bluuebunny/crossref_metadata_2025 huggingface dataset:
Adjusting Our View of Injury Risk: The Burden of Nonfatal Injuries in Infancy
Authors: Powell Elizabeth C. , Tanz Robert R.
Published: August 2004

Objective. To describe the incidence, external cause, and types of injuries among infants treated in US emergency departments (EDs) and to compare the external cause of nonfatal to fatal injuries.

Design. ED survey from the National Center for Health Statistics (NCHS) National Hospital Ambulatory Medical Care Survey for 1992–1999 and NCHS mortality data.

Patients. National probability sample of patients treated in EDs; data for children <1 year old were used.

Outcome Measures. Incidence and external cause of nonfatal injury among infants. Rates were calculated using NCHS data for live births.

Results. The 8-year annualized, weighted estimate of infant injuries was 426 957, a rate of 108.2 per 1000 infant years (95% confidence interval [CI]: 94.8–121.5). There were no significant differences in rates by sex, race, or ethnicity. An estimated 6% were admitted to the hospital (admission rate: 6.1 per 1000). Most injuries occurred in the home. Head trauma accounted for injuries in 12% of children (injury rate: 13.4 per 1000 per year [95% CI: 9.3–17.3]; 21% of children with head trauma had a skull fracture or an intracranial injury. An estimated 30.2 per 1000 (95% CI: 23.8–36.6) had face trauma and 23.9 per 1000 (95% CI: 18.2–29.6) had extremity injuries; open wounds or superficial injuries accounted for many of these injuries. An estimated 4% had extremity fractures (annual rate: 4.6/1000). Falls were the most frequent cause of injury (an estimated 35.1 per 1000 infant years). The rate of motor vehicle traffic injuries was 8.8 per 1000. Foreign bodies accounted for an estimated 5.2 injuries and poisonings for an estimated 3.8 injuries per 1000 infant years. A comparison with infant mortality data showed the ratio of nonfatal to fatal falls to be 8789:1. The ratio of nonfatal to fatal motor vehicle traffic injuries was 197:1. There were an estimated 1271 nonfatal poisonings for each poisoning fatality.

Conclusions. Nonfatal injuries far outnumber fatalities. Injuries from falls are very common, but they are rarely fatal. Surveillance of nonfatal injuries is essential to accurately describe and understand the burden of injury among infants. Prevention strategies must be developed to address extremely frequent, less serious injuries in infancy.
The Future of Pneumococcal Conjugate Vaccines for Prevention of Pneumococcal Diseases in Infants and Children
Authors: Pelton Stephen I. , Klein Jerome O.
Published: August 2004

Seven-valent pneumococcal conjugate vaccine (PCV7) was licensed in February 2000. In June 2000, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics recommended the universal administration of pneumococcal conjugate vaccine for all children 23 months of age and younger and for children 24 to 59 months of age who are at high risk for serious pneumococcal disease. Since then, >23 million doses have been administered in the United States. Postlicensure surveillance of invasive pneumococcal disease (IPD) in the United States from the Active Bacterial Core Surveillance program at the Centers for Disease Control and Prevention and the Northern California Kaiser Permanente Vaccine Study Center has reported a decline in IPD and in pneumococcal disease incidence as a result of vaccine serotypes, respectively. During this period, issues critical to the long-term success of PCV7 have become more relevant: Will PCV7 be as effective in groups of children who are at high risk for IPD as in healthy children? Will nonvaccine types replace vaccine serotypes in the nasopharynx and in disease? Why are the results of the clinical trials different for IPD and for acute otitis media? How many doses of PCV7 and what concentrations of antibody are necessary for protection? Will universal administration of PCV7 to children younger than 2 years reduce antimicrobial drug resistance and alter prescribing patterns of physicians for febrile infants? Have there been unanticipated adverse events or benefits observed? The purpose of this report is to review the current data available to address these questions and to identify gaps that will require additional knowledge to determine the ultimate value of pneumococcal conjugate vaccines in reducing the burden of pneumococcal disease in infants and children.
Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: Addendum
Authors:   Committee on Drugs
Published: August 2004

The purpose of this addendum to the 1992 policy statement is to clarify some of the terms used in that document and to more thoroughly delineate the responsibilities of the practitioner when sedating children.
Smallpox Vaccine
Authors:   Committee on Infectious Diseases
Published: August 2004

This Policy Statement was retired January 2006.

After an extensive worldwide eradication program, the last nonlaboratory case of smallpox occurred in 1977 in Somalia. In 1972, routine smallpox immunization was discontinued in the United States, and since 1983, vaccine production has been halted. Stockpiled vaccine has been used only for laboratory researchers working on orthopoxviruses. In recent years, there has been concern that smallpox virus stocks may be in the hands of bioterrorists, and this concern has been heightened by the terrorist attack on the World Trade Center and the Pentagon on September 11, 2001. Because most of the population is considered to be nonimmune, there is debate as to whether smallpox immunization should be resumed. This statement reviews the current status of smallpox vaccine, the adverse effects that were associated with smallpox vaccine in the past, and the major proposals for vaccine use. The statement provides the rationale for a policy based on the so-called ring vaccination strategy recommended by the Centers for Disease Control and Prevention, in which cases of smallpox are rapidly identified, infected individuals are isolated, and contacts of the infected individuals as well as their contacts are immunized immediately.
Summary Statistics for Pediatric Psychiatric Visits to US Emergency Departments, 1993–1999
Authors: Sills Marion R. , Bland Shayne D.
Published: August 2004

Objectives. To describe characteristics of emergency department (ED) encounters for pediatric patients with an acute mental health diagnosis.

