bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes After Judicious Antibiotic Use for Respiratory Tract Infections Seen in a Private Pediatric Practice
Authors: Pichichero Michael E. , Green John L. , Francis Anne B. , Marsocci Steven M. , Murphy Marie L.
Published: August 2004

Background.

Most respiratory tract infections (RTIs) in children have a viral cause, they resolve on their own, and antibiotics need not be prescribed.

Objective.

We sought to provide evidence that judicious antibiotic use can be accomplished in private pediatric practice without observing an increase in return office visits or in the rate of bacterial infections that may follow.

Study Design.

This was a prospective 12-month study from July 1, 1996 through June 30, 1997. On the same 1 day each week, a representative convenience sample of acute respiratory tract illness patients was enrolled, and laboratory studies performed as appropriate, including viral cultures on all. Children were then followed for 30 days to ascertain the outcomes of not prescribing antibiotics except when specific bacterial infections were present at the initial visit.

Results.

Three hundred eighty-three children were enrolled; 293 (77%) did not receive antibiotics at the enrollment visit. Ninety children (23%) received antibiotics based on a diagnosis of acute otitis media (n = 53), acute streptococcal tonsillopharyngitis (n = 18), or other presumed or documented bacterial infections (n = 19). An unscheduled return visit related to the initial visit occurred for 86 (29%) of the 293 children not receiving antibiotics initially and in 40 (44%) of 90 children receiving antibiotics initially. Eighty-seven children (23%) had positive viral culture results. The most frequently isolated viruses were adenovirus, enterovirus, parainfluenzae virus, and influenza virus.

Conclusion.

Children with RTIs without a concomitant presumed or proven bacterial infection do not require antibiotics. In this busy office practice, >75% of the children presenting with an RTI did not have a presumed or proven bacterial infection. These children did not have a higher rate of return office visits or an increase in bacterial infections. This reinforces the judicious use of antibiotics in managing children with RTIs. outcomes, antibiotic, respiratory infections.
Access to Health Care for Children With Special Health Care Needs
Authors: Newacheck Paul W. , McManus Margaret , Fox Harriette B. , Hung Yun-Yi , Halfon Neal
Published: August 2004

Objective.

To assess the role health insurance plays in influencing access to care and use of services by children with special health care needs.

Methods.

We analyzed data on 57 553 children younger than 18 years old included in the 1994–1995 National Health Interview Survey on Disability. The survey obtained information on special health care needs, insurance status, and access to and use of health services. Bivariate and multivariate analyses were used to assess the association of insurance with several measures of access and utilization, including usual source of care, site of usual care, missed or delayed care, and use of ambulatory physician services.

Results.

Using the federal Maternal and Child Health Bureau definition of children with special health care needs, we estimate that 18% of US children under 18 years old had an existing special health care need in 1994–1995. An estimated 89% of these children had some form of health insurance coverage, most often private health insurance. Insured children were more likely than uninsured children to have a usual source of care (96.9% vs 79.2%). Among those with a usual source of care, insured children were more likely than uninsured children to have an identified regular clinician (87.6% vs 80.7%). Insured children were less likely to report unmet health needs, including medical care (2.2% vs 10.5%), dental care (6.1% vs 23.9%), prescriptions, and/or eyeglasses (3.1% vs 12.3%), and mental health care (.9% vs 3.4%). Insured children were also more likely to have a physician contact in the past year (89.3% vs 73.6%) and have more physician contacts on an annual basis (8.5 vs 4.1 contacts). Unexpectedly, no differences were found between insured and uninsured children in availability of after hours medical care (evenings and weekends) or satisfaction with care. We also found some modest differences in access between publicly and privately insured children. Privately insured children were more likely to have a usual source of care (97.6% vs 95.3%) and a regular clinician (91.0% vs 81.1%). Privately insured children were also less likely to report dissatisfaction with care at their usual site of care (14.9% vs 21.0%) and have access to care on evenings and weekends (6.8% vs 13.4%). No substantial differences were found between privately and publicly insured children in prevalence of unmet health needs or delays in obtaining care due to cost.

Conclusions.

This study illustrates the importance of health insurance for children with special health care needs. Continued efforts are needed to ensure that all children with special health care needs have insurance and that remaining access and utilization barriers for currently insured children with special health care needs are also addressed.
Potential to Prevent Carbon Dioxide Rebreathing of Commercial Products Marketed to Reduce Sudden Infant Death Syndrome Risk
Authors: Carolan Patrick L. , Wheeler William B. , Ross James D. , Kemp RCP*; and James S.
Published: August 2004

Objective.

Rebreathing of exhaled air is one proposed mechanism for the increased risk for sudden infant death syndrome among prone sleeping infants. We evaluated how carbon dioxide (CO2) dispersal was affected by a conventional crib mattress and 5 products recently marketed to prevent prone rebreathing.

Setting.

Infant pulmonary laboratory.

Equipment.

An infant mannequin with its nares connected via tubing to an 100-mL reservoir filled with 5% CO2. The sleep surfaces studied included: firm mattress covered by a sheet, Bumpa Bed, Breathe Easy, Kid Safe/Baby Air, Halo Sleep System, and Sleep Guardian. The mannequin was positioned prone face-down or near-face-down. The sleep surfaces were studied with the covering sheet taut, covering sheet wrinkled, and with the mannequin arm positioned up, near the face.

