bluuebunny/crossref_metadata_2025 huggingface dataset:
Early Television Exposure and Subsequent Attentional Problems in Children
Authors: Christakis Dimitri A. , Zimmerman Frederick J. , DiGiuseppe David L. , McCarty Carolyn A.
Published: August 2004

Objective. Cross-sectional research has suggested that television viewing may be associated with decreased attention spans in children. However, longitudinal data of early television exposure and subsequent attentional problems have been lacking. The objective of this study was to test the hypothesis that early television exposure (at ages 1 and 3) is associated with attentional problems at age 7.

Methods. We used the National Longitudinal Survey of Youth, a representative longitudinal data set. Our main outcome was the hyperactivity subscale of the Behavioral Problems Index determined on all participants at age 7. Children who were ≥1.2 standard deviations above the mean were classified as having attentional problems. Our main predictor was hours of television watched daily at ages 1 and 3 years.

Results. Data were available for 1278 children at age 1 and 1345 children at age 3. Ten percent of children had attentional problems at age 7. In a logistic regression model, hours of television viewed per day at both ages 1 and 3 was associated with attentional problems at age 7 (1.09 [1.03–1.15] and 1.09 [1.02–1.16]), respectively.

Conclusions. Early television exposure is associated with attentional problems at age 7. Efforts to limit television viewing in early childhood may be warranted, and additional research is needed.
Pediatric Generalized Joint Hypomobility and Musculoskeletal Complaints: A New Entity? Clinical, Biochemical, and Osseal Characteristics
Authors: Engelbert Raoul H.H. , Uiterwaal Cuno S.P.M. , van de Putte Elise , Helders Paul J.M. , Sakkers Ralph J.B. , van Tintelen Peter , Bank Ruud A.
Published: August 2004

Objective. To describe the clinical features, osseal characteristics, and collagen biochemistry in children who attended our clinic with predominantly generalized hypomobility of the joints, in combination with musculoskeletal complaints or abnormal walking, and no known syndrome or known rheumatic, neurologic, skeletal, metabolic, or connective tissue disorder was present.

Methods. Nineteen children who attended the Children’s Hospital of the University Medical Center Utrecht for generalized hypomobility of the joints (mean age: 11.6; standard deviation: 2.7), in combination with musculoskeletal complaints or abnormal walking as primary complaints (symptomatic generalized hypomobility [SGH]), were compared with an age-matched reference group of 284 healthy children with normal mobility of the joints. Anthropometrics, range of joint motion, muscle strength, exercise tolerance, motor development, quantitative ultrasound measurements of bone, and degradation products of collagen in urine were studied. Collagen modifications were determined in skin biopsies of 3 children and in hypertrophic scar tissue of another child, all with SGH.

Results. The range of joint motion was significantly decreased in almost all joints of all 19 children and after adjustment for age, gender, body weight, and height, significantly lower than that of the reference group (−108.3 degrees; 95% confidence interval [CI]: −136.9 to −79.8). Quantitative ultrasound measurements as well as urinary pyridinoline cross-link levels were, after adjustment for possible confounders, significantly lower in SGH children (broad-band ultrasound attenuation: −9.6 dB/MHz [95% CI: −17.4 to −1.9]; speed of sound: −25.0 m/s [95% CI: −39.7 to −10.3]; hydroxylysylpyridinoline: −50.1 μmol/mmol [95% CI: −87.6 to −12.6], lysylpyridinoline: −21.3 μmol/mmol [95% CI: −34.0 to −8.6]). An increased amount of pyridinoline cross-links per collagen molecule was observed in skin and hypertrophic scar tissue, in combination with increased amounts of collagen.

Conclusion. SGH in children is considered a new clinical entity with specific clinical characteristics and might be related to an increased stiffness of connective tissue as a result of higher amounts of collagen with increased cross-linking.
A Review of Internet-Based Home Drug-Testing Products for Parents
Authors: Levy Sharon , Van Hook Shari , Knight John
Published: August 2004

Objective. To review home drug-testing products and the Internet-based recommendations intended for parents.

Methods. A qualitative review of drug-testing products and structured analysis of information presented on company Internet sites were conducted. Eight Internet sites that sold home drug-testing products and contained a “parent’s section” were identified by Ixquick using the search term “home drug testing.” Description and prices of products sold by each Internet site and recommended indications for testing, consent, collection procedures, and follow-up of positive and negative test results were researched.

Results. A variety of drug-testing products were available, including breath and saliva tests for alcohol, a multidrug panel hair test, and a variety of laboratory and instant urine tests. Prices ranged from $2.75 for a single alcohol test to $89.00 for a multidrug combination urine/hair package. A total of 14 indications for home drug-testing were cited; all sites claimed that drug testing was a way to know with certainty whether a child has used drugs. Only 1 web site made a clear statement against testing an adolescent against his or her will. Little information was presented on valid specimen collection procedures and the risks of false-positive and false-negative tests. Only half of the sites recommended that parents consult a professional if a test is positive.

