bluuebunny/crossref_metadata_2025 huggingface dataset:
Pulmonary Tuberculosis in Children in a Developing Country
Authors: Salazar Guillermo E. , Schmitz Tracy L. , Cama Rosa , Sheen Patricia , Franchi Luis Miguel , Centeno Gilberto , Valera Carlos , Leyva Marianella , Montenegro-James Sonia , Oberhelman Richard , Gilman Robert H. , Thompson Matthew J. ,   the Working Group on TB in Peru
Published: August 2004

Objective.

We evaluated the clinical and epidemiologic characteristics of Peruvian children presenting with pulmonary tuberculosis (PTB) to determine whether features predictive of confirmed PTB could be identified.

Study Design.

This was a cross-sectional study of 135 children (mean age: 6.8 years) presenting to the Hospital del Niño in Lima, Peru, with presumptive diagnosis of PTB. Clinical, epidemiologic, and laboratory findings were compared between 3 groups of pediatric patients with a presumptive diagnosis of PTB: those with positive Mycobacterium tuberculosis (MTB) cultures, those likely to have PTB based on clinical criteria but with negative cultures, and those who did not meet clinical diagnostic criteria or have positive cultures.

Results.

A total of 50 (37%) patients were diagnosed with definitive PTB based on positive sputum culture. Another 55 (47%) patients were classified as having probable PTB based on meeting at least 2 of the following criteria: cough lasting for at least 2 weeks, typical chest radiograph changes, purified protein derivative (PPD) ≥10 mm, or history of tuberculosis family contact. Patients with definitive or probable PTB were significantly older than patients without clinical PTB, and those with symptomatic disease were significantly older than those with asymptomatic disease. Patients with PTB diagnosed by culture were significantly more likely than those diagnosed using clinical criteria to have cough lasting ≥2 weeks, fever, and a PPD ≥10 mm.

Conclusions.

The typical presentation of PTB in Peruvian children includes symptoms of active pulmonary disease similar to those seen in adults. This presentation differs significantly from that reported in developed countries, where many children have minimal or no symptoms at the time of presentation. The diagnostic criteria for pediatric PTB must be modified in hyperendemic developing country environments where features may differ from those described in the United States. The triad of cough lasting ≥2 weeks, fever, and a PPD ≥10 mm was highly predictive for culture-positive PTB among children in this low-income Peruvian population.
Methyl Ethyl Ketone Peroxide Ingestion: Toxicity and Outcome in a 6-Year-Old Child
Authors: Bates Nicola , Driver Christopher P. , Bianchi Adrian
Published: August 2004

A 6-year-old boy developed respiratory distress, metabolic acidosis, severe esophageal and gastric burns, and a coagulopathy after ingestion of an unknown volume of methyl ethyl ketone peroxide (MEKP) in dimethyl phthalate. He was discharged from the pediatric intensive care unit 19 days postingestion but subsequently developed a stricture of the gastroesophageal junction and complete fibrosis of the middle third of the stomach, necessitating gastric resection and reconstruction. He was discharged 93 days postingestion on a program of dilation for the residual esophageal stricture. MEKP acts by initiating lipid peroxidation via free radical production that results in cellular dysfunction and death. Acetylcysteine, a glutathione precursor and possible free radical scavenger, may be of use in severe MEKP poisoning. This case demonstrates the severe effects that some industrial chemicals can have both systemically and locally at the point of contact with the gastrointestinal tract, as well as the long-term management required to ensure good quality of life.
Psychotropic Medication in Children: A Study From The Netherlands
Authors: Schirm Eric , Tobi Hilde , Zito Julie M. , de Jong-van den Berg Lolkje T. W.
Published: August 2004

Objective.

Although there is a global concern about the increased use of psychotropic agents in children, most research literature originates in the United States and is based on figures from the first half of the 1990s. Also, few studies document the use of various types of psychotropic agents. The objective of this study was to investigate the use of psychotropic medication in children in the Netherlands and to determine whether this corresponds with previously reported figures from the United States.

Methods.

A drug utilization study based on computerized pharmacy dispensing records was conducted from 1995 to 1999 for children aged 0 to 19 years in the north of the Netherlands.

Results.

Stimulants were the most widely used psychotropic agents among 0- to 19-year-olds (prevalence: 7.4/1000 in 1999), followed by hypnotics/anxiolytics (6.9/1000) and antidepressants (4.4/1000). Prevalence rates of stimulants increased from 1.5/1000 in 1995 to 7.4/1000 in 1999. Incidence rates, proportion of girls, and duration of stimulant treatment increased as well. Changes in prevalence rates of other psychotropic agents were much smaller than those of stimulants. Finally, the vast majority of children who were treated with psychotropic agents used only 1 agent at a time.

Conclusion.

The prevalence of stimulant use in the Netherlands is much lower than reported previously (28/1000 children in 1995) from the United States, and differences also existed with regard to the use of other psychotropic agents and combinations of psychotropic agents. However, the increase in Dutch stimulant use agrees with the previously reported 2.5-fold increase in the United States and shows that the increased use of stimulants is not limited to the United States.
Chronic Oxygen Dependency in Infants Born at Less Than 32 Weeks' Gestation: Incidence and Risk Factors
Authors: Egreteau Laurent , Pauchard Jean-Yves , Semama Denis S. , Matis Jacqueline , Liska Anne , Romeo Bernard , Cneude Fabrice , Hamon Isabelle , Truffert Patrick
Published: August 2004

Objective.

