bluuebunny/crossref_metadata_2025 huggingface dataset:
Point Mutation in Exon 12 of the Receptor Tyrosine Kinase Proto-oncogene RET in Ondine-Hirschsprung Syndrome
Authors: Sakai Tetsuo , Wakizaka Akira , Matsuda Hiroo , Nirasawa Yuji , Itoh Yasuo
Published: August 2004

A 5-year-old girl with congenital central hypoventilation syndrome associated with Hirsch-sprung's disease (Ondine-Hirschsprung syndrome) representing a missense mutation in exon 12 of the receptor tyrosine kinase (RET) proto-oncogene is reported. Using a direct sequencing technique, genomic DNA obtained from the patient's peripheral leukocytes was analyzed for its nucleotide sequences in all 20 exons of the RET proto-oncogene, seven regions of the 1st to the 7th exon of the endothelin-B receptor gene and endothelin 3 gene, including sequences corresponding to proteolytic cleavage sites. The analysis revealed that adenine at the 2116th base in the 12th exon in the RET proto-oncogene was substituted by guanine, supposedly resulting in a mutation of Thr 706 to Ala. No other mutational change was observed in the gene examined in this case. Mutation analysis has not been described previously on the gene in this disease complex. Mutation in this case might impair the maturation of the tyrosine kinase protein and subsequently cause neurocristopathy supposedly originating from the neural crest.
Growth Hormone Deficiency in Patients With a 22q11.2 Deletion: Expanding the Phenotype
Authors: Weinzimer Stuart A. , McDonald-McGinn Donna M. , Driscoll Deborah A. , Emanuel Beverly S. , Zackai Elaine H. , Moshang Thomas
Published: August 2004

The list of findings associated with the 22q11.2 deletion is quite long and varies from patient to patient. The hallmark features include: conotruncal cardiac anomalies, palatal defects, thymic aplasia or hypoplasia, T cell abnormalites, mild facial dysmorphia, and learning disabilities. The 22q11.2 deletion has been seen in association with the DiGeorge sequence, velocardiofacial syndrome (VCFS), conotruncal anomaly face syndrome, isolated conotruncal cardiac anomalies, and some cases of autosomal dominant Opitz G/BBB syndrome. Short stature has been seen in one to two thirds of children reported in the literature with a diagnosis of VCFS, but growth hormone deficiency (GHD) has not been described in conjunction with this diagnosis. We present 4 patients with a 22q11.2 deletion and short stature who were found to have abnormalities in the growth hormone-insulin-like growth factor I axis. All had growth factors less than −2 SD for age and failed provocative growth hormone testing. Two patients were found to have abnormal pituitary anatomy. In our population, the incidence of GHD in 4 of 95 children with 22q11 deletion is significantly greater than the estimated incidence of GHD in the general population. Children with a 22q11.2 deletion appear to be at a greater risk for pituitary abnormalities. Therefore, those children with the 22q11.2 deletion and short stature or poor growth should be evaluated for GHD, as replacement growth hormone therapy may improve their growth velocity and final height prediction.
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Education in Schools
Authors:   Committee on Pediatric AIDS
Published: August 2004

This Policy Statement was retired May 2004.

The human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic has grown during the past 15 years. Education remains a critical component of our efforts to prevent HIV infection/AIDS in school children and young adults. To accomplish this goal, school personnel should receive updated information about HIV infection/AIDS so that accurate teaching on this topic can be included in the K–12 health education curriculum. Informed pediatricians and nurses can serve as important resources for school health services and administration to provide current information for the curriculum. Each community should have a school health advisory committee that enlists community support and provides input to health education programs in schools.
The Role of the Pediatrician in Rural EMSC
Authors:   Committee on Pediatric Emergency Medicine
Published: August 2004

This Policy Statement was revised. See https://doi.org/10.1542/peds.2012-2547.

In rural America pediatricians can play a key role in the development, implementation, and ongoing supervision of emergency medical services for children (EMSC). Often the only pediatric resource for a large region, rural access pediatricians are more likely to treat pediatric emergencies in their own offices, and are a vital resource for rural physicians, or other rural health care professionals (physician assistants, nurse practitioners), and emergency medical technicians (EMTs) to improve system-wide EMSC by providing education about issues from prevention to rehabilitation, technical assistance in protocol writing, hospital care, and data accumulation, and as advocates for community and state legislation to support the goals of EMSC.
Symptomatic Splenic Hamartoma: Case Report and Literature Review
Authors: Hayes Teresa C. , Britton Howard A. , Mewborne E. Bruce , Troyer Dean A. , Saldivar Victor A. , Ratner Irving A.
Published: August 2004