Methods. Data are from the National Hospital Ambulatory Medical Care Survey, which includes abstracts from the medical records of a national probability sample of visits to EDs. Analysis was limited to records of patients who were younger than 19 years and had a diagnosis of either confirmed or suspected mental disorder or a suicide attempt.

Results. There was an estimated annual average of 434 000 ED pediatric mental health visits from 1993 to 1999, an average annual rate of 326.8 visits per 10 000 people. Visit rates varied by patient’s region, age, race, and gender. Psychosis was the diagnosis in 10.8% of these patients, and suicide attempt was the diagnosis in 13.6%. ED pediatric mental health visits accounted for 1.6% of all ED visits in this age group.

Conclusions. The significant increase in emergency department pediatric mental health (EDPMH) visits from 1993–1999 is greatest among patients who are non-white, teenaged, female, and live in the Northeast or Midwest. This variation in EDPMH visits may reflect variability in the shortage of mental health providers. The lack of increase in the 2 categories of diagnoses mandatorily seen in EDs—psychoses and suicide attempts—suggests that the overall rise in EDPMH visits may have been attributable to nonurgent complaints more appropriately managed by a primary mental health provider.
Patterns of Colonization WithUreaplasma urealyticumDuring Neonatal Intensive Care Unit Hospitalizations of Very Low Birth Weight Infants and the Development of Chronic Lung Disease
Authors: Castro-Alcaraz Susana , Greenberg Ellen M. , Bateman David A. , Regan Joan A.
Published: August 2004

Background. Ureaplasma urealyticum and its association with chronic lung disease (CLD) of prematurity has remained a controversial topic. To readdress this question, we performed a longitudinal study using culture and polymerase chain reaction to detect U urealyticum in the respiratory tract of very low birthweight infants throughout their neonatal intensive care unit hospitalizations.

Methods. We screened 125 infants weighing <1500 g and/or <32 weeks’ gestational age over a 12-month period, collecting endotracheal, nasopharyngeal, and throat specimens on days of age 1, 3, 7, and weekly thereafter. CLD was defined as dependency on supplemental oxygen at 28 days and at 36 weeks’ postconceptional age.

Results. Forty infants (32%) had 1 or more positive specimens by culture or polymerase chain reaction. We identified 3 patterns of U urealyticum colonization: persistently positive (n = 18), early transient (n = 14), and late acquisition (n = 8). We compared the rates of CLD in each of the 3 colonized groups with the rate of CLD in the noncolonized group. We found a significantly higher rate of CLD at 28 days of age (odds ratio: 8.7; 95% confidence interval: 3.3, 23) and at 36 weeks’ postconception (odds ratio: 38.5, 95% confidence interval: 4.0, 374) only for infants with persistently positive colonization.

Conclusions. This study demonstrates that the risk of developing CLD varies with the pattern of U urealyticum colonization. Only the persistently positive colonization pattern, which accounted for 45% of the U urealyticum-positive infants, was associated with a significantly increased risk of development of CLD.
Paroxysmal Nonepileptic Events in Children and Adolescents
Authors: Kotagal Prakash , Costa Maristela , Wyllie Elaine , Wolgamuth Barbara
Published: August 2004

Objective. Paroxysmal nonepileptic events (PNEs) are frequently encountered in children and adolescents; however, there is little information concerning the relative frequency of various types of these disorders. We report our experience with PNEs in a group of children and adolescents who underwent prolonged video-electroencephalographic monitoring.

Methods. During a 6-year period, 883 patients were monitored in the Pediatric Epilepsy Monitoring Unit and 134 patients (15.2%) were documented to have PNEs on the basis of a typical spell recorded during monitoring. Their hospital charts were reviewed and videotapes of these events were analyzed.

Results. Patients were divided into 3 age groups: 1) the Infant, Toddler, and Preschool Group (2 months–5 years) that comprised 26 patients. The most common diagnoses were stereotyped movements, hypnic jerks, parasomnias, and Sandifer syndrome. Concomitant epilepsy was present in 12 patients (46%). 2) The School-Age Group (5–12 years) consisted of 61 patients. The most frequent diagnoses were conversion disorder (psychogenic seizures), inattention or daydreaming, stereotyped movements, hypnic jerks, and paroxysmal movement disorders. Fifteen patients (25%) had concomitant epilepsy. 3) The Adolescent Group (12–18 years) consisted of 48 patients, of whom 40 patients (83%) were diagnosed with conversion disorder. Nine patients (19%) had concomitant epilepsy.

Conclusions. In our patients with PNEs, conversion disorder was seen in children >5 years old and its frequency increased with age, becoming the most common type of PNEs among adolescents. In adolescents, conversion disorder was more common in females, whereas males predominated in the school-aged group. Concomitant epilepsy with nonepileptic events occurred in all 3 age groups to a varying extent.
Stunting May Determine the Severity of Malaria-Associated Anemia in African Children
Authors: Verhoef Hans , West Clive E. , Veenemans Jacobien , Beguin Yves , Kok Frans J.
Published: August 2004

Objective. Evidence from previous studies that malnourished children are protected against malaria is controversial. In individuals repeatedly exposed to malaria, immunity may develop first against severe disease, then against pyrogens, and last, against parasites. If this is true, this would suggest that reduced immune function that may exist in stunted children exacerbates the severity of malarial signs and symptoms, rather than the occurrence of parasitemia. On the other hand, several studies have suggested that malnourished children are protected to some degree against malaria. Our aim was to evaluate whether observational data support the hypothesis that nutritional inadequacies that cause stunting modify the associations between malaria and hematologic indicators such as hemoglobin concentration and serum concentrations of C-reactive protein and soluble transferrin receptor (sTfR). We showed earlier that increased serum concentrations of these receptors in asymptomatic malaria may be explained, at least in part, by increased erythropoiesis to compensate for malaria-induced hemolysis.

