bluuebunny/crossref_metadata_2025 huggingface dataset:
Pilot Interferon-β Trial in Children With Chronic Hepatitis B Who Had Previously Not Responded to Interferon-α Therapy
Authors: Ruı́z-Moreno Mercedes , Fernández Patricia , Leal Ana , Bartolomé Javier , Castillo Inmaculada , Oliva Horacio , Carreño Vicente
Published: August 2004

Background. Recombinant interferon α (IFN-α) treatment is useful in 40% of children with chronic hepatitis B. However, nonresponder children continue to have viral replication and a progressive disease.

Objective. To administer natural IFN-β to hepatitis B virus chronic carrier children who had not responded to a previous IFN-α cycle.

Methods. Twenty-two children with chronic hepatitis B, nonresponders to a previous IFN-α cycle, were retreated with 5 MU/m2 of body surface of natural IFN-β, administered intramuscularly, three times per week for 24 weeks.

Results. At the end of treatment, 9 (41%) of 22 children became hepatitis B virus DNA negative. Hepatitis B e antibodies (anti-HBe) developed in 5 of these children, and 6 had normal alanine aminotransferase values. At the end of the posttreatment follow-up (21 months from the beginning of the study), 10 (45%) of 22 children were viral DNA negative, 7 (32%) of 22 were anti-HBe positive (none of them had viral DNA in serum), and 11 (50%) of 22 had normal alanine aminotransferase levels (10 without detectable viral DNA and 7 anti-HBe positive).

Conclusion. IFN-β seems to be an effective retreatment therapy for children with chronic hepatitis B who are nonresponders to a first IFN-α cycle; however, a controlled study should be performed to confirm these results.
Effect of Corticosteroids on Intracranial Pressure, Computed Tomographic Findings, and Clinical Outcome in Young Children With Tuberculous Meningitis
Authors: Schoeman Johan F. , Van Zyl Lana E. , Laubscher Jacoba A. , Donald Peter R.
Published: August 2004

Objective. To study the effect of high-dose prednisone on intracranial pressure (ICP), cranial computed tomographic (CT) findings, and clinical outcome in young children with moderate to severe tuberculous meningitis (TBM).

Study Design. Prospective, controlled, randomized study.

Methods. Continuous lumbar cerebrospinal fluid pressure monitoring and contrasted CT scanning were performed in 141 consecutive children with TBM at admission. All children were then randomly allocated to a nonsteroid group (71 children) or a steroid group (70 children) who received prednisone (first 16 children, 2 mg/kg per day; next 54 children, 4 mg/kg per day) for the first month of treatment. ICP monitoring and CT scanning were repeated regularly, and clinical outcome was assessed after 6 months of antituberculosis treatment.

Results. No statistically significant difference in ICP or the degree of hydrocephalus (as demonstrated by CT scan) was found between the steroid and nonsteroid groups after the first month of treatment. Basal ganglia infarcts developed in 16% of children in the steroid group and 24% in the nonsteroid group during the first month of treatment. Neither this incidence nor the eventual size of infarcts present at admission differed significantly between the two treatment groups. Single or multiple tuberculomas were seen on the first CT scans of 7 children (5%), whereas tuberculomas developed in 11 children (8%) at treatment. Both the response of the tuberculomas to treatment and the incidence of new tuberculomas were significantly improved by steroid therapy. Basal enhancement was also significantly less in the steroid group after 1 month of treatment. Steroids lowered mortality in stage III TBM significantly. Similarly, more surviving children in the steroid group had IQs of greater than 75 than did the those in the nonsteroid group. No significant difference was found in the incidence of motor deficit, blindness, or deafness.

Conclusions. Corticosteroids significantly improved the survival rate and intellectual outcome of children with TBM. Enhanced resolution of the basal exudate and tuberculomas by steroids was shown by serial CT scanning. Corticosteroids did not affect ICP or the incidence of basal ganglia infarction significantly.
“Inactive” Ingredients in Pharmaceutical Products: Update (Subject Review)
Authors:   Committee on Drugs
Published: August 2004

This Clinical Report was retired January 2004.

Because of an increasing number of reports of adverse reactions associated with pharmaceutical excipients, in 1985 the Committee on Drugs issued a position statement1recommending that the Food and Drug Administration mandate labeling of over-the-counter and prescription formulations to include a qualitative list of inactive ingredients. However, labeling of inactive ingredients remains voluntary. Adverse reactions continue to be reported, although some are no longer considered clinically significant, and other new reactions have emerged. The original statement, therefore, has been updated and its information expanded.
The Impact of Asthma on the Health Status of Adolescents
Authors: Forrest Christopher B. , Starfield Barbara , Riley Anne W. , Kang Myungsa
Published: August 2004

Objective. To identify a characteristic pattern of health and illness for adolescents with asthma, we compared the health status of teenagers with asthma to those without asthma using a recently developed generic health status instrument, the Child Health and Illness Profile, Adolescent Edition (CHIP-AE).

Methods. This was a cross-sectional survey using a school sample of 3109 teenagers. Participants completed the CHIP-AE during school in northern Baltimore City, rural western Maryland, and rural Arkansas. The health and functioning scores of teens without asthma (“well” group) were compared with those with asthma with and without recent wheezing.