Conclusions. Pediatricians should advise parents of the limitations and potential risks associated with home drug-testing products.
Factors That Influence Parents’ Assessments of the Risks and Benefits of Research Involving Their Children
Authors: Tait Alan R. , Voepel-Lewis Terri , Malviya Shobha
Published: August 2004

Objective. The ability to assess accurately the risks and benefits of a study are important to ensure that the subject can make an informed decision regarding his or her own or his or her surrogate’s participation. This study was designed to examine factors that influence parents’ assessments of the risks and benefits of anesthesia and surgery research involving their children.

Methods. The study population consisted of parents of 505 children who had been approached to participate in 1 of several ongoing clinical studies. Regardless of their decision to allow or decline their child’s participation in a study, parents completed a questionnaire that elicited information regarding their perceptions of the risks and benefits of the study and factors that had influenced their decision.

Results. Factors that influenced positive risk/benefit assessments by the parents included use of a placebo, the designated risk category of the study, the clarity of information given, the parents’ perceptions of the amount of time provided to make a decision, and the amount of privacy afforded them in making a decision. Furthermore, positive risk/benefit assessments were associated with low decisional uncertainty and greater trust in the medical system.

Conclusions. Identification of factors that influence parents’ perceptions of the risks and benefits of a research study is important as a means to optimize the manner in which consent information is disclosed and to ensure that parents and subjects can assess accurately the relative importance of the risks and benefits.
Antibody Response to Diphtheria-Tetanus-Pertussis Immunization in Preterm Infants Who Receive Dexamethasone for Chronic Lung Disease
Authors: Robinson Michael J , Heal Carrie , Gardener Elizabeth , Powell Peter , Sims Douglas G.
Published: August 2004

Objective. To study the effect of dexamethasone in preterm infants with chronic lung disease (CLD) on antibody response to routine immunization against diphtheria, tetanus, and pertussis (DTP).

Methods. Serum samples were obtained before and after immunization with DTP (Trivax-AD) from an unselected cohort of 93 preterm infants in the United Kingdom. Antibodies to diphtheria and tetanus and to 4 pertussis antigens (pertussis toxin, filamentous hemagglutinin, pertactin, and fimbrial agglutinogens 2 + 3) were measured by an enzyme-linked immunosorbent assay. Linear regression models were fitted to the natural log of antibody titers to compare the dexamethasone-treated and -untreated infants adjusting for potential risk factors.

Results. Sixty-seven (72%) of 93 infants received dexamethasone. Preimmunization geometric mean titers (GMTs) were comparable in both groups for all antibodies. The rise in GMT after immunization was reduced in the dexamethasone-treated group. Final GMT was significantly lower for tetanus, diphtheria, pertussis toxin, and fimbrial agglutinogens 2 + 3 but not for filamentous hemagglutinin or pertactin. Using the minimum protective titer of 0.01 IU/mL, there was no significant reduction in protection for diphtheria and tetanus in the dexamethasone-treated infants. Using the higher reference titer of 0.1 IU/mL, there was a 16% reduction in protection for diphtheria (95% confidence interval: 3%–27%) and a 9% reduction in protection for tetanus (95% confidence interval: −7% to 20%).

Conclusions. The use of dexamethasone for CLD in preterm infants is associated with a reduction in antibody titer to routine immunization against diphtheria and tetanus. Antibody responses to 2 of 4 pertussis antigens are reduced, but the clinical significance of this observation is unclear. Protection against tetanus and diphtheria is not impaired when the lower reference value for protective antibody is used. On the basis of this study of UK preterm infants who were treated with dexamethasone for the management of CLD, we conclude that the current DTP immunization schedule is adequate and do not recommend additional booster protection against tetanus or diphtheria during early infancy. When diphtheria prevalence is increased, however, additional protection should be considered.
Preschool Outcome of Less Than 801-Gram Preterm Infants Compared With Full-Term Siblings
Authors: Kilbride Howard W. , Thorstad Karla , Daily Donna K.
Published: August 2004

Objective. Extremely low birth weight (ELBW) infants are at greater risk for neurodevelopmental delay than full-term infants. Outcomes may be compromised secondary to abnormal brain development associated with complications of prematurity. Long-term cognitive outcome has also been reported to be significantly influenced by postnatal factors. The objective of this study was to clarify the effects of prematurity separate from environmental factors on growth and neurodevelopmental outcomes by comparing ELBW children with their full-term siblings.

Methods. The study consisted of 25 ELBW children, a subset selected from a larger population of infants who were <801 g birth weight and enrolled in a longitudinal follow-up project from birth and their 25 full-term, full-weight siblings. Twenty-three sets of siblings were evaluated at 5 years of age and 2 sets at 3 years of age with standardized medical, social, cognitive, motor, and language testing. Physical and neurodevelopmental outcomes were compared between groups, controlling for gender and socioeconomic status (SES).

Results. At follow-up, ELBW children were lighter, were shorter, and had smaller head circumference. The ELBW children had lower Stanford-Binet IQs (85 ± 12 [mean ± SD] and 95 ± 11), with lower Stanford-Binet subtests except short-term memory and quantitative reasoning, lower spelling scores on the Wide Range Achievement Test, and lower Peabody motor quotients (79 ± 11 and 92 ± 17). Preschool Language Scale quotients were not different, but other receptive language measures were lower for ELBW children. High SES seemed to modify the impact of preterm status on cognitive and language but not motor scores. The mean IQ for high-SES ELBW children was equivalent to that of the low-SES term siblings.

