bluuebunny/crossref_metadata_2025 huggingface dataset:
Barriers to Asthma Care in Urban Children: Parent Perspectives
Authors: Mansour Mona E. , Lanphear Bruce P. , DeWitt Thomas G.
Published: August 2004

Background.

Despite improved treatment regimens for asthma, the prevalence and morbidity from asthma are increasing, especially among underserved, minority children.

Objective.

The purpose of this study was to identify barriers to the treatment of asthma among urban, minority children as perceived by parents.

Methods.

Parents were recruited from 4 schools located in low-income, urban areas with high rates of asthma hospitalizations. Focus groups involving parents of children 5 to 12 years old with asthma were conducted using a standardized questionnaire. Parents' comments were analyzed to identify barriers, and 3 independent raters coded parents' comments to assess reliability of interpretation.

Results.

Forty parents who represented 47 children participated in the focus groups. All parents described their racial background as black. Parents' average age was 36.8 years, 92% were females, 70% were nonmarried, and 38% had less than a high school education. Forty-five percent of children had intermittent or mild asthma and 55% had moderate to severe asthma. The most frequent types of barriers identified by parents were patient or family characteristics (43%), followed by environmental (28%), health care provider (18%), and health care system (11%). Parents were specifically concerned about the use, safety and long-term complications of medications, the impact of limitation of exercise on their child's quality of life, and their own quality of life.

Conclusions.

In contrast with the widespread beliefs that access to medical care, health insurance, and continuity of care are the major barriers to quality asthma care, the barriers most frequently reported by parents were related to patient and family characteristics, health beliefs, or to their social and physical environment. To improve asthma management and health outcomes for urban, minority children with asthma, it is critical to tailor education about asthma and its treatment, and address quality of life issues for both children and parents.
Effects of Negative Life Events on Immune Suppression in Children and Youth Infected With Human Immunodeficiency Virus Type 1
Authors: Howland Lois C. , Gortmaker Steven L. , Mofenson Lynne M. , Spino Cathie , Gardner Jane D. , Gorski Heather , Fowler Mary Glenn , Oleske James
Published: August 2004

Objectives.

To evaluate the association of negative stressful life events experienced over 12 months and the risk of moderate to severe immune suppression among children and youth infected with human immunodeficiency virus type 1 (HIV-1).

Methods.

Longitudinal study of 618 HIV-1-infected children, baseline ages 1 to 20 years (mean age: 6.4 years), who completed 52 weeks of participation in the Pediatric Late Outcomes Study (Pediatric AIDS Clinical Trials Group Protocol 219). Severity of immune suppression was indicated by the Centers for Disease Control and Prevention Pediatric HIV Disease Classification System, based on CD4 percentages. The total number of negative life events—categorized as none, 1, or >1 life event reported as having occurred in the previous 12 months (previous 6 months for children <3 years of age)—was the predictor variable. Multiple logistic regressions were estimated to assess the relationship of negative life events and immune suppression at outcome, controlling for baseline measures of immune suppression, continuous CD4%, negative life events, age, race/ethnicity, gender, primary caretaker, education level of caretaker, and acquired immunodeficiency syndrome status.

Results.

At week 52, 379 subjects (61% of total study population) had moderate to severe immune suppression. Of 275 children with normal immune function at baseline, 68 (24.7%) subsequently developed moderate to severe suppression levels by week 52 of follow-up. Of 343 children with immune suppression at baseline, 32 (9.2%) had recovered to normal CD4% levels by week 52. More than 1 negative life event was associated with an increased risk (prevalence) of immune suppression (odds ratio [OR]: 2.76; 95% confidence interval [CI]: 1.44,5.31), controlling for baseline CD4%, total life events, and other covariates. Children without immune suppression at baseline who experienced >1 negative life event had an increased incidence of immune suppression (OR: 2.93; 95% CI: 1.34,6.39), controlling for baseline covariates.

Conclusions.

Results indicate that negative stressful life events increase the risk of children with HIV-1 infection having impaired immune function. Further research is needed to identify potential mechanisms of the relationship between stressful life events and impaired immune function. These mechanisms include psychoneuroendocrinologic response and difficulties in adherence to therapy after exposure of a child to major negative life events.
Functional Limitations and Special Health Care Needs of 10- to 14-Year-Old Children Weighing Less Than 750 Grams at Birth
Authors: Hack Maureen , Taylor H. Gerry , Klein Nancy , Mercuri-Minich Nori
Published: August 2004

Objective.

To examine the health status, functioning, and special health care needs of children 10 to 14 years old weighing <750 g at birth.

Methods.

We compared outcomes of a regional cohort of 59 children born from 1982 through 1986 weighing <750 g at birth (mean: 665 g; gestational age: 26 weeks) to matched groups of 54 children weighing 750 to 1499 g at birth and 49 children born at term. Assessments of limitations in functioning, compensatory dependence and needs for services above routine, at a mean age of 11 years, were based on responses to maternal questionnaires. Rates of these outcomes were compared between groups using logistic regression analyses that controlled for gender and social risk.

Results.