To assess incidence and clinical risk factors of chronic oxygen dependency (COD) among survivors who were born at or before 31 weeks' gestation.

Methods.

This prospective, multicenter study enrolled 802 infants who were born at or before 31 weeks' gestation and admitted to 8 level III neonatal intensive care units in northern and eastern France from January 1 through December 31, 1997. Need for oxygen to maintain oxygen saturation between 92% and 96% was assessed at 28 days of life and at 36 and 42 weeks' postconceptional age (PCA). Stepwise logistic regression analysis was used to identify the incidence of COD and the risk factors related to its occurrence.

Results.

The mortality rate was 14%. Antenatal corticotherapy was administered to 51% of patients, surfactant therapy to 76% of the ventilated patients, and high-frequency oscillatory ventilation at day 1 to 32%. At 28 days and 36 and 42 weeks' PCA, respectively, 25%, 15%, and 6% of survivors had COD. After adjustment for intercenter variations, we identified the significant risk factors for COD at these dates: a low gestational age, a high score on the Clinical Risk Index for Infants, intrauterine growth restriction, and surfactant treatment.

Conclusion.

COD incidence was high at 28 days of life but decreased dramatically by 42 weeks' PCA. This study confirmed previously reported risk factors and underlined the importance of intrauterine growth restriction and the Clinical Risk Index for Infants as significant risk factors.
A New and Improved Population-Based Canadian Reference for Birth Weight for Gestational Age
Authors: Kramer Michael S. , Platt Robert W. , Wen Shi Wu , Joseph K.S. , Allen Alexander , Abrahamowicz Michal , Blondel Béatrice , Bréart Gérard ,   for the Fetal/Infant Health Study Group of the Canadian Perinatal Surveillance System
Published: August 2004

Background.

Existing fetal growth references all suffer from 1 or more major methodologic problems, including errors in reported gestational age, biologically implausible birth weight for gestational age, insufficient sample sizes at low gestational age, single-hospital or other non-population–based samples, and inadequate statistical modeling techniques.

Methods.

We used the newly developed Canadian national linked file of singleton births and infant deaths for births between 1994 and 1996, for which gestational age is largely based on early ultrasound estimates. Assuming a normal distribution for birth weight at each gestational age, we used the expectation-maximization algorithm to exclude infants with gestational ages that were more consistent with 40-week births than with the observed gestational age. Distributions of birth weight at the corrected gestational ages were then statistically smoothed.

Results.

The resulting male and female curves provide smooth and biologically plausible means, standard deviations, and percentile cutoffs for defining small- and large-for-gestational-age births. Large-for-gestational age cutoffs (90th percentile) at low gestational ages are considerably lower than those of existing references, whereas small-for-gestational-age cutoffs (10th percentile) postterm are higher. For example, compared with the current World Health Organization reference from California (Williams et al, 1982) and a recently proposed US national reference (Alexander et al, 1996), the 90th percentiles for singleton males at 30 weeks are 1837 versus 2159 and 2710 g. The corresponding 10th percentiles at 42 weeks are 3233 versus 3086 and 2998 g.

Conclusions.

This new sex-specific, population-based reference should improve clinical assessment of growth in individual newborns, population-based surveillance of geographic and temporal trends in birth weight for gestational age, and evaluation of clinical or public health interventions to enhance fetal growth. fetal growth, birth weight, gestational age, preterm birth, postterm birth.
Impact of a Waiting Room Videotape Message on Parent Attitudes Toward Pediatric Antibiotic Use
Authors: Wheeler J. Gary , Fair Melinda , Simpson Pippa M. , Rowlands Leigh Ann , Aitken Mary E. , Jacobs Richard F.
Published: August 2004

Objective.

To reduce the injudicious use of antibiotics, we developed an educational strategy that focused on parents of pediatric patients and their physicians.

Methods.

This intervention was conducted in 5 pediatric practices in Arkansas during a 9-month period. Baseline data on parent attitudes about antibiotics and physician practice habits were measured by questionnaire. During the following 36 weeks, an educational videotape about the judicious use of antibiotics was played in waiting rooms. The videotape on antibiotics used a standard script based on the recommendations of the American Academy of Pediatrics. The physicians and staff at each site were actors in the videotape. During week 2 and week 36 of videotape use, parent attitudes were measured again. After the baseline week, the physicians and staff in each site were provided a standard in-service review of the American Academy of Pediatrics recommendations for judicious use of antibiotics. A study nurse recruited patients, administered questionnaires, and reviewed charts onsite.

Results.

Parents who were exposed to the videotape were significantly less inclined to seek antibiotics for viral infections. Passively provided pamphlets were not read. No significant change in antibiotic prescribing by physicians was seen.

Conclusion.

