial hemorrhage. These infants may survive to discharge. Long-term neurodevelopmental follow-up is necessary to establish the ultimate outcome of these infants. Future prospective study, using posterolateral fontanellar imaging, may elucidate further the pathophysiology of cerebellar hemorrhage in low birth weight infants.
Musculoskeletal Pain in Primary Pediatric Care: Analysis of 1000 Consecutive General Pediatric Clinic Visits
Authors: de Inocencio Jaime
Published: August 2004

Objectives.

1) To determine the number of primary care clinic visits attributable to musculoskeletal pain (MSP) in children ≥3 and <15 years of age. 2) To describe the demographic characteristics of this population assessed for limb/back pain. 3) To characterize the etiology of musculoskeletal pain in an urban general pediatric clinic in Madrid, Spain.

Methods.

Prospective evaluation of 1000 consecutive clinic visits to an urban general pediatric clinic. Inclusion criteria were 1) age ≥3 and <15 years and 2) musculoskeletal evaluation requested by the family or patient. All consultations related to MSP were recorded via standard protocol and data record form.

Results.

During the study period, 61 of 1000 (6.1%; confidence interval: 4.6–7.5) clinic visits for children ≥3 and <15 years were related to MSP. Patients' age, mean ± SD, was 9.7 ± 3.3 years. Musculoskeletal complaints were more frequent in boys (57.4%), although there was no statistical difference. The presenting complaints included knee arthralgias in 33%; other joint (eg, ankles, wrists, elbows) arthralgias in 28%; soft tissue pain in 18%; heel pain in 8%; hip pain in 6%; and back pain in 6%. Symptoms were attributable to trauma in 30%; overuse syndromes in 28% (eg, chondromalacia patellae, mechanical plantar fasciitis, overuse muscle pain); and normal skeletal growth variants (eg, Osgood–Schlatter syndrome, hypermobility, Sever's disease) in 18% of patients.

Conclusion.

MSP represents a frequent presenting complaint in general pediatric practice. A new heightened awareness of the frequent occurrence of MSP should be adopted when designing pediatrics continuing medical education and training programs. musculoskeletal pain, limb pain, arthralgia, children, general pediatrics, pediatric primary care.
Results of the Nationwide Epidemiologic Survey of Kawasaki Disease in 1995 and 1996 in Japan
Authors: Yanagawa Hiroshi , Nakamura Yosikazu , Yashiro Mayumi , Ojima Toshiyuki , Tanihara Shinichi , Oki Izumi , Zhang Tuohong
Published: August 2004

Objective.

The objective of the study is to describe recent epidemiologic patterns of Kawasaki disease based on information included in patient records that had been obtained through a nationwide hospital survey in Japan.

Methods.

A questionnaire and diagnostic criteria for Kawasaki disease that had been approved by the Kawasaki Disease Research Committee were sent to all pediatric departments of hospitals (2638 hospitals) with a bed capacity of at least 100. The subjects all were new patients who were treated during a 2-year period from 1995 to 1996.

Results.

A total of 12 531 children contracted the disease during the observation period. The incidence was 102.6 for 1995 and 108.0 for 1996 per 100 000 children younger than age 5 years. The male:female ratio was 1.37. The age distribution pattern showed a peak near 6 months of age. Geographic variations in the incidence suggested the existence of local outbreaks. Cardiac sequelae were seen in 12% of the patients.

Conclusion.

More than 6000 patients suffered from Kawasaki disease each year, and its annual incidence is increasing steadily. The probable existence of local outbreaks is worthy of note. Other epidemiologic patterns were unchanged from previous years.
One-Year Follow-up of Symptoms of Gastroesophageal Reflux During Infancy
Authors: Nelson Suzanne P. , Chen Edwin H. , Syniar Gina M. , Christoffel Katherine Kaufer ,   for the Pediatric Practice Research Group
Published: August 2004

Objectives.

1) Determine what percentage of infants outgrow regurgitation over 1 year. 2) Determine whether they develop feeding or mealtime problems. 3) Determine whether they develop frequent respiratory illnesses, including ear, sinus, and upper respiratory infections, or wheezing episodes.