Methodology. Community-based cluster survey among Kenyan children aged 2 to 36 months asymptomatic for malaria or anemia (n = 318).

Results. When adjusted for age and wasting, the malaria-associated decrease in mean hemoglobin concentration was 8.5 g/L and 15.8 g/L in nonstunted and stunted children, respectively. The malaria-associated increase in geometric mean serum concentrations of sTfR was 1.1-fold and 1.8-fold in nonstunted and stunted children, respectively. The malaria-associated increase in geometric mean serum concentrations of C-reactive protein was 1.4-fold and 2.3-fold in nonstunted and stunted children, respectively. Thus, children with malaria and those who were stunted suffered from more severe anemia and had higher serum concentrations of C-reactive protein and sTfR than would be expected from the combined effect of the 2 working independently.

Conclusions. Our results are consistent with the notion that the nutritional inadequacies causing stunting also impair host immunity, thus increasing the degree to which malaria is associated with decreased concentrations of hemoglobin, with increased inflammation, and with increased iron demand in developing erythroblasts. Increased intake of micronutrients may not only reduce stunting and nutritional anemia, but also reduce malaria-associated anemia.
Differences in Admission Rates of Children With Bronchiolitis by Pediatric and General Emergency Departments
Authors: Johnson David W. , Adair Carol , Brant Rollin , Holmwood Joanne , Mitchell Ian
Published: August 2004

Objective. It is uncertain whether pediatric and general emergency departments have different admitting practices regarding children with bronchiolitis. The objective of this study was to quantify the differences in admission practices between pediatric and general emergency departments of children with bronchiolitis in 1 North American metropolitan area, controlling for various factors such as clinical severity, comorbid conditions, and socioeconomic status.

Design. Retrospective cohort review of emergency department visits from April 1992 to March 1997.

Setting. Five emergency departments (1 pediatric and 4 general) serving the Calgary Health Region, which encompasses ∼850 000 people.

Patients. All children residing within the region who visited a regional emergency department and were diagnosed to have bronchiolitis (International Classification of Diseases, Ninth Revision code 466.1, primary or secondary diagnosis).

Main Outcome Measure. Population-standardized estimates of admission rates.

Results. The medical charts of 3091 children diagnosed to have bronchiolitis during the study period were reviewed. Of this number, 2496 children were evaluated at the pediatric emergency department, and 629 (25%) were admitted. The remaining 595 (19%) were evaluated at the general emergency departments, and 221 (37%) were admitted. Controlling for age, gender, estimated family income based on postal code, medical comorbidity, and clinical severity estimated by presenting respiratory rate and room air oxygen saturation, population-standardized estimates for admission rates at the pediatric and general emergency departments were 24% (standard error: 1%) and 43% (standard error: 2%), respectively.

Conclusion. Children diagnosed to have bronchiolitis at the Calgary Health Region’s pediatric emergency department were about half as likely to be admitted to the hospital as children diagnosed at the region’s general emergency departments.
Moderate Hyperbilirubinemia Induces a Transient Alteration of Neonatal Behavior
Authors: Paludetto Roberto , Mansi Giuseppina , Raimondi Francesco , Romano Antonia , Crivaro Valeria , Bussi Marianna , D’Ambrosio Giovanna
Published: August 2004

Objective. To investigate the behavioral changes induced by moderate hyperbilirubinemia in the otherwise healthy, untreated newborn infant.

Methods. Fifty term neonates (23 boys) with untreated moderate hyperbilirubinemia (median: 14.3 mg/dL; range: 13.2–20 mg/dL) and 50 matched control subjects with lower bilirubin concentrations (median: 9.1 mg/dL; range: 5.3–12 mg/dL) were administered the Brazelton Neonatal Behavioral Scale at 87 hours of life (range: 72–110 hours). A subgroup analysis was also performed at 104 hours of life (range: 96–134 hours) and at 3 weeks of age.

Results. At the first examination, all behavioral clusters were significantly altered in the group with moderate hyperbilirubinemia. The visual and auditory capabilities of the hyperbilirubinemic infant were especially compromised. Although social-interactive cluster scores significantly correlated both with serum bilirubinemia and birth weight, the former accounted for 8.7% of the variance and the latter accounted for only 4.7%. The moderate hyperbilirubinemia neonates’ scores also showed a negative correlation with the autonomic system and more frequent presence of tremors. After 24 hours, a decrease in serum bilirubin within the moderate hyperbilirubinemic group was associated with improved scores. At 3 weeks of age, the behavioral assessment of the 2 groups did not show significant differences.