An 11-year-old girl with low-grade fever, night sweats, thrombocytopenia, and an 8-year history of progressive splenomegaly underwent an elective splenectomy. Pathologic diagnosis was multiple splenic hamartoma. The patient's symptoms resolved after the splenectomy. Since first described by Rokitansky in 1861, ∼140 cases of splenic hamartoma have been described in the literature. Most of the splenic hamartomas were discovered incidentally. A minority of these lesions were associated with hematologic symptoms such as pancytopenia, anemia, and thrombocytopenia. Only 20 of the reported cases of splenic hamartoma occurred in pediatric patients. However, compared with the adult patients, nearly half of these cases in pediatric patients was associated with symptoms. Splenectomy and partial splenectomy have relieved these symptoms. With advances in imaging, splenic hamartomas are being discovered with increasing frequency. A multimodal radiologic work-up has enabled some cases of splenic hamartoma to be diagnosed preoperatively. Inclusion of this benign entity in the differential diagnoses of symptomatic splenomegaly in a pediatric patient is important in the preoperative management and counseling of the patient and family. In patients who have discrete lesions, consideration of this entity preoperatively may avoid total splenectomy.
Adverse Effects of High-dose Vitamin A Supplements in Children Hospitalized With Pneumonia
Authors: Stephensen Charles B. , Franchi Luis Miguel , Hernandez Herminio , Campos Miguel , Gilman Robert H. , Alvarez Jose O.
Published: August 2004

Objective. To test the hypothesis that high-dose vitamin A supplements will enhance recovery of children hospitalized for the treatment of community-acquired pneumonia.

Design. We conducted a randomized, double-blind, placebo-controlled clinical trial of high-dose vitamin A supplements among children 3 months to 10 years of age (N = 95) admitted to hospital with community-acquired pneumonia in Lima, Peru. Children ≤1 year of age received 100 000 IU of water-miscible vitamin A on admission to the hospital and an additional 50 000 IU the next day. Children >1 year of age received 200 000 IU on admission and 100 000 IU the next day.

Results. Children receiving vitamin A (n = 48) had lower blood oxygen saturation (the mean difference on day 3 in hospital was 1.1%), higher prevalence rates of retractions (37% in the vitamin A group vs 15% in the placebo group on day 3), auscultatory evidence of consolidation (28% in the vitamin A group vs 17% in the placebo group on day 3), and were more likely to require supplemental oxygen (21% in the vitamin A group vs 8% in the placebo group on day 3) than children in the placebo group (n = 47). Adjustment for baseline severity of disease and nutritional status did not alter the association of vitamin A with increased clinical severity, although the difference in blood oxygen saturation was no longer statistically significant. No differences were seen in duration of hospitalization or in chest x-ray changes 14 days after admission. No deaths occurred, and toxicity of vitamin A was not seen.

Conclusions. This study indicates that high-dose vitamin A supplements cause modest adverse effects in children recovering from pneumonia and should not be used therapeutically in such patients unless there is clinical evidence of vitamin A deficiency or concurrent measles infection.
Attitudes of the Physician Membership of the Society for Adolescent Medicine Toward Medical Abortions for Adolescents
Authors: Miller Nancy H. , Miller David J. , Pinkston Koenigs Laura M.
Published: August 2004

Objective. To document the practices and attitudes of the US physician members of the Society for Adolescent Medicine (SAM) regarding adolescent abortion and contraception, as well as physician willingness to prescribe medical abortion if approved by the Food and Drug Administration (FDA).

Design. Cross-sectional questionnaire survey.

Participants. The entire physician membership of SAM (N = 1001) was surveyed. A total of 713 physicians responded, with 668 usable surveys yielding an adjusted response rate of 70%.

Results. Of the respondents, 81% were trained as pediatricians; 58% had additional adolescent medicine training. Ninety-six percent prescribed contraception for their patients. Sixty-one percent of respondents identified abortion as an option for pregnant adolescents in all circumstances, whereas 4% believed abortion should never be an option. Eighty-nine percent referred their patients for abortions; 90% were aware of medications to induce abortions medically. If these medications (methotrexate and misoprostol, RU-486) were FDA-approved, 42% would prescribe them for their patients; 34% were unsure. Fifty-four percent believed if medical abortions were routinely available, they should be available from primary care physicians.

Physicians were significantly more likely to consider prescribing medical abortions if the physician were female, offered postcoital contraception, performed Norplant insertions, referred adolescents for abortions, or performed postabortion medical checkups. Physicians were no more likely to consider prescribing medical abortions according to physician age, specialty training, or date of residency training. Religious affiliation per se was not associated with likelihood of prescribing medical abortions, but Catholic physicians were significantly less likely to consider prescribing medical abortions.

Conclusions. Virtually all SAM physician respondents (96%) reported that abortion for pregnant adolescents should be available under some circumstances. Forty-two percent would prescribe medical abortion if the medications were FDA-approved, suggesting that medical abortion would potentially be available to adolescents from a larger group of physicians than is currently available.
Anabolic Steroid Use by Male and Female Middle School Students
Authors: Faigenbaum Avery D. , Zaichkowsky Leonard D. , Gardner Douglas E. , Micheli Lyle J.
Published: August 2004

Background. The prevalence of anabolic steroid use by high school and college students has been reported in the literature. However, rumors persist regarding the use of steroids by younger populations.

Objective. To assess the extent of steroid use by male and female middle school students and to explore their attitudes and perceptions about these drugs.

Methods. A confidential self-report questionnaire was administered to 466 male and 499 female students between 9 and 13 years of age (mean ± SD, 11.4 ± 0.9 years) in 5th, 6th, and 7th grades from four public middle schools in Massachusetts. The number of students reporting steroid use and differences between users' and nonusers' underlying attitudes and perceptions about these drugs were evaluated.