Parent-focused passive education tools are effective at changing parent attitudes toward the use of antibiotics. Although physicians have blamed parent attitudes and demands for the overuse of antibiotics, changes in parent attitudes in this study were not associated with changes in prescribing rates. Changes in parent attitudes may be necessary but do not seem sufficient for changes in antimicrobial prescribing patterns.
Randomized, Controlled Trial of Acetazolamide and Furosemide in Posthemorrhagic Ventricular Dilation in Infancy: Follow-Up at 1 Year
Authors: Kennedy Colin R. , Ayers Sarah , Campbell Michael J. , Elbourne Diane , Hope Peter , Johnson Ann ,   on behalf of The International PHVD Drug Trial Group
Published: August 2004

Objective.

Posthemorrhagic ventricular dilation (PHVD) is a complication of intraventricular hemorrhage in preterm infants and is associated with a high risk of long-term disability. Furosemide and acetazolamide are used widely in the treatment of PHVD in the hope of avoiding the need for placement of a ventriculoperitoneal shunt, but these drugs have not been evaluated in a controlled trial. This article reports a multicenter, randomized, controlled trial designed to test the hypothesis that these drugs would reduce the rate of shunt placement (or death) and increase survival to 1 year of age without disability.

Methods.

Between 1992 and 1996, 177 infants who were less than 3 months past term and had ventricular width >4 mm above the 97th centile following intraventricular hemorrhage were assigned randomly to either standard therapy or standard therapy plus drug therapy with acetazolamide (100 mg/kg/d) plus furosemide (1 mg/kg/d). Infants who were enrolled in the trial had a median gestational age of 28.6 weeks and were enrolled at a mean postnatal age of 3.6 weeks. Forty-four percent were reported to have a cerebral parenchymal lesion on ultrasound scan at randomization. The primary outcome measure of death or shunt placement (known in all but 1 infant) occurred in 56 of 88 infants who were allocated to drug plus standard therapy compared with 46 of 88 who were allocated to standard therapy. The risk ratio was 1.23 (95% confidence interval: 0.95–1.59). Neurodevelopmental outcome information at a corrected age of 1 year (known in all but 3 of 149 surviving infants) included disability or neuromotor impairment in 54 of 67 infants (81%) who were allocated to drug plus standard therapy and 52 of 69 infants (66%) who were allocated to standard therapy. Seventy-two of 85 infants (85%) who were allocated to drug therapy either died or were disabled or impaired at 1 year compared with 62 of 89 infants (70%) who were treated with standard therapy (risk ratio: 1.22; 95% confidence interval: 1.03–1.4376). The excess risk of these adverse outcomes was greater among infants who did not have a cerebral parenchymal lesion seen on ultrasound examination at trial entry.

Conclusions.

These results suggest that the use of acetazolamide and furosemide in preterm infants with PHVD is ineffective in decreasing the rate of shunt placement and is associated with increased neurologic morbidity. This treatment therefore cannot be recommended.
Randomized, Controlled Trial of Single Versus 3-Times-Daily Ferrous Sulfate Drops for Treatment of Anemia
Authors: Zlotkin Stanley , Arthur Paul , Antwi Kojo Yeboah , Yeung George
Published: August 2004

Objective.

Adherence to treatment of iron-deficiency anemia often is poor in both developed and developing countries. The current standard therapy is ferrous sulfate drops (or syrup) administered 3 times daily. It is possible that adherence would improve with a single-dose daily treatment regimen. We compared the use of single versus 3-times-daily ferrous sulfate drops, at the same total iron dose, on treatment of anemia in infants.

Methods.

To obtain a large enough cohort of anemic subjects, we performed the study in rural Ghana. Using a prospective, randomized, controlled design, we studied 557 anemic children (age range: 6–24 months; hemoglobin values: 70–99 g/L). One group (n = 280) received ferrous sulfate drops once daily (40 mg elemental iron), and the control group (n = 277) received ferrous sulfate drops 3 times per day (total dose, 40 mg elemental iron). Treatment lasted for 2 months. Hemoglobin and serum ferritin values were measured at baseline and at the end of the study.

Results.

Successful treatment of anemia (hemoglobin >100 g/L) occurred in 61% of the single-dose and in 56% of the 3-times-daily group. Geometric mean ferritin levels increased significantly in each group from baseline to the final visit. Side effects were minimal and similar between the 2 groups.

Conclusion.

A single versus a 3-times-daily dose of ferrous sulfate drops over 2 months resulted in a similar rate of successful treatment of anemia, without side effects. To our knowledge, this is the first demonstration of the use of a single-dose daily regimen to treat anemia. Although not examined in the current study, use of a single-dose daily regimen may improve adherence to treatment of anemia in infants.
The Cause of Infant and Toddler Subdural Hemorrhage: A Prospective Study
Authors: Feldman Kenneth W. , Bethel Ross , Shugerman Richard P. , Grossman David C. , Grady M. Sean , Ellenbogen Richard G.
Published: August 2004

Objective.

To determine the frequency of child abuse and unintentional injury as a cause of infant and toddler subdural hemorrhage (SDH).

Methods.

A prospective case series of a level I regional trauma center, regional children's hospital, and county medical examiner's office assessed consecutive children who were ≤36 months old and had SDH. Children who had previously known hemorrhagic disease, previous neurosurgical procedure, previously recognized perinatal brain injury, meningitis, renal dialysis, and severe dehydration were excluded. Concurrent medical, retinal, skeletal, and social work abuse evaluation were measured. Etiologic assessment using predetermined criteria was conducted.

Results.