Measurements.

We measured the fall in percentage end-tidal CO2 as the reservoir was ventilated with the piston pump. The half-time for CO2 dispersal (t1/2) is an index of the ability to cause or prevent rebreathing.

Results.

Compared with the face-to-side control, 5 of 6 surfaces allowed a significant increase in t1/2 in all 3 prone scenarios. The firm mattress and 4 of the 5 surfaces designed to prevent rebreathing consistently allowed t1/2 above thresholds for the onset of CO2 retention and lethal rebreathing in an animal model (J Appl Physiol. 1995;78:740).

Conclusions.

With very few exceptions, infants should be placed supine for sleep. For infants placed prone or rolling to the prone position, significant rebreathing of exhaled air would be likely on all surfaces studied, except one.
An Elementary School-Based Health Clinic: Can It Reduce Medicaid Costs?
Authors: Adams E. Kathleen , Johnson Veda
Published: August 2004

Objective.

School-based health services have evolved from primarily controlling communicable disease to comprehensive programs with direct services, education, and improvement of the school environment. School-based health clinics (SBHCs), currently 1157 in number, are used to reach children for preventive and other routine care. Although several studies have examined the costs and effects of such programs, few, if any, have examined their potential to save Medicaid program outlays. The objective of this study was to assess the effect of the Whitefoord Elementary School-Based Health Clinic (WESBHC), located in Atlanta, Georgia, on health care costs paid by Georgia Medicaid over the 1994–1996 period. This clinic has been in operation since late 1994.

Design.

The analysis uses 1994–1996 claims data for Medicaid-enrolled children 4 through 12 years old served by the WESBHC and similar children in a comparison school district without such a clinic. Descriptive and multivariate analyses are used to discern the differences in the changes in Medicaid expenses per child-year enrolled for these 2 groups of children. Both those who only used the WESBHC sporadically and those for whom it was their medical home were identified for analysis.

Results.

The descriptive analysis shows that although there were no significant differences in the Medicaid expenses for the WESBHC and comparison children in 1994, before the operation of the WESBHC, by 1995, the WESBHC children had significantly lower emergency department expenses. In addition, they had higher Early Periodic Screening Diagnosis and Treatment preventive care expenses. By 1996, the WESBHC children had significantly lower inpatient, nonemergency department transportation, drug, and emergency department Medi- caid expenses. Multivariate analysis confirmed the effect of the WESBHC on lowering emergency department expenses.

Conclusions.

The results strongly suggest that the operation of a SBHC can have effects on the child's use of services and health care expenses. Given that these clinics serve all those who come for care and many of these are low-income children, these savings are likely to accrue to the Medicaid program of the state. As states continue to implement Medicaid-managed care for their child populations, they will need to consider the ability of SBHCs to participate in and receive Medicaid revenues through health maintenance organization networks.
Newborn Circumcision Decreases Incidence and Costs of Urinary Tract Infections During the First Year of Life
Authors: Schoen Edgar J. , Colby Christopher J. , Ray G. Thomas
Published: August 2004

Objective.

To assess the effect of newborn circumcision on the incidence and medical costs of urinary tract infection (UTI) during the first year of life for patients in a large health maintenance organization.

Setting.

Kaiser Permanente Medical Care Program of Northern California (KPNC).

Patients.

The population consisted of members of KPNC. The study group consisted of a cohort of 28 812 infants delivered during 1996 at KPNC hospitals; of the 14 893 male infants in the group, 9668 (64.9%) were circumcised. A second cohort of 20 587 infants born in 1997 and monitored for 12 months was analyzed to determine incidence rates.

Design.

Retrospective study of all infants consecutively delivered at 12 facilities.

Outcome Measures.

Diagnosis of UTI was determined from the KPNC computerized database using the International Classification of Diseases, Ninth Revision code for inpatients and KPNC Outpatient Summary Clinical Record codes for outpatients. A sample of 52 patient charts was reviewed to confirm theInternational Classification of Diseases, Ninth Revisionand KPNC Outpatient Summary Clinical Record codes and provide additional data.

Results.

Infants <1 year old who were born in 1996 had 446 UTIs (292 in females; 154 in males); 132 (86%) of the UTIs in males occurred in uncircumcised boys. The mean total cost of managing UTI was 2 times as high in males ($1111) as in females ($542). This higher total cost reflected the higher rate of hospital admission in uncircumcised males with UTIs (27.3%) compared with females (7.5%); mean age at hospitalization for UTI was 2.5 months old for uncircumcised boys and 6.5 months old for girls. In 1996, total cost of managing UTI in uncircumcised males ($155 628) was 10 times higher than for circumcised males ($15 466) despite the fact that uncircumcised males made up only 35.1% of the male patient base in 1996, reflecting the more frequent occurrence of UTI in uncircumcised males (132 episodes) than in circumcised males (22 episodes), and the larger number of hospital admissions in uncircumcised males (38) than in circumcised males (4). The incidence of UTI in the first year of life was 1:47 (2.15%) in uncircumcised males, 1:455 (.22%) in circumcised males, and 1:49 (2.05%) in females. The odds ratio of UTI in uncircumcised:circumcised males was 9.1:1.