Children weighing <750 g at birth had significantly higher rates of functional limitations, greater compensatory dependence, and need for services above routine than the other 2 groups. Compared with children born at term, the odds ratio for mental or emotional delay was 4.7 (95% confidence interval [CI]: 2.0–11.0), for restrictions in activity, 5.1 (CI: 1.6–16.3) and for blindness or difficulty seeing 3.9 (CI:1.3–11.4). With the exception of 3% of children who were severely impaired, the only compensatory aid that differentiated the children weighing <750 g at birth from the children born at term was the greater need for glasses (odds ratio [OR]: 2.8 [CI: 1.3–6.3]). Increased services above routine included special education (OR: 5.0 [CI: 2.1–11.7]), counseling (OR: 4.8 [CI: 1.0–23.1]) and special arrangements in school (OR: 9.5 [C.I. 2.1–43.6]).

Conclusion.

Parents and educators need to be informed of the potential for disability and special health care needs of children weighing <750 g at birth.
Effect of Prenatal Steroids on Potassium Balance in Extremely Low Birth Weight Neonates
Authors: Omar Said A. , DeCristofaro Joseph D. , Agarwal Bajrang I. , LaGamma Edmund F.
Published: August 2004

Objective.

Potassium is the most abundant intracellular cation and plays an important role in a variety of cell functions. Potassium homeostasis and regulation are important aspects of fluid and electrolyte homeostasis in extremely low birth weight (ELBW) infants. Because prenatal steroid (PNS) treatment promotes maturation of many epithelial cell systems, we sought to determine whether PNS affects potassium homeostasis in ELBW infants (<1000 g) during the first week of life.

Method.

Serum potassium (SK) concentration, potassium intake and output, and renal clearance were collected prospectively each day during the first week of life. Infants whose mothers received a full course of steroids before delivery (PNS group:n = 16) were compared with those infants whose mothers did not receive steroids (nonsteroid group [NSG]:n = 14). The decision to treat with PNS was made entirely by the obstetric staff in a nonrandomized manner. Potassium intake and excretion and serum and urine electrolytes were measured every 12 hours, and urine output was monitored every 2 to 3 hours. Hyperkalemia was defined as SK >6.5 mmol/L in a nonhemolyzed sample on at least 1 measurement from a central line.

Results.

There were no significant differences between the groups in gestational age, Apgar score, and birth weight. SK increased initially after birth in the absence of exogenous K intake in all infants, then subsequently decreased and stabilized by day 4 of life. The peak SK was significantly lower in the PNS group than in the NSG group (5.2 ± .2 mmol/L vs 6.2 ± .4 mmol/L). Moreover, the peak SK was higher than 6.5 mmol/L in 70% of the NSG infants and in none of the PNS group. Hyperkalemia occurred in the NSG infants within the first 2 days when urine output was significantly lower than in PNS infants. SK peaked in the absence of potassium intake with similar potassium excretion in both groups. PNS infants had similar cumulative potassium intake with a lower cumulative potassium excretion than did NSG infants. PNS infants had a significantly less negative potassium balance than did NSG infants by day 7 of life (−1.0 mmol/kg vs −7.0 mmol/kg). There was no statistical difference in the daily serum creatinine levels, fractional excretion of potassium, and in the daily creatinine clearance between the 2 groups.

Conclusion.

We conclude that treatment with PNS prevents the nonoliguric hyperkalemia known to occur in ELBW neonates. We speculate that PNS induces upregulation of cell membrane sodium, potassium-adenosinetriphosphatase activity in the fetus. The differences in negative potassium balance may be accounted for by stabilization of cell membranes that may result in a decrease in potassium shift from intracellular to extracellular compartments.
Apolipoprotein ε2 Allele Is Associated With an Anti-atherogenic Lipoprotein Profile in Children: The Columbia University BioMarkers Study
Authors: Isasi Carmen R. , Shea Steven , Deckelbaum Richard J. , Couch Sarah C. , Starc Thomas J. , Otvos James D. , Berglund Lars
Published: August 2004

Objective.

We examined associations between allelic variation in the apo ε gene, which codes for apolipoprotein E, and plasma lipid levels in children.

Materials and Methods.

We analyzed genotype and fasting lipid levels, including lipid particle size by nuclear magnetic resonance spectroscopy, in 515 children from 297 families.

Results.

Children carrying the apo ε2 allele (1 or 2 ε2 alleles; n = 45) had higher mean high-density lipoprotein (HDL) cholesterol level (49.5 ± 13.0 vs 42.4 ± 8.9 mg/dL) and lower mean low-density lipoprotein (LDL) cholesterol level (82.2 ± 48.6 vs 105.9 ± 45.0 mg/dL) compared with apo ε3/ε3 children (n = 322). Mean HDL size was larger and mean level of the atheroprotective large HDL subpopulation was higher among apo ε2 carriers compared with ε3/ε3 children (9.5 ± 0.4 vs 9.3 ± .4 nm, and 32.8 ± 9.9 vs 27.6 ± 8.2 mg/dL). In multivariate models adjusting for age, sex, ethnicity, family history, body mass index, and fasting triglyceride level, the apo ε2 allele was independently predictive of higher levels of HDL cholesterol and the large HDL subpopulation and of lower level of LDL cholesterol.

Conclusion.

The apo ε2 allele is associated with an anti-atherogenic lipid pattern in children.apolipoprotein ε, children, cholesterol.
Infant Sleep Position Policies in Licensed Child Care Centers After Back to Sleep Campaign
Authors: Moon Rachel Y. , Biliter Wendy M.
Published: August 2004

Background.