From March 1995 through December 1998, 66 children were admitted with SDH. Abuse was confirmed in 39 (59%), unintentional injury in 15 (23%), and indeterminate cause in 12 (18%). The mean age of abused children was 8.7 ± 8.1 months and of children with unintentional injuries was 19.1 ± 10.0 months. The predominant presenting histories for abusive injury were a minor fall or no mechanism for 33 (84%) of 39 patients. All unintentional injuries resulted from a motor vehicle accident or other documented major trauma. Chronic or mixed acute and chronic SDH were found only in abused children (17 [44%] of 39) and in children whose injuries were indeterminate (8 [67%] of 12), not in children who were unintentionally injured (0 [0%] of 15). Long bone and/or rib fractures were found in 20 (51%) of 39 abused children but in only 1 unintentionally injured child. Retinal bleeding was present in 28 (72%) of 39 of the abused children. Only 1 of the 3 unintentionally injured children who had a retinal examination had bleeding, which was of the type associated with acute increased intracranial pressure.

Conclusions.

Nearly one fifth of infant and toddler SDH resulted from unintentional trauma. Of those without obvious unintentional trauma, 76% were corroborated to have been abused. Abused children were younger, more likely to have chronic SDH, and more likely to have multiple associated injuries. Their injury history usually was minor or absent.
Diagnosis and Treatment of Feeding Disorders in Children With Developmental Disabilities
Authors: Schwarz Steven M. , Corredor Julissa , Fisher-Medina Julie , Cohen Jennifer , Rabinowitz Simon
Published: August 2004

Objectives.

To determine the results of diagnostic evaluation and the effects of nutritional intervention on energy consumption, weight gain, growth, and clinical status of children with neurodevelopmental disabilities and suspected feeding disorders.

Methods.

We studied 79 children with moderate to severe motor or cognitive dysfunction (male:female, 38:41; age, 5.8 ± 3.7 years) who were referred for diagnosis and treatment of feeding or nutritional problems. Initial assessments included a 3-day calorie intake record, videofluoroscopic swallowing study (VFSS), 24-hour intraesophageal pH monitoring, milk scintigraphy, and esophagogastroduodenoscopy.

Results.

These studies demonstrated gastroesophageal reflux (GER) with or without aspiration in 44 of 79 patients (56%), oropharyngeal dysphagia in 21 (27%), and aversive feeding behaviors in 14 (18%). Diagnosis-specific approaches included medical GER therapy in 20 patients (25%), fundoplication plus gastrostomy tube (GT) in 18 (23%), oral supplements in 17 (22%), feeding therapy only in 14 (18%), and GT only in 10 (13%). After 24.6 ± 3.0 months, relative calorie intake, expressed as intake (kcal/d)/recommended daily allowance (RDA, kcal/d), improved significantly (initial:final = 0.78 ± 0.36:1.23 ± 0.27). The z scores increased significantly for both weight (initial:final = −2.80 ± 1.33:−0.81 ± 0.69) and height (−3.14 ± 0.98:−2.00 ± 0.67). Improved subcutaneous tissue stores were demonstrated by increased thickness of both subscapular skinfolds (change = 71% ± 26%) and triceps skinfolds (38% ± 17%). After nutritional intervention, the acute care hospitalization rate, compared with the 2-year period before intervention, decreased from 0.4 ± 0.18 to 0.15 ± 0.06 admissions per patient-year and included only 3 admissions (0.02 per patient-year) related to feeding problems.

Conclusions.

In children with developmental disabilities, diagnosis-specific treatment of feeding disorders results in significantly improved energy consumption and nutritional status. These data also indicate that decreased morbidity (reflected by a lower acute care hospitalization rate) may be related, at least in part, to successful management of feeding problems. Our results emphasize the importance of a structured approach to these problems, and we propose a diagnostic and treatment algorithm for children with developmental disabilities and suspected feeding disorders.children, developmental disabilities, fundoplication, gastroesophageal reflux, gastrostomy, hospitalization, nutrition.
Pulmonary Edema Associated With Child Abuse: Case Reports and Review of the Literature
Authors: Rubin David M. , McMillan Clare O. , Helfaer Mark A. , Christian Cindy W.
Published: August 2004

Pulmonary edema has been an unreported finding in the evaluation of abused children. We describe 2 cases of pulmonary edema in abused infants, 1 after confessed suffocation and the other after inflicted head injury. A review of the literature regarding postobstructive and neurogenic pulmonary edema suggests useful inferences for the forensic evaluation of maltreated children who present with this finding.
Age-Related Effects of Genetic Variation on Lipid Levels: The Columbia University BioMarkers Study
Authors: Talmud Philippa J. , Berglund Lars , Hawe Emma M. , Waterworth Dawn M. , Isasi Carmen R. , Deckelbaum Richard E. , Starc Thomas , Ginsberg Henry N. , Humphries Steve E. , Shea Steven
Published: August 2004

Objectives.

To examine the genotype:phenotype association in children compared with their parents.

Methods.

Variations at 4 key gene loci, namely lipoprotein lipase (LPL S447X), hepatic lipase (HL −480C>T), cholesteryl ester transfer protein (CETP TaqIB), and apolipoprotein CIII (APOC3 −455T>C and −482C>T), were examined in children (n = 495) and their parents (n = 353) in the Columbia University BioMarkers Study, 1994 to 1998.