Conclusions.

Newborn circumcision results in a 9.1-fold decrease in incidence of UTI during the first year of life as well as markedly lower UTI-related medical costs and rate of hospital admissions. Newborn circumcision during the first year of life is, thus, a valuable preventive health measure, particularly in the first 3 months of life, when uncircumcised males are most likely to be hospitalized with severe UTI.
Evaluation of Emergency Department Referrals by Telephone Triage
Authors: Barber Judson W. , King William D. , Monroe Kathy W. , Nichols Michele H.
Published: August 2004

Objective.

Telephone triage programs are becoming very common at children's hospitals across the nation. One of the proposed benefits of these programs is the more efficient use of health care resources by triaging patients to the appropriate level of health care. The purpose of this study is to examine the appropriateness of referrals to a pediatric emergency department (ED) by the Pediatric Health Information Line (PHIL), a hospital-based telephone triage program, versus all other sources of referrals.

Methods.

A blinded Delphi rating system was used to review the physician's sheets of 133 consecutive ED referrals by PHIL for medical appropriateness. A total of 260 randomly selected control patients seen in the ED during the same period were similarly reviewed. If 2 of 3 pediatric emergency medicine physicians agreed that an ED visit was appropriate, then it was considered appropriate. A comparison of the 2 groups' ED appropriateness was made using a contingency table χ2 test. An odds ratio with confidence limits was also calculated. Demographic data were collected for both groups including age, race, gender, and insurance status.

Results.

The PHIL group had an appropriateness rate of 80.2%, compared with 60.5% for the control group (χ2 = 14.6369; odds ratio = 2.65; 95% confidence interval [1.5759,4.5008]).

Conclusions.

This demonstrated that for the period studied, PHIL referrals to the ED had a 33% higher rate of appropriateness than controls. This evidence supports telephone triage as an efficient gatekeeper for health care resources.
Neonatal Assisted Ventilation: Predictors, Frequency, and Duration in a Mature Managed Care Organization
Authors: Wilson Alexandra , Gardner Marla N. , Armstrong Mary A. , Folck Bruce F. , Escobar Gabriel J.
Published: August 2004

Objectives.

Reference data are lacking on the frequency and duration of assisted ventilation in neonates. This information is essential for determining resource needs and planning clinical trials. As mortality becomes uncommon, ventilator utilization is increasingly used as a measure for assessing therapeutic effect and quality of care in intensive care medicine. Valid comparisons require adjustments for differences in a patient's baseline risk for assisted ventilation and prolonged ventilator support. The aims of this study were to determine the frequency and length of ventilation (LOV) in preterm and term infants and to develop models for predicting the need for assisted ventilation and length of ventilator support.

Methods.

We performed a retrospective, population-based cohort study of 77 576 inborn live births at 6 Northern California hospitals with level 3 intensive care nurseries in a group-model managed care organization. The gestational age-specific frequency and duration of assisted ventilation among surviving infants was determined. Multivariable regression was performed to determine predictors for assisted ventilation and LOV.

Results.

Of 77 576 inborn live births in the study, 11 199 required admission to the neonatal intensive care unit and of these, 1928 survivors required ventilator support. The proportion of infants requiring assisted ventilation and the median LOV decreased markedly with increasing gestational age. In addition to gestational age, admission illness severity, 5-minute Apgar scores, presence of anomalies, male sex, and white race were important predictors for the need for assisted ventilation. The ability of the models to predict need for ventilation was high, and significantly better than birth weight alone with an area under the receiver operating characteristic curve of .90 versus .70 for preterm infants, and .88 versus .50 for term infants. For preterm infants, gestational age, admission illness severity, oxygenation index, anomalies, and small-for-gestational age status were significant predictors for LOV, accounting for 60% of the variance in the length of assisted ventilation. For term infants, oxygenation index and anomalies were significant predictors but only accounted for 29% of the variance.

Conclusions.

Considerable variation exists in the utilization of ventilator support among infants of closely related gestational age. In addition, a number of medical risk factors influence the need for, and length of, assisted ventilation. These models explain much of the variance in LOV among preterm infants but explain substantially less among term infants. neonatal intensive care, assisted ventilation, Score for Neonatal Acute Physiology, resource consumption, prematurity.
Effect of Seating Position and Restraint Use on Injuries to Children in Motor Vehicle Crashes
Authors: Berg Marc D. , Cook Lawrence , Corneli Howard M. , Vernon Donald D. , Dean J. Michael
Published: August 2004

Objective.

To determine the effect of restraint use and seating position on injuries to children in motor vehicle crashes, with stratification by area of impact.

Methods.

Children <15 years old involved in serious automobile crashes in Utah from 1992 through 1996 were identified from statewide motor vehicle crash records. Serious crashes are defined as those resulting in occupant injuries with broken bones or significant bleeding or property damage exceeding $750. Probabilistic methods were used to link these records with hospital records. Analysis used logistic regression controlling for age, restraint use, occupant seating position, and type of crash.

Results.

