METHODS. A prospective, randomized, clinical trial was performed in 2 level III neonatal referral units. Patients of ≤28 weeks of gestation who required active resuscitation were randomly assigned to the low-oxygen group (fraction of inspired oxygen: 30%) or the high-oxygen group (fraction of inspired oxygen: 90%). Every 60 to 90 seconds, the fraction of inspired oxygen was increased in 10% steps if bradycardia occurred (<100 beats per minute) or was decreased in similar steps if pulse oxygen saturation reached values of >85%. Preductal pulse oxygen saturation was continuously monitored.
RESULTS. The fraction of inspired oxygen in the low-oxygen group was increased stepwise to 45% and that in the high-oxygen group was reduced to 45% to reach a stable pulse oxygen saturation of ~85% at 5 to 7 minutes in both groups. No differences in oxygen saturation in minute-to-minute registers were found independent of the initial fraction of inspired oxygen used 4 minutes after cord clamping. No differences in mortality rates in the early neonatal period were detected.
CONCLUSIONS. Resuscitation can be safely initiated for extremely low gestational age neonates with a low fraction of inspired oxygen (~30%), which then should be adjusted to the infant's needs, reducing the oxygen load to the neonate.
]]>METHODS. Prospective comparison of Pa
RESULTS. We evaluated 976 paired Pa
CONCLUSIONS. High Pa
METHODS. Healthy children with ≥2 incidences of low-energy fractures were recruited (n = 68). Children with no history of fractures served as control subjects (n = 57). Food logs, activity surveys, physical examinations, laboratory tests, and dual-energy radiographic absorptiometry were used.
RESULTS. Bone mineral density z scores were significantly reduced in case subjects, compared with control subjects. Three case subjects (4.3%) and 1 control subject (1.8%) had bone mineral density z scores below the expected range. Of those 4 subjects, 2 had dairy avoidance and 2 had delayed puberty. An additional case subject had evidence of vitamin D deficiency. A significant number of subjects (20% of case subjects and 23% of control subjects) had idiopathic hypercalcuria, based on 24-hour urine collections. Among the case subjects, bone mineral density z scores were significantly lower for those with idiopathic hypercalcuria. Among the control subjects, the presence of idiopathic hypercalcuria did not affect bone mineral density. The case subjects with idiopathic hypercalcuria accounted for virtually all of the differences in bone mineral density between the case and control groups. Analysis of parathyroid hormone and 1,25-dihydroxy-vitamin D levels showed that children with frequent fractures and hypercalcuria had renal hypercalcuria, whereas children with no fractures and hypercalcuria had absorptive hypercalcuria.
CONCLUSIONS. We identified a significant association between a history of frequent fractures and hypercalcuria in children. We propose that the appropriate screening evaluation for children who present with a history of frequent fractures consists of a dietary history targeted at calcium and vitamin D intakes, a physical examination to assess for pubertal delay, and urinary calcium concentration/creatinine ratio determination to assess for hypercalcuria. Children with abnormalities in this screening should undergo dual-energy radiographic absorptiometry and appropriate evaluation.
]]>METHODS. We performed a retrospective cohort study using electronic health record data from 4 urban practices affiliated with an academic medical center. Participants included all children born between September 1, 2003, and July 31, 2004, with a visit at a study practice before 6 weeks of age and ≥1 sick visit (n = 1675). The main outcome measures were (1) attendance at a well-child visit within 60 days after an index sick visit by children due for vaccines and preventive care and (2) the overall number of well-child visits kept by children between 6 weeks and 13 months of age.
RESULTS. Among all demographic and health-related factors considered, immunization receipt at a sick visit was associated most strongly with decreased subsequent well-child care. Among children already delayed (late) for vaccines, 31% returned for well-child care if immunizations were given at eligible sick visits, compared with 47% of those who received no vaccines (risk difference, with adjustment for covariates: –16%). Among those without immunization delay, 42% of children who received vaccines returned for well-child care, compared with 73% of those who received no vaccines (risk difference: –31%). Although 5 well-child visits are recommended, children with no immunizations at sick visits had an adjusted predicted number of 3.8 well-child visits, those with 1 sick visit with immunizations had 3.3 visits, and those with ≥2 sick visits with immunizations had 2.8 visits between 6 weeks and 13 months of age.