Results.

The frequencies of the rare alleles of theHL −480C>T and APOC3 −455T>C and −482C>T (but not LPL S447X or CETPTaqIB) were significantly lower in non-Hispanic white participants compared with Hispanics. Overall, genotype effects seen in the adults were weaker in the children, although similar trends were seen. In an examination of the effect of body fat on the genotypic effects in the children, there was significant HL−480C>T:sum of skinfold interaction.

Conclusions.

All genotypes were associated with clear relationships to plasma lipid levels in adults, but the effects were weaker in their children, unless stressed by body fat. atherosclerosis, cardiovascular disease, child, lipids, genetics.
Imperforate Hymen: Congenital or Acquired From Sexual Abuse?
Authors: Botash Ann S. , Jean-Louis Florence
Published: August 2004

Imperforate hymen diagnosed beyond the newborn period may present a dilemma for the physician. Three case studies are reviewed in which children with the diagnoses of imperforate hymen presented for evaluation of suspected sexual abuse. Clear descriptions of genital anatomy documented at well-child visits may be critical to later interpretations of findings encountered during examinations for suspected sexual abuse.
Technical Report: Evidence for the Diagnosis and Treatment of Acute Uncomplicated Sinusitis in Children: A Systematic Overview
Authors: Ioannidis John P. A. , Lau Joseph
Published: August 2004

Objective.

To evaluate and analyze the existing evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children.

Design.

A systematic overview and meta-analysis considered all pertinent studies with at least 10 children younger than 18 years with acute symptoms of <30 days and without serious complications.

Outcomes.

Clinical improvement rates for intervention studies of antibiotics or ancillary measures; concordance of diagnostic tests (expressed as likelihood ratios).

Results.

Of 1857 citations originally reviewed, we identified 21 qualifying studies, compared with 450 reports on complications of acute sinusitis and 233 nonsystematic reviews of the subject. The qualifying studies included 5 randomized, controlled trials and 8 case series on antibiotic therapy, 3 randomized, controlled trials on ancillary treatments, and 8 studies with information on diagnostic tests (including 3 therapeutic trials). Definitions and inclusion criteria were heterogeneous across studies. The pooled clinical improvement rate with antibiotics was 88% (177/202) in randomized, controlled trials and 92% (318/345) in nonrandomized studies; the improvement rates on no antibiotics were 60% and 80%, respectively. Improvement rates were significantly higher in nonrandomized studies (Mantel-Haenszel odds ratio: 1.79; 95% CI: 1.05–3.04, stratified for use of antibiotics). Data on ancillary measures were sparse and heterogeneous. In studies comparing clinical findings with plain film radiography, the pooled rate of abnormal radiographic findings against a clinical diagnosis of sinusitis was 73% (596/814; range: 55% to 96% between studies). There was poor concordance between clinical criteria, plain radiographs, ultrasonography, computed tomography, and fluid on aspiration in all available paired assessments (all positive likelihood ratios were ≤4 and all negative likelihood ratios were ≥0.2).

Conclusions.

Good, high-quality evidence for acute uncomplicated sinusitis in children is limited. Diagnostic modalities show poor concordance, and treatment options are based on inadequate data. More evidence is needed for defining the optimal treatment and diagnostic methods for this common condition.
Prevention of Agricultural Injuries Among Children and Adolescents
Authors:   Committee on Injury and Poison Prevention and Committee on Community Health Services
Published: August 2004

Although the annual number of farm deaths to children and adolescents has decreased since publication of the 1988 American Academy of Pediatrics statement, “Rural Injuries,” the rate of nonfatal farm injuries has increased. Approximately 100 unintentional injury deaths occur annually to children and adolescents on US farms, and an additional 22 000 injuries to children younger than 20 years occur on farms. Relatively few adolescents are employed on farms compared with other types of industry, yet the proportion of fatalities in agriculture is higher than that for any other type of adolescent employment. The high mortality and severe morbidity associated with farm injuries require continuing and improved injury-control strategies. This statement provides recommendations for pediatricians regarding patient and community education as well as public advocacy related to agricultural injury prevention in childhood and adolescence.
Improving Substance Abuse Prevention, Assessment, and Treatment Financing for Children and Adolescents
Authors:   Committee on Child Health Financing and Committee on Substance Abuse
Published: August 2004

The numbers of children, adolescents, and families affected by substance abuse have sharply increased since the early 1990s. The American Academy of Pediatrics recognizes the scope and urgency of this problem and has developed this policy statement for consideration by Congress, federal and state agencies, employers, national organizations, health care professionals, health insurers, managed care organizations, advocacy groups, and families.
Bicycle Helmets
Authors:   Committee on Injury and Poison Prevention
Published: August 2004

Bicycling remains one of the most popular recreational sports among children in America and is the leading cause of recreational sports injuries treated in emergency departments. An estimated 23 000 children younger than 21 years sustained head injuries (excluding the face) while bicycling in 1998. The bicycle helmet is a very effective device that can prevent the occurrence of up to 88% of serious brain injuries. Despite this, most children do not wear a helmet each time they ride a bicycle, and adolescents are particularly resistant to helmet use. Recently, a group of national experts and government agencies renewed the call for all bicyclists to wear helmets. This policy statement describes the role of the pediatrician in helping attain universal helmet use among children and teens for each bicycle ride.
Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder
Authors:   Subcommittee on Attention-Deficit/Hyperactivity Disorder Committee on Quality Improvement
Published: August 2004

This clinical practice guideline provides evidence-based recommendations for the treatment of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). This guideline, the second in a set of policies on this condition, is intended for use by clinicians working in primary care settings. The initiation of treatment requires the accurate establishment of a diagnosis of ADHD; the American Academy of Pediatrics (AAP) clinical practice guideline on diagnosis of children with ADHD1 provides direction in appropriately diagnosing this disorder.