Since the Back to Sleep (BTS) campaign was initiated in 1994, the rate of prone sleeping has decreased to approximately 20%. However, child care centers may have an increased rate of prone sleeping in infants. In 1996, a study of licensed child care centers demonstrated that 43% were unaware of the association between sudden infant death syndrome (SIDS) and prone sleeping and that 49% positioned infants prone.

Objective.

To determine effectiveness of a mailing from the BTS campaign to licensed child care centers by assessing the following: 1) child care center awareness of the recommendations of the American Academy of Pediatrics regarding infant sleep position and 2) implementation of the recommendations of the American Academy of Pediatrics in child care center practice.

Design.

A descriptive, cross-sectional survey of licensed child care centers in the metropolitan Washington, DC, region. All licensed child care centers caring for infants <6 months old in Washington, DC, and Montgomery, Prince Georges, Howard, Anne Arundel, Frederick, and Charles Counties in Maryland were recruited for the study.

Results.

Out of 236 eligible centers, 172 completed the survey. Seventy-five percent (129) of the centers were aware of recommendations regarding infant sleep position. Infants were placed prone in 27.9% of centers, although only 2.9% placed infants exclusively in the prone position. The most common reasons for avoiding prone position entirely were SIDS risk reduction and licensing regulations. Half of the centers had a written policy regarding sleep position. Twenty centers who were aware of the dangers of prone sleeping continued to placed infants prone at least some of the time, largely because of parental request. Only 56.9% of centers had heard of the BTS campaign despite the mass mailing. The mailing resulted in policy change for 14 centers.

Conclusions.

Since 1996, the percentage of licensed child care centers in the greater Washington, DC, area that are aware of the association between SIDS and infant sleep position has increased from 57% to 75%. In addition, the rate of placing infants prone in these centers has declined from 49% in 1996 to 27.9% in this study. When child care centers are aware of the risk of prone sleeping, the most likely reason for continued prone placement is parental request. Although media and mailings have been largely effective in communicating BTS information to many child care centers, nonprone positioning is not universal among child care providers. Additional educational efforts toward child care providers and parents remain necessary.
Are Household Firearms Stored Safely? It Depends on Whom You Ask
Authors: Azrael Deborah , Miller Matthew , Hemenway David
Published: August 2004

Objective.

To determine gun storage practices in gun-owning households with children.

Design.

National random digit-dial telephone survey of 2521 households conducted in March 1999 through July 1999. This study uses a subsample of 434 households with children <18 years old in which a respondent reported either: 1) personally owning a gun, or 2) living in a gun-owning household but not owning a gun themselves. Respondents were asked whether any household gun was currently stored loaded, and, if yes, whether any gun was currently stored loaded and unlocked.

Results.

Twenty-one percent of gun owners compared with 7% of nonowners reported that a household gun was stored loaded, while 9% and 2%, respectively, reported that a household gun was stored loaded and unlocked. Nongun owners were significantly more likely than were gun owners to be female (87% vs 22%) and to report that they lived in a house with only 1 gun (70% vs 57%) and no handguns (51% vs 31%). Based on the reports of actual gun owners (n = 252), households with children <13 years old were significantly less likely to store a gun loaded and unlocked (multivariate odds ratio: .1; 95% confidence interval: .0,.4) than were households with teenagers only.

Conclusions.

We find that among gun-owning households with children, nongun owners report significantly lower rates of guns stored loaded and unlocked than do gun owners. These findings are consistent with recent studies that have found that married men are far more likely to report household gun ownership than are married women, and that gun users are far more likely to report that a gun is stored loaded or loaded and unlocked than are never users. Our findings suggest that nongun owners, the vast majority of whom are women (87%), may be unaware that guns in their homes are stored in a manner that experts agree is unsafe.

Our findings reinforce the importance of many pediatricians' current efforts to offer anticipatory guidance about firearms to gun-owning families, and, in addition, suggest that this guidance can be adapted depending on whether the physician is speaking with a gun-owning or nongun-owning parent. In particular, because gun owners (mostly fathers) are less likely to bring children to the pediatrician's office than are nonowners (mostly mothers), physicians should take advantage of any opportunities that they have to address gun-related issues with parents who personally own guns. More commonly, physicians can encourage nongun owners to participate more fully in household decision-making about gun storage by letting them know not only about recommended storage practices, but also that many nonowners may not know how guns are actually stored in their own homes. firearm, storage, children, survey.
Dose-Response Effect of Cocaine on Newborn Head Circumference
Authors: Bateman David A. , Chiriboga Claudia A.
Published: August 2004

Objective.

To evaluate the relationship between head circumference, birth weight, and cocaine dose in healthy term and near-term newborns exposed to cocaine in utero.

Methods.

We used radioimmune assay (RIAH) of cocaine metabolite in maternal hair to quantify third trimester cocaine exposure in 240 healthy newborn infants (gestational age: >36 weeks). Cocaine exposure was categorized into 3 levels: no exposure (n = 136), low cocaine exposure (n = 52; RIAH: 2–66 ng/10 mg hair), and high cocaine exposure (n = 52; RIAH: 81–4457 ng/10 mg hair). We collected information on maternal demographic characteristics, the pregnancy, and the use of substances through a structured interview and from the medical record.

Results.