CONCLUSIONS. Immunization at sick visits was associated with decreased rates of well-child care, especially among those without previous vaccine delay. This strong association between immunization at sick visits and well-child care should be considered in any plan to restructure pediatric preventive care.
]]>METHODS. We identified, among 500 term neonates with encephalopathy who were studied with MRI between 1992 and 2005, 48 infants with evidence of a preceding acute hypoxic event, and we reviewed their MRI scans retrospectively. Prenatal and perinatal data were compared with those for term normal low-risk infants. Neurodevelopmental outcomes were assessed at a minimum of 12 months.
RESULTS. Five patterns of brain injury were identified, as follows: pattern I, basal ganglia and thalami lesions associated with severe white matter damage (n = 6; 14%); pattern II, basal ganglia and thalami lesions with mild or moderate white matter changes (n = 24; 56%); pattern III, isolated thalamic injury (n = 2; 5%); pattern IV, moderate white matter damage only (n = 1; 2%); pattern V, mild white matter changes or normal findings (n = 10; 23%). No scan showed evidence of long-standing injury. The internal capsule was abnormal in 93% of infants with patterns I and II, and 86% of those infants died or developed cerebral palsy. Infants with patterns III and IV had developmental delay and diplegic cerebral palsy, respectively. Pattern V was associated with normal outcomes. Case infants were significantly more often of African descent, born to pluriparous or hypertensive mothers. Uterine rupture followed previous cesarean section in 8 of 11 cases. Cord prolapse accompanied undiagnosed breech presentation in 4 of 9 cases.
CONCLUSIONS. Basal ganglia and thalami lesions are the imaging signature in term neonates exposed to hypoxic-ischemic sentinel events. Patterns of central gray matter and secondary white matter injury were associated with higher risks of severe morbidity and death. Affected infants did not seem intrinsically different from our low-risk population. These data support the need for anticipating sentinel events and expediting delivery.
]]>METHODS. A retrospective, interventional study using an interrupted time-series design was conducted to compare central line–associated bloodstream infection rates during 3 time periods for all patients admitted to our pediatric cardiac ICU between April 1, 2004, and December 31, 2006. During the preintervention period (April 2004 to December 2004), a committee was convened to track and prevent nosocomial infections. Pretesting demonstrated knowledge deficits regarding nosocomial infection prevention, and educational tools were developed. During the partial intervention period (January 2005 to March 2006), a comprehensive central line–associated bloodstream infection prevention initiative was implemented, including establishment of a unit-based infection control nurse position, education for physicians and nurses, real-time feedback on central line–associated bloodstream infection data, implementation of central venous line insertion, access, and maintenance bundles, and introduction of daily goal sheets on rounds that emphasized timely central venous line removal. Central line–associated bloodstream infection rates in the preintervention, partial intervention, and full intervention (April 2006 to December 2006) periods were compared.
RESULTS. The estimated mean preintervention central line–associated bloodstream infection rate was 7.8 infections per 1000 catheter-days, which decreased to 4.7 infections per 1000 catheter-days in the partial intervention period and 2.3 infections per 1000 catheter-days in the full intervention period. The preintervention central line–associated bloodstream infection rate was significantly higher than the median rate of 3.5 infections per 1000 catheter-days for multidisciplinary PICUs reporting to the National Healthcare Safety Network. During the full intervention period, our central line–associated bloodstream infection rate was lower than this pediatric benchmark, although statistical significance was not achieved.
CONCLUSIONS. A multidisciplinary, evidence-based initiative resulted in a significant reduction in central line–associated bloodstream infections in our pediatric cardiac ICU.
]]>METHODS. This retrospective cohort study included 437 black and white subjects (70% white and 40% male) who participated in the Bogalusa Heart Study as children 5 to 17 years of age and as adults 16 to 19 years later.