Results. The response rate was 82% (965/1175 eligible). Results indicated that 2.7% of all middle school students reported using steroids; 2.6% were males and 2.8% were females. When steroid users were compared with nonusers, 47% versus 43% thought that steroids make muscles bigger; 58% versus 31% thought that steroids make muscles stronger; 31% versus 11% thought that steroids improve athletic performance; 23% versus 13% thought that steroids make one look better; 23% versus 9% knew someone their own age who currently took steroids; 38% versus 4% were asked by someone to take steroids; 54% versus 91% thought that steroids were bad for them; and 35% versus 2% indicated that they would take steroids in the future. Additional analyses determined steroid user involvement in sports and activities.

Conclusion. The results of this study suggest that the problem of illicit steroid use extends to children and young adolescents and that a segment of this population is mindful of the potential physiologic effects of steroids. This information will be useful to pediatricians, sport authorities, and school teachers whose guidance will become increasingly more important as steroid educational interventions for male and female middle school students are developed.
Early Dexamethasone Therapy in Preterm Infants: A Follow-up Study
Authors: Yeh Tsu F. , Lin Yuh J. , Huang Chao C. , Chen Yung J. , Lin Chyi H. , Lin Hong C. , Hsieh Wu S. , Lien Yu J.
Published: August 2004

Objectives. To study the outcome at 2-year corrected age of infants who participated in a double-blind controlled trial of early (<12 hours) dexamethasone therapy for the prevention of chronic lung disease (CLD).

Methods and Materials. A total of 133 children (70 in the control group, 63 in the dexamethasone-treated group) who survived the initial study period and lived to 2 years of age were studied. All infants had birth weights of 500 to 1999 g and had severe respiratory distress syndrome requiring mechanical ventilation within 6 hours after birth. For infants in the treatment group, dexamethasone was started at a mean age of 8.1 hours and given 0.25 mg/kg every 12 hours for 1 week and then tapered off gradually over a 3-week period. The following variables were evaluated: interim medical history, socioeconomic background, physical growth, neurologic examinations, mental and psychomotor development index score (MDI and PDI), pulmonary function, electroencephalogram, and auditory and visual evoked potential.

Results. Infants in the control group tended to have a higher incidence of upper respiratory infection and rehospitalization than did the dexamethasone-treated group because of respiratory problems. Although there was no difference between the groups in somatic growth in girls, the dexamethasone-treated boys had significantly lower body weight and shorter height than the control boys (10.7 ± 3.0 vs 11.9 ± 2.0 kg; 84.9 ± 5.7 vs 87.5 ± 4.8 cm). The dexamethasone-treated group had a significantly higher incidence of neuromotor dysfunction (25/63 vs 12/70) than did the control group. The dexa-methasone-treated infants also had a lower PDI score (79 ± 26) than did the control group (87 ± 23), but the difference was not statistically significant. Both groups were comparable in MDI, incidence of vision impairment, and auditory and visual evoked potential. Significant handicap, defined as severe neurologic defect and/or intellectual defect (MDI and/or PDI ≤ 69), was seen in 22 children (31.4%) in the control group and 26 (41.2%) in the dexamethasone-treated group.

Conclusions. Although early postnatal dexamethasone therapy for 4 weeks significantly reduces the incidence of CLD, this therapeutic regimen cannot be recommended at present because of its adverse effects on neuromotor function and somatic growth in male infants, detected at 2 years of age. A longer follow-up is needed. If early dexamethasone therapy is to be used for the prevention of CLD, the therapeutic regimen should be modified. The proper route of administration, the critical time to initiate the therapy, and the dosage and duration of therapy remain to be defined further.
Valproate Therapy Does Not Deplete Carnitine Levels in Otherwise Healthy Children
Authors: Hirose Shinichi , Mitsudome Akihisa , Yasumoto Sawa , Ogawa Atsushi , Muta Yukiko , Tomoda Yasuko
Published: August 2004

Objective. To determine whether children with epilepsy undergoing valproate (VPA) antiepileptic therapy and who are otherwise healthy have a lower serum level of carnitine (CAR) and a higher plasma level of plasma ammonia than do normal children.

Methodology. A total of 45 children with epilepsy, 6.3 to 21.7 years of age, who were treated solely with VPA and were free of abnormal neurologic findings or nutritional problems were randomly selected (VPA-treated group). An age-matched control group (n = 45) was selected from subjects without epilepsy (control group). Total (T) and free (F) serum CAR, serum VPA concentration, and the plasma ammonia level were measured and analyzed.

Results. Serum VPA concentration exhibited a weak negative correlation with both T- (r = −0.34) and F-CAR (r = −0.41). The T-CAR levels were 55.7 ± 12.4 and 57.6 ± 12.1 mM, and the F-CAR levels 42.7 ± 9.9 and 44.4 ± 9.9 mM in the VPA-treated and control groups, respectively. Thus, there was no significant difference in T- or F-CAR levels between the VPA-treated and control groups. Plasma ammonia levels were the same in the two groups: 26 ± 9.2 and 29.4 ± 11.8 mM in the VPA-treated and control groups, respectively. There was no significant correlation between blood ammonia and either T- (r = +0.024) or F-CAR (r = −0.026).