Results. Of the 12% who reported that a physician had ever told them they had asthma, 50% had problems with wheezing in the past 28 days. Compared with well teenagers, those with asthma and recent wheezing had lower perceived well-being, more physical and emotional symptoms, greater limitations in activity, more comorbidities, and more negative behaviors that threaten social development. These findings held true in multivariable regression models that controlled for sociodemographics and sites of data collection. Teenagers with asthma without recent wheezing reported a greater number of comorbidities than well teens and showed similar trends in health status as those with recently symptomatic asthma.

Conclusions. Multiple aspects of adolescent health status are affected by asthma, particularly if it is recently symptomatic. These results argue for incorporating a generic health status instrument, such as the CHIP-AE, in studies that document the health needs or outcomes of medical care for populations of teenagers with asthma. asthma, quality of life, adolescence.
Survey of the Use of Peripherally Inserted Central Venous Catheters in Children
Authors: Thiagarajan Ravi R. , Ramamoorthy Chandra , Gettmann Theresa , Bratton Susan L.
Published: August 2004

Objective. Use of peripherally inserted central venous catheters (PICCs) to provide prolonged intravenous (IV) access in children is increasing. Our goal was to describe the children treated with PICCs in our institution, and to study catheter features such as catheter life, completion of therapy, and complications. Furthermore, we also evaluated PICC use in children completing therapy after discharge from our institution.

Methods. A prospective study of all PICCs inserted at the Children’s Hospital and Medical Center (CHMC), a university-affiliated teaching institution, during a period of 18 months (January 1994 to July 1995).

Results. A total of 441 PICCs were inserted in 390 patients. Patient age ranged from 0 to 22 years with a mean of 5.4 ± 6.0 years. No insertion complications occurred. Treatment of infectious disease (46%) was the most frequent reason for PICC insertion. All pediatric medical and surgical services used PICCs. Average catheter life was 13 ± 12 days. Sixty-one percent of PICCs were used entirely at CHMC, while 39% were also used at home or at an outside hospital. Completion of therapy was achieved in 69% of PICCs. Among children who completed therapy outside our hospital, there was no difference in the rates of occlusion, accidental dislodgment, or infection.

One hundred twenty-nine (29%) PICCs were removed for complications. Occlusion (7%), accidental displacement (8%), and suspicion of sepsis (8%) were the most common complications. Only 2% of PICCs had documented catheter-associated sepsis.

Conclusions. PICCs provide reliable and safe access for prolonged IV therapy in neonates and children. The low incidence of complications with PICCs make them an attractive device for prolonged IV access. Similar complication rates with use in and out of hospital suggest that home IV therapy can be safely delivered with PICCs, avoiding expensive hospitalization. peripherally inserted central venous catheter, vascular access, catheter related sepsis, completion of therapy, occlusion, accidental dislodgment, home therapy, phlebitis.
Effect of Otitis Media With Effusion on Gross Motor Ability in Preschool-aged Children: Preliminary Findings
Authors: Orlin Margo N. , Effgen Susan K. , Handler Steven D.
Published: August 2004

Objective. To investigate whether gross motor skills in preschool-aged children 24 to 60 months old with otitis media with effusion (OME) are different from those of preschool children without OME.

Children and Methods. The gross motor portion of the Peabody Developmental Motor Scales (PDMS-GM) was used to compare 13 children with OME before and after tympanostomy tube placement to 12 children without OME.

Results. The children with OME had significantly reduced scores preoperatively compared to those without OME on the PDMS-GM. After surgery, the children with OME had higher scores than those without OME, indicating an accelerated rate of development.

Conclusions. Balance and motor development are additional factors to be considered in the medical and surgical management of the young child with chronic OME. Chronic OME may represent an additional problem for young children with existing motor deficits or other disabilities.
Psychiatric Disorders in Adult Patients With Early-treated Phenylketonuria
Authors: Pietz Joachim , Fätkenheuer Brigitte , PhD Peter Burgard , Armbruster Meinrad , Esser Günther , Schmidt Hildgund
Published: August 2004

Objective. To determine psychiatric disorders in patients with phenylketonuria (PKU) and to test whether biochemical control, intellectual functioning, white matter abnormalities visible on magnetic resonance imaging (MRI), and/or style of parenting influence psychopathology.

Design and Subjects. This cross-sectional study consisted of 35 PKU patients 17 to 33 years of age (mean: 22.2). From a total of 67 patients, 3 patients were selected because of other causes of possible brain damage. Then 35 patients were randomly drawn with comparison with a control sample (n = 181) from an epidemiologic study.

Methods. We used a standardized, highly structured, face-to-face interview; intelligence quotient (IQ) test; cranial MRI (n = 26); and monitoring of plasma phenylalanine.

Results. The overall rate of psychiatric disorders was 25.7% in PKU patients and 16.1% in controls. This difference was not statistically significant. The pattern of psychiatric disturbances was different for PKU patients and controls (Fisher's exact test): in PKU patients, externalizing disorders were reduced (PKU: not present, controls: 7.8%), whereas internalizing disorders (PKU: 25.7%, controls: 8.3%) were increased. International Classification of Diseases, version 10, diagnoses were predominantly those of the depressive category and more frequent in women (8 of 18 females and 1 of 17 males). A correlation between IQ and both biochemical control up to 12 years of age and school education of parents was confirmed. No correlation was found between the severity or pattern of psychiatric disturbances and school education of parents, biochemical control, IQ, or the extension of MRI-visible, white matter abnormalities. It was found that a restrictive controlling style of parenting is a risk factor for the development of psychiatric symptoms.