We studied 5751 children and found 53% were rear seat passengers. More than 40% were unrestrained. Sitting in the rear seat offered a significant protective effect (adjusted odds ratio: 1.7; 95% confidence interval: 1.6–2.0), and restraint use enhanced this effect (adjusted odds ratio: 2.7; 95% confidence interval: 2.4–3.1). Mean hospital charges were significantly greater for front seat passengers.

Conclusions.

Rear seat position during a motor vehicle crash provides a significant protective effect, restraint use furthers this effect, and usage rates of restraint devices are low. The rear seat protective effect is in addition to and independent of the protection offered from restraints.
Use of Telemedicine for Children With Special Health Care Needs
Authors: Karp Warren B. , Grigsby R. Kevin , LCSW DSW, , McSwiggan-Hardin Maureen , Pursley-Crotteau Suzanne , Adams CARN§; Laura N. , Bell Wyndolyn , Stachura Max E. , Kanto William P.
Published: August 2004

Objective.

In 1995, the Children's Medical Services (CMS) of the State of Georgia contracted with the Department of Pediatrics of the Medical College of Georgia (MCG) and the MCG Telemedicine Center to develop telemedicine programs to provide subspecialty care for children with special health care needs. This article presents project statistics and results of client evaluation of services, as well as physician faculty attitudes toward telemedicine.

Design.

A demonstration project using telemedicine between a tertiary center and a rural clinic serving children with special health care needs was established. Data were collected and analyzed for December 12, 1995 to May 31, 1997, during which 333 CMS telemedicine consultations were performed.

Results.

Most CMS telemedicine consultations (35%) involved pediatric allergy/immunology. Other subspecialties included pulmonology (29%), neurology (19%), and genetics (16%). Overall, patients were satisfied with the services received. Initially, physician faculty members were generally positive but conservative in their attitudes toward using telemedicine for delivering clinical consultation. After a year's exposure and/or experience with telemedicine, 28% were more positive, 66% were the same, and only 4% were more negative about telemedicine. The more physicians used telemedicine, the more positive they were about it (r = .30).

Conclusions.

In terms of family attitudes and individual care, telemedicine is an acceptable means of delivering specific pediatric subspecialty consultation services to children with special health care needs, living in rural areas distant to tertiary centers. Telemedicine is more likely to be successful as part of an integrated health services delivery than when it is the sole mode used for delivery of care.
Use of Psychoactive Medication During Pregnancy and Possible Effects on the Fetus and Newborn
Authors:   Committee on Drugs
Published: August 2004

This Policy Statement was retired May 2011.

Psychoactive drugs are those psychotherapeutic drugs used to modify emotions and behavior in the treatment of psychiatric illnesses. This statement will limit its scope to drug selection guidelines for those psychoactive agents used during pregnancy for prevention or treatment of the following common psychiatric disorders: schizophrenia, major depression, bipolar disorder, panic disorder, and obsessive-compulsive disorder. The statement assumes that pharmacologic therapy is needed to manage the psychiatric disorder. This decision requires thoughtful psychiatric and obstetric advice.
Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip
Authors:   Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip
Published: August 2004

Developmental dysplasia of the hipis the preferred term to describe the condition in which the femoral head has an abnormal relationship to the acetabulum. Developmental dysplasia of the hip includes frank dislocation (luxation), partial dislocation (subluxation), instability wherein the femoral head comes in and out of the socket, and an array of radiographic abnormalities that reflect inadequate formation of the acetabulum. Because many of these findings may not be present at birth, the termdevelopmental more accurately reflects the biologic features than does the term congenital. The disorder is uncommon. The earlier a dislocated hip is detected, the simpler and more effective is the treatment. Despite newborn screening programs, dislocated hips continue to be diagnosed later in infancy and childhood,1–11 in some instances delaying appropriate therapy and leading to a substantial number of malpractice claims. The objective of this guideline is to reduce the number of dislocated hips detected later in infancy and childhood. The target audience is the primary care provider. The target patient is the healthy newborn up to 18 months of age, excluding those with neuromuscular disorders, myelodysplasia, or arthrogryposis.
Chiropractors and Vaccination: A Historical Perspective
Authors: Campbell James B. , Busse Jason W. , Injeyan H. Stephen
Published: August 2004

Although there is overwhelming evidence to show that vaccination is a highly effective method of controlling infectious diseases, a vocal element of the chiropractic profession maintains a strongly antivaccination bias. Reasons for this are examined. The basis seems to lie in early chiropractic philosophy, which, eschewing both the germ theory of infectious disease and vaccination, considered disease the result of spinal nerve dysfunction caused by misplaced (subluxated) vertebrae. Although rejected by medical science, this concept is still accepted by a minority of chiropractors. Although more progressive, evidence-based chiropractors have embraced the concept of vaccination, the rejection of it by conservative chiropractors continues to have a negative influence on both public acceptance of vaccination and acceptance of the chiropractic profession by orthodox medicine.
Cause and Clinical Characteristics of Rib Fractures in Infants
Authors: Bulloch Blake , Schubert Charles J. , Brophy Patrick D. , Johnson Neil , Reed Martin H. , Shapiro Robert A.
Published: August 2004

Objective.

Rib fractures are uncommon in infancy and, when diagnosed, often raise the suspicion of child abuse. However, the prevalence of other causes of rib fractures has not been well defined. The purpose of this study was to determine the causes and clinical presentations of rib fractures in infants <12 months old.