Conclusion. Children on a regular diet ingest a sufficient amount of CAR that more than meets their daily CAR requirement. The level of neither T- nor F-CAR in patients with epilepsy and without severe neurologic or nutritional problems being treated with VPA appeared to be affected by VPA therapy. Because the blood CAR level depends on nutritional condition rather than on blood VPA concentration, CAR deficiency caused by VPA is not likely to occur in this population. The usefulness of supplementation of CAR for this type of patient with epilepsy, therefore, must be reevaluated carefully.
Baclofen Overdose: Drug Experimentation in a Group of Adolescents
Authors: MD Holly E. Perry , MD Robert O. Wright , MD Michael W. Shannon , MD Alan D. Woolf
Published: August 2004

Background. Baclofen, a lipophilic analog of gamma-aminobutyric acid, is clinically used to control spasticity. We report a mass exposure to baclofen in adolescents seeking intoxication; toxicokinetic data are included.

Case Series. A group of adolescents became symptomatic after ingesting 3 to 30 20-mg tablets of baclofen during a party at a suburban Boys' Club. Several children were noted to be very lethargic by chaperones, ingestion was suspected, and paramedics were called. Some white tablets were found in a couch at the site of the party. The Massachusetts Poison Control Center was called, and the tablets were identified as baclofen (20 mg). Fourteen patients were taken to local hospitals; 9 required intubation. Eight adolescents were transferred to our institution. In these 8 patients, symptoms were noted within 1 to 2 hours after overdose. The most common clinical findings included coma (7), hypothermia (6), bradycardia (5), hypertension (4), and hyporeflexia (8). Mean length of mechanical ventilation was 40 hours. Three patients had unifocal premature ventricular contractions. Two patients had tonic–clonic seizures. A single dose of activated charcoal was given to all patients. Drugs administered included nifedipine (1), flumazenil (1), naloxone (1), lorazepam (2), and phosphenytoin (2). All patients recovered and were discharged home within 5 days of ingestion.

Serial serum baclofen levels were obtained in all intubated patients (range, 0.049 to 6.0; normal, 0.08 to .40 μg/mL). Levels obtained 14 hours after ingestion showed a linear correlation with length of mechanical ventilation (R2 = 0.9863). Persistent symptoms were noted in some patients, despite nondetectable baclofen levels. Toxicologic screening for drugs of abuse was negative except in 2 patients with ethanol levels, both <5 mg/dL.

Conclusion. Baclofen overdose may result in coma, apnea, autonomic disturbances, cardiac conduction abnormalities, and seizures. Levels obtained shortly after overdose correlate with length of mechanical ventilation.
The Potential Benefits of the Pediatric Nonheartbeating Organ Donor
Authors: Koogler Tracy , Costarino Andrew T.
Published: August 2004

Objective. To examine the population of the pediatric intensive care unit in a large children's hospital to determine the potential importance of pediatric nonheartbeating organ donors (NHBDs).

Study Design. We analyzed retrospectively the 6307 admissions to the pediatric intensive care unit at the Children's Hospital of Philadelphia from January 1992 to July 1996 to identify all deaths. The hospital records of the children who had died were then reviewed to determine the mode of death, organ donation rate of heartbeating donors, and the number of potential NHBDs. Criteria for the NHBD included the decision to forgo life-sustaining therapy, death occurring within 2 hours of withdrawal of life support, and the absence of sepsis, HIV, hepatitis, or extracranial malignancy.

Results. Of 319 deaths, 102 (32.0%) died with resuscitation, 84 (26.3%) were brain-dead, 111 (34.8%) had withdrawal of life support, and 22 (6.9%) were on do-not-resuscitate orders. Of the 84 brain-dead children, 74 (88.1%) were medically suitable heartbeating donors, and 43 (58.1%) donated organs. Of the 111 patients who had life support withdrawn, 31 (27.9%) qualified for NHBDs.

Conclusions. The routine use of the NHBD has the potential to increase organ donation at our institution by 42%. We discuss the ethical issues relating to NHBDs required to properly include these patients as potential organ donors.
The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women
Authors:   Committee on Child Abuse and Neglect
Published: August 2004

Pediatricians are in a position to recognize abused women in pediatric settings. Intervening on behalf of battered women is an active form of child abuse prevention. Knowledge of local resources and state laws for reporting abuse are emphasized.
Initiating the First DTP Vaccination Age-appropriately: A Model for Understanding Vaccination Coverage
Authors: Ross Alan , Kennedy Anne Baber , Holt Elizabeth , Guyer Bernard , Hou William , Hughart Nancy
Published: August 2004

Objective. Our earlier research found that the strongest predictor of not being up to date on the full series of immunizations by 24 months is failure to receive the first diphtheria vaccine and tetanus toxoid and pertussis vaccine (DTP1) on time. To learn more about the relationship between successful vaccination during the DTP1 age-appropriate (DTP1-AA) period (between 42 and 92 days of life, inclusive) and an infant's early visit to the physician (before 42 days of life), we quantified children's progression through a sequence of provider visits and outcomes.