Means of birth weight, length, and head circumference of infants with high cocaine exposure differed significantly from those with low exposure and no exposure, but were similar between low exposure and no exposure. We used a multiple linear regression model to assess the association between newborn head circumference and cocaine level, adjusting for the effects of birth weight; gestational age; infant sex; and several maternal factors, including height, weight gain during pregnancy, syphilis during pregnancy, and the use of alcohol, cigarettes, marijuana, and opiates during pregnancy. Only birth weight, sex, and high cocaine exposure were significantly associated with newborn head circumference. The predicted head circumference deficit associated with high cocaine exposure (.44 cm) represents 34% of the unadjusted difference (1.28 cm) between mean head circumferences of infants in the high cocaine exposure and no exposure groups.

Conclusion.

Newborns exposed to a high level of cocaine in utero (RIAH: >81 ng/10 mg hair) exhibit asymmetric intrauterine growth retardation in which the head circumference is disproportionately smaller than would be predicted from the birth weight (head wasting). The deficit in head size associated with cocaine exposure may reflect the effects of a specific central nervous system insult that interferes with prenatal brain growth.
Unsafe Sleep Practices and an Analysis of Bedsharing Among Infants Dying Suddenly and Unexpectedly: Results of a Four-Year, Population-Based, Death-Scene Investigation Study of Sudden Infant Death Syndrome and Related Deaths
Authors: Kemp James S. , Unger Benjamin , Wilkins Davida , Psara Rose M. , Ledbetter Terrance L. , Graham AD¶; Michael A. , Case Mary , Thach Bradley T.
Published: August 2004

Background.

Prone sleep and unsafe sleep surfaces increase the risk of sudden infant death. Recent epidemiologic studies also suggest that when an infant's head or face is covered by bedding, or when a sleep surface is shared with others, the risk of dying increases. The inference of a causal role for these risk factors is supported by physiologic studies and by the consistent finding that fewer infants die when risk factors are reduced. The prevalence of most of these risk factors in infant deaths in the United States is uncertain.

Objective.

To describe the prevalence of several important risk factors related to sleep practices among a defined population of infants dying suddenly and unexpectedly.

Methods.

In this population-based study, we retrospectively reviewed death-scene information and medical examiners' investigations of deaths in the city of St Louis and St Louis County between January 1, 1994 and December 31, 1997. Because of the potential for diagnostic overlap, all deaths involving infants <2 years old with the diagnoses of sudden infant death syndrome (SIDS), accidental suffocation, or cause undetermined were included.

Results.

The deaths of 119 infants were studied. Their mean age was 109.3 days (range: 6–350). The diagnoses were SIDS in 88 deaths, accidental suffocation in 16, and undetermined in 15. Infants were found prone in 61.1% of cases and were found on a sleep surface not designed for infants in 75.9%. The head or face was covered by bedding in 29.4%. A shared sleep surface was the site of death in 47.1%. Only 8.4% of deaths involved infants found nonprone and alone, with head and face uncovered.

Conclusions.

Using detailed death-scene descriptions, we found that similar unsafe sleeping practices occurred in the large majority of cases diagnosed as SIDS, accidental suffocation, and cause undetermined. Considering these diagnoses together may be useful in public health campaigns during a time when there may be diagnostic overlap. Regardless of the diagnosis, recommendations that infants sleep supine on firm sleep surfaces that lessen the risk of entrapment or head covering have the potential to save many lives. Campaigns are needed to heighten awareness of these messages and of the risks of dangerous bedsharing.
Cerebral Intravascular Oxygenation Correlates With Mean Arterial Pressure in Critically Ill Premature Infants
Authors: Tsuji Miles , Saul J. Philip , du Plessis Adre , Eichenwald Eric , Sobh Jamil , Crocker Robert , Volpe Joseph J.
Published: August 2004

Objectives.

Premature infants experience brain injury, ie, germinal matrix–intraventricular hemorrhage (GMH-IVH) and periventricular leukomalacia (PVL), in considerable part because of disturbances in cerebral blood flow (CBF). Because such infants are susceptible to major fluctuations in mean arterial blood pressure (MAP), impaired cerebrovascular autoregulation would increase the likelihood for the changes in CBF that could result in GMH-IVH and PVL. The objectives of this study were to determine whether a state of impaired cerebrovascular autoregulation could be identified reliably and conveniently at the bedside, the frequency of any such impairment, and the relation of the impairment to the subsequent occurrence of severe GMH-IVH and PVL.

Patients and Methods.

To monitor the cerebral circulation continuously and noninvasively, we used near-infrared spectroscopy (NIRS) to determine quantitative changes in cerebral concentrations of oxygenated hemoglobin (HbO2) and deoxygenated hemoglobin (Hb) from the first hours of life. Our previous experimental study showed a strong correlation between a measure of cerebral intravascular oxygenation (HbD), ie, HbD = HbO2 − Hb, determined by NIRS, and volemic CBF, determined by radioactive microspheres. We studied 32 very low birth weight premature infants (gestational age: 23–31 weeks; birth weight: 605-1870 g) requiring mechanical ventilation, supplemental oxygen, and invasive blood pressure monitoring by NIRS from 1 to 3 days of age. MAP measured by arterial catheter pressure transducer and arterial oxygen saturation measured by pulse oximetry were recorded simultaneously. The relationship of MAP to HbD was quantitated by coherence analysis.