Conclusions. Our results support a psychological perspective for the development of psychiatric symptoms in PKU. Thus, optimizing medical treatment necessary to prevent brain damage should be accompanied by psychiatric monitoring and psychological support for the families.
High-dose Epinephrine Is Not Superior to Standard-dose Epinephrine in Pediatric In-hospital Cardiopulmonary Arrest
Authors: Carpenter Todd C. , Stenmark Kurt R.
Published: August 2004

Objective. To compare the efficacy of high-dose epinephrine (HDE) with that of standard-dose epinephrine (SDE) for resuscitation from in-hospital pediatric cardiopulmonary arrest (CPA).

Design. Fifty-four-month retrospective study of all pediatric patients who had a CPA while hospitalized at a tertiary care children's hospital. Standard pediatric advanced life support techniques were used for all patients. Patients received HDE or SDE in accordance with physician orders and standard protocols at the time of CPA. Primary outcome measures were the return of spontaneous circulation (ROSC), the duration of survival after resuscitation, survival to hospital discharge, and Pediatric Overall Performance Category scores at the time of discharge.

Results. During the study period, 51 patients met entry criteria and had a total of 58 CPAs. Twenty-one patients received HDE during resuscitation from 24 arrests, at a dose of 0.12 ± 0.05 mg/kg (mean ± SD); 30 patients received SDE during resuscitation from 34 arrests, at a dose of 0.01 ± 0.01 mg/kg (mean ± SD). The HDE and SDE groups were not significantly different in terms of gender, initial cardiac rhythm, location of CPA, primary diagnoses at the time of CPA, initial pH, or additional resuscitation medications received; the SDE group had a significantly higher mean age, although the median ages were not different. Fourteen of 24 resuscitations using HDE resulted in ROSC (58%) with a mean time to ROSC of 19 minutes; 7 (29%) of 24 led to survival for 24 hours, and 6 (26%) of 23 patients survived to hospital discharge, all with moderate to severe neurologic and functional impairment. Twenty-four of 34 resuscitations using SDE resulted in ROSC (71%) with a mean time to ROSC of 12 minutes; 17 (50%) of 34 led to survival for 24 hours; and 7 (23%) of 30 patients survived to hospital discharge, 4 with mild to moderate neurologic impairment. No significant differences in rates of ROSC, survival rates, or Pediatric Overall Performance Category scores of survivors were found between the two groups. The mean time to ROSC was significantly longer in the HDE group.

Conclusions. In this study, the use of HDE did not improve the rates of ROSC, short-term survival, or long-term survival after pediatric in-hospital CPA, nor did it improve overall outcome scores. Given the conflicting evidence surrounding possible detrimental effects of HDE use, a large, blinded, prospective trial of HDE use in this setting is necessary to clarify the appropriate role for HDE in pediatric resuscitation.
Respiratory Syncytial Virus (RSV) Immune Globulin Intravenous Therapy for RSV Lower Respiratory Tract Infection in Infants and Young Children at High Risk for Severe RSV Infections
Authors: Rodriguez William J. , Gruber William C. , Welliver Robert C. , Groothuis Jessie R. , Simoes Eric A. F. , Meissner H. Cody , Hemming Val G. , Hall Caroline B. , Lepow Martha L. , Rosas Angela J. , Robertsen Christine , Kramer Andrew A. ,   for the Respiratory Syncytial Virus Immune Globulin Study Group
Published: August 2004

Objectives. To evaluate the efficacy of high-titer intravenous respiratory syncytial virus immune globulin (RSVIG) in the treatment of children at high risk for severe RSV infection who were hospitalized with proven RSV.

Methods. Infants and young children younger than 2 years with bronchopulmonary dysplasia, chronic lung disease, congenital heart disease, or prematurity (<32 weeks' gestational age), hospitalized with a history of lower respiratory tract infection (LRI) of less than 4 days, were enrolled in this study. Patients were randomized in a blinded fashion to receive either 1500 mg/kg RSVIG or placebo in equal volumes. They were evaluated daily for safety and respiratory scores and for RSV nasal shedding.

Results. One hundred seven high-risk children were randomized—54 in the RSVIG group and 53 in the placebo group. Of these children, 51 in each group were considered evaluable. Children with pulmonary disease, congenital heart disease, or prematurity were equally distributed between the two treatment groups. However, two important differences were found in baseline variables between the two groups: there were more patients in the placebo group who had histories of previous LRI and there was a trend toward more severe disease at study entry in the RSVIG group. This was manifested by a higher entry respiratory score in the RSVIG group than in the placebo group (3.4 ± 0.2 vs 3.1 ± .01). A higher proportion of children in the RSVIG group (47%) than in the placebo group (28%) required intensive care at entry and mechanical ventilation at study entry (31% RSVIG-treated vs 18% placebo-treated patients). No significant difference was found between groups in the mean unadjusted duration of hospitalization (RSVIG group, 9.10 ± 1.18 days; control group, 8.17 ± 1.08 days). When the mean was adjusted for entry respiratory score, likewise, no difference was observed between each group (8.41 ± 0.97 vs 8.89 ± .99 days). The lack of efficacy observed in the study primary endpoint was observed in all diagnostic groups. No differences between the RSVIG and placebo groups were observed in the following secondary endpoints: duration of intensive care unit stay, duration of intensive care unit stay for RSV, mechanical ventilation, or supplemental oxygen. No significant differences in adverse events were reported in the RSVIG group (16 children) when compared with the control group (10 children).