Methods.

Retrospectively, we identified all infants with rib fractures under 12 months old over a 3-year period using computerized databases at the Children's Hospital Medical Center in Cincinnati, Ohio and at the Children's Hospital, Winnipeg, Manitoba, Canada. Data extracted from the individual patient charts included: age, sex, chief complaint, number and location of rib fractures, associated injuries, birth history, history of cardiopulmonary resuscitation, and any evidence of bone dysplasia. After the chart review and a review of the radiographs by a pediatric radiologist, all fractures were determined to be attributable to one of the following causes: child abuse, birth injury, bone fragility, or accidental trauma. A determination of abuse was made when there were other injuries indicative of abuse, there was no clinical or radiographic evidence of bone fragility, there was a confession of abuse, when no reasonable history of trauma was provided, or when the history was not plausible to explain the rib fractures. Standard practice at these hospitals involves obtaining skeletal surveys on all children <2 years old when abuse is suspected. The child abuse team, which consists of physicians, nurses, and social workers, conducts these investigations and works closely with police in evaluating these children.

Results.

Thirty-nine infants with rib fractures were identified. Thirty-two (82%) were caused by child abuse. Three (7.7%) were attributable to accidental injuries, 1 (2.6%) was secondary to birth trauma, and 3 (7.7%) were attributable to bone fragility. All 3 infants with fractures from accidental injury had sustained notable trauma (a motor vehicle collision, a forceful direct blow, and a fall from a height). Of the 3 infants with fractures secondary to bone fragility, 1 infant had osteogenesis imperfecta, 1 infant had rickets, and 1 infant, who was born at 23 weeks' gestation, had fragile bones attributable to prematurity.

Conclusions.

Most rib fractures in infants are caused by child abuse. Although much less common, rib fractures can also occur after serious accidental injuries, birth trauma, or secondary to bone fragility. A thorough clinical and imaging evaluation is mandatory.
Poorer Behavioral and Developmental Outcome More Than 10 Years After Treatment for Iron Deficiency in Infancy
Authors: Lozoff Betsy , Jimenez Elias , Hagen John , Mollen Eileen , Wolf Abraham W.
Published: August 2004

Objective.

To determine the long-term effects of iron deficiency in infancy.

Design.

Longitudinal follow-up study of children who had been tested and treated for iron deficiency as infants.

Setting.

Periurban community near San Jose, Costa Rica.

Participants.

Of the original 191 participants, 87% were reevaluated at 11 to 14 years old (average age: 12.3 years). The children were free of iron deficiency and growing normally by US standards. Those who had chronic, severe iron deficiency in infancy (n = 48) were compared with those who had good iron status before and/or after iron therapy in infancy (n = 114).

Outcome Measures.

Comprehensive set of cognitive, socioemotional, and motor tests and measures of school functioning.

Results.

Children who had severe, chronic iron deficiency in infancy scored lower on measures of mental and motor functioning. After control for background factors, differences remained statistically significant in arithmetic achievement and written expression, motor functioning, and some specific cognitive processes (spatial memory, selective recall, and tachistoscopic threshold). More of the formerly iron-deficient children had repeated a grade and/or been referred for special services or tutoring. Their parents and teachers rated their behavior as more problematic in several areas, agreeing in increased concerns about anxiety/depression, social problems, and attention problems.

Conclusions.

Severe, chronic iron deficiency in infancy identifies children who continue at developmental and behavioral risk >10 years after iron treatment.
Prepubertal Gynecomastia: Indirect Exposure to Estrogen Cream
Authors: Felner Eric I. , White Perrin C.
Published: August 2004

Objective.

To describe the clinical course of 3 prepubertal boys who presented with gynecomastia resulting from indirect exposure to a custom-compounded preparation of estrogen cream used by each child's mother.

Methodology.

Each child was initially referred to the Children's Medical Center of Dallas' Endocrinology Center and followed for over 1 year.

Results.

All 3 boys presented with gynecomastia and elevated estradiol levels. Two had accelerated growth and advanced bone ages. Within 4 months after each child's mother discontinued use of the topical estrogen preparation, each child's gynecomastia regressed and estradiol levels returned to normal.

Conclusion.

Indirect exposure to excessive amounts of topical estrogen may cause gynecomastia, rapid changes in growth, and advanced bone age in prepubertal children. Because custom-compounded topical estrogen preparations are not regulated by the Food and Drug Administration and may contain high concentrations of estrogen, we recommend that women requiring estrogen use an alternate form of estrogen delivery if they are in frequent close contact with children.
Alternating Antipyretics: Is This an Alternative?
Authors: Mayoral Clara E. , Marino Ronald V. , Rosenfeld Warren , Greensher Joseph
Published: August 2004

Objectives.

To identify current fever management strategies and their basis, and to assess the frequency of alternating acetaminophen and ibuprofen.

Background.

Practicing pediatricians confront the dilemma of elevated temperature and the anxiety this creates for parents. An informal survey of pediatricians revealed a variety of management strategies, including alternating acetaminophen and ibuprofen. There are no scientific data regarding alternating these 2 products.

Design.

During professional meetings, pediatricians voluntarily filled out a 15-item questionnaire.