Design.

One-year follow-up survey of parents of children identified at 6 to 12 months of age as those who regurgitate (case subjects) and matched control subjects.

Participants.

Sixty-three case subjects and 92 control subjects attending 12 different (urban, suburban, and rural) practices in the Pediatric Practice Research Group in the Chicago area.

Primary Outcome Measures.

The Infant Gastroesophageal Reflux Questionnaire–Shortened and Revised Form and the Children's Eating Behavior Inventory (CEBI).

Results.

At 1-year follow-up, no parents of case or control subject described spitting up as currently a problem. The parent of only one control subject (and no case subject) reported spitting up one or more times a day. Parents of subjects were more likely than those of control subjects to report frequent feeding refusal: odds ratio = 4.2, adjusted by age (95% confidence interval: 1.4–12.0). Case and control subjects had comparable average total CEBI scores (case subjects, x̄ = 83 ± 10 vs control subjects, x̄ = 82 ± 11) and comparable average proportion of items identified as a problem (8% ± 11% case subjects vs 6% ± 9% control subjects). Case subjects were more likely to respond positively to two CEBI questions indicating specific feeding problems: 1) “my child takes more than an hour to eat his/her meals” (8% case subjects vs 0% control subjects) and 2) “I get upset when I think about our meals” (14% case subjects vs 4% control subjects). The frequencies of ear, sinus, and upper respiratory infections and of episodes of wheezing were comparable in both groups.

Conclusions.

1) Infants with daily or problematic regurgitation at 6 to 12 months of age outgrew this within the following year. 2) Infants with daily or problematic regurgitation were more likely to develop feeding problems. 3) There was no increase in respiratory illnesses in infants with a history of regurgitation.
Inborn Errors of Metabolism in Infancy: A Guide to Diagnosis
Authors: Burton Barbara K.
Published: August 2004

Recent advances in the diagnosis and treatment of inborn errors of metabolism have improved substantially the prognosis for many of these conditions. This makes it essential that the practicing pediatrician be familiar with the clinical presentation of these disorders. A practical clinical approach to the recognition of inborn errors of metabolism in the young infant is presented in this review. Indications for specific laboratory studies are discussed. Guidelines are provided for the stabilization and emergency treatment of critically ill infants. This approach will identify those infants who will benefit from additional evaluation and specific treatment.

Many of the inborn errors of metabolism, including urea cycle defects, organic acidemias, and certain disorders of amino acid metabolism, present in the young infant with symptoms of an acute or chronic metabolic encephalopathy. Typical symptoms include lethargy, poor feeding, apnea or tachypnea, and recurrent vomiting. Metabolic acidosis and/or hyperammonemia are observed in many of these conditions, but there are notable exceptions, including nonketotic hyperglycinemia and molybdenum co-factor deficiency. Therefore, appropriate laboratory testing for metabolic disorders should be performed in any infant who exhibits these findings. Although sepsis may be the initial consideration in a neonate with these symptoms, inborn errors of metabolism should always be in the differential diagnosis, particularly in a full-term infant with no specific risk factors.

Hypoglycemia may be the predominant finding in a number of inborn errors of metabolism, including glycogen storage disorders, defects in gluconeogenesis, and fatty acid oxidation defects. The latter disorders, among the most common encountered, exhibit marked clinical variability and also may present as a sudden death, a Reye's-like episode, or a cardiomyopathy. Jaundice or other evidence of hepatic dysfunction is the mode of presentation of another important group of inborn errors of metabolism including galactosemia, hereditary tyrosinemia, neonatal hemochromatosis, and a number of other conditions. A subset of lysosomal storage disorders may present very early with coarse facial features, organomegaly, or even hydrops fetalis. Specific patterns of dysmorphic features and congenital anomalies characterize yet another group of inherited metabolic disorders, such as Zellweger syndrome and the Smith–Lemli–Opitz syndrome. Each of these symptom complexes, and the appropriate evaluation of the affected infants, is discussed in more detail in this review.