Design. This study analyzed data from 426 children living in the 57 poorest census tracts in Baltimore. For each DTP1-AA visit, we calculated the percentage of times a DTP1-AA vaccination, provider missed opportunity, or deferral for a valid contraindication occurred. Relative and attributable risks were computed to assess associations between DTP1-AA vaccination and early visits and missed opportunities.

Results. We found the following: 1) Children who made a visit before 42 days of life were more than twice as likely to receive a DTP1-AA vaccination; 2) the missed opportunity rate for children who did not make an early visit was approximately twice that of the early-visit group; and 3) well visits were more likely to result in DTP1-AA immunization than sick visits. Attributable risk calculations show that DTP1-AA vaccination rates could be increased in this population by one third if all infants had an early visit.

Conclusions. Early in-office visits seem to make DTP1-AA vaccination more likely. These rates may be amenable to intervention by increasing early visits and reducing DTP1-AA missed opportunities. Introduction of the hepatitis B vaccine to the recommended series may place more emphasis on early visits and result in increased DTP1-AA rates and, ultimately, higher vaccination coverage rates.
Emergency Department Utilization by Adolescents in the United States
Authors: Ziv Amitai , Boulet Jack R. , Slap Gail B.
Published: August 2004

Background. Adolescents in the United States have been shown to underutilize primary care services and therefore may rely heavily on emergency service. Although several small studies have explored local emergency services for youth, there are no published reports of adolescent utilization of emergency services on a national scale. Furthermore, emergency services data have not been aggregated according to the age subgroups used by the current guidelines for adolescent care.

Objective. To explore the utilization of emergency departments in the United States by early (11 to 14 years), middle (15 to 17 years), and late (18 to 21 years) adolescent subgroups.

Design. Secondary analysis of the emergency department component of the 1994 National Hospital Ambulatory Medical Care Survey.

Setting. Nationally representative sample of 418 emergency departments in the United States.

Patients. Approximately 26 547 visits by patients of all ages, representing 93.4 million total visits in 1994 and 14.8 million adolescent visits.

Outcome Measures. Number of visits, health insurance, reasons for visits, urgency of visits, resulting diagnoses, and hospitalization rates.

Results. Adolescents accounted for 15.4% of the population and 15.8% of emergency department visits in 1994. Late adolescents were overrepresented in emergency department visits relative to their population proportion (6.8% of visits, 5.3% of population), whereas early adolescents were underrepresented (4.6% of visits, 5.9% of population). Lack of health insurance was more common among 11- to 21-year-olds (26.2%) than either children (13.6%) or adults (22.7%). By ages 18 to 21 years, 40.5% of male visits and 27.6% of female visits were uninsured. Injury-related visits were more common among adolescents (28.6%) than either children (23.1%) or adults (18.2%). Injury was the leading reason for visits among all adolescent age-sex subgroups (36.6% to 42.0% of male visits and 14.1% to 27.2% of female visits) except females aged 18 to 21 years for whom digestive reasons ranked first (18.8%). Injury was the leading diagnosis for all adolescent age-sex subgroups, with peaks at early adolescence of 61.6% for males and 45.8% for females. Across all adolescent age-sex subgroups, 3.1% to 5.3% of visits resulted in hospitalization, and 41.0% to 52.5% of visits were urgent. These rates did not differ from those of children but were lower than those of adults.

Conclusions. Utilization of emergency departments increases and health insurance decreases during adolescence, suggesting that adolescents with inadequate health insurance may rely heavily on emergency departments for their health care needs. Most adolescent visits to emergency departments are not urgent and might be better treated through nonemergency, primary care sites.
Length of Stay, Jaundice, and Hospital Readmission
Authors: Maisels M. Jeffrey , Kring Elizabeth
Published: August 2004

Objective. To evaluate the effect of postnatal age at the time of discharge on the risk of readmission to hospital with specific reference to readmission for hyperbilirubinemia.

Design. Case-control study based on chart review.

Setting. Large suburban community hospital in southeastern Michigan, delivering more than 5000 infants annually.

Patients. Newborn infants, born between December 1, 1988, and November 30, 1994, who were readmitted to hospital within 14 days of discharge, were compared with a randomly selected control group who were not readmitted.

Results. Of 29 934 infants discharged, 247 (0.8%) were readmitted by the age of 14 days. One hundred twenty-seven (51%) were admitted because of hyperbilirubinemia and 74 (30%) with the diagnosis of “rule out sepsis.” The factors associated with an increased risk of readmission to the hospital were: infant of diabetic mother [odds ratios (OR), 3.45; 95% confidence limits (CL), 1.39 to 8.60]; gestation ≤36 weeks (OR, 4.56; CL, 1.45 to 14.33), and 3717 to 38 weeks (OR, 2.95; CL, 1.63 to 5.35) versus ≥40 weeks; presence of jaundice in the nursery (OR, 1.73; CL, 1.14 to 2.63); breastfeeding (OR, 1.78; CL, 1.13 to 2.81); male sex (OR, 1.58; CL, 1.07 to 2.34); length of stay <48 hours (OR, 1.91; CL, 1.15 to 3.16) and 48 to <72 hours (OR, 2.09; CL, 1.25 to 3.50) versus ≥72 hours. Factors associated with readmission for jaundice were gestation ≤36 weeks (OR, 13.2; CL, 2.70 to 64.6), 3617 to 37 weeks (OR, 7.7; CL, 2.69 to 22.0), 3717 to 38 weeks (OR, 7.2; CL, 3.05 to 16.97) versus ≥40 weeks; jaundice during nursery stay (OR, 7.80; CL, 3.38 to 18.0); length of stay <48 hours (OR, 2.40; CL, 1.09 to 5.30) and 48 to <72 hours (OR, 3.15; CL, 1.40 to 7.09) versus ≥72 hours; male sex (OR, 2.89; CL, 1.46 to 5.74); and breastfeeding (OR, 4.21; CL, 1.80 to 9.87). Infants whose length of stay was <48 hours were at no greater risk for readmission for jaundice or other causes than those whose length of stay was ≥48 hours to <72 hours.