Results.

One hundred sixty-one completed surveys were reviewed. Respondents were mostly general pediatricians (67.7%), with ≥20 years in practice (55.9%). Most respondents chose a temperature of 101oF to start antipyretic treatment (61.9%). A small percentage used discomfort alone as the indication (13%). The antipyretic of choice was temperature-dependent in 50% of respondents; 57% used ibuprofen for temperature ≥102°F. Fifty percent of respondents advised parents to alternate acetaminophen and ibuprofen. The method of alternation varied. The most common answers given for choosing a particular antipyretic regime were recommendations of the American Academy of Pediatrics (29%) and opinions of colleagues and mentors (25%). Physicians with <5 years of practice were significantly more likely to alternate antipyretics (69.7%).

Conclusion.

Acetaminophen and ibuprofen are commonly being used in an alternating manner for management of fever. There is presently no scientific evidence that this combination is safe or achieves faster antipyresis than either agent alone. There is evidence that the improper use of these agents may cause harm. Despite 29% of participants citing American Academy of Pediatrics recommendations as the basis for fever management, no such policy or recommendations exist. The observation that this practice is more common in younger practitioners may reflect their continued anxiety about fever (fever phobia). Until properly controlled studies have assessed the risk of combining these 2 products, practitioners should proceed with caution.
Quality of Care and Use of the Medical Home in a State-Funded Capitated Primary Care Plan For Low-Income Children
Authors: Kempe Allison , Beaty Brenda , Englund Brian P. , Roark Robert J. , Hester Nellie , Steiner John F.
Published: August 2004

Objective.

To evaluate the quality of care and use of the medical home in a state-funded capitated insurance plan for low-income children—the Colorado Child Health Plan (CCHP).

Design.

A retrospective cohort study using medical record review at pediatric and family practice offices in 4 geographic areas of Colorado. At each practice, CCHP-enrolled children (6 months to 6.5 years) and 2 controls were selected, 1 with Medicaid (MK) and 1 with private insurance (PI), matched by date of birth to the CCHP-enrolled child (N = 596). CCHP-enrolled children with a diagnosis of asthma, aged 3 to 18 years, and asthmatic children with MK and PI, matched by age, were also selected from each practice (N = 139).

Results.

Quality of preventive services were comparable in the 3 groups. CCHP-enrolled children made more health maintenance visits than MK-enrolled children (1.3 CCHP vs .9 MK vs 1.1 PI) and were more frequently screened for lead (8.1% CCHP vs 3.4% MK vs 1.2% PI) and anemia (5.0% CCHP vs 4.4% MK vs 2.4% PI) than children in either control group. Documented immunization rates were similar in the 3 groups, but a shift in location of immunization from public health clinics to the primary care site was seen in the CCHP group. CCHP-enrolled children made more office visits for acute care than did MK-enrolled children (4.1 CCHP vs 3.1 MK vs 3.4 PI), but a higher proportion of these visits took place at the medical home rather than the emergency department for the CCHP group (.04) as compared with the MK (.07) or PI (.06) groups. Asthmatic children in the CCHP group made more preventive office visits for maintenance therapy and more frequently used the primary care site rather than the emergency department for acute exacerbations than did children with PI (mean ratio of emergency department visits to total acute visits .04 CCHP vs .06 MK vs .19 PI).

Conclusions.

Despite capitated reimbursement for primary care services, CCHP provided children from low-income families with preventive, acute, and chronic care services of comparable quantity and quality to those received by children with MK or PI. The program was associated with a shift of immunization location to the primary care site and increased health maintenance care for new enrollees. CCHP-enrolled children used their medical home for the majority of acute health needs and were not high utilizers of emergency department or hospital services.
Outcomes Evaluation of a Comprehensive Intervention Program for Asthmatic Children Enrolled in Medicaid
Authors: Kelly Cynthia Szelc , Morrow Ardythe L. , Shults Justine , Nakas Nermina , Strope Gerald L. , Adelman Raymond D.
Published: August 2004

Objectives.

To evaluate health care and financial outcomes in a population of Medicaid-insured asthmatic children after a comprehensive asthma intervention program.

Design.

Controlled clinical trial.

Setting.

Pediatric allergy clinic in an urban, tertiary care children's hospital.

Subjects.

Eighty children, 2 to 16 years old, with a history of frequent use of emergent health care services for asthma.

Intervention.

Children in the intervention group received asthma education and medical treatment in the setting of a tertiary care pediatric allergy clinic. An asthma outreach nurse maintained monthly contact with the families enrolled in the intervention group.

Outcome Measures.

Emergency department (ED) visits, hospitalizations, and health care charges per patient in the year after enrollment.

Results.

Baseline demographics did not differ significantly between the 2 groups. In the year before the study, there were no significant differences between intervention and control children in ED visits (mean, 3.5 per patient), hospitalizations (mean, .6 per patient) or health care charges ($2969 per patient). During the study year, ED visits decreased to a mean of 1.7 per patient in the intervention group and 2.4 in controls, while hospitalizations decreased to a mean of .2 per patient in the intervention group and .5 in the controls. Average asthma health care charges decreased by $721/child/year in the intervention group and by $178/patient/year in the control group.

Conclusions.