RESULTS. In analyses of each lipoprotein measure as a risk factor for predicting excess carotid intima-media thickness in adulthood, non–high-density lipoprotein cholesterol level, low-density lipoprotein cholesterol level, total cholesterol/high-density lipoprotein cholesterol ratio, apolipoprotein B level, and apolipoprotein B/apolipoprotein A-I ratio emerged as significant predictors, with respective odds ratios of 2.60, 2.95, 1.78, 1.44, and 1.69, after adjustment for childhood BMI, systolic blood pressure, other lipoprotein measures, and follow-up years; the odds ratios for high-density lipoprotein cholesterol, triglyceride, and apolipoprotein A-I levels were not significant. Regarding the discriminating value of different childhood lipoprotein measures in predicting excess carotid intima-media thickness in adulthood, analyses of the area under the receiver operating characteristic curve for each lipoprotein measure, adjusted for the aforementioned nonlipoprotein covariates, indicated that the value of 0.65 for the non–high-density lipoprotein cholesterol level was similar in magnitude to those for other lipoprotein measures, with values ranging from 0.62 to 0.66.
CONCLUSIONS. Childhood non–high-density lipoprotein cholesterol levels are as good as other lipoprotein measures in predicting subclinical atherosclerosis in adulthood, which has practical implications for coronary artery disease risk assessment and intervention in pediatric populations.
]]>METHODS. We conducted a retrospective analysis of data for infants ≤12 months of age from the National Electronic Surveillance System-All Injury Program for 2001–2004. Sample weights provided by the National Electronic Surveillance System-All Injury Program were used to make national estimates.
RESULTS. An estimated 1314000 injured infants were treated in US emergency departments for nonfatal unintentional injuries during the 4-year period of 2001–2004, ~1 infant every 1.5 minutes. Falls were the leading cause of nonfatal unintentional injuries for infants. Overall, the patients were more likely to be male (55.2%) than female (44.8%). Contusions/abrasions were the leading diagnosis overall (26.7%). Contusion/abrasion, laceration, hematoma, foreign-body, and puncture injuries occurred most frequently to the head or neck region. More than one third of fractures (37.2%) were to the arm or hand. Bed was the product most frequently noted as being involved in the injury event for every age except 2 and 12 months (car seat was the most frequently noted product at 2 months of age, and stairs were top ranked at 12 months). Product rank changed markedly as age increased.
CONCLUSIONS. The influences of the social environment, the physical environment, and products change as infants mature in the first year of life; this was substantiated in our study by the shift in the relative importance of products involved in injuries according to month of age. The concept that aspects of safety must adapt in anticipation of developmental stage is critical.
]]>METHODS. We compared immunization coverage with the 4 diphtheria-tetanus-pertussis, 3 poliovirus, 1 measles-mumps-rubella, 3 Haemophilus influenza type b, and 3 hepatitis B(4:3:1:3:3) series and its individual vaccine components (≥4 doses of diphtheria, tetanus, and pertussis vaccine; ≥3 doses of oral or inactivated polio vaccine; ≥1 dose of measles, mumps, and rubella vaccine; ≥3 doses of Haemophilus influenzae type b vaccine; and ≥3 doses of hepatitis B vaccine) between American Indian/Alaska Native children and non-Hispanic white children from 2000 to 2005, using data from the National Immunization Survey.
RESULTS. Although immunization coverage increased for both populations from 2001 to 2004, American Indian/Alaska Native children had significantly lower immunization coverage, compared with non-Hispanic white children, over that time period. In 2005, coverage continued to increase for American Indian/Alaska Native children but decreased for non-Hispanic white children, and no statistically significant disparity in 4:3:1:3:3 coverage was evident in that year.
CONCLUSIONS. Disparities in immunization coverage for American Indian/Alaska Native children have been present, but unrecognized, since 2001. The absence of a disparity in coverage in 2005 is encouraging but is tempered by the fact that coverage for non-Hispanic white children decreased in that year.
]]>METHODS. Preterm baboons (treated prenatally with glucocorticoids) were delivered at 125 days of gestation (term: 185 days), given surfactant, and ventilated for 14 days. Twenty-four hours after birth, newborns were randomly assigned to receive either ibuprofen (to close the patent ductus arteriosus; n = 8) or no drug (control; n = 13).