Conclusions. Discharge at any time <72 hours significantly increases the risk for readmission to hospital and the risk for readmission with hyperbilirubinemia when compared with discharge after 72 hours. The American Academy of Pediatrics recommends that infants discharged <48 hours should be seen by a health care professional within 2 to 3 days of discharge. Our observations, as well as those of others, suggest that this recommendation should also be extended to those discharged at <72 hours after birth. One approach to decreasing the risk of morbidity and readmission, particularly from hyperbilirubinemia, would be to help mothers to nurse their infants more effectively from the moment of birth.
Screening for Urinary Tract Infection in Infants in the Emergency Department: Which Test Is Best?
Authors: Shaw Kathy N. , McGowan Karin L. , Gorelick Marc H. , Schwartz J. Sanford
Published: August 2004

Objective. Comparison of rapid tests and screening strategies for detecting urinary tract infection (UTI) in infants.

Methods. Cross-sectional study conducted in an urban tertiary care children's hospital emergency department and clinical laboratories of 3873 infants <2 years of age who had a urine culture obtained in the emergency department by urethral catheterization; results of urine dipstick tests for leukocyte esterase or nitrites, enhanced urinalysis (UA) (urine white blood cell count/mm3plus Gram stain), Gram stain alone, and dipstick plus microscopic UA (white blood cells and bacteria per high-powered field) compared with urine culture results (positive urine results defined as ≥104 colony-forming units per milliliter of urinary tract pathogen) for each sample. Cost comparison of 1) dipstick plus culture of all urine specimens versus 2) cell count ± Gram stain of urine, culture only those with positive results.

Results. The enhanced UA was most sensitive at detecting UTI (94%; 95% confidence interval: 83,99), but had more false-positive results (16%) than the urine dipstick or Gram stain (3%). The most cost-effective strategy was to perform cultures on all infants and begin presumptive treatment on those whose dipstick had at least moderate (+2) leukocyte esterase or positive nitrite at a cost of $3.70 per child. With this strategy, all infants with UTI were detected. If the enhanced UA was used to screen for when to send the urine for culture, 82% of cultures would be eliminated, but 4% to 6% of infants with UTI would be missed and the cost would be higher ($6.66 per child).

Conclusion. No rapid test can detect all infants with UTI. Physicians should send urine for culture from all infants and begin presumptive treatment only on those with a significantly positive dipstick result. The enhanced UA is most sensitive for detecting UTI, but is less specific and more costly, and should be reserved for the neonate for whom a UTI should not be missed at first visit.
Racial/Ethnic Differences in the Decision to Breastfeed Among Adolescent Mothers
Authors: Wiemann Constance M. , DuBois Jacqueline C. , Berenson Abbey B.
Published: August 2004

Objective. To identify racial/ethnic differences in prevalence and the factors that influence decisions to breastfeed among adolescent mothers.

Methods. A total of 696 Mexican-American, African-American, and Caucasian adolescent mothers ≤18 years of age were interviewed on the postpartum ward of university hospital within 48 hours of delivery. Self-reported factors associated with the decision to breastfeed were assessed.

Results. The decision to breastfeed was reported by 55% of Mexican-American, 45% of Caucasian, and 15% of African-American adolescent mothers. With the exception of perceived benefits of breastfeeding and exposure to educational materials, most factors associated with breastfeeding differed by race/ethnicity. Among Mexican-Americans, important factors included having relied on feeding advice (adjusted odds ratio [AOR] = 7.6); the feeding preference of a partner (AOR = 7.0) or mother (AOR = 6.6); and feeding decisions made in early pregnancy (AOR = 4.7). Among African-Americans, important factors included living with a partner (AOR = 10.6); having a mother who breastfed (AOR = 5.9); the feeding preference of a partner (AOR = 5.6) or health care provider (AOR = 4.7); and low family support (AOR = 3.4). Among Caucasians, health care providers' feeding preference (AOR = 6.1); having two or more breastfeeding role models (AOR = 4.1); not being enrolled in Women, Infants, and Children's Supplemental Nutrition Program (AOR = 3.0); having relied on infant-feeding advice (AOR = 3.0); and prenatal alcohol use (AOR = 2.6) were associated with the decision to breastfeed.