Conclusions. Untreated moderate hyperbilirubinemia is associated with a transient and apparently reversible alteration of neonatal behavior, particularly in the social-interactive area.
Caller Satisfaction With After-Hours Telephone Advice: Nurse Advice Service Versus On-Call Pediatricians
Authors: Lee Thomas J. , Guzy Judith , Johnson David , Woo Heide , Baraff Larry J.
Published: August 2004

Objective. To compare caller satisfaction with after-hours medical advice provided by a for-profit nurse advice service with advice provided by on-call pediatricians.

Methods. The study setting was the general pediatrics faculty practice of an urban university medical center. Participants were parents or guardians of a population of ∼6000 children calling for after-hours medical advice over a 10-month period from January 18 to November 20, 2000. After-hours medical advice calls were randomized to either a nurse advice service or the on-call pediatrician. Caller satisfaction and subsequent health care utilization were measured by a telephone survey of callers and review of all health care visits within 3 days of the initial telephone advice call.

Results. Five hundred sixty-six (48%) callers were enrolled in the on-call pediatrician group, and 616 (52%) were enrolled in the advice nurse group. Caller satisfaction was rated as very good or excellent significantly more often for the on-call pediatrician than for the nurse advice service as follows: telephone call overall (68.5% vs 55.0%; 95% confidence interval [CI] of difference: 8.0%–19.0%), thoroughness and competence of the person they spoke with (74.0% vs 59.1%; 95% CI of difference: 9.6%–20.2%), courtesy and friendliness of the person they spoke with (77.4% vs 73.9%; 95% CI of difference: −1.4%-8.4%), length of time spent waiting (70.8% vs 60.1%; 95% CI of difference: 5.4%–16.2%), time spent talking with the on-call pediatrician or advice nurse (68.2% vs 52.4%; 95% CI of difference: 10.2%–21.3%), and the medical advice given (68.6% vs 53.9%; 95% CI of difference: 9.2%–20.1%). Compliance with the advice given was significantly higher for office care in the on-call pediatrician group (51.5% vs 29.6%; 95% CI of difference: 8.9%–34.2%). Repeat calls for advice were significantly more frequent for the nurse advice service, both within 4 hours (13.0% vs 4.8%; 95% CI of difference: 5.0%–11.4%), and within 72 hours (23.4% vs 13.3%; 95% CI of difference: 5.8%–14.5%).

Conclusion. Callers were less satisfied with medical advice provided by a nurse advice service compared with the traditional on-call pediatrician. The lower satisfaction was associated with somewhat poorer compliance with recommended triage dispositions and more frequent repeat calls for medical advice.
Lead and Mercury in Breast Milk
Authors: Gundacker Claudia , Pietschnig Beate , Wittmann Karl J. , Lischka Andreas , Salzer Hans , Hohenauer Leonhard , Schuster Ernst
Published: August 2004

Objective. Heavy metals are potentially toxic substances, especially for the susceptible infant. Exposure to mercury (Hg) and lead (Pb) may result in neurotoxic and nephrotoxic impairment and in anemia. Previous data on breast milk Pb and Hg contents are sparse or missing for the Austrian population. No evaluations of the influence of mothers’ lifestyles on Pb and Hg levels in breast milk are available.

Methods. Five- to 10-mL individual samples of breast milk were provided from healthy mothers in Vienna (urban; n = 59), Linz (industrial; n = 47), and Tulln (rural; n = 59). A questionnaire about area of residence, maternal nutrition, smoking habits, and dental fillings was filled out by the lactating mothers. Milk samples and infant formulas were lyophilized, wet-ashed with nitric acid (65%), and analyzed with atomic absorption spectrophotometry. Spiked skim milk powder was used as reference material. Statistical analysis included the Kruskal-Wallis test and multiple robust regression analysis.

Results. Breast milk showed low Hg and Pb concentrations (Hg: 1.59 ± 1.21 1g/l, n = 116; Pb: 1.63 ± 1.66 6g/l, n = 138). Eight percent of the breast milk samples marginally exceeded the screening level of 3.5 μg/L for Hg. Austrian Pb values declined strongly during the last 20 years. Bivariate comparison revealed that the factors significantly related to metal levels in breast milk were area of residence (Hg, Pb), prematurity (Hg), consumption of fish (Pb) and cereals (Hg), vitamin supplementation (Hg), and smoking (Pb). The Hg and Pb contents of cow milk and infant formulas were far below respective guideline values.

Conclusions. Neither Hg nor Pb concentrations exceeded critical levels. There are no reports on infants harmed by the intake of milk from unexposed mothers. We conclude that even theoretical risks from current Hg or Pb levels for the breastfed infant of a healthy mother can be ruled out.
Cardiorespiratory Stability of Premature and Term Infants Carried in Infant Slings
Authors: Stening Waltraud , Nitsch Patrizia , Wassmer Gernot , Roth Bernhard
Published: August 2004

Objective. Parents in industrialized societies make increasing use of infant slings to carry their infants. This study was conducted to determine whether infants who are carried in slings are at risk of experiencing clinically relevant changes in cardiorespiratory measurements.

Methods. In a 3-period crossover trial, 24 preterm and 12 term newborns were continually monitored while being carried horizontally or vertically in a sling or lying in a pram. Oxygen saturation, heart rate, nasal airflow, abdominal breathing, and movements were recorded.