RESULTS. After treatment was started, the ibuprofen group had significantly lower pulmonary/systemic flow ratio, higher systemic blood pressure, and lower left ventricular end diastolic diameter, compared with the control group. There were no differences in cardiac performance indices between the groups. Ventilation index and dynamic compliance were significantly improved with ibuprofen. The improved pulmonary mechanics in ibuprofen-treated newborns were not attributable to changes in levels of surfactant protein B, C, or D, saturated phoshatidylcholine, or surfactant inhibitory proteins. There were no differences in tracheal concentrations of cytokines commonly associated with the development of bronchopulmonary dysplasia. The groups had similar messenger RNA expression of genes that regulate inflammation and remodeling in the lung. Lungs from ibuprofen-treated newborns were significantly drier (lower wet/dry ratio) and expressed 2.5 times more epithelial sodium channel protein than did control lungs. By 14 days after delivery, control newborns had morphologic features of arrested alveolar development (decreased alveolar surface area and complexity), compared with age-matched fetuses. In contrast, there was no evidence of alveolar arrest in the ibuprofen-treated newborns.
CONCLUSIONS. Ibuprofen-induced patent ductus arteriosus closure improved pulmonary mechanics, decreased total lung water, increased epithelial sodium channel expression, and decreased the detrimental effects of preterm birth on alveolarization.
]]>METHODS. The sample studied (N = 1004) comprised an ethnically (33.3% minority) and socioeconomically (17.8% living in poverty and 11.3% living in borderline poverty) diverse, healthy, birth cohort from a metropolitan region of the northeastern United States. When children were 12 to 36 months of age (mean age: 23.8 months; SD: 7.1 months), parents completed the Brief Infant-Toddler Social and Emotional Assessment and questions concerning their level of worry about their child's behavior, emotions, and social development. When children were in early elementary school (mean age: 6.0 years; SD: 0.4 years), parents completed the Child Behavior Checklist and teachers completed the Teacher Report Form regarding behavioral problems. In a subsample (n = 389), parents reported child psychiatric status.
RESULTS. Brief Infant-Toddler Social and Emotional Assessment screen status and parental worry were associated significantly with school-age symptoms and psychiatric disorders. In multivariate analyses that included Brief Infant-Toddler Social and Emotional Assessment status and parental worry, Brief Infant-Toddler Social and Emotional Assessment scores significantly predicted all school-age problems, whereas worry predicted only parent reports with the Child Behavior Checklist. Children with of-concern scores on the problem scale of the Brief Infant-Toddler Social and Emotional Assessment were at increased risk for parent-reported subclinical/clinical levels of problems and for psychiatric disorders. Low competence scores predicted later teacher-reported subclinical/clinical problems and parent-reported disorders. Worry predicted parent-reported subclinical/clinical problems. Moreover, the Brief Infant-Toddler Social and Emotional Assessment identified 49.0% of children who exhibited subclinical/clinical symptoms according to teachers and 67.9% of children who later met the criteria for a psychiatric disorder.
CONCLUSIONS. Screening with a standardized tool in early childhood has the potential to identify the majority of children who exhibit significant emotional/behavioral problems in early elementary school.
]]>METHODS. An anonymous questionnaire describing 8 currently incompetent patients with potential neurologic sequelae who required resuscitation was administered to groups of physicians and students. Survival and morbidity rates were explicitly described; a very preterm infant, a full term infant and a 2-month-old infant had identical outcomes. Two patients, a 7-month-old infant and an 80-year-old patient, were previously significantly impaired. Respondents were asked whether resuscitation was in the patient's best interest and whether they would comply with the families' wishes if resuscitation was refused.
RESULTS. There was an 85% response rate (n = 524). The largest proportions of respondents stated that it was in the best interests of the 2-month-old infant and the 7-year-old child to be resuscitated (97% and 94%, respectively), followed by the 50-year-old patient and the term infant (87%), the 2 patients with 5% chance of survival (76% and 80%), the premature infant (69%), and finally the 80-year-old patient (32%). Approximately one fifth of the respondents who thought that it was in a patient's best interests to be resuscitated would nevertheless accept the family's refusal of resuscitation for all scenarios except the 80-year-old patient (72% acceptance) and the preterm infant (54% acceptance).
CONCLUSIONS. Whether resuscitation is considered in a patient's best interests is not closely related to survival rates or disability. Newborn infants and particularly preterm infants are systematically devalued, in comparison with older patients whose outcomes are the same or worse. Accepting a family's refusal of resuscitation, even among respondents who thought that resuscitation was in the patient's best interest, was much more common for the newborns.