Conclusions. Preschool-age cognitive and language functioning in ELBW children seemed to be affected by both prenatal and birth influences (preterm status) and postnatal influences (SES variables). Motor scores were significantly related to preterm status but not to SES.
Preventing Provider Errors: Online Total Parenteral Nutrition Calculator
Authors: Lehmann Christoph U. , Conner Kim G. , Cox Jeanne M.
Published: August 2004

Objective. To describe the development of a pragmatic low-cost medical information system that reduces errors in the ordering of total parenteral nutrition (TPN) in the newborn intensive care unit at the Johns Hopkins Hospital.

Methods. We designed an online total parenteral nutrition order entry system (TPNCalculator) using Internet technologies. Utilization, impact on medical errors, and user satisfaction were evaluated prior to and immediately after introduction of TPNCalculator (intervention 1) and after 2 years (intervention 2).

Results. Total software development time was 3 weeks. The number of orders was similar during the 3 periods: 0.39 orders per patient per day (N = 557) were received compared with 0.35 and 0.43 orders per patient per day (N = 471 and N = 656) in 2 intervention periods. During the control period, an average of 10.8 errors were detected per 100 TPN orders compared with 4.2 per 100 orders in the first intervention period (61% reduction of error rate) and 1.2 per 100 orders after 2 years and some redesign of TPNCalculator (89% reduction of error rate). We found a reduction in the following types of problems (intervention 1; intervention 2): calculation errors (100%; 100%), osmolality outside the allowed range (88%; 91%), and other knowledge problems (84%; 100%). There was a 35% increase in the number of incomplete forms in the first intervention period and a 100% reduction in the second. Rapid cycle development was used in the development of this application. Users of the system were enthusiastic and supportive and compared it favorably to the previous paper-based system.

Conclusion. Low-cost, pragmatic approaches using Internet technology in the design of medical information systems can reduce medical errors and might pose a viable option for the prevention of adverse drug events.
National Institute of Mental Health Multimodal Treatment Study of ADHD Follow-up: 24-Month Outcomes of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder
Authors:   MTA Cooperative Group
Published: August 2004

Objective. In the Multimodal Treatment Study of ADHD (MTA), the effects of medication management (MedMgt) and behavior modification therapy (Beh) and their combination (Comb) and usual community comparison (CC) in the treatment of attention-deficit/hyperactivity disorder (ADHD) differed at the 14-month assessment as a result of superiority of the MTA MedMgt strategy (Comb or MedMgt) over Beh and CC and modest additional benefits of Comb over MedMgt alone. Here we evaluate the persistence of these beneficial effects 10 months beyond the 14 months of intensive intervention.

Methods. Of 579 children who entered the study, 540 (93%) participated in the first follow-up 10 months after the end of treatment. Mixed-effects regression models explored possible persisting effects of the MTA medication strategy, the incremental benefits of Comb over MedMgt alone, and the possible superiority of Beh over CC on 5 effectiveness and 4 service use domains.

Results. The MTA medication strategy showed persisting significant superiority over Beh and CC for ADHD and oppositional-defiant symptoms at 24 months, although not as great as at 14 months. Significant additional benefits of Comb over MedMgt and of Beh over CC were not found. The groups differed significantly in mean dose (methylphenidate equivalents 30.4, 37.5, 25.7, and 24.0 mg/day, respectively). Continuing medication use partly mediated the persisting superiority of Comb and MedMgt.

Conclusion. The benefits of intensive MedMgt for ADHD extend 10 months beyond the intensive treatment phase only in symptom domains and diminish over time.
Short-Term Use of Umbilical Artery Catheters May Not Be Associated With Increased Risk for Thrombosis
Authors: Coleman Mae M. , Spear Michael L. , Finkelstein Mark , Leef Kathleen H. , Pearlman Stephen A. , Chien Christopher , Taylor Scott M. , McKenzie Steven E.
Published: August 2004

Objective. Umbilical arterial catheters (UACs) have rare but serious complications related to thrombus formation. Two specific serum markers of thrombogenesis—prothrombin fragment (F1.2) and thrombin-antithrombin (TAT)—can be assayed and correlated with abdominal ultrasound visualization of UAC thrombosis. Levels of these markers of thrombogenesis have not been studied in infants with UACs. The objective of this study was to determine F1.2 and TAT levels longitudinally and compare the levels with platelet counts and ultrasound evidence of thrombi during the first week of life in infants with UACs.

Methods. This study was conducted as a prospective, nonblinded, observational study performed between June 2001 and January 2002 at Christiana Care Hospital, a level III neonatal intensive care unit. Infants with a UAC in place in the first 24 hours of life were studied. All received equal amounts of heparin in the UAC. F1.2, TAT, platelet counts, and abdominal aorta ultrasounds were examined every other day starting within 24 hours of life. Studies were not done when the UAC was removed within the 5-day study period. Enzyme-linked immunosorbent assay for TAT and F1.2 was performed using a commercially available kit from Enzyngost. Data were analyzed with repeated measures analysis of variance evaluating TAT, F1.2, and platelet count over time.