Conclusion. RSVIG treatment was safe but not efficacious in the treatment of children with bronchopulmonary dysplasia, congenital heart disease, or premature gestation who were hospitalized with RSV LRI.
The Use of Physical Restraint Interventions for Children and Adolescents in the Acute Care Setting
Authors:   Committee on Pediatric Emergency Medicine
Published: August 2004

This statement defines physical restraint and provides recommendations for its use in children and adolescents.
Risk of Diarrhea Related to Iron Content of Infant Formula: Lack of Evidence to Support the Use of Low-iron Formula as a Supplement for Breastfed Infants
Authors: Scariati Paula D. , Grummer-Strawn Laurence M. , Fein Sara Beck , Yip Ray
Published: August 2004

Background. Concern has been raised by infant feeding experts that supplementing breastfed infants with iron-fortified formula rather than low-iron formula may have an undesirable impact on their gastrointestinal flora. Thus far, there have been no clinical studies to address this issue directly. We compared the reported frequency of diarrhea for breastfed infants given iron-fortified formula with those fed low-iron formula.

Methods. Mothers participating in a mail panel provided feeding and diarrhea information on their infants at 2, 3, 4, 5, 6, 7, 9, and 12 months (n = 1743). Infants were grouped into five feeding categories: (1) breast milk only, (2) breast milk and low-iron formula, (3) breast milk and iron-fortified formula, (4) low-iron formula only, and (5) iron-fortified formula only. We calculated the number of diarrheal episodes per week for each feeding category and used rate ratios to estimate the relative impact of low-iron and iron-fortified formulas.

Results. Among infants who received both breast milk and formula, the rate ratio for iron-fortified formula versus low-iron formula was 1.06 (confidence interval, 0.84 to 1.34), indicating that the type of formula a breastfed infant receives does not significantly affect the frequency of diarrhea.

Conclusions. We found no evidence to support the hypothesis that breastfed infants given iron-fortified formula are at greater risk of having diarrhea. This, in addition to the fact that iron-fortified formula has played a major role in preventing childhood iron deficiency anemia, supports the current recommendation that any formula given to infants be fortified with iron. infant food, diarrhea, breastfeeding, iron.
Admixture of a Multivitamin Preparation to Parenteral Nutrition: The Major Contributor to In Vitro Generation of Peroxides
Authors: Lavoie Jean-Claude , Bélanger Sylvie , Spalinger Monica , Chessex Philippe
Published: August 2004

Background. Peroxides have been reported to contaminate lipid emulsions and amino acid solutions used in total parenteral nutrition (TPN). This is particularly disturbing in newborn infants who are prone to several diseases related to immature defense mechanisms against oxidative challenges. It is not clear whether the antioxidants in multivitamins help protect parenteral nutrients against the hazards of oxidation.

Objective. To evaluate the role of a multivitamin preparation (MVI) on the actual peroxide load received by patients on TPN.

Methodology. The generation of peroxides in parenteral nutrition was tested first using test solutions. We compared the relative contribution of commercially available amino acid solutions, a lipid emulsion, and MVI on the level of peroxides in clinically relevant TPN solutions. Second, we measured the level of peroxides actually infused at the bedside. In both circumstances, the effects of time and light exposure were isolated. The level of peroxides was determined by a colorimetric technique and expressed as μm equivalents tert-butyl hydroperoxide (μm = TBH).

Results. Even when protected from light, the addition of MVI produced a 10-fold increase in peroxides (mean ± SEM, n = 3, 19 ± 4 to 189 ± 8 μm = TBH at 4 h) in the fat-free TPN solution and a fourfold increase (64 ± 6 to 244 ± 8 μm = TBH at 4 h) in the lipid-containing TPN solution. A dose–response relationship was found between the concentration of MVI and peroxide levels. The effect of light was the strongest in the presence of multivitamins. The amino acid solutions had a relative inhibitory effect on the generation of peroxides by MVI, which varied (from 54 ± 1% to 72 ± 1%) all according to the amino acid blend. In parenterally fed premature infants, protecting the intravenous set from light decreased the load of infused peroxides (146 ± 15 vs 215 ± 24 μm= TBH).

Conclusions. The lipid emulsion had a significant but minor additive effect compared with the multivitamin preparation, which was the major contributor to the generation of peroxides. Protection from photooxidation is not sufficient to prevent peroxidation of TPN solutions. Contrary to what one would expect, increasing the concentration of MVI will lead to a greater generation of peroxides, suggesting that the essential antioxidants in MVI do not have antiperoxide properties. amino acids, antioxidants, detergents, lipids, newborn infants, oxidation, parenteral nutrition.
Have Medicaid Reimbursements Been a Credible Measure of the Cost of Pediatric Care?
Authors: Broyles R. Sue , Tyson Jon E. , Swint J. Michael
Published: August 2004

Objective. Despite uncertain validity as a measure of cost, Medicaid reimbursements may be used to compare the costs of different pediatric interventions. We explored the credibility of Medicaid reimbursements as a measure of the costs of inpatient care associated with two different approaches to follow-up care for high-risk indigent infants.