A comprehensive asthma intervention program for Medicaid-insured asthmatic children can significantly improve health outcomes while reducing health care costs.asthma education, health care outcomes, Medicaid, asthma outreach, utilization.
Estimation of Neonatal Outcome and Perinatal Therapy Use
Authors: Morse Steven B. , Haywood James L. , Goldenberg Robert L. , Bronstein Janet , Nelson Kathleen G. , Carlo Waldemar A.
Published: August 2004

Objectives.

To learn whether US obstetricians and pediatricians accurately estimate rates of survival and freedom from handicap in preterm infants and to learn whether their knowledge and attitudes influence their choice of interventions that may enhance survival.

Methods.

A cross-sectional survey of obstetricians and pediatricians practicing in the United States was performed using a pretested questionnaire designed to identify their knowledge regarding survival and handicap-free rates of infants born at 23 to 36 weeks of gestation. At each week of gestation, they were asked whether they would provide specific therapeutic interventions to either the expectant mother or infant. Survival and handicap-free rates were compared with published national rates. Obstetricians and pediatricians were divided into an optimists group and a pessimists group, based on their estimates of survival. The rates at which each group used therapeutic interventions were compared.

Results.

Both obstetricians and pediatricians underestimated survival rates from 24 through 35 weeks of gestation and freedom from serious handicap from 23 through 36 weeks of gestation. On the average, optimists accurately predicted neonatal survival. Obstetricians who underestimated neonatal survival would less often administer antenatal corticosteroids, perform a cesarean section for fetal distress, and transfer a mother to a tertiary center. Pediatricians who underestimated neonatal survival would less often use mechanical ventilation, cardiopulmonary resuscitation, inotropes, intravenous fluids, thermal support, and oxygen supplementation.

Conclusion.

Physicians underestimate survival and freedom from handicap in preterm infants. Underestimation of outcome is associated with restriction in the use of appropriate interventions.
A Randomized Comparison of Home and Clinic Follow-Up Visits After Early Postpartum Hospital Discharge
Authors: Lieu Tracy A. , Braveman Paula A. , Escobar Gabriel J. , Fischer Allen F. , Jensvold Nancy G. , Capra Angela M.
Published: August 2004

Background.

Recently enacted federal legislation mandates insurance coverage of at least 48 hours of postpartum hospitalization, but most mothers and newborns in the United States will continue to go home before the third postpartum day. National guidelines recommend a follow-up visit on the third or fourth postpartum day, but scant evidence exists about whether home or clinic visits are more effective.

Methods.

We enrolled 1163 medically and socially low-risk mother-newborn pairs with uncomplicated delivery and randomly assigned them to receive home visits by nurses or pediatric clinic visits by nurse practitioners or physicians on the third or fourth postpartum day. In contrast with the 20-minute pediatric clinic visits, the home visits were longer (median: 70 minutes), included preventive counseling about the home environment, and included a physical examination of the mother.

Clinical utilization and costs were studied using computerized databases. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks' postpartum.

Results.

Comparing the 580 pairs in the home visit group and the 583 pairs in the pediatric clinic visit group, no significant differences occurred in clinical outcomes as measured by maternal or newborn rehospitalization within 10 days postpartum, maternal or newborn urgent clinic visits within 10 days postpartum, or breastfeeding discontinuation or maternal depressive symptoms at the 2-week interview. The same was true for a combined clinical outcome measure indicating whether a mother-newborn pair had any of the above outcomes. In contrast, higher proportions of mothers in the home visit group rated as excellent or very good the preventive advice delivered (80% vs 44%), the provider's skills and abilities (87% vs 63%), the newborn's posthospital care (87% vs 59%), and their own posthospital care (75% vs 47%). On average, a home visit cost $255 and a pediatric clinic visit cost $120.

Conclusions.

For low-risk mothers and newborns in this integrated health maintenance organization, home visits compared with pediatric clinic visits on the third or fourth postpartum hospital day were more costly, but were associated with equivalent clinical outcomes and markedly higher maternal satisfaction. This study had limited power to identify group differences in rehospitalization, and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.
Effect of Early Versus Late Administration of Human Recombinant Erythropoietin on Transfusion Requirements in Premature Infants: Results of a Randomized, Placebo-Controlled, Multicenter Trial
Authors: Donato Hugo , Vain Nestor , Rendo Pablo , Vivas Norma , Prudent Luis , Larguı́a Miguel , Digregorio Jorge , Vecchiarelli Carmen , Valverde Regina , Garcı́a Cecilia , Subotovsky Patricia , Solana Claudio , Gorenstein Adriana ,   for the Private Hospitals Neonatal Network
Published: August 2004

Objective.

The administration of recombinant human erythropoietin (rHuEPO), started after the first 2 weeks of life, reduces the transfusion requirement in premature infants. However, its use throughout the first 2 weeks of life, when anemia results predominantly from phlebotomy losses, remains controversial. We investigated whether early use of rHuEPO would reduce the total transfusion requirement and/or the number of transfusions throughout the first 2 weeks of life.

Methods.