Conclusions. Prevalence and influences to breastfeed differ by patient race/ethnicity. We speculate that targeting the adolescent mother and members of her support system, educating them before and during pregnancy, and stressing benefits of this method while eliminating misinformation, especially among African-Americans, may be important intervention strategies to promote breastfeeding.
Childhood Caffeine Tic Syndrome
Authors: Davis Richard E. , Osorio Ivan
Published: August 2004

Objective. To determine whether caffeine ingestion was temporally correlated with tics in 2 healthy children.

Methods. Two first-degree cousins were observed over a period of ∼3 years, and the presence and absence of tics was recorded and correlated with consumption of or abstinence from caffeinated foods or beverages.

Results. Appearance and disappearance of tics were closely and clearly temporally correlated with ingestion and elimination of caffeine in the cousins' diets.

Conclusions. Our observations suggest that caffeine may precipitate tics in susceptible children.
Circumcision Practice Patterns in the United States
Authors: Stang Howard J. , Snellman Leonard W.
Published: August 2004

Objective. To determine 1) the performing of circumcision by medical specialty, gender, and years of practice; 2) the pattern of anesthetic use for this procedure; and 3) the reasons physicians cite for not using anesthesia.

Design. A total of 3066 questionnaires were received from a mailing to a representative sampling of physicians stratified by specialty and geographic location.

Results. Fifty-eight percent (1768) of the questionnaires were returned and interpretable from the following specialists: pediatricians (PEDs), 73% (n = 691); family practitioners (FPs), 52% (n = 464); and obstetricians (OBs), 51% (n = 623).

Of the respondents, 956 (54%) perform at least one circumcision per month (35% of PEDs; 60% of FPs; 70% of OBs). Of the physicians performing circumcisions, 45% use anesthesia (71% of PEDs; 56% of FPs; 25% of OBs). Of physicians using anesthesia, 85% use dorsal penile nerve block.

A significantly higher percentage of male physicians (57%) are performing circumcisions than are females (45%), but there was no difference in the percent using anesthesia. Recently trained PEDs and FPs were more likely to use anesthetics than were their older colleagues, but OB use of pain relief was independent of their practice longevity. Physicians in the western states were significantly more likely to use anesthesia than were other physicians from the rest of the United States.

Respondents who did not use anesthesia cited “concern over adverse drug effects” (54%) followed by “procedure does not warrant anesthesia” (44%) as the most common explanations.

Conclusions. A substantial number of PEDs are performing circumcisions, and they are most likely to use anesthesia (71%), followed by FPs (56%), then OBs (25%). With recent recognition of the importance of pain reduction in neonatal procedures and the lack of substantiated contraindications to newborn anesthetic use, additional education of current practitioners, residents, and parents is required to increase the use of anesthesia for circumcision.
Ifosfamide-induced Nephrotoxicity in Children: Critical Review of Predictive Risk Factors
Authors: Loebstein Ronen , Koren Gideon
Published: August 2004

Ifosfamide is widely used in the treatment of pediatric solid tumors. Its main adverse effects are various forms of renal tubular and glomerular damage. Many risk factors have been proposed to play a role in the development and severity of nephrotoxicity in children receiving ifosfamide, among which are 1) patient's age, 2) cumulative ifosfamide dose, 3) concurrent administration of cis or carboplatinum, 4) unilateral nephrectomy, and 5) method of ifosfamide administration. However, presently there is no consensus regarding the weight of each one of them. Therefore, we critically reviewed the major studies that have evaluated the different risk factors in an attempt to determine the relative importance of each.

Cumulative ifosfamide doses of ≥60 g/m2 appears to be the most consistent independent predictor for both the development and the severity of nephrotoxicity, whereas a younger age (<5 years of age) was associated primarily with the more severe and chronic forms of proximal tubulopathy. Comparable incidence and severity forms of proximal tubulopathy among children who had been treated with cis platinum in addition to ifosfamide and those who had not indicate that platinums probably potentiate ifosfamide-induced renal damage rather than act as a major independent risk factor. Finally, although unilateral nephrectomy has been proposed as a significant risk factor in different studies, the relatively small number of nephrectomized children in these cohorts limit the strength of this association.

To reduce the frequency and severity of ifosfamide-induced nephrotoxicity, it appears that cumulative doses of 60 g/m2should be considered carefully, especially in children <5 years of age.
Periorbital Vasculitis Complicating Kawasaki Syndrome in an Infant
Authors: Felz Michael W. , Patni Arif , Brooks Steven E. , Tesser Rachel A.
Published: August 2004

Periorbital vasculitis is a previously unreported complication of Kawasaki syndrome (KS). We describe an infant with severe KS refractory to initial management with salicylate and intravenous immunoglobulin (IVIG). Retreatment with IVIG and high-dose pulsed steroids was required for persistent fever and inflammatory manifestations. Despite aggressive medical therapy, a large left coronary artery aneurysm developed. After apparent complete KS remission, acute periorbital vasculitis developed in the left upper eyelid and orbit, requiring operative intervention for diagnosis and high-dose pulsed steroids for therapy. The significance of this previously unreported ophthalmic complication of KS is reviewed, along with a discussion of the role of steroids in KS manifestations refractory to IVIG.
A Phase I/II Study of the Protease Inhibitor Indinavir in Children With HIV Infection
Authors: Mueller Brigitta U. , Sleasman John , Nelson Robert P. , Smith Sharon , Deutsch Paul J. , Ju William , Steinberg Seth M. , Balis Frank M. , Jarosinski Paul F. , Brouwers Pim , Mistry Goutam , Winchell Gregory , Zwerski Sheryl , Sei Shizuko , Wood Lauren V. , Zeichner Steve , Pizzo Philip A.
Published: August 2004