Results. Thirty-three patients were investigated (mean ± standard deviation; gestational age: 27.4 ± 3.5 weeks; birth weight: 1139 ± 729 g). A total of 66 measurements of TAT, F1.2, and platelet counts were obtained. Sixty-one abdominal ultrasounds were performed; only 1 study was positive for UAC thrombus. There was no significant difference between F1.2 and TAT over time during the study period. Platelet counts seemed to fall over the 5-day study period, although this decrease did not reach statistical significance.

Conclusion. Indwelling UACs in sick infants may not carry an increased risk of thrombosis during the first 5 days of use.
Educational and Social Competencies at 8 Years in Children With Threshold Retinopathy of Prematurity in the CRYO-ROP Multicenter Study
Authors: Msall Michael E. , Phelps Dale L. , Hardy Robert J. , Dobson Velma , Quinn Graham E. , Summers C. Gail , Tremont Michelle R. ,   for the Cryotherapy for Retinopathy of Prematurity Cooperative Group
Published: August 2004

Objective. To describe the educational status and special education services at 8 years among children who had threshold retinopathy of prematurity (ROP).

Methods. A prospective study was conducted of a cohort of children who had birth weight of <1251 g and threshold ROP in the Cryotherapy for Retinopathy of Prematurity multicenter study. At age 5.5 years, visual status, functional skills, and social information were obtained. At 8 years, special education classes, developmental disabilities, rehabilitation therapies, and academic and social competencies were determined by questionnaire. Visual status was considered favorable/unfavorable on the basis of the better eye.

Results. Of 255 survivors, 216 (85%) were evaluated at both 5.5 and 8 years. Major impairments were significantly more prevalent in children with unfavorable versus favorable visual status: cerebral palsy (39% vs 16%), developmental disability (57% vs 22%), autism (9% vs 1%), and epilepsy (23% vs 3%). Special education services (63% vs 27%), below-grade-level academic performance (84% vs 48%), and school-based rehabilitation services were significantly less common in children with favorable visual status. Favorable visual status, favorable functional ratings at 5.5 years, markers of higher socioeconomic status, and nonblack race were associated with significantly lower rates of both special education placement and below-grade-level academic performance at age 8. On multivariate logistic regression, only favorable visual status and functional status remained significant predictors for decreasing special education placement.

Conclusion. Threshold ROP is associated with high rates of developmental, educational, and social challenges in middle childhood; preserved vision was associated with a clear advantage, with more than half of the children with favorable visual status performing at grade level.
Maternal, Neonatal, and Placental Features Associated With Diffuse Chorioamniotic Hemosiderosis, With Special Reference to Neonatal Morbidity and Mortality
Authors: Ohyama Makiko , Itani Yasufumi , Yamanaka Michiko , Goto Akiko , Kato Keisuke , Ijiri Rieko , Tanaka Yukichi
Published: August 2004

Objective. Our purpose was to examine the significance of diffuse chorioamniotic hemosiderosis (DCH) on neonatal morbidity and mortality.

Methods. Using data from a retrospective case-control study, we analyzed 46 singleton placentas with DCH from infants who were delivered and/or admitted to the neonatal intensive care unit of Kanagawa Children’s Medical Center during 1987–2001 and 92 control placentas without DCH from infants of comparable gestational age, birth weight, and duration.

Results. Mean and standard deviation of gestational age and infants’ birth weight at delivery from the DCH group were 27 ± 3 weeks and 939 ± 342 g, respectively. Macroscopically, the placentas with DCH were more likely to show old peripheral blood clots (46% in the DCH group vs 8% in control group), subchorionic hematoma (20% vs 1%), and circumvallation (13% vs 1%). Histologically, amniotic necrosis was significantly more frequent in the DCH group (63% vs 24%). Of the obstetric factors, incidence of recurrent episodes of vaginal bleeding (70% vs 11%), oligohydramnios (59% vs 8%), and chronic abruption-oligohydramnios sequence (57% vs 5%) were significantly higher in the DCH group. Of the neonatal factors, persistent pulmonary hypertension of the newborn (29% vs 8%) and dry lung and/or pulmonary hypoplasia (20% vs 4%) were more common. However, respiratory distress syndrome was rare (15% vs 45%) in the DCH group. Neonatal death including stillbirth was increased in the DCH group but was not significant (24% vs 15%). Of infants who survived beyond day 28, chronic lung disease (CLD) was more frequent in the DCH group (51% vs 22%). The association of DCH, especially accompanied by amniotic necrosis, with CLD was still evident using likelihood ratio test.

Conclusion. DCH is closely associated with preterm delivery, pulmonary hypertension of the newborn, and dry lung syndrome and is a significant risk factor for CLD.
Risk Factors for Emesis After Therapeutic Use of Activated Charcoal in Acutely Poisoned Children
Authors: Osterhoudt Kevin C. , Durbin Dennis , Alpern Elizabeth R. , Henretig Fred M.
Published: August 2004

Objectives. Vomiting frequently complicates the administration of activated charcoal. The incidence of such vomiting is not defined precisely in the pediatric population. Little is known about the patient-, poison-, or procedure-specific factors that contribute to emesis of charcoal. This study aimed to estimate the incidence of vomiting subsequent to therapeutic administration of charcoal to poisoned children ≤18 years of age and to examine the relative contributions of several risk factors to the occurrence of vomiting.