We randomized 114 infants with birth weight (BW) <1250 g to receive rHuEPO (1250 units/kg/week; IV; early group:n = 57) or placebo (late group:n = 57) from day 2 to day 14 of life; subsequently, all the patients received rHuEPO (750 units/kg/week, subcutaneously) for 6 additional weeks. All infants were given oral iron (6 mg/kg/day) and folic acid (2 mg/day).

Results.

The early group showed higher hematocrit and reticulocyte counts than the late group in the first 3 weeks of life, but there was no difference in the total number of transfusions (early: 1.8 ± 2.3 vs late: 1.8 ± 2.5 transfusion/patient) or the transfusion requirement throughout the first 2 weeks of life (early: .8 ± 1.1 vs late: .9 ± 1.3) could be demonstrated. In infants with BW <800 g and total phlebotomy losses >30 mL/kg (n = 29), a lower number of transfusions was received by infants in the early group, compared with late group, from the second week to the end of the treatment (early: 3.4 ± 1.1 vs late: 5.4 ± 3.7 transfusion/patient). No clinical adverse effects were observed. Thrombocytosis was detected during the treatment with rHuEPO in 31% of the infants.

Conclusions.

In the whole population, the early administration of rHuEPO induced a rise of reticulocyte counts, but not enough to reduce the transfusion requirement. The most severely ill infants (BW <800 g and phlebotomy losses >30 mL/kg) seemed to benefit from early use of rHuEPO, and this deserves additional study.
Neurodevelopmental Outcome and Lifestyle Assessment in School-Aged and Adolescent Children With Hypoplastic Left Heart Syndrome
Authors: Mahle William T. , Clancy Robert R. , Moss Edward M. , Gerdes Marsha , Jobes David R. , Wernovsky Gil
Published: August 2004

Objectives.

The purposes of this study are to describe the quality of life and cognitive function in school-aged children who have undergone staged palliation for hypoplastic left heart syndrome (HLHS), and to identify factors that are predictive of neurodevelopmental outcome in this population.

Methods.

School-aged survivors with HLHS who had undergone palliative surgery at our institution were identified and mailed a questionnaire to assess subjectively quality of life, school performance, and incidence of medical complications. A subgroup of local patients underwent standardized testing of cognitive function and neurologic examination. These patients were compared with the larger (remote) group of questionnaire respondents to determine whether results may be generalizable to the entire HLHS population. Potential predictors of neurologic and cognitive outcome were tested for their association with test scores using multivariate regression analysis.

Results.

Questionnaire results were obtained from 115 of 138 eligible children (83%; mean age: 9.0 ± 2.0 years). Standardized testing was performed in 28 of 34 (82%) eligible local patients (mean age: 8.6 ± 2.1 years). The majority of parents or guardians described their child's health as good (34%) or excellent (45%) and their academic performance as average (42%) or above average (42%). One third of the children, however, were receiving some form of special education. Chronic medication usage was common (64%); the incidence of medical complications was comparable to that previously reported in children with Fontan physiology. Cognitive testing of the local group demonstrated a median full scale IQ of 86 (range: 50–116). Mental retardation (IQ: <70) was noted in 18% of patients. In multivariate analysis, only the occurrence of preoperative seizures predicted lower full scale IQ.

Conclusions.

Although the majority of school-aged children with HLHS had IQ scores within the normal range, mean performance for this historical cohort of survivors was lower than that in the general population.
Electrocardiographic Findings in Adolescents With Eating Disorders
Authors: Panagiotopoulos Constadina , McCrindle Brian W. , Hick Katherine , Katzman Debra K.
Published: August 2004

Objectives.

We sought to determine the prevalence and clinical correlates of electrocardiographic findings in adolescents with eating disorders.

Study Design.

We undertook matched case–control study of electrocardiographic findings at initial assessment in 62 adolescents with anorexia nervosa, 9 with bulimia nervosa, and 26 with eating disorder not otherwise specified presenting from March 1995 to September 1996.

Results.

Mean (± 1 standard deviation) age was 15.0 ± 1.4 years (95% were female). Patients with anorexia nervosa had significantly lower heart rates (mean case–control difference: −20 ± 17 beats per minute), lower R in V6(−2.6 ± 5.5 mm), longer QRS interval (+.004 ± .010 seconds), shorter mean QTc (−.0136 ± .033 seconds) and lesser QTc dispersion (−.010 ± .031 seconds). The bulimia nervosa group had slightly longer mean QTc (.019 ± .020 seconds), with no significant case–control differences in the eating disorder not otherwise specified group.

Conclusion.

Electrocardiographic findings are abnormal in adolescents with anorexia nervosa but not in adolescents with bulimia nervosa or eating disorder not otherwise specified.
Prevention of Premature Birth: Do Pediatricians Have a Role?
Authors: Hall Robert T.
Published: August 2004

The rate of prematurity in the United States has increased over the past 15 years despite a reduction in overall infant mortality and birth weight-specific mortality. The major factors contributing to premature birth exist before pregnancy and therefore will require intervention strategies in the pediatric patient. The high-risk factors include young age at conception (16 years), use of illicit drugs and smoking, poor nutritional status, and certain vaginal infections. Pediatric intervention strategies should include sociologic as well as health education stressing heightened self-esteem and communication skills, avoidance of pregnancy and unprotected sexual activity, avoidance of smoking and drug use, and promotion of a good nutritional status.