Design. Analysis of Medicaid reimbursements within a randomized trial of primary follow-up care.

Patients. Infants ≤1500 g at birth in a large county hospital (Parkland Memorial Hospital).

Intervention. Conventional care after nursery discharge (with well-baby care and care for chronic illnesses provided in our follow-up clinic) or primary care (with care for acute illnesses also provided in the follow-up clinic). Measures to prevent a lapse in Medicaid coverage were included in all clinic visits.

Outcome Measures. The completeness, comparability, and plausibility of Medicaid reimbursements for inpatient care of the two groups between nursery discharge and 1 year adjusted age.

Results. A high percentage (90% to 91%) of both groups were enrolled in Medicaid. However, with fewer clinic visits in the conventional care group, Medicaid coverage often lapsed in this group, particularly among the highest risk infants. As a result, the proportion of hospital days reimbursed by Medicaid was substantially lower for conventional care than primary care infants (53% [92/174] vs 96% [298/310]). An even larger disparity was observed for pediatric intensive care days (10% [6/61] vs 100% [33/33]). Implausible Medicaid reimbursements included a lower reimbursement rate per day in the pediatric intensive care unit than on the pediatric floor (1 infant), a lower reimbursement rate per day for hospital care than home care (1 infant), and a mean reimbursement rate per day for our private pediatric teaching hospital ($1244/day) that did not exceed that for the private nonteaching pediatric hospital ($1268/day). The reimbursement rate for our public teaching hospital was particularly low ($507/day) despite a high acuity of illness (21% of hospital days in the pediatric intensive care unit).

Conclusions. Without proper validation, reimbursements from Medicaid (or any program that replaces it) should not be assumed to provide an unbiased or acceptably accurate measure of the relative or absolute cost of pediatric health care interventions. primary care, follow-up care, cost, Medicaid, economic analysis, health care delivery.
Secondary Sexual Characteristics and Menses in Young Girls Seen in Office Practice: A Study from the Pediatric Research in Office Settings Network
Authors: Herman-Giddens Marcia E. , Slora Eric J. , Wasserman Richard C. , Bourdony Carlos J. , Bhapkar Manju V. , Koch Gary G. , Hasemeier Cynthia M.
Published: August 2004

Objective. To determine the current prevalence and mean ages of onset of pubertal characteristics in young girls seen in pediatric practices in the United States.

Methods. A cross-sectional study was conducted by 225 clinicians in pediatric practices belonging to Pediatric Research in Office Settings, a practice-based research network. After standardized training in the assessment of pubertal maturation, practitioners rated the level of sexual maturation on girls 3 through 12 years who were undergoing complete physical examinations.

Results. Data were analyzed for 17 077 girls, of whom 9.6% were African-American and 90.4% white. At age 3, 3% of African-American girls and 1% of white girls showed breast and/or pubic hair development, with proportions increasing to 27.2% and 6.7%, respectively, at 7 years of age. At age 8, 48.3% of African-American girls and 14.7% of white girls had begun development. At every age for each characteristic, African-American girls were more advanced than white girls. The mean ages of onset of breast development for African-American and white girls were 8.87 years (SD, 1.93) and 9.96 years (SD, 1.82), respectively; and for pubic hair development, 8.78 years (SD, 2.00) and 10.51 years (SD, 1.67), respectively. Menses occurred at 12.16 years (SD, 1.21) in African-American girls and 12.88 years (SD, 1.20) of age in white girls.

Conclusions. These data suggest that girls seen in a sample of pediatric practices from across the United States are developing pubertal characteristics at younger ages than currently used norms. Practitioners may need to revise their criteria for referral of girls with precocious puberty, with attention to racial differences.
Outcome of Very Low Birth Weight Infants at 12 to 18 Months of Age in Soweto, South Africa
Authors: Cooper Peter A. , Sandler Daniel L.
Published: August 2004

Objective. To describe the long-term outcome of very low birth weight infants growing up in poor socioeconomic conditions in Soweto, South Africa.

Methods. A stratified sample of infants weighing <1500 g surviving to hospital discharge was enrolled. Group 1 consisted of 49 infants 1000 to 1499 g who required mechanical ventilation; group 2 consisted of 39 infants 1000 to 1499 g who did not require mechanical ventilation; and group 3 consisted of 25 infants <1000 g (such infants are not routinely ventilated). Growth and neurological status were recorded at follow-up visits at 3, 6, and 12 months' corrected age and the infants were evaluated further using the Bayley scales of infant development between 12 and 18 months.

Results. Fifteen infants died during the period between hospital discharge and 1 year corrected age, and 12 others were lost to follow-up. Although some catch-up growth was noted in the early months, all group means for weight and length were below the 25th percentile at 1 year. Cerebral palsy was diagnosed in nine infants (8 from group 1). Periventricular leukomalacia and/or porencephaly was diagnosed in eight of the nine infants during their initial hospital stay and was also the strongest negative predictor of the Bayley scores. Higher maternal education and better intrauterine growth were associated with higher Bayley scores.