Results.

Concordant changes (coherence scores >.5) in HbD and MAP, consistent with impaired cerebrovascular autoregulation, were observed in 17 of the 32 infants (53%). Eight of the 17 infants (47%) developed severe GMH-IVH or PVL or both. Of the 15 infants with apparently intact autoregulation, ie, coherence scores <.5, only 2 (13%) developed severe ultrasonographic lesions. Thus, for the entire study population of 32 infants, 8 of the 10 with severe lesions exhibited coherence scores >.5.

Conclusions.

We conclude that NIRS can be used in a noninvasive manner at the bedside to identify premature infants with impaired cerebrovascular autoregulation, that this impairment is relatively common in such infants, and that the presence of this impairment is associated with a high likelihood of occurrence of severe GMH-IVH/PVL.
Neonatal Outcome of Preimplantation Genetic Diagnosis by Polar Body Removal: The First 109 Infants
Authors: Strom Charles M. , Levin Rebecca , Strom Sam , Masciangelo Christina , Kuliev Anver , Verlinsky Yury
Published: August 2004

Context.

Our center developed the technique of preimplantation genetic diagnosis (PGD) by sequential polar body removal (PBR) for the diagnosis of Mendelian disorders and aneuploidies. This study examines the obstetric and neonatal outcome of the first 109 live births after PGD by PBR.

Objective.

To determine if there were any observable effects of PGD by PBR on perinatal morbidity and mortality, birth defects, and growth parameters.

Design.

Data on perinatal outcome were gathered for the first 109 infants by parental reporting and confirmed by telephone interview and chart review when indicated. In infants >6 months old, a follow-up telephone interview was performed establishing the developmental milestones attained by the child.

Setting.

A research center conducting an institutional review board-approved research protocol in PGD.

Patients.

All patients who had PGD by PBR who had clinical pregnancies.

Main Outcome Measures.

Gestational age, mode of delivery, perinatal mortality, birth weight, birth length, the presence of birth defects, and developmental milestones.

Results.

There was no significant decrease in birth length or weight, or the frequency of small for gestational age infants. No specific pattern of birth defects was observed.

Conclusion.

Thus far, there are no observable detrimental effects of PGD by PBR on children born after the procedure.
Pilot Study of Treatment With Whole Body Hypothermia for Neonatal Encephalopathy
Authors: Azzopardi Denis , Robertson Nicola J. , Cowan Frances M. , Rutherford Mary A. , Rampling Michael , Edwards A. David
Published: August 2004

Background.

There is extensive experimental evidence to support the investigation of treatment with mild hypothermia after birth asphyxia. However, clinical studies have been delayed by the difficulty in predicting long-term outcome very soon after birth and by concern about adverse effects of hypothermia.

Objectives.

The objectives of this study were to determine whether it is feasible to select infants with a bad neurological prognosis and to begin hypothermic therapy within 6 hours of birth, and to observe the effect of this therapy on relevant physiologic variables.

Methods.

Sixteen newborn infants with clinical features of birth asphyxia (median cord blood pH: 6.74; range: 6.58–7.08) were assessed by amplitude integrated electroencephalography (aEEG), and mild whole body hypothermia was instituted within 6 hours of birth in the 10 infants with an aEEG prognostic of a bad outcome. Rectal temperature was maintained at 33.2 ± (standard deviation) .6°C for 48 hours. Rectal and tympanic membrane temperature, blood pressure, heart rate, blood gases, blood lactate, full blood count, blood electrolytes, high and low shear rate viscosity, and coagulation studies were monitored during and after cooling. A preliminary assessment of neurological outcome was made by repeated magnetic resonance imaging (MRI) and neurological examination.

Results.

All infants selected to receive hypothermia developed convulsions and a severe encephalopathy. During 48 hours of hypothermia infants had prolonged metabolic acidosis (median pH: 7.30; base excess: −6.3 mmol · L−1, a high blood lactate (median lactate: 5.3 mmol · L−1) and low blood potassium levels (median value: 3.9 mmol · L−1). Hypothermia was associated with lower heart rate and higher mean blood pressure. However, these changes did not seem to be clinically relevant and no significant complication of hypothermia was encountered. Blood viscosity and coagulation studies were similar during and after cooling. Unusual MRI findings were noted in 3 infants: transverse sinus thrombosis with subsequent small cerebellar infarct; probable thrombosis in the straight sinus; and hemorrhagic cerebral infarction. Six of the 10 cooled infants had minor abnormalities only or normal follow-up neurological examination; 3 infants died and 1 had major abnormalities. None of the 6 infants with a normal aEEG developed severe neonatal encephalopathy or neurological sequel.

Conclusions.

After birth asphyxia infants can be objectively selected by aEEG and hypothermia started within 6 hours of birth in infants at high risk of developing severe neonatal encephalopathy. Prolonged mild hypothermia to 33°C to 34°C is associated with minor physiologic abnormalities. Further studies of both the safety and efficacy of mild hypothermia, including further neuroimaging studies, are warranted.
Dexamethasone Treatment of Virilizing Congenital Adrenal Hyperplasia: The Ability to Achieve Normal Growth
Authors: Rivkees Scott A. , Crawford John D.
Published: August 2004

Objective.

To assess whether treatment of virilizing congenital adrenal hyperplasia (CAH) with long-acting glucocorticoids is associated with favorable growth outcomes.