Methods. Data were collected on a prospective cohort of 275 consecutive children who were treated with activated charcoal for acute poisoning exposure. The study was set in the emergency department of an urban, tertiary-care children’s hospital. Sorbitol content of the charcoal was alternately assigned. Potential risk factors for vomiting were recorded prospectively, and the occurrence of vomiting within 2 hours of charcoal administration was measured.

Results. A total of 56 (20.4%) of 275 patients vomited. Median time to vomiting was 10 minutes. Previous vomiting (relative risk: 3.41; 95% CI: 1.48–7.85) and nasogastric tube administration (relative risk: 2.40; 95% CI: 1.13–5.09) were found to be the most significant independent risk factors for vomiting. The increased risk among children >12 years of age, compared with younger children, approached significance. Sorbitol content, large charcoal volumes, or fast administration rates did not increase vomiting risk significantly.

Conclusions. One of every 5 children who are given activated charcoal within our pediatric emergency department vomited. Children with previous vomiting or nasogastric tube administration were at highest risk, and these factors should be accounted for in future investigation of antiemetic strategies. Sorbitol content of charcoal was not a significant risk factor for emesis.
Medication Adherence in Pediatric and Adolescent Liver Transplant Recipients
Authors: Shemesh Eyal , Shneider Benjamin L. , Savitzky Jill K. , Arnott Lindsay , Gondolesi Gabriel E. , Krieger Nancy R. , Kerkar Nanda , Magid Margret S. , Stuber Margaret L. , Schmeidler James , Yehuda Rachel , Emre Sukru
Published: August 2004

Objective. Nonadherence to medications is a leading cause of morbidity in children and adolescents who have had a transplant, yet there are no published data about the use of different methods for detecting whether these children are taking their medications. There are also no published data about the age of transition at which a child assumes responsibility over taking the medications. This information is important if interventions to improve adherence are contemplated.

Methods. We present an analysis of data obtained in the first year of the implementation of an adherence assessment protocol at a pediatric liver transplant clinic in a tertiary medical care center. Data were obtained for children and adolescents who had a liver transplant at least 1 year before the assessments took place. We used 5 adherence detection methods. The 4 subjective methods were self-reported, scaled questionnaires answered by nurses, physicians, caregivers, and patients. For the objective method, a standard deviation (SD) was calculated for tacrolimus blood levels obtained from each patient over time. A higher SD suggests increased variation among patients’ blood levels and hence more erratic medication taking. We also asked the patients and caregivers who is responsible for taking the medications and what are the reasons for not taking them. The medical outcome measures were biopsy-proven rejection episodes, number of biopsies regardless of the results, number of hospital admissions, and number of in-patient days.

Results. An analysis of 81 cases (258 assessments) revealed that the only method that predicted the medical outcome variables (biopsy-proven rejection and number of biopsies) was the SD of medication blood levels. Patients’, clinicians’, and caregivers’ reports were not predictive. Clinicians’ ratings of adherence were not correlated with patients’ or caregivers’. The transition of responsibility for medication taking occurred approximately at the age of 12 years. Forgetfulness was cited as the most common reason for nonadherence by patients and caregivers; medication side effects were not frequently cited.

Conclusions. Our results indicate that clinical impression is not sufficient to determine whether children and adolescents are taking their medications after they have had a liver transplant. An objective assessment method should be used. Interventions targeting adherence should address the child’s increasing role beginning in early adolescence. A clinical protocol incorporating objective assessments of adherence could potentially be implemented in other settings. It could form the basis for the evaluation of efficacy of interventions seeking to improve adherence to medications.
Rest-Activity Patterns of Premature Infants Are Regulated by Cycled Lighting
Authors: Rivkees Scott A. , Mayes Linda , Jacobs Harris , Gross Ian
Published: August 2004

Objectives. Many hospitalized premature infants are exposed to continuous dim lighting rather than to cycled lighting. However, we do not know whether dim lighting or low-intensity cycled lighting is more conducive to the development of rest-activity patterns that are in phase with the solar light-dark cycle. Thus, we examined the effects of nursery lighting conditions on the development of activity patterns in premature infants.

Methods. Premature infants who were born at <32 weeks’ postmenstrual age and were medically stable in neonatal intensive care unit rooms were randomly assigned between 32 and 34 weeks’ postmenstrual age to either continuous dim lighting (<25 lux; duration 24 days; control group; n = 29) or cycled lighting (239 ± 29 lux, 7:00 am to 7:00 pm; <25 lux, 7:00 pm to 7:00 am; duration: 25 days; experimental group; n = 33). Activity was continuously monitored from enrollment until approximately 1 month after discharge from the hospital. Weight and head circumference were also assessed up to 6 months after discharge from the hospital.

Results. Over the first 10 days at home, distinct day-night differences in activity were not seen in control subjects (D day-night: N 1.07 ± 0.02), but experimental group infants were more active during the day than at night (day-night: 1.25 ± 0.03). It was not until 21 to 30 days after discharge that day-night activity ratios in control infants matched those seen in experimental group infants shortly after discharge, yet even at this age, experimental group infants (day-night: 2.13 ± 0.19) were considerably more active during the day than at night as compared with control subjects (day-night: 1.43 ± 0.09).