Results. Infants who were carried in slings were not at risk of clinically relevant changes of oxygen saturation or heart rate. The 90% confidence interval of oxygen saturation in both infant sling positions remained within a ±2% interval around the average oxygen saturation in the pram. However, a significant decrease of oxygen saturation was observed while infants were carried in a sling with a mean oxygen saturation of 96.3% (standard deviation [SD]: 1.8) in the vertical and 96.1% (SD: 2.0) in the horizontal sling position compared with the mean oxygen saturation in the pram (97.1%; SD: 1.5). The degree and the incidence of desaturations and bradycardia did not change while the infants were carried. Both types of episodes were seen only in preterm infants.

Conclusion. The use of carrying slings is not associated with an increased risk of clinically relevant cardiorespiratory changes in term and preterm infants.
Effect of Supplemental Oxygen on Sleep Architecture and Cardiorespiratory Events in Preterm Infants
Authors: Simakajornboon Narong , Beckerman Robert C. , Mack Cindy , Sharon Denise , Gozal David
Published: August 2004

Objective. To investigate the effect of low-flow supplemental oxygen (SupOx) on sleep architecture and cardiorespiratory events in asymptomatic preterm infants.

Methods. An overnight polysomnographic evaluation was conducted prospectively in 23 premature infants who were born at 30.0 ± 3.2 (standard deviation) weeks’ gestational age and studied at 38.1 ± 4.4 weeks’ postconceptional age. Infants were free of any adverse events, including cardiorespiratory monitor alarms in the nursery for at least 1 week before the study. Infants received room air (RA) or SupOx via nasal cannula at 0.25 L/min.

Results. Quiet sleep density was increased during SupOx (33.3 ± 10.8% vs 26.6 ± 10.0% total sleep time [TST] in RA), and a reciprocal decrease in active sleep density was observed (61.5 ± 11.1% vs 68.4 ± 9.9% TST in RA). No differences in sleep efficiency emerged (69.7 ± 10.6% SupOx vs 69.7 ± 8.8% RA). SupOx elicited significant decreases in apnea index (3.8 ± 2.4 events/h vs 11.1 ± 6.4 events/h in RA) and in the percentage of time spent in periodic breathing (1.8 ± 2.9% vs 6.7 ± 8.9% in RA). In addition, SupOx decreased the frequency of bradycardic events (0.3 ± 0.8 events vs 2.5 ± 0.03 events in RA) and improved overall oxygen saturation (98.7 ± 1.1% vs 96.4 ± 2.2%). No changes in alveolar ventilation, as derived from end-tidal CO2 measurements, was detected (38.6 ± 5.8 mm Hg in SupOx vs 38.4 ± 5.4 mm Hg in RA).

Conclusions. Asymptomatic preterm infants exhibit frequent and potentially clinically adverse cardiorespiratory events when assessed in the sleep laboratory. Administration of SupOx to these infants is associated with an increase in the overall duration and percentage TST spent in quiet sleep with reciprocal changes in active sleep. In addition, improvement in respiratory stability is observed with the use of low-flow SupOx, as evidenced by a decrease in apnea, periodic breathing, and bradycardia, without adverse effects on alveolar ventilation.
Short-Term Growth Hormone Treatment in Girls With Turner Syndrome Decreases Fat Mass and Insulin Sensitivity: A Randomized, Double-Blind, Placebo-Controlled, Crossover Study
Authors: Gravholt Claus Højbjerg , Naeraa Rune Weis , Brixen Kim , Kastrup Knud William , Mosekilde Leif , Jørgensen Jens Otto Lunde , Christiansen Jens Sandahl
Published: August 2004

Background. Most girls with Turner syndrome (TS) receive growth hormone (GH) treatment during childhood and adolescence, but controlled data on the effects on body composition and glucose metabolism are lacking.

Objective. To study the effects of GH treatment on insulin sensitivity, glucose metabolism, bone turnover, and body composition.

Methods. A randomized, placebo-controlled, crossover study was conducted with girls with TS. All girls with TS were treated with GH 0.1 IU/kg/d subcutaneously at bedtime or with placebo for 2 months and studied at the end of each period. Control subjects were studied once without treatment. Twelve girls with TS, aged 9.5 to 14.8 years (median: 12.9 years) and 16 age-matched control subjects (10.3–16.0 years; median: 12.1 years) were studied. Twenty-four-hour sampling of blood was performed; GH, insulin-like growth factor I (IGF-I), IGF binding proteins (IGFBPs), insulin, glucose, and lipolytic and gluconeogenic precursors were assayed, followed by an oral glucose tolerance test. Body composition was evaluated by dual-energy x-ray absorptiometry scanning and body mass index (BMI). Fasting bone markers were measured.

Results. Height was reduced in TS as compared with control subjects. In the placebo situation, 24-hour integrated GH as well as IGF-I was significantly reduced in girls with TS compared with control subjects. Controlling for differences in lean body mass (LBM; or fat mass [FM]) and sexual development did not explain the difference in 24-hour integrated GH. Differences in sexual development, BMI, FM, insulin sensitivity, and IGFBP-3 could explain the difference in IGF-I between TS and control subjects. Carbohydrate metabolism in TS was comparable with control subjects. GH treatment induced insulin resistance, with increments in fasting glucose andinsulin, as well as 24-hour insulin. Circulating levels of lipid and gluconeogenic substrates were comparable in TS and control subjects and unchanged in response to treatment. Bone markers increased in response to GH. Total FM was increased in girls with TS, accounted for by an increased FM in the arms and trunk, whereas LBM was decreased. Especially LBM in the legs was decreased. Overall, bone mineral content was diminished. Treatment with GH reduced FM in TS, especially in the arms and legs, and likewise increased total LBM, primarily in the trunk.