The AAP Committee on Quality Improvement selected a subcommittee composed of primary care and developmental-behavioral pediatricians and other experts in the fields of neurology, psychology, child psychiatry, education, family practice, and epidemiology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Evidence-based Practice Center at McMaster University, Ontario, Canada, to develop the evidence base of literature on this topic.2 The resulting systematic review, along with other major studies in this area, was used to formulate recommendations for treatment of children with ADHD. The subcommittee also reviewed the multimodal treatment study of children with ADHD3 and the Canadian Coordinating Office for Health Technology Assessment report (CCOHTA).4 Subcommittee decisions were made by consensus where definitive evidence was not available. The subcommittee report underwent extensive review by sections and committees of the AAP as well as by numerous external organizations before approval from the AAP Board of Directors.

The guideline contains the following recommendations for the treatment of a child diagnosed with ADHD:Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition.The treating clinician, parents, and child, in collaboration with school personnel, should specify appropriate target outcomes to guide management.The clinician should recommend stimulant medication and/or behavior therapy as appropriate to improve target outcomes in children with ADHD.When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions.The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects, with information gathered from parents, teachers, and the child.
What If Pediatric Residents Could Bill for Their Outpatient Services?
Authors: Ng Manny , Lawless Stephen T.
Published: August 2004

Objective.

We prospectively studied the potential of billing and coding practices of pediatric residents in outpatient clinics and extrapolated our results to assess the financial implications of billing inaccuracies. Using Medicare as a common measure of “currency,” we also used the relative value unit (RVU) and ambulatory payment class methodologies as means of assessing the productivity and financial value of resident-staffed pediatric clinics.

Methods.

Residents were asked to submit voluntarily shadow billing forms and documentation of outpatient clinic visits. Documentation of work was assessed by a blinded reviewer, and current procedure terminology evaluation and management codes were assigned. Comparisons between resident codes and calculated codes were made. Financial implications of physician productivity were calculated in terms of dollar amounts and RVUs. Resource intensity was measured using the ambulatory payment class methodology.

Results.

A total of 344 charts were reviewed. Coding agreement for health maintenance visits was 86%, whereas agreement for acute care visits was 38%. Eighty-three percent of coding disagreement in the latter group was resulting from undercoding by residents. Errors accounted for a 4.79% difference in potential reimbursement for all visit types and a 19.10% difference for acute care visits. No significant differences in shadow billing discrepancies were found between different levels of training. Residents were predicted to generate $67 230, $87 593, and $96 072 in Medicare revenue in the outpatient clinic setting during each successive year of training. On average, residents generated 1.17 ± 0.01 and 0.81 ± 0.02 work RVUs for each health maintenance visit and office visit, respectively. Annual productivity from outpatient clinic settings was estimated at 548, 735, and 893 work RVUs in the postgraduate levels 1, 2, and 3, respectively.

Conclusion.

When pediatric residents are not trained adequately in proper coding practices, the potential for billing discrepancies is high and potential reimbursement differences may be substantial. Discussion of financial issues should be considered in curriculum development.
Improving Parent Knowledge About Antibiotics: A Video Intervention
Authors: Bauchner Howard , Osganian Stavroula , Smith Kevin , Triant Randi
Published: August 2004

Objective.

To determine whether an educational video could improve parent knowledge, beliefs, and behaviors about the appropriate use of oral antibiotics.

Study Design.

A randomized, controlled trial was conducted in an urban primary care clinic and a suburban pediatric practice. Parents were randomly assigned to the intervention or control groups. Parents in the intervention group were asked to view a 20-minute video, specifically developed for this project, over a 2-month period, and given a brochure about antibiotics. Parent knowledge, beliefs, and behaviors were assessed at the time of enrollment and then by telephone 2 months later.

Results.

A total of 193 (94%) of 206 parents completed the study. The groups were equivalent with respect to all important baseline characteristics. No differences were found for adjusted posttest means between the intervention and control groups for knowledge, beliefs, or behavior. For example, the intervention group scored 8.04 on the knowledge questionnaire (11 true–false questions), compared with 7.82 for the control group. Subgroup analysis, based on site of enrollment, indicated that families in the intervention group from the primary care urban clinic improved their knowledge score (6.03 to 6.92) and were more likely to report that there were problems with children receiving too many antibiotics (intervention 67% vs control 34%).

Conclusion.