Background. Indinavir, an inhibitor of the human immunodeficiency virus type 1 (HIV-1) protease, is approved for the treatment of HIV infection in adults when antiretroviral therapy is indicated. We evaluated the safety and pharmacokinetic profile of the indinavir free-base liquid suspension and the sulfate salt dry-filled capsules in HIV-infected children, and studied its preliminary antiviral and clinical activity in this patient population. In addition, we evaluated the pharmacokinetic profile of a jet-milled suspension after a single dose.

Methods. Previously untreated children or patients with progressive HIV disease despite antiretroviral therapy or with treatment-associated toxicity were eligible for this phase I/II study. Three dose levels (250 mg/m2, 350 mg/m2, and 500 mg/m2 per dose given orally every 8 h) were evaluated in 2 age groups (<12 years and ≥12 years). Indinavir was initially administered as monotherapy and then in combination with zidovudine and lamivudine after 16 weeks.

Results. Fifty-four HIV-infected children (ages 3.1 to 18.9 years) were enrolled. The indinavir free-base suspension was less bioavailable than the dry-filled capsule formulation, and therapy was changed to capsules in all children. Hematuria was the most common side effect, occurring in 7 (13%) children, and associated with nephrolithiasis in 1 patient. The combination of indinavir, lamivudine, and zidovudine was well tolerated. The median CD4 cell count increased after 2 weeks of indinavir monotherapy by 64 cells/mm3, and this was sustained at all dose levels. Plasma ribonucleic acid levels decreased rapidly in a dose-dependent way, but increased toward baseline after a few weeks of indinavir monotherapy.

Conclusions. Indinavir dry-filled capsules are relatively well tolerated by children with HIV infection, although hematuria occurs at higher doses. Future studies need to evaluate the efficacy of indinavir when combined de novo with zidovudine and lamivudine.
An Epidemiologic Profile of Children With Special Health Care Needs
Authors: Newacheck Paul W. , Strickland Bonnie , Shonkoff Jack P. , Perrin James M. , McPherson Merle , McManus Margaret , Lauver Cassie , Fox Harriette , Arango Polly
Published: August 2004

Objective. To present an epidemiologic profile of children with special health care needs using a new definition of the population developed by the federal Maternal and Child Health Bureau.

Methods. We operationalized the new definition using the recently released 1994 National Health Interview Survey on Disability. Estimates are based on 30 032 completed interviews for children <18 years old. The overall response rate was 87%.

Results. Eighteen percent of US children <18 years old in 1994, or 12.6 million children nationally, had a chronic physical, developmental, behavioral, or emotional condition and required health and related services of a type or amount beyond that required by children generally. This estimate includes children with existing special health care needs but excludes the at-risk population. Prevalence was higher for older children, boys, African-Americans, and children from low-income and single-parent households. Children with existing special health care needs had three times as many bed days and school absence days as other children. An estimated 11% of children with existing special health care needs were uninsured, 6% were without a usual source of health care, 18% were reported as dissatisfied with one or more aspects of care received at their usual source of care, and 13% had one or more unmet health needs in the past year.

Conclusions. A substantial minority of US children were identified as having an existing special health care need using national survey data. Children with existing special health care needs are disproportionately poor and socially disadvantaged. Moreover, many of these children face significant barriers to health care.
Decreasing Nonurgent Emergency Department Utilization by Medicaid Children
Authors: Grossman Lindsey K. , Rich Leslie N. , Johnson Catherine
Published: August 2004

Objective. To test interventions to decrease the utilization of hospital emergency departments (EDs) for routine, nonemergent health care among Medicaid recipients.

Methods. Families of a Medicaid-recipient child presenting to a children's hospital ED for nonurgent problems received information from either a health professional or a clerical employee about the importance of a primary care provider and assistance with making an appointment to the provider of their choice. The health professional continued to work with her assigned families in eliminating barriers to appropriate utilization of a primary care provider for up to 3 months after the index ED visit. A third (comparison) group received no intervention. Subsequent health care utilization for each enrollee was tracked via Ohio Medicaid claims data throughout the four subsequent 6-month periods after the index ED visit.

Results. Children in the intervention groups had 11.1% and 14.5% fewer nonurgent ED visits in the 6 months after the index ED visit with a concomitant decrease in cost for this type of care when compared with the comparison group during the same time period. No difference in the number of preventive or ill-child primary care visits was seen. There was no difference in health care cost or utilization in the time period 6 to 24 months after the intervention.

Conclusions. Interventions in pediatric EDs aimed at decreasing subsequent ED utilization for nonurgent care can be effective, resulting in modest decreases in the cost of health care for a Medicaid population.