Conclusion. This study documented evidence of impaired GH secretion and action, disproportionate body composition, but a normal carbohydrate metabolism in girls with TS. Short-term GH administration was associated with favorable changes in body composition but also with relative impairment of glucose tolerance and insulin sensitivity. We recommend that glucose metabolism be monitored carefully during long-term GH treatment in these patients.
National Estimates of the Timing of Sexual Maturation and Racial Differences Among US Children
Authors: Sun Shumei S. , Schubert Christine M. , Chumlea William Cameron , Roche Alex F. , Kulin Howard E. , Lee Peter A. , Himes John H. , Ryan Alan S.
Published: August 2004

Objective. To provide clinically meaningful, normative reference data that describe the timing of sexual maturity indicators among a national sample of US children and to determine the degree of racial/ethnic differences in these estimates for each maturity indicator.

Methods. Tanner staging assessment of sexual maturity indicators was recorded from 4263 non-Hispanic white, black, and Mexican American girls and boys aged 8.00 to 19.00 years as part of the Third National Health and Nutrition Examination Survey (NHANES III) conducted between 1988 and 1994. NHANES III followed a complex, stratified, multistage probability cluster design. SUDAAN was used to calculate the mean age and standard error for each maturity stage and the proportion of entry into a maturity stage and to incorporate the sampling weight and design effects of the NHANES III complex sampling design. Probit analysis and median age at entry into a maturity stage and its fiducial limits were calculated using SAS 8.2.

Results. Reference data for age at entry for maturity stages are presented in tabular and graphical format. Non-Hispanic black girls had an earlier sexual development for pubic hair and breast development either by median age at entry for a stage or for the mean age for a stage than Mexican American or non-Hispanic white girls. There were few to no significant differences between the Mexican American and non-Hispanic white girls. Non-Hispanic black boys also had earlier median and mean ages for sexual maturity stages than the non-Hispanic white and Mexican American boys.

Conclusion. Non-Hispanic black girls and boys mature early, but US children completed their sexual development at approximately the same ages. The present reference data for the timing of sexual maturation are recommended for the interpretation of assessments of sexual maturity in US children.
Discrepancies Between Direct and Indirect Blood Pressure Measurements Using Various Recommendations for Arm Cuff Selection
Authors: Clark Jeff A. , Lieh-Lai Mary W. , Sarnaik Ashok , Mattoo Tej K.
Published: August 2004

Objective. The current recommendation for choosing an appropriate size cuff for measuring blood pressure (BP) is a bladder width to equal 40% of the upper arm circumference (UAC). However, most physicians use the older two-thirds or three-fourths upper arm length (UAL) recommendations to choose a cuff. The aim of this study was to verify the disparity in cuff size by using two-thirds UAL, three-fourths UAL, and 40% UAC criteria for cuff selection and to compare the indirectly measured BP by these criteria with directly measured radial intra-arterial BP.

Methods. A prospective, cross-sectional, observational study was conducted in 65 hemodynamically stable patients, aged 5 days to 22 years. Direct BP measurements were obtained from a radial intra-arterial catheter. Indirect BP measurements were taken from the same arm as the arterial catheter with a mercury sphygmomanometer and standard-size arm cuffs. UAL and UAC of each patient were measured, and the 3 cuffs closest to two-thirds and three-fourths UAL and 40% UAC were used. For each cuff, 3 direct and 3 indirect BP measurements were taken. Student t test was used to compare mean systolic and diastolic BP for direct and indirect measurements.

Results. A total of 172 observations were recorded, including 56 by two-thirds UAL, 55 by three-fourths UAL, and 61 by 40% UAC criteria. There was no significant difference between the means of the ideal cuff size by 40% UAC criterion and the actual cuffs used from the available standard cuffs. However, because of an unavailability of the larger cuffs for UAL criteria, the actual cuffs used were significantly smaller than ideal. Comparison of direct and indirect BP measurements revealed no significant difference in systolic BP when the latter was obtained by 40% UAC criterion. However, the difference in diastolic BP was significant. With available cuffs, a significant difference in systolic as well as diastolic BP was seen with both UAL criteria.

Conclusions. Practitioners are likely to use significantly larger arm cuffs when following the two-thirds and three-fourths UAL criteria than when following the 40% UAC criterion. Of the 3 criteria for cuff selection, systolic BP by 40% UAC criterion most accurately reflects directly measured radial arterial pressure. However, the 40% UAC cuff significantly overestimates the diastolic pressure. Using available cuffs for indirect measurements by two-thirds and three-quarters UAL criteria significantly underestimates systolic as well as diastolic BP when compared with radial intra-arterial BP.
Time Lag to Diagnosis of Stroke in Children
Authors: Gabis Lidia V. , Yangala Ravi , Lenn Nicholas J.
Published: August 2004

Objective. Strokes occur rarely in children, and the causes are different from those in adults. Frequently, more than 1 cause is found. The consequences are lifelong significant disability in a majority of cases. Children who are younger than 18 years have not been included in therapeutic trials of thrombolytic or neuroprotective agents. We evaluated whether children who receive a diagnosis of stroke meet a major inclusion criterion for such trials, namely time to diagnosis of <3 to 6 hours.

Methods. Prospective documentation and retrospective chart review was conducted of children who were 0 to 18 years and carried a diagnosis of stroke during the last 2 years in the hospital database, including children who presented with either ischemic or hemorrhagic strokes.