Conclusion. Exposure of premature infants to low-intensity cycled lighting in the hospital nursery induces distinct patterns of rest-activity that are apparent within 1 week after discharge. In comparison, the appearance of distinct patterns of rest and activity are delayed in infants who are exposed to continuous dim lighting in the hospital. These observations show that day-night rhythms in activity patterns can be detected shortly after discharge to home in premature infants and that the circadian clock of developing infants is entrained by cycled lighting.
Flavor Programming During Infancy
Authors: Mennella Julie A. , Griffin Cara E. , Beauchamp Gary K.
Published: August 2004

Objective. Although individuals differ substantially in their flavor and food preferences, the source of such differences remains a mystery. The present experimental study was motivated by clinical observations that early experience with formulas establishes subsequent preferences.

Design. Infants whose parents had chosen to formula-feed them were randomized into 1 of 4 groups by the second week of life. One group was assigned to be fed a milk-based formula (Enfamil), whereas another was assigned to be fed (Nutramigen), a particularly unpleasant-tasting protein hydrolysate formula. The remaining groups were assigned to be fed Nutramigen for 3 months and Enfamil for 4 months; the timing of exposure differed between the groups. After 7 months of exposure, infants were videotaped on 3 separate days while feeding, in counterbalanced order, Enfamil, Nutramigen, and Alimentum, a novel hydrolysate formula.

Results. For each of the 4 interrelated measures of behavior (intake, duration of formula feeding, facial expressions, and mothers’ judgments of infant acceptance), previous exposure to Nutramigen significantly enhanced subsequent acceptance of both Nutramigen and Alimentum. Seven months of exposure led to greater acceptance than did 3 months.

Conclusions. The bases for clinical difficulties in introducing hydrolysate formulas during older infancy are clarified in this study. More broadly, variation in formula flavor provided a useful model for demonstrating experimentally the effects of long-term exposure differences on later acceptance. Such early variation, under more species-typical circumstances (eg, via exposure to different flavors in amniotic fluid and mothers’ milk), may underlie individual differences in food acceptability throughout the life span.
Early Experience Alters Brain Function and Structure
Authors: Als Heidelise , Duffy Frank H. , McAnulty Gloria B. , Rivkin Michael J. , Vajapeyam Sridhar , Mulkern Robert V. , Warfield Simon K. , Huppi Petra S. , Butler Samantha C. , Conneman Nikk , Fischer Christine , Eichenwald Eric C.
Published: August 2004

Objective. To investigate the effects of early experience on brain function and structure.

Methods. A randomized clinical trial tested the neurodevelopmental effectiveness of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Thirty preterm infants, 28 to 33 weeks’ gestational age (GA) at birth and free of known developmental risk factors, participated in the trial. NIDCAP was initiated within 72 hours of intensive care unit admission and continued to the age of 2 weeks, corrected for prematurity. Control (14) and experimental (16) infants were assessed at 2 weeks’ and 9 months’ corrected age on health status, growth, and neurobehavior, and at 2 weeks’ corrected age additionally on electroencephalogram spectral coherence, magnetic resonance diffusion tensor imaging, and measurements of transverse relaxation time.

Results. The groups were medically and demographically comparable before as well as after the treatment. However, the experimental group showed significantly better neurobehavioral functioning, increased coherence between frontal and a broad spectrum of mainly occipital brain regions, and higher relative anisotropy in left internal capsule, with a trend for right internal capsule and frontal white matter. Transverse relaxation time showed no difference. Behavioral function was improved also at 9 months’ corrected age. The relationship among the 3 neurodevelopmental domains was significant. The results indicated consistently better function and more mature fiber structure for experimental infants compared with their controls.

Conclusions. This is the first in vivo evidence of enhanced brain function and structure due to the NIDCAP. The study demonstrates that quality of experience before term may influence brain development significantly.
Meta-analysis of Cephalosporin Versus Penicillin Treatment of Group A Streptococcal Tonsillopharyngitis in Children
Authors: Casey Janet R. , Pichichero Michael E.
Published: August 2004

Objective. To conduct a meta-analysis of randomized, controlled trials of cephalosporin versus penicillin treatment of group A β-hemolytic streptococcal (GABHS) tonsillopharyngitis in children.

Methodology. Medline, Embase, reference lists, and abstract searches were conducted to identify randomized, controlled trials of cephalosporin versus penicillin treatment of GABHS tonsillopharyngitis in children. Trials were included if they met the following criteria: patients <18 years old, bacteriologic confirmation of GABHS tonsillopharyngitis, random assignment to antibiotic therapy of an orally administered cephalosporin or penicillin for 10 days of treatment, and assessment of bacteriologic outcome using a throat culture after therapy. Primary outcomes of interest were bacteriologic and clinical cure rates. Sensitivity analyses were performed to assess the impact of careful clinical illness descriptions, compliance monitoring, GABHS serotyping, exclusion of GABHS carriers, and timing of the test-of-cure visit.