Overall, this video had only a modest effect on parent knowledge, beliefs, and self-reported behaviors regarding oral antibiotics. We believe that any campaign promoting the judicious use of oral antibiotics must use a multifaceted approach and target both parents and physicians.
Randomized, Controlled Trial of OROS Methylphenidate Once a Day in Children With Attention-Deficit/Hyperactivity Disorder
Authors: Wolraich Mark L. , Greenhill Laurence L. , Pelham William , Swanson James , Wilens Timothy , Palumbo Donna , Atkins Marc , McBurnett Keith , Bukstein Oscar , August Gerald ,   on behalf of the Concerta Study Group
Published: August 2004

Objective.

A new once-a-day methylphenidate (MPH) formulation, Concerta (methylphenidate HCl) extended-release tablets (OROS MPH), has been developed. This study was conducted to determine the safety and efficacy of OROS MPH in a multicenter, randomized, clinical trial.

Methods.

Children with attention-deficit/hyperactivity disorder (ADHD; n = 282), all subtypes, ages 6 to 12 years, were randomized to placebo (n = 90), immediate-release methylphenidate (IR MPH) 3 times a day (tid; dosed every 4 hours; n = 97), or OROS MPH once a day (qd;n = 95) in a double-blind, 28-day trial. Outcomes in multiple domains were assessed, and data were analyzed using analysis of variance and Kaplan Meier product limit estimates for time to study cessation. The primary time point for analysis was the last available patient visit using last observation carried forward.

Results.

Children in the OROS and IR MPH groups showed significantly greater reductions in core ADHD symptoms than did children on placebo. This was true both at the end of week 1 and at the end of treatment on the basis of mean teacher and parent IOWA Conners ratings. IR MPH tid and OROS MPH qd did not differ significantly on any direct comparisons. Forty-eight percent of the placebo group discontinued early compared with 14% and 16% in the IR MPH and OROS MPH groups, respectively.

Conclusions.

For the treatment of core ADHD symptoms, OROS MPH dosed qd and IR MPH dosed tid were superior to placebo and were not significantly different from each other.attention-deficit/hyperactivity disorder, methylphenidate, OROS, Concerta.
Preimmunization Anti-Pneumococcal Antibody Levels Are Protective in a Majority of Patients With Cystic Fibrosis
Authors: Lahiri Thomas , Waltz David A.
Published: August 2004

Objective.

Although invasive pneumococcal disease is infrequent in cystic fibrosis (CF), it is recommended that all patients with CF receive pneumococcal immunization. As part of a comprehensive program to immunize our clinic population, we obtained preimmunization anti-pneumococcal antibody levels. We hypothesized that the percentage of CF patients without protective levels of anti-pneumococcal antibody levels would be high, as they are exposed to frequent antibiotic therapy that may eradicate organisms before generation of an antibody response.

Methods.

An observational study of 100 patients with CF, aged 1 to 39 years, was conducted in a regional CF center. Preimmunization anti-pneumococcal antibody levels against 6 serotypes were measured by enzyme-linked immunosorbent assay. Protective antibody levels were defined as >200 ng/mL.

Results.

A majority of CF patients—61% to 100%, depending on age and serotype—had protective levels of pneumococcal antibody. There was a significant positive correlation between antibody level and age for 5 of the 6 serotypes tested.

Conclusions.

In contradistinction to our hypothesis, the majority of CF patients have protective preimmunization anti-pneumococcal antibody levels. However, a significant proportion—between 17% and 39%, depending on the serotype—did not exhibit adequate levels. Therefore, we concur with current recommendations for pneumococcal immunization in CF.
Neonatal Screening for Congenital Adrenal Hyperplasia: 17-Hydroxyprogesterone Levels and CYP21 Genotypes in Preterm Infants
Authors: Nordenström Anna , Wedell Anna , Hagenfeldt Lars , Marcus Claude , Larsson Agne
Published: August 2004

Objective.

Neonatal screening for congenital adrenal hyperplasia (CAH) among preterm infants is complicated by the fact that healthy preterm infants have higher levels of 17-hydroxyprogesterone (17-OHP) than term infants, resulting in a higher false-positive rate. Even when gestational age–related cutoff levels after ether extraction were used, the false-positive cases primarily comprised preterm infants. The aim of the study was to optimize the procedure for neonatal screening for CAH in preterm infants.

Methods.

The 17-OHP levels in 6200 preterm infants were correlated to the gestational age. We also calculated the number of recalls for different putative cutoff levels of the 17-OHP by direct assay and after extraction in 1275 preterm infants who represented the most elevated cases in a population of approximately 30 000 preterm infants. The CYP21 genotypes and screening levels were determined in the 12 preterm infants with CAH diagnosed since the start of screening. The effect of possible interfering factors such as gestational age, neonatal stress, and prenatal glucocorticoid treatment for pulmonary maturation was studied.

Results.

The extraction procedure did not significantly improve the sensitivity or specificity of the screening, whereas it delayed the day of recall from 8 to 13 days (median). We could not demonstrate any systematic influence of the studied stress factors or the prenatal glucocorticoid treatment on the 17-OHP screening levels. In the patients with CAH, the 17-OHP levels correlated better with disease severity than with the degree of prematurity.

Conclusions.