Results. Forty-seven events were encountered in 41 children. Twelve neonates with stroke, diagnosed in the neonatal period, were excluded from the subsequent analysis. In the remaining 29 children, the mean age at presentation was 8.67 years. Accurate time records were available in 24 children. In this group, 28 events were recorded. Time from clinical onset to first medical contact averaged 28.5 hours, and the time to diagnosis of stroke averaged 35.7 hours. We subsequently separated between children with ischemic (21 documented events) and hemorrhagic strokes (7 documented events), because the presentation and the intervention options are different.

Conclusions. Stroke in children is rarely diagnosed in the time frame of 3 to 6 hours. Given the causes and outcome of stroke in children, this age group might benefit from thrombolysis and from neuroprotective therapy, yet the long delay in diagnosis in this age group excludes most cases from being considered for such treatments. This situation should encourage attempts to increase public and professional awareness of stroke in children and of the potential value of early diagnosis and treatment, preferably by broadening current educational efforts to all age groups.
Hepatitis B Vaccination Among Adolescents in 3 Large Health Maintenance Organizations
Authors: González Idalia M. , Averhoff Francisco M. , Massoudi Mehran S. , Yusuf Hussain , DeStefano Frank , Kramarz Piotr , Maher Julie E. , Mullooly John P. , Chun Colleen , Davis Robert L. , Black Steven B. , Shinefield Henry R. ,   the Vaccine Safety Datalink Team
Published: August 2004

Objective. In 1995, the Advisory Committee on Immunization Practices (ACIP) recommended routine hepatitis B (HB) vaccination of all unvaccinated 11- to 12-year-old adolescents. Little is known about the implementation of these recommendations in a managed care setting. The objective of this study was to determine the impact of ACIP recommendations on HB vaccination among adolescents in 3 managed care settings.

Methods. We assessed HB vaccination coverage among adolescents who were enrolled in 3 large health maintenance organizations (HMOs) and who turned 13 years old after the 1995 ACIP recommendations. Children who were 8 to 10 years of age during May 1993 and were continuously enrolled through December 1998 were eligible. We used the HMOs’ computerized immunization tracking system to collect HB vaccination dates. The percentage of adolescents who received 3 doses of HB vaccine was determined.

Results. In HMOs A, B, and C, coverage levels for 3 doses of HB vaccine were 43.4%, 65.5%, and 25.7%, respectively, among 13-year-olds in 1998 compared with 26.1%, 50.4%, and 5.5% among 13-year-olds in 1996. Between the ages of 11 and 13 years, coverage rates among adolescents aged 13 in 1998 rose more than the coverage among adolescents aged 13 in 1996. The proportion of 13-year-olds in 1998 who received the first dose of HB vaccine by December 1998 was much higher at 89.6%, 65.2%, and 56.6% in HMOs A, B, and C, respectively, compared with the proportion who completed the 3-dose series (43.4%, 65.5%, and 25.7%, respectively).

Conclusions. After the 1995 ACIP recommendations, HB vaccination coverage levels among 13-year-olds increased in each of the HMOs, suggesting adherence with national recommendations. Differences among the 3 HMOs may reflect differences in internal policies. More effective strategies may be needed to achieve the Healthy People 2010 goal of 90% vaccination coverage rates among adolescents.
Timeliness of Childhood Immunizations
Authors: Luman Elizabeth T. , McCauley Mary Mason , Stokley Shannon , Chu Susan Y. , Pickering Larry K.
Published: August 2004

Objective.To examine the timeliness of vaccine administration among infants and young children in the United States.

Methods. We analyzed age at receipt of vaccines among 16 211 children aged 24 to 35 months in the 2000 National Immunization Survey and examined receipt at the recommended time of each dose and selected vaccination series, as well as receipt at 4 additional time frames: acceptably early, late, never by 24 months, and too early to be considered valid. We also examined the relationship between timeliness of vaccinations and characteristics of the child, mother, and immunization provider, using multivariate logistic regression.

Results. Only 9% of children received all recommended vaccines at the recommended ages. The rates varied significantly by antigen, ranging from 24% for all Haemophilus influenzae type b doses to 75% for all hepatitis B doses as recommended. Overall, 55% of children did not receive all recommended doses by 24 months of age, and 8% of children received at least 1 vaccination dose too early to be considered valid. Factors associated with not receiving all vaccines as recommended were having more children in the household, mothers younger than 30 years, use of public providers, and multiple vaccination providers.

Conclusions. By 24 months of age, 9 of 10 children received at least 1 vaccine outside the recommended age ranges. High vaccination status of children at 24 months of age does not reflect the reality that many vaccinations are not given at the appropriate ages. Timeliness of vaccination is critical to prevent disease outbreaks, protect children through their first 2 years of life, and minimize the need to repeat doses.
Effect of Child Health Insurance Plan Enrollment on the Utilization of Health Care Services by Children Using a Public Safety Net System
Authors: Eisert Sheri , Gabow Patricia
Published: August 2004

Objective. To examine differences in health care services utilization between children who are enrolled in the Child Health Insurance Plan (CHIP) and uninsured children and between children before and during their enrollment period in CHIP.