]]>METHODS. Retrospective chart review was performed for newborns who had abnormal hearing screening results and positive urine cytomegalovirus culture results at Parkland Memorial Hospital between September 1, 1999, and August 31, 2004.
RESULTS. During the 5-year study period, 572 of 79047 newborns (7 of 1000 live births) did not pass hearing screening tests. Cytomegalovirus infection was identified in 24 (5%) of 483 tested infants and 16 (6%) of the 256 infants with subsequently confirmed hearing impairment. Of those 16 infants, 12 (75%) were identified as having congenital cytomegalovirus infection only because of failure to pass newborn hearing screening tests.
CONCLUSIONS. Congenital cytomegalovirus infection was present for 6% of newborns with confirmed hearing impairment, and the majority of those infants were identified on the basis of abnormal newborn hearing screening results.
]]>METHODS. We reviewed the medical charts of jaundiced newborns of ≥34 weeks of gestation who underwent automated auditory brainstem response testing within 4 hours of plasma total bilirubin concentration and unbound bilirubin concentration measurements. We tested the hypothesis that the likelihood of abnormal automated auditory brainstem response results would increase as total bilirubin and unbound bilirubin concentrations increased.
RESULTS. Forty-four infants with proximate total bilirubin concentration, unbound bilirubin concentration, and automated auditory brainstem response measurements were identified, and 4 (9%) had bilateral refer automated auditory brainstem response results. The mean total bilirubin concentration of 21.4 mg/dL (SD: 4.0 mg/dL; range: 14.4–29.5 mg/dL) for the 40 infants with bilateral pass automated auditory brainstem response results was not significantly different from that of 23.0 mg/dL (range: 14.9–33.1 mg/dL) for the 4 infants with bilateral refer automated auditory brainstem response results. However, the mean unbound bilirubin concentration of 1.32 µg/dL (range: 0.22–2.99 µg/dL) for the 40 infants with bilateral pass results was significantly lower than the mean of 2.62 µg/dL (range: 0.88–4.41 µg/dL) for the 4 infants with bilateral refer results. Logistic regression showed that increasing unbound bilirubin concentrations but not increasing total bilirubin concentrations were associated with of bilateral refer automated auditory brainstem response results.
CONCLUSIONS. The probability of bilateral refer automated auditory brainstem response results increases significantly with increasing unbound bilirubin concentrations but not with increasing total bilirubin concentrations. Because unbound bilirubin concentrations are also more closely correlated with bilirubin neurotoxicity than are total bilirubin concentrations, bilateral refer automated auditory brainstem response results for jaundiced newborns may indicate increased risk of bilirubin neurotoxicity, in addition to the possibility of congenital deafness.
]]>METHODS. Pediatric patients (3–18 years of age) were randomly assigned to treatment with the needle-free powder lidocaine delivery system (0.5 mg of lidocaine and 21 ± 1 bar of pressure; n = 292) or a sham placebo system (n = 287) at the antecubital fossa or the back of the hand 1 to 3 minutes before venipuncture or cannulation. All patients rated the administration comfort of the needle-free systems and the pain of the subsequent venous access procedures with the Wong-Baker Faces Pain Rating Scale (from 0 to 5). Patients 8 to 18 years of age also provided self-reports with a visual analog scale, and parents provided observational visual analog scale scores for their child's venous access pain. Safety also was assessed.
RESULTS. Immediately after administration, mean Wong-Baker Faces scale scores were 0.54 and 0.24 in the active system and sham placebo system groups, respectively. After venipuncture or cannulation, mean Wong-Baker Faces scale scores were 1.77 ± 0.09 and 2.10 ± 0.09 and mean visual analog scale scores were 22.62 ± 1.80 mm and 31.97 ± 1.82 mm in the active system and sham placebo system groups, respectively. Parents' assessments of their child's procedural pain were also lower in the active system group (21.35 ± 1.43 vs 28.67 ± 1.66). Treatment-related adverse events were generally mild and resolved without sequelae. Erythema and petechiae were more frequent in the active system group.
CONCLUSIONS. The needle-free powder lidocaine delivery system was well tolerated and produced significant analgesia within 1 to 3 minutes.