Method.

We examined the long-term growth of 17 boys and 9 girls with CAH treated with dexamethasone (.27 ± .01 mg/m2/day).

Results.

For individuals with comparable bone age (BA) and chronological age (CA) at the onset of dexamethasone therapy, males were 2.8 ± .8 years (mean ± standard error of the mean;n = 13) and females were 2.4 ± 1.0 years (n = 6). Males were treated for 7.3 ± 1.1 years (ΔCA) over which time the change in BA (ΔBA) was 7.0 ± 1.3 years, and the change in height age (ΔHA) was 6.9 ± 1.1 years. Females were treated for 6.8 ± 1.3 years, over which time the ΔBA was 6.5 ± 1.0 years, and the ΔHA was 6.3 ± .8 years. During treatment 17 ketosteroid excretion rates were normal for age and 17-hydroxyprogesterone values were 69.6 ± 18 ng/dL. Testicular enlargement was first detected at 10.7 ± .8 years and breast tissue at 9.9 ± 1.2 years. Three boys and 1 girl had final heights of 171.8 ± 6 cm and 161 cm, respectively, compared with midparental heights of 176.1 ± 4.1 cm and 160 cm. Predicted adult heights for 6 other boys and 5 girls were 176.8 ± 2.0 cm and 161.4 ± 2.8 cm, respectively, compared with midparental heights of 174.6 ± 1.4 cm and 158.2 ± 2.0 cm. Statural outcomes were less favorable for 7 children started on dexamethasone when BAs were considerably advanced, although height predictions increased during therapy.

Conclusions.

These observations show that children treated with dexamethasone for CAH can achieve normal growth with the convenience of once-a-day dosing in most cases. congenital adrenal hyperplasia, dexamethasone, growth.
Respiratory Syncytial Virus Infection in Patients With Phagocyte Defects
Authors: Uzel Gulbu , Premkumar Ahalya , Malech Harry L. , Holland Steven M.
Published: August 2004

Patients with phagocyte defects frequently develop bacterial or fungal pneumonias, but they are not considered to be at increased risk for viral infections. We describe 3 patients with known phagocyte immunodeficiencies who developed lower respiratory tract infections (LRTI) caused by respiratory syncytial virus (RSV). All 3 patients had dense pneumonias as indicated by computed tomography scan of the lungs and RSV was recovered. We conclude that RSV can present as a dense pneumonia in patients with phagocyte defects. Along with common pathogens causing LRTI, RSV should be considered in the differential diagnosis. Viral cultures as well as rapid antigen detection assays for respiratory viruses should be included in the evaluation of LRTI in patients with phagocyte defects.respiratory syncytial virus, phagocyte, immunodeficiency, pneumonia.
Raccoon Roundworm (Baylisascaris procyonis) Encephalitis: Case Report and Field Investigation
Authors: Park Sarah Y. , Glaser Carol , Murray William J. , Kazacos Kevin R. , Rowley Howard A. , Fredrick Douglas R. , Bass Nancy
Published: August 2004

Baylisascaris procyonis is a common and widespread parasite of raccoons in the United States and Canada. With large raccoon populations occurring in many areas, the potential risk of human infection with B procyonis is high. We report a case of severe raccoon roundworm (B procyonis) encephalitis in a young child to illustrate the unique clinical, diagnostic, and treatment aspects, as well as public health concerns ofB procyonis infection. Acute and convalescent serum and cerebrospinal fluid samples from the patient were tested for antibodies against B procyonis to assist in documenting infection. An extensive field survey of the patient's residence and the surrounding community was performed to investigate raccoon abundance and to determine the extent of raccoon fecal contamination and B procyonis eggs in the environment. The patient evidenced serologic conversion, and the field investigation demonstrated a raccoon population far in excess of anything previously reported. There was abundant evidence of B procyonis eggs associated with numerous sites of raccoon defecation around the patient's residence and elsewhere in the community. Because B procyonis can produce such severe central nervous system disease in young children, it is important that pediatricians are familiar with this infection. The public should be made aware of the hazards associated with raccoons and B procyonis to hopefully prevent future cases of B procyonisinfection.
Vulvar Carcinoma in a 12-Year-Old Girl With Vertically Acquired Human Immunodeficiency Virus Infection
Authors: Giaquinto Carlo , Del Mistro Annarosa , De Rossi Anita , Bertorelle Roberta , Giacomet Vania , Ruga Ezia , Minucci Daria
Published: August 2004

We report the first case of a girl with vertically acquired human immunodeficiency virus (HIV) infection, who developed invasive squamous cell carcinoma of the vulva at 12 years of age. Lesions resembling bowenoid papulosis covered the perianal area as well. She underwent a nonmutilating surgical excision of the infiltrating lesion. More than 3 years later, her clinical condition is excellent, although dysplastic, noninfiltrating multifocal lesions persist. This case highlights the need to perform careful periodic genital examinations in all HIV-infected children and adolescents born to HIV-positive mothers.
Factors Influencing Infant Visits to Emergency Departments
Authors: Sharma Vidya , Simon Stephen D. , Bakewell Janice M. , Ellerbeck Edward F. , Fox Michael H. , Wallace Dennis D.
Published: August 2004

Objectives.