On the basis of these results, we omitted the extraction step and changed the cutoff levels in the Swedish screening program for preterm infants. We chose to use a cutoff level of 400 nmol/L plasma in infants who were born before week 35 and 150 nmol/L for infants who were born in weeks 35 and 36. For detecting more patients, the cutoff level would have to be much lower, which would result in a number of false-positive tests that we consider to be unacceptably high. It is clear that neonatal screening cannot detect all infants with CAH. Some milder forms of the disease, just like in the past, will have to be diagnosed on the basis of clinical signs and symptoms.
Impact of Protease Inhibitor-Containing Combination Antiretroviral Therapies on Height and Weight Growth in HIV-Infected Children
Authors: Buchacz Kate , Cervia Joseph S. , Lindsey Jane C. , Hughes Michael D. , Seage George R. , Dankner Wayne M. , Oleske James M. , Moye Jack ,   for the Pediatric AIDS Clinical Trials Group 219 Study Team
Published: August 2004

Objective.

To examine beneficial or detrimental effects of protease inhibitor (PI)-containing antiretroviral regimens on height and weight growth in children with human immunodeficiency virus (HIV) infection.

Methods.

A prospective cohort study was conducted of 906 HIV-infected children, from pediatric research clinics in the United States, who were between 3 months and 18 years of age and who had height and weight assessed in 1995 (before introduction of PIs in this population) and at least once more through 1999. Changes in age- and gender-adjusted height and weight growth associated with PI use were assessed.

Results.

Compared with a healthy reference population, children were more affected in height (mean z score: −0.90 [18th percentile]) than in weight (mean zscore: −0.42 [34th percentile]) at baseline (1995). Two thirds of children received at least 1 PI during 1996 to 1999. In the multivariate mixed effects regression models adjusted for baseline log10 CD4 cell count, baseline age, gender, and race/ethnicity, the use of PIs was associated with per-year gains of 0.13 z scores in height and 0.05 z scores in weight relative to the expected growth with non–PI-containing regimens (eg, after 1 year of PI use, a representative 6-year-old boy in our study would be approximately 0.7 cm taller and 0.1 kg heavier than if he had not received PIs). No significant differential effects of PIs on height or weight growth according to specific agents or children's sociodemographic or clinical characteristics were found.

Conclusions.

Although the use of PI-containing regimens was not associated with growth retardation, it was associated with only small annual increments in height and weight growth in HIV-infected children.
Treatment of Febrile Seizures: The Influence of Treatment Efficacy and Side-Effect Profile on Value to Parents
Authors: Gordon Kevin E. , Dooley Joseph M. , Camfield Peter R. , Camfield Carol S. , MacSween Judith
Published: August 2004

Objectives.

We examined parents' perception of the value of treatments designed to reduce the risk of febrile seizure recurrence.

Study Design.

The families of 42 children with febrile seizures were recruited after pediatric or neuropediatric consultation. A mail questionnaire addressed the family's willingness to pay for a hypothetical treatment for febrile seizures with risk reductions for future febrile seizures of 25%, 50%, 75%, and 100%. The hypothetical clinical scenario was then modified to include the side- effect profiles of either daily phenobarbital or valproic acid, or intermittent diazepam prophylaxis. Covariates included the nature of the child's febrile seizure(s), parents' familiarity with febrile seizures, experiences at the time of febrile seizures or with medication side effects, education and income, and mastery and trait anxiety.

Results.

Thirty-eight parents, representing 22 of 42 families, completed questionnaires. There was a dramatic inflection in parents' willingness to pay for 100% risk reduction as opposed to 75% or lower risk reductions. Introduction of side effects dramatically reduced the value attached to each level of treatment benefit. Nevertheless, a few parents (3/38) would pay “as much as it takes” to be rid of their child's recurrence risk.

Conclusions.

Given the range of value assigned to prophylactic medication for febrile seizures, management strategies for children with febrile seizures must be responsive to the needs and values of individual families.
A Survey of the Use of Off-Label and Unlicensed Drugs in a Dutch Children's Hospital
Authors: 't Jong Geert W. , Vulto Arnold G. , de Hoog Matthijs , Schimmel Kirsten J. M. , Tibboel Dick , van den Anker John N.
Published: August 2004

Background.

The treatment of pediatric patients with drugs in hospitals is being impeded by a shortage in the availability of licensed drugs in an appropriate formulation. We have studied the extent of use of drugs that are not licensed for use in children (unlicensed) and drugs that are used outside the terms of the product license (off-label). We conducted this study in a Dutch academic children's hospital.

Methods.

In a prospective study of 5 weeks' duration, we reviewed drug prescriptions in a pediatric ward and 3 intensive care units. We classified the prescribed drugs in 3 main categories—licensed, unlicensed, and off-label—and determined the nature of their unlicensed and off-label use.

Results.

Two thousand one hundred thirty-nine courses of drugs were administered to 237 patients in 442 patient-days. Of 2139 prescriptions, 725 (34%) were licensed, 1024 (48%) were unlicensed, and 390 (18%) were off-label. In 392 (90%) of 435 patient-days, children received 1 or more courses of an unlicensed or off-label drug prescription in hospital.

Conclusion.

With regard to the availability of drugs of proven quality and adequate license for pediatric patients in hospital, dramatic shortcomings exist. As a result, drug legislation originally designed to protect patients and prescribing physicians against unsafe drug use and unjustified claims has turned into an insurmountable threshold to make proper drugs available for a vulnerable minority of patients.