Methods. Denver County CHIP enrollment data from 1998 through 2000 were merged with Denver Health utilization data from 1998 through 2000 to determine utilization rates for CHIP-enrolled children at Denver Health (n = 2005). The first method compared the rates of CHIP-enrolled children with those of uninsured children (n = 20 374) during the same time period. The second method compared the utilization of services for children enrolled in CHIP during 1999 before CHIP enrollment (n = 748) and during CHIP enrollment (n = 757). The outcomes measured include emergency, urgent care, specialty care, well-child care, dental visits, and immunizations.

Results. For the first method, CHIP children were more likely to have well-child care, dental, and specialty visits and the recommended immunizations than uninsured children. They were less likely to have an emergency care visit than uninsured children. For the second method, before enrolling in CHIP, children had fewer outpatient visits and were less likely to have a well-child care visit than during their enrollment span in CHIP. There was not a significant difference before and during enrollment for the other outcome measures for these children.

Conclusions. These results indicate that children who are enrolled in CHIP are more likely to receive preventive care services and less likely to use emergency care than uninsured children, even within a safety net institution, emphasizing the benefits of public insurance programs for children.
Asthma Management and Environmental Tobacco Smoke Exposure Reduction in Latino Children: A Controlled Trial
Authors: Hovell Melbourne F. , Meltzer Susan B. , Wahlgren Dennis R. , Matt Georg E. , Hofstetter C. Richard , Jones Jennifer A. , Meltzer Eli O. , Bernert J. Thomas , Pirkle James L.
Published: August 2004

Objectives. This study tested the efficacy of coaching to reduce environmental tobacco smoke (ETS) exposure among asthmatic Latino children.

Design. After asthma management education, families were randomly assigned to no additional service (control condition) or to coaching for ETS exposure reduction (experimental condition).

Setting. The study was conducted in San Diego, California.

Participants. Two hundred four Latino children (ages 3–17 years) with asthma participated.

Intervention. Approximately 1.5 hours of asthma management education was provided; experimental families also obtained 7 coaching sessions (∼45 minutes each) to reduce ETS exposure.

Outcome Measures. Reported ETS exposure and children’s urine cotinine were measured.

Results. Parents in the coached condition reported their children exposed to significantly fewer cigarettes than parents of control children by 4 months (postcoaching). Reported prevalence of exposed children decreased to 52% for the coached families, but only to 69% for controls. By month 4, mean cotinine levels decreased among coached and increased among control children. Cotinine prevalence decreased from 54% to 40% among coached families, while it increased from 43% to 49% among controls. However, cotinine levels decreased among controls to the same level achieved by coached families by the 13-month follow-up.

Conclusions. Asthma management education plus coaching can reduce ETS exposure more than expected from education alone, and decreases in the coached condition may be sustained for about a year. The delayed decrease in cotinine among controls is discussed.
Neurologic Disorders After Measles-Mumps-Rubella Vaccination
Authors: Mäkelä Annamari , Nuorti J. Pekka , Peltola Heikki
Published: August 2004

Objective. The possibility of adverse neurologic events has fueled much concern about the safety of measles-mumps-rubella (MMR) vaccinations. The available evidence concerning several of the postulated complications is controversial. The aim of this study was to assess whether an association prevails between MMR vaccination and encephalitis, aseptic meningitis, and autism.

Methods. A retrospective study based on linkage of individual MMR vaccination data with a hospital discharge register was conducted among 535 544 1- to 7-year-old children who were vaccinated between November 1982 and June 1986 in Finland. For encephalitis and aseptic meningitis, the numbers of events observed within a 3-month risk interval after vaccination were compared with the expected numbers estimated on the basis of occurrence of encephalitis and aseptic meningitis during the subsequent 3-month intervals. Changes in the overall number of hospitalizations for autism after vaccination throughout the study period were searched for. In addition, hospitalizations because of inflammatory bowel diseases were checked for the children with autism.

Results. Of the 535 544 children who were vaccinated, 199 were hospitalized for encephalitis, 161 for aseptic meningitis, and 352 for autistic disorders. In 9 children with encephalitis and 10 with meningitis, the disease developed within 3 months of vaccination, revealing no increased occurrence within this designated risk period. We detected no clustering of hospitalizations for autism after vaccination. None of the autistic children made hospital visits for inflammatory bowel diseases.

Conclusions. We did not identify any association between MMR vaccination and encephalitis, aseptic meningitis, or autism.
Gastroesophageal Reflux and Cow Milk Allergy: Is There a Link?
Authors: Salvatore Silvia , Vandenplas Yvan
Published: August 2004

Gastroesophageal reflux (GER) and cow milk allergy (CMA) occur frequently in infants younger than 1 year. In recent years, the relation between these 2 entities has been investigated and some important conclusions have been reached: in up to half of the cases of GER in infants younger than 1 year, there may be an association with CMA. In a high proportion of cases, GER is not only CMA associated but also CMA induced. The frequency of this association should induce pediatricians to screen for possible concomitant CMA in all infants who have GER and are younger than 1 year. With the exception of some patients with mild typical CMA manifestations (diarrhea, dermatitis, or rhinitis), the symptoms of GER associated with CMA are the same as those observed in primary GER. Immunologic tests and esophageal pH monitoring (with a typical pH pattern characterized by a progressive, slow decrease in esophageal pH between feedings) may be helpful if an association between GER and CMA is suspected, although the clinical response to an elimination diet and challenge is the only clue to the diagnosis. This article reviews the main features of GER and CMA, focusing on the aspects in common and the discrepancies between both conditions.