To follow the 1995 birth cohort of infants, born in the State of Missouri, through their first birthday to: 1) examine their rates of visits to emergency departments (EDs), 2) identify predictors of any ED visit, 3) examine rates of nonurgent ED visits, and 4) identify predictors of nonurgent visits.

Methods.

This was a retrospective population cohort study. Using deterministic linkage procedures, 2 databases at the Missouri Department of Health (DOH; (the patient abstract database and the birth registry database) were linked by DOH personnel. International Classification of Diseases, Ninth Revision-Clinical Modification codes for ED visits were classified as emergent, urgent, or nonurgent by 2 researchers. Eight newborn characteristics were chosen for analysis. Negative binomial regression was used to examine the rates and predictors of both total and nonurgent ED visits.

Results.

There were 935 total ED visits and 153 nonurgent ED visits per 1000 infant years. The average number of visits was .94, with 59% of infants having no visits, 21% having 1 ED visit, and 20% having 2 or more visits.

Factors associated with increases in both total and nonurgent ED visits were Medicaid, self-pay, black race, rural region, presence of birth defects, and a nursery stay of >2 days. Significant interactions were found between Medicaid and race and Medicaid and rural regions on rates of ED use and nonurgent use.

The highest rate of ED use, 1.8 per person year, was seen in white, rural infants on Medicaid, and the lowest rate (.4 per person year) was seen in urban white infants not on Medicaid. The highest rates of nonurgent use, .3 per person year, were among urban and rural Medicaid infants of both races and among black infants on commercial insurance. The lowest nonurgent rate, .04 per person year, was seen in white urban infants on commercial insurance.

Conclusion.

Infants in the State of Missouri have high rates of ED visits. Nonurgent visits are only a small portion of ED visits and cannot explain large variations in ED usage. Increased ED use by Medicaid patients may reflect continuing difficulties in accessing primary care.
Using a Health Concerns Checklist as a Bridge From Reason for Encounter to Diagnosis of Girls Attending an Adolescent Health Service
Authors: Wilf-Miron Rachel , Glasser Saralee , Sikron Fabienne , Barell Vita
Published: August 2004

Objective.

We assessed the extent to which a health concerns checklist (HCC) helps bridge the gap between the reason for encounter (RFE) described by girls entering an adolescent health service and the ultimate diagnosis.

Methods.

The sample, 547 consecutive 12- to 18-year-old girls visiting an adolescent health service, first underwent a structured intake procedure, including a self-administered form on which they described their RFEs and other health concerns, as well as a psychosocial interview and medical evaluation performed by staff members. The RFEs, HCC items, and diagnoses, grouped into somatic, sexuality-related, and psychosocial categories, were then compared.

Results.

Among the 399 girls expressing specific RFEs on entering the clinic, one-third were diagnosed with psychosocial disorders and one-fifth with sexuality-related concerns. Of the patients receiving a sexuality-related diagnosis, 57% presented with a sexuality-related request; another 26% noted it on the checklist. For those diagnosed with psychosocial problems, 22% stated this as the RFE, and another 50% indicated it on the HCC. The contribution of the HCC to the diagnosis was higher among adolescents not stating a specific RFE.

Conclusion.

The findings highlight the HCC's contribution in identifying health problems, especially among adolescents who find it difficult to verbalize sensitive issues.
Necrotizing Enterocolitis in Neonates With Congenital Heart Disease: Risk Factors and Outcomes
Authors: McElhinney Doff B. , Hedrick Holly L. , Bush David M. , Pereira Gilberto R. , Stafford Perry W. , Gaynor J. William , Spray Thomas L. , Wernovsky Gil
Published: August 2004

Objective.

Necrotizing enterocolitis (NEC) is primarily a disease of the premature infant. Among children born at term, however, congenital heart disease may be an important predisposing factor for this condition. To determine risk factors for NEC in patients with congenital heart disease, we conducted a case–control study of neonates with cardiac disease admitted to the cardiac intensive care unit at our center during the 4-year period from January 1995 to December 1998.

Methods.

Cardiac diagnosis and age at admission were analyzed for association with NEC among the 643-patient inception cohort. Demographic, preoperative, and operative variables were recorded retrospectively in 21 neonates with congenital heart disease who developed NEC and 70 control neonates matched by diagnosis and age at admission. Using parametric and nonparametric analysis, cases and controls were compared with respect to previously identified risk factors for NEC.

Results.

Among the entire cohort of 643 neonates with heart disease admitted to the cardiac intensive care unit, diagnoses of hypoplastic left heart syndrome (odds ratio [OR] = 3.8 [1.6–9.1]) and truncus arteriosus or aortopulmonary window (OR = 6.3 [1.7–23.6]) were independently associated with development of NEC by multivariable analysis. In the case–control analysis, earlier gestational age at birth (36.7 ± 2.7 weeks vs 38.1 ± 2.3 weeks), prematurity (OR = 3.9 [1.2–12.5]), highest dose of prostaglandin >0.05 μg/kg/minute (OR = 3.9 [1.2–12.5]), and episodes of low cardiac output (meeting specific laboratory criteria) or clinical shock (OR = 6.5 [1.8–23.5]) correlated with the development of NEC. Earlier gestational age and episodes of low output were the only factors that remained significantly associated with NEC by multivariable analysis. Although there was no difference in hospital mortality between patients with and without NEC, mean hospital stay was significantly longer in those who developed NEC (36 ± 22 days vs 19 ± 14 days).