Results. Thirty-five trials involving 7125 patients were included in the meta-analysis. The overall summary odds ratio (OR) for the bacteriologic cure rate significantly favored cephalosporins compared with penicillin (OR: 3.02; 95% confidence interval [CI]: 2.49–3.67, with the individual cephalosporins [cephalexin, cefadroxil, cefuroxime, cefpodoxime, cefprozil, cefixime, ceftibuten, and cefdinir] showing superior bacteriologic cure rates). The overall summary OR for clinical cure rate was 2.33 (95% CI: 1.84–2.97), significantly favoring the same individual cephalosporins. There was a trend for diminishing bacterial cure with penicillin over time, comparing the trials published in the 1970s, 1980s, and 1990s. Sensitivity analyses for bacterial cure significantly favored cephalosporin treatment over penicillin treatment when trials were grouped as double-blind (OR: 2.31; 95% CI: 1.39–3.85), high-quality (OR: 2.50; 95% CI: 1.85–3.36) trials with well-defined clinical status (OR: 2.12; 95% CI: 1.54–2.90), with detailed compliance monitoring (OR: 2.85; 95% CI: 2.33–3.47), with GABHS serotyping (OR: 3.10; 95% CI: 2.42–3.98), with carriers eliminated (OR: 2.51; 95% CI: 1.55–4.08), and with test of cure 3 to 14 days posttreatment (OR: 3.53; 95% CI: 2.75–4.54). Analysis of comparative bacteriologic cure rates for the 3 generations of cephalosporins did not show a difference.

Conclusions. This meta-analysis indicates that the likelihood of bacteriologic and clinical failure of GABHS tonsillopharyngitis is significantly less if an oral cephalosporin is prescribed, compared with oral penicillin.
The Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infection (PANDAS) Etiology for Tics and Obsessive-Compulsive Symptoms: Hypothesis or Entity? Practical Considerations for the Clinician
Authors: Kurlan Roger , Kaplan Edward L.
Published: August 2004

Clinicians have been faced with much publicity and contradictory scientific evidence regarding a recently described condition termed pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). It has been proposed that children with PANDAS experience tics, obsessive-compulsive behavior, and perhaps other neuropsychiatric symptoms as an autoimmune response to streptococcal infection. We review current scientific information and conclude that PANDAS remains a yet-unproven hypothesis. Until more definitive scientific proof is forthcoming, there seems to be insufficient evidence to support 1) routine microbiologic or serologic testing for group A streptococcus in children who present with neuropsychiatric symptoms or 2) the clinical use of antibiotic or immune-modifying therapies in such patients. The optimum diagnostic and therapeutic approach awaits the results of additional research studies.
First Experiences With Early Intervention: A National Perspective
Authors: Bailey Donald B. , Hebbeler Kathleen , Scarborough Anita , Spiker Donna , Mallik Sangeeta
Published: August 2004

Background. Families of young children with disabilities are eligible for early intervention services as mandated by Part C of the Individuals With Disabilities Education Act. Although prior research has shown that families are generally satisfied with early intervention, this research has not been based on a nationally representative sample of families, nor has it systematically examined perceptions of the initial experiences entering early intervention.

Objective. This study was designed to determine families’ initial experiences in determining their child’s eligibility, interactions with medical professionals, effort required to obtain services, participation in planning for services, satisfaction with services, and interactions with professionals.

Method. We interviewed a nationally representative sample of 3338 parents of young children with or at risk for disability. All the children had recently entered an early intervention program operated under the auspices of Part C of the Individuals With Disabilities Education Act.

Results. The average age at which families reported a concern about their child was 7.4 months. A diagnosis was made, on average, 1.4 months later, the child was referred for early intervention an average of 5.2 months after the diagnosis, and the individualized family service plan was developed 1.7 months later or at an average age of 15.7 months. Most families were very positive about their entry into early intervention programs. They reported discussing their concerns with a medical professional and finding that person helpful. Families reported relative ease in accessing services, felt that services were related to their perceived needs, rated positively the professionals working in early intervention, and felt that they had a role in making key decisions about child and family goals. A small percentage of families experienced significant delays in getting services, wanted more involvement in service planning, or felt that services were inadequate, and nearly 20% were unaware of the existence of a written plan for services. Minority families, families with limited income, and families with less-educated mothers were more likely to report negative experiences.

Conclusions. We conclude that the beginning of early intervention services generally is highly successful and responsive, a finding that should give pediatricians more confidence in referring families for early intervention services. However, research and local evaluation efforts are needed to develop strategies to assure that all families receive services in a timely and appropriate fashion.
Kangaroo Transport Instead of Incubator Transport
Authors: Sontheimer Dieter , Fischer Christine B. , Buch Kerstin E.
Published: August 2004

Objective. Compared with in utero transport, incubator transport for preterm infants has several disadvantages including instability during transport with increased mortality and morbidity, lack of adequate systems for securing the infant in the event of an accident, and separation of mother and infant. As a new kind of postnatal transportation that bears some analogy to in utero transport and may be safer than incubator transport, we investigated kangaroo transport, transporting the infant on the mother’s or other caregiver’s chest. This article presents a description and preliminary data for kangaroo transport.

Design. We conducted kangaroo transports of 31 stable preterm and term infants in different settings and recorded data regarding transport conditions and cardiorespiratory stability. Eighteen transports were back transfers, and 13 were transfers in. Twenty-seven transports were conducted by the mother, 1 by the father, 2 by nurses, and 1 by a doctor. Transport distance was 2 to 400 km.