Conclusions. Mortality after hospital discharge in this study cohort was extremely high. However, despite marked differences in socioeconomic conditions and tertiary care facilities, the handicap rates were comparable with recent studies from developed countries, and some of the predictors of handicap, eg, periventricular leukomalacia and porencephaly, were also similar.
Elevated Plasma Norepinephrine After In Utero Exposure to Cocaine and Marijuana
Authors: Mirochnick Mark , Meyer Jerrold , Frank Deborah A. , Cabral Howard , Tronick Edward Z. , Zuckerman Barry
Published: August 2004

Objective. To compare plasma catecholamine concentrations between cocaine-exposed and unexposed term newborns and to determine the relationship between plasma catecholamines and newborn behavior.

Methods. Forty-six newborn infants participating in a prospective study of the neonatal and long-term effects of prenatal cocaine exposure were studied. Based on maternal self-report, maternal urine screening, and infant meconium analysis, 24 infants were classified as cocaine-exposed and 22 as unexposed. Between 24 and 72 hours postpartum, plasma samples for norepinephrine (NE), epinephrine, dopamine, and dihydroxyphenylalanine analysis were obtained. The Neonatal Behavioral Assessment Scale was administered at 1 to 3 days of age and at 2 weeks of age by examiners masked to the drug exposure status of the newborns.

Results. The cocaine-exposed newborns had increased plasma NE concentrations when compared to the unexposed infants (geometric mean, 923 pg/mL vs 667 pg/mL). There were no significant differences in plasma epinephrine, dopamine, or dihydroxyphenylalanine concentrations. Analysis for the effect of potential confounding variables revealed that maternal marijuana use was also associated with increased plasma NE, although birth weight, gender, and maternal use of alcohol or cigarettes were not. Geometric mean plasma NE was 1164 pg/mL in those infants with in utero exposure to both cocaine and marijuana compared to 812 pg/mL in those exposed to only cocaine and 667 pg/mL in those exposed to neither. Among the cocaine-exposed infants, plasma NE concentration correlated with an increased score for the depressed cluster (r = .53) and a decreased score for the orientation cluster (r = −.43) of the Neonatal Behavioral Assessment Scale administered at 1 to 3 days of age. Adjusting for marijuana exposure had no effect on these relationships between plasma NE and the depressed and orientation clusters.

Conclusion. Plasma NE is increased in newborns exposed to cocaine and marijuana. Increased plasma NE is associated with selected neurobehavioral disturbances among cocaine exposed infants at 1 to 3 days of life but not at 2 weeks.
Regression in Pervasive Developmental Disorders: Seizures and Epileptiform Electroencephalogram Correlates
Authors: Tuchman Roberto F. , Rapin Isabelle
Published: August 2004

Background. Approximately one third of the parents of children with pervasive developmental disorders or autistic spectrum disorders reports an early regression of unknown cause in their children's language, sociability, and play. Seizures or an epileptiform electroencephalogram (EEG) are associated with language regression in acquired epileptic aphasia (Landau–Kleffner syndrome) and some other pediatric epileptic syndromes. The importance of epilepsy or epileptic EEGs as contributors to autistic regression is not known.

Method. Subjects were 482 boys and 103 girls on the autistic spectrum seen consecutively in consultation by one child neurologist. Data on autistic regression, seizures, sleep EEGs, and cognitive function were entered prospectively into a data base.

Results. Of the 585 children, 176 (30%) had a history of regression, and 66 children (11%) had a history of epilepsy, defined as two or more unprovoked seizures. Among 392 children with available sleep EEGs, the EEG was epileptiform in 59% of the 66 epileptic children and 8% of the 335 nonepileptic children. Regression had occurred equally among children without seizures and in those with epilepsy. Regression was associated with an epileptiform EEG in 14% of 155 nonepileptic children who had undergone a regression, as opposed to 6% of 364 children with neither regression nor epilepsy. Mean age at regression was 21 months. There was no difference in the proportion of children with epilepsy or epileptiform EEGs who had regressed before or after 2 years of age. Approximately half of the epileptiform discharges were centrotemporal, whether or not the child was epileptic or had regressed. Children with lower cognitive function were more likely to have undergone regression than those with better cognitive skills (34% vs 20%).

Conclusion. Epilepsy or epileptiform EEGs occur in a significant minority of autistic children with a history of regression and in a smaller minority without regression. Prompt recognition of regression and recording of prolonged sleep EEGs is recommended, even though information on the potential efficacy of antiepileptic treatment to improve language and behavior in autistic children with epilepsy or an epileptiform EEG is still lacking.
General Principles in the Care of Children and Adolescents With Genetic Disorders and Other Chronic Health Conditions
Authors:   Committee on Children With Disabilities
Published: August 2004

This Policy Statement was retired January 2004.

The intent of this statement is to describe the breadth of issues that have special pertinence to pediatricians who care for children and families affected by genetic disorders and other chronic health conditions. The Committee on Children With Disabilities believes that because these children are leading healthier and longer lives, pediatricians are the more highly qualified to serve them, by virtue of their training and experience, and to provide them a “medical home.” This statement is designed to assist pediatricians in the treatment of these patients by describing their potential roles in relationship to their patients' changing needs, as they work with various members of the health care team and as they respond to the requirements of government agencies and various third-party payers.
The Resurgence of Breastfeeding in the United States
Authors: Ryan Alan S.
Published: August 2004

Objective. To update reported rates of breastfeeding through 1995 and to compare rates in 1995 with those from 1989.