Conclusions.

The risk of NEC in neonates with congenital heart disease is substantial. Factors associated with an elevated risk of NEC in infants with heart disease include premature birth, hypoplastic left heart syndrome, truncus arteriosus, and episodes of poor systemic perfusion or shock. Heightened suspicion is warranted in newborns with these risk factors.
Do Parents Understand Immunizations? A National Telephone Survey
Authors: Gellin Bruce G. , Maibach Edward W. , Marcuse Edgar K. ,   for the National Network for Immunization Information Steering Committee∥
Published: August 2004

Background.

Immunization may now be undervalued because vaccines have largely eliminated the threat of serious infectious diseases in childhood. As the incidence of vaccine-preventable diseases has declined, concern about vaccine safety has increased. Significant erosion of public confidence in vaccine safety could lead to reduced immunization rates and a resurgence of vaccine-preventable diseases.

Objective and Methods.

To assess parents' understanding of vaccine-preventable diseases, vaccines, immunization practices, and policies, we conducted a telephone survey in the United States with a nationally representative sample (n = 1600) of parents with children ≤6 years of age, and expectant parents in April and May 1999.

Results.

Eighty-seven percent of respondents deemed immunization an extremely important action that parents can take to keep their children well. Although respondents' overall rating of immunization safety was high, a substantial minority held important misconceptions. For example, 25% believed that their child's immune system could become weakened as a result of too many immunizations, and 23% believed that children get more immunizations than are good for them. Children's health care providers were cited as the most important source of information on immunizations.

Conclusions.

Although the majority of parents understand the benefits of immunization and support its use, many parents have important misconceptions that could erode their confidence in vaccines. A systematic educational effort addressing common misconceptions is needed to ensure informed immunization decision-making. Physicians, nurses, and other providers of primary care have a unique opportunity to educate parents because parents see them as the most important source of information about immunizations. vaccination, immunization, pediatric, safety, health beliefs.
Forgoing Life-Sustaining Medical Treatment in Abused Children
Authors:   Committee on Child Abuse and Neglect and Committee on Bioethics
Published: August 2004

A decision to forgo life-sustaining medical treatment (LSMT) for a critically ill child injured as the result of abuse should be made using the same criteria as those used for any critically ill child. The parent or guardian of an abused child may have a conflict of interest when a decision to forgo LSMT risks changing the legal charge faced by a parent, guardian, relative, or acquaintance from assault to manslaughter or homicide. If a physician suspects that a parent or guardian is not acting in a child's best interest, further review and consultation should be sought in hopes of resolving the conflict. A guardian ad litem who will represent the child's interests regarding LSMT should be appointed in all cases in which a parent or guardian may have a conflict of interest.
Predictors of Bacteremia in Febrile Children 3 to 36 Months of Age
Authors: Isaacman Daniel J. , Shults Justine , Gross Toni K. , Davis Paris H. , Harper Marvin
Published: August 2004

Purpose.

To develop an improved model for the prediction of bacteremia in young febrile children.

Methods.

A retrospective review was performed on patients 3 to 36 months of age seen in a children's hospital emergency department between December 1995 and September 1997 who had a complete blood count and blood culture ordered as part of their regular care. Exclusion criteria included current use of antibiotics or any immunodeficient state. Clinical and laboratory parameters reviewed included age, gender, race, weight, temperature, presence of focal bacterial infection, white blood cell count (WBC), polymorphonuclear cell count (PMN), band count, and absolute neutrophil count (ANC). Logistic regression analyses were used to identify factors associated with bacteremia, defined as growth of a pathogen in a blood culture. The model that was developed was then validated on a second dataset consisting of febrile patients 3 to 36 months of age collected from a second children's hospital (validation set).

Results.

There were 633 patients in the derivation set (46 bacteremic) and 9465 patients in the validation set (149 bacteremic). The mean age of patients in the derivation and validation sets were 15.8 months (95% confidence interval [CI]: 15.2–16.5) and 16.6 months (95% CI: 16.5–16.8), respectively; the mean temperatures were 39.1°C (95% CI: 39.0–39.2) and 39.8°C (95% CI: 39.7–39.8); 56% were male in the derivation set and 55% male in the validation set. Predictors of bacteremia identified by logistic regression included ANC, WBC, PMN, temperature, and gender. Receiver operator characteristic (ROC) analysis showed similar performance of ANC and WBC as predictors of bacteremia. When placed into a multivariate logistic regression model, band count was not significantly associated with bacteremia. Information regarding focal infection was available for 572 patients in the derivation set. The percentage of patients diagnosed with bacteremia with a focal bacterial infection was not significantly different from the percentage who had bacteremia without a focal bacterial infection (16/200 vs 30/372). Based on this dataset, a logistic regression formula was developed that could be used to develop a unique risk value for each patient based on temperature, gender, and ANC. When the final model was applied to the validation set, the area under the ROC curve (AUC) constructed from these data indicated that the model retained good predictive value (AUC for the derivation vs validation data = .8348 vs 0.8221, respectively).

Conclusions.

Use of the formulas derived here allows the clinician to estimate a child's risk for bacteremia based on temperature, ANC, and gender. This approach offers a useful alternative to predictions based on fever and WBC alone. bacteremia, detection, white blood cell.