]]>METHODS. Children (0–18 years of age) for whom death was determined with neurologic criteria between January 2000 and December 2004, in southern California, were included. Medical charts were reviewed for documented performance of 14 specific elements derived from the 1987 brain death guidelines and confirmatory testing.
RESULTS. A total of 51.2% of children (142 of 277 children) referred to OneLegacy became organ donors. Care locations varied, including PICUs (68%), adult ICUs (29%), and other (3%). One patient was <7 days, 6 were 7 days to 2 months, 22 were 2 months to 1 year, and 113 were >1 year of age. The number of brain death examinations performed was 0 (4 patients), 2 (122 patients), 3 (14 patients), or 4 (2 patients). Recommended intervals between examinations were followed for 18% of patients >1 year of age and for no younger patients. A mean of only 5.5 of 14 examination elements were completed by neurologists and pediatric intensivists and 5.8 by neurosurgeons. No apnea testing was recorded in 60% of cases, and inadequate Pa
CONCLUSIONS. Children suffering brain death are cared for in various locations by a diverse group of specialists. Clinical practice varies greatly from established guidelines, and documentation is incomplete for most patients. Physicians rely on cerebral blood flow measurements more than electroencephalography for confirmatory testing. Codifying clinical and testing criteria into a checklist could lend uniformity and enhance the quality and rigor of this crucial determination.
]]>METHODS. We used caregivers' responses in the National Survey of Children with Special Health Care Needs (2001). Functional limitation was categorized as severe, some, or no limitation. We performed analyses of the relationships of functional limitation to measures of health care needs and experiences.
RESULTS. Children with special health care needs with severe functional limitation were more likely to have received specialized educational services, to have had physician visits, and to have needed health services, compared with those with no limitation. They had significantly greater odds of delayed care, unmet health care and care-coordination needs, referral problems, dissatisfaction, and difficulty using health services, compared with those without limitation. Caregivers of children with special health care needs with severe limitation were twice as likely as those with no limitation to report that providers did not spend enough time, listen carefully, provide needed information, and make family members partners in the child's care. Compared with children with special health care needs without limitation, those with severe limitation had worse health insurance experiences, in terms of insurance coverage, copayments, being able to see needed providers, and problems with health insurance. The impact on families (financial problems, need to provide home care, or need to stop or to cut work) of children with special health care needs with severe functional limitation was much greater than the impact on families of children with special health care needs without limitation. For most measures examined, results for some limitation were between those for severe limitation and no limitation.
CONCLUSIONS. Functional limitation is significantly associated with the health care needs and experiences of children with special health care needs.
]]>METHODS. A total of 384 participating general practices from the United Kingdom General Practice Research Database were used to identify patients 0 to 18 years of age who were prescribed ≥1 antipsychotic medication between January 1, 1992, and December 31, 2005. Annual age-specific prevalences and incidences of antipsychotic prescribing were calculated.
RESULTS. The overall prevalence of use of all antipsychotics increased from 1992 (0.39 users per 1000 patient-years) to 2005 (0.77 users per 1000 patient-years). The prescribing prevalence for patients 7 to 12 years of age almost tripled between 1992 (0.23 users per 1000 patient-years) and 2005 (0.61 users per 1000 patient-years). Atypical antipsychotic prescribing increased 60-fold from 1994 (0.01 users per 1000 patient-years) to 2005 (0.61 users per 1000 patient-years). However, typical antipsychotic prescribing decreased significantly from 2000 (0.44 users per 1000 patient-years) to 2005 (0.18 users per 1000 patient-years). The incidences for typical and atypical antipsychotics showed trends similar to those of the respective prevalences. However, the overall incidence (number of new starters) for all antipsychotics was relatively stable between 1992 and 2005, which suggests that patients remain on treatment longer.
CONCLUSIONS. The overall prevalence of antipsychotics almost doubled between 1992 and 2005; however, the rate of increase was much lower than the reported figures in the United States. The prescribing of atypical antipsychotic drugs has increased despite the lack of conclusive evidence showing their superiority over older conventional antipsychotics. Additional investigation is required to evaluate their efficacy and safety in children and adolescents.
]]>METHODS. A prospective cohort study of respiratory system compliance was conducted of infants ≤32 weeks' gestation within 72 hours of life and before surfactant therapy if needed. The study (remote) group was composed of infants who were treated with antenatal steroids >7 days