Methods. The Ross Laboratories Mothers’ Survey, first conducted in 1955, is a large, national, mail survey designed to determine patterns of milk feeding to 6 months of age. Questionnaires are mailed to a representative sample of mothers when their infants are 6 months of age. In 1989, 196 000 questionnaires were mailed, and in 1995, 720 000 questionnaires were mailed. Mothers were asked to recall the type of milk fed to their infants immediately after birth, in the hospital, and during each of the first 6 months of age. The rates of breastfeeding in the hospital and at 6 months of age were evaluated.

Results. The Ross Laboratories Mothers’ Survey demonstrates recent increases in both the initiation of breastfeeding and continued breastfeeding at 6 months of age. Comparing rates in 1989 and 1995, the initiation of breastfeeding increased more than 14% (from 52.2% to 59.7%). There was a 19.3% increase in the rate of breastfeeding at 6 months of age (from 18.1% to 21.6%). The increases in breastfeeding were observed across all sociodemographic groups but were greater among groups that have historically been less likely to practice breastfeeding: women who were black, younger (<25 years of age), in the lowest income group (<$10 000), no more than grade school educated, primiparous, and living in the South Atlantic region of the United States; women who had infants of low birth weight; women who were employed full time outside the home; and women who participated in the Women, Infants, and Children supplemental food program. Nevertheless, breastfeeding was most common in the western states and among women who were older, college educated, and multiparous, did not enroll in the Women, Infants, and Children program, were not employed outside the home, had infants of normal birth weight, and had higher disposable incomes.

Conclusion. The sharp increase in rates of breastfeeding among groups that are less likely to breastfeed is encouraging. However, these groups are still the least likely to initiate breastfeeding. Educational efforts that extol positive attitudes about breastfeeding must be continued to support mothers who are young, poor, and less educated. breastfeeding, infant feeding, demography.
Maternal Receipt of Magnesium Sulfate Does Not Seem to Reduce the Risk of Neonatal White Matter Damage
Authors: Leviton Alan , Paneth Nigel , Susser Mervyn , Reuss M. Lynn , Allred Elizabeth N. , Kuban Karl , Sanocka Ulana , Hegyi Thomas , Hiatt Mark , Shahrivar Farrokh , Van Marter Linda J.
Published: August 2004

Objective. To investigate whether in utero exposure to magnesium sulfate is associated with a lower incidence of cranial ultrasonographic abnormalities that predict cerebral palsy in infants who weigh less than 1501 g at birth.

Design. For a prospective study of the antecedents of cranial ultrasonographic abnormalities, we enrolled infants who weighed 500 to 1500 g when born at five institutions. Data were collected by interview of the mothers and review of medical records. Protocol cranial ultrasonograms were obtained as close as possible to postnatal days 1, 7, and 21. Abnormality on cranial ultrasound scans was determined by a consensus committee of three sonologists.

Results. Of the 1518 infants for whom we knew whether the mothers received magnesium sulfate, the first protocol cranial ultrasound scan was available for 1409 infants, the second for 1274 infants, and the third for 1050 infants. Forty-five percent of infants were exposed to magnesium sulfate before delivery. The major correlates of magnesium sulfate exposure were receipt of antenatal corticosteriods and a diagnosis of preeclampsia and/or pregnancy-induced hypertension. Maternal magnesium receipt was not associated with a reduced incidence of hypoechoic or hyperechoic images of white matter parenchyma, intraventricular hemorrhage, or ventriculomegaly, even when the sample was stratified by each of six potential confounders. When adjustment was made for gestational age, a measure of birth weight for gestational age, antenatal corticosteroid exposure, preeclampsia and pregnancy-induced hypertension, route of delivery, and the occurrence of any labor, the risk ratios for each cranial ultrasonographic abnormality associated with magnesium sulfate exposure hovered close to 1.

Conclusion. Maternal receipt of magnesium sulfate does not seem to be associated with an appreciably reduced risk of cranial ultrasonographically defined neonatal white matter damage, intraventricular hemorrhage, or ventriculomegaly. low birth weight, magnesium sulfate, periventricular leukomalacia, antenatal corticosteriods, intraventricular hemorrhage, pregnancy-induced hypertension.
Collaborative Office Rounds: Continuing Education in the Psychosocial/Developmental Aspects of Child Health
Authors: Fishman Michael E. , Kessel Woodie , Heppel David E. , Brannon M. Elizabeth , Papai James J. , Bryn Stephanie D. , Nora Audrey H. , Hutchins Vince L.
Published: August 2004

Objectives. In recent years there has been increasing emphasis on the mental health aspects of primary health care for children and adolescents. The Health Resources and Services Administration’s Maternal and Child Health Bureau has contributed to efforts aimed at strengthening primary care not only in early identification and beginning intervention with mental disorders, but also in prevention of emotional and behavioral problems and in promotion of positive psychosocial development. The Collaborative Office Rounds (COR) Program is a noteworthy part of these efforts.

Methods. The COR program supports small discussion groups that meet at regular intervals over sustained periods of time to address the mental health aspects of pediatric care. The groups are jointly led by pediatricians and child psychiatrists. Although they vary in a number of ways, all are concerned with the day-to-day psychosocial issues that confront primary care providers serving children, adolescents, and their families.

Results. COR groups have addressed a wide range of areas including numerous problems and disorders, health supervision issues, family and community topics, personal challenges and practical complexities, and clinical management issues. Evaluation information indicates a positive response on the part of participants and moderators. This is reflected in group stability, high attendance rates, universal readiness to recommend the COR experience, and a variety of collateral accomplishments.