Results. Heart rate, respiratory rate, oxygen saturation, and rectal temperature remained stable during all kangaroo transports lasting 10 to 300 minutes. Weight at transport was 1220 to 3720 g. Parents felt very comfortable and safe and appreciated this method of transport.

Conclusions. Kangaroo transport promotes mother-infant closeness and might ameliorate several of the risks associated with incubator transport.
Sensitivity of a Rapid Antigen Detection Test for Group A Streptococci in a Private Pediatric Office Setting: Answering the Red Book’s Request for Validation
Authors: Armengol Carlos E. , Schlager Theresa A. , Hendley J. Owen
Published: August 2004

In the office laboratory of our private practice, the sensitivity of a single rapid antigen detection (RAD) test for group A streptococci (compared with backup throat culture) was examined over 3 winter periods. When cultures were held only 24 hours, the sensitivity was 92%; in the second period, when cultures were held to 48 hours, the sensitivity declined significantly to 86%; when the cultures were read without knowledge of the RAD test result, the sensitivity was 85%. As the Red Book Committee has suggested, physician office laboratories should validate the sensitivity of their RAD test against culture onto blood agar before abandoning the backup throat culture.
Severe Hydrogen Sulfide Exposure in a Working Adolescent
Authors: Nikkanen Heikki E. , Burns Michele M.
Published: August 2004

We describe an occupational exposure to hydrogen sulfide gas in a 16-year-old boy. While cleaning the reoxygenation tank of a fish hatchery, he and an adult supervisor lost consciousness. The adult died, and the adolescent regained consciousness briefly when emergency medical services personnel administered oxygen. At a local emergency department, he was intubated for respiratory distress. He was transferred to a tertiary care facility for additional management and, over the next 2 weeks, had a recovery to normal function.

Hydrogen sulfide is a colorless, malodorous gas that results from the decay of organic material. It is a byproduct of industry and agriculture. The mechanism of its toxicity is related primarily to inhibition of oxidative phosphorylation, which causes a decrease in available cellular energy. Although there is some anecdotal evidence to suggest that the early use of hyperbaric oxygen is beneficial, supportive care remains the mainstay of therapy. This report highlights the sources of exposure, management, and need for more stringent application of safety regulations in industries in which adolescents are employed.
How Should Parents Protect Their Children From Environmental Tobacco-Smoke Exposure in the Home?
Authors: Johansson AnnaKarin , Hermansson Gören , Ludvigsson Johnny
Published: August 2004

Background. Children’s exposure to tobacco smoke is known to have adverse health effects, and most parents try to protect their children.

Objective. To examine the effectiveness of parents’ precautions for limiting their children’s tobacco-smoke exposure and to identify variables associated to parents’ smoking behavior.

Design and participants. Children, 2.5 to 3 years old, participating in All Babies in Southeast Sweden, a prospective study on environmental factors affecting development of immune-mediated diseases. Smoking parents of 366 children answered a questionnaire on their smoking behavior. Cotinine analyses were made on urine specimen from these children and 433 age-matched controls from nonsmoking homes.

Results. Smoking behavior had a significant impact on cotinine levels. Exclusively outdoor smoking with the door closed gave lower urine cotinine levels of children than when mixing smoking near the kitchen fan and near an open door or indoors but higher levels than controls.

Variables of importance for smoking behavior were not living in a nuclear family (odds ratio: 2.1; 95% confidence interval: 1.1–4.1) and high cigarette consumption (odds ratio: 1.6; 95% confidence interval: 1.2-2.1).

An exposure score with controls as the reference group (1.0) gave an exposure score for outdoor smoking with the door closed of 2.0, for standing near an open door + outdoors of 2.4, for standing near the kitchen fan + outdoors of 3.2, for mixing near an open door, kitchen fan, and outdoors of 10.3, and for indoor smoking of 15.2.

Conclusion. Smoking outdoors with the door closed was not a total but the most effective way to protect children from environmental tobacco-smoke exposure. Other modes of action had a minor effect.
Clinical Features and Anaphylaxis in Children With Cold Urticaria
Authors: Alangari Abdullah A. , Twarog Frank J. , Shih Mei-Chiung , Schneider Lynda C.
Published: August 2004

Objective. To characterize the features of cold urticaria in children, with particular focus on systemic reactions, because little pediatric data are available.

Methodology. Chart reviews of 30 children <18 years old who were evaluated in the past 3 years at the Children’s Hospital Allergy Program (Boston, MA) and a private allergy practice. Demographic, diagnostic, and therapeutic data were collected. Telephone interviews of patients and/or their parents were performed to obtain follow-up data.

Results. Our data showed that the mean and median ages of onset were ∼7 years. No secondary causes were found. One third of patients had anaphylactic reactions. These reactions could not be predicted based on available variables. Patients with negative cold-stimulation test (ice-cube challenge) at 10 minutes had similar symptoms and response to antihistamines as those patients with positive ice-cube-challenge test. In addition, our group of patients with cold urticaria had a strikingly high rate of asthma (46.7%) and allergic rhinitis (50%). The rate of family history of atopic diseases was even higher (89.3%).

Conclusions. Cold urticaria occurs in children and may be associated with anaphylaxis. In our series, no secondary causes were found. All patients with cold urticaria and their parents should be cautioned regarding the risk of anaphylaxis and provided with an epinephrine autoinjector.