Conclusions. Experience to date points to the COR group as a useful tool for addressing psychosocial issues in primary care. Its potential may be more fully realized by applying this approach more widely, even as further assessment is pursued. continuing education, discussion groups, psychosocial.
Racial Differences in Choice of Dialysis Modality for Children With End-stage Renal Disease
Authors: Furth Susan L. , Powe Neil R. , Hwang Wenke , Neu Alicia M. , Fivush Barbara A.
Published: August 2004

Objective. Black-white disparities in the use of specific medical and surgical services have been reported in adult populations. Such disparities are not well documented in children. We sought to determine whether racial disparities in the use of medical services exist among children with chronic illness who have similar health insurance, specifically the choice of dialysis modality for individuals with end-stage renal disease.

Design. National cross-sectional study.

Setting. Outpatient dialysis facilities throughout the United States.

Patients and Participants. All Medicare-eligible children (age, ≤19 years) undergoing renal replacement therapy in 1990 in the United States, using data from the Medicare ESRD registry.

Outcome Measures. The odds of receiving hemodialysis versus peritoneal dialysis according to race. Adjustment was made for differences in age, gender, cause, and duration of end-stage renal disease, income, education, and facility chracteristics using multiple logistic regression.

Results. In 1990, 870 white and 368 black children received chronic (>1 year) renal replacement therapy in the United States. In bivariate analysis, blacks were two times (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.7, 2.8) more likely than whites to receive hemodialysis versus peritoneal dialysis. After controlling for other patient and facility characteristics in multivariate analysis, black children were still significantly more likely than white children to receive hemodialysis (OR, 2.4; 95% CI, 1.7, 3.5).

Conclusions. Black race is strongly associated with the use of hemodialysis in children. Family, patient, or provider preferences could account for the difference in choice of therapy by race. chronic renal failure, children; racial disparities, peritoneal dialysis, health insurance.
Tolerance to the Bronchoprotective Effect of Salmeterol in Adolescents With Exercise-induced Asthma Using Concurrent Inhaled Glucocorticoid Treatment
Authors: Simons F. Estelle R. , Gerstner Thomas V. , Cheang Mary S.
Published: August 2004

Objectives. The long-acting β2-adrenergic agonist salmeterol prevents exercise-induced asthma, but tolerance may develop to its bronchoprotective effect. We wanted to ascertain if the development of tolerance could be prevented by using a low-dose treatment regimen of 50 μg once daily, instead of the usual dose of 50 μg twice daily, in adolescents receiving regular glucocorticoid inhalations.

Methods. In a randomized, double-blind, 2x28-day crossover study, we administered salmeterol (50 μg) or placebo once daily via a metered-dose inhaler and Nebulizer Chronolog device to monitor compliance. Exercise challenge tests were performed 1 and 9 hours after salmeterol or placebo inhalation on the 1st and 28th day of each treatment period. The primary outcome variable was the maximum decrease in percent predicted FEV1 postexercise.

Results. Fourteen subjects with a mean age of 13.1 years completed the study. The first dose of salmeterol had an excellent bronchoprotective effect against exercise-induced asthma at 1 and 9 hours. After the 28th consecutive daily dose of salmeterol, the bronchoprotective effect was significantly greater than that of placebo at 1 hour, but not at 9 hours.

Conclusions. We conclude that a single 50-μg dose of salmeterol has an excellent protective effect against exercise-induced asthma for at least 9 hours, but that this effect may wane during regular once-daily salmeterol treatment, despite the reduced frequency of dosing and despite concomitant use of inhaled glucocorticoids.
Pulse Oximetry as a Fifth Pediatric Vital Sign
Authors: Mower William R. , Sachs Carolyn , Nicklin Emily L. , Baraff Larry J.
Published: August 2004

Purpose. To determine the utility of pulse oximetry as a routine fifth vital sign in acute pediatric assessment.

Design. Prospective study using pulse oximetry to measure oxygen saturation in children presenting to emergency department triage. Saturation values were disclosed to clinicians only after they had completed medical evaluations and were ready to discharge or admit each child. We measured changes in medical treatment and diagnoses initiated after the disclosure of pulse oximetry values.

Setting and Participants. The study included 2127 consecutive children presenting to triage at a university emergency department.

Measurements. Changes in select diagnostic tests: chest radiography, complete blood count, spirometry, arterial blood gases, pulse oximetry, and ventilation-perfusion scans; treatments: antibiotics, β-agonists, supplemental oxygen; and hospital admission and final diagnoses that occurred after disclosure of triage pulse oximetry values.

Results. Of 305 children having triage pulse oximetry values less than 95%, physicians ordered second oximetry for 49, additional chest radiography for 16, complete blood counts for 7, arterial blood gas measurements for 4, spirometry for 2, and ventilation-perfusion scans for 2. Physicians ordered 39 new therapies for 33 patients, including antibiotics for 15, supplemental oxygen for 11, and β-agonists for 8. Five patients initially scheduled for hospital discharge were subsequently admitted. Physicians changed or added diagnoses in 25 patients.

Conclusions. Using pulse oximetry as a routine fifth vital sign resulted in important changes in the treatment of a small proportion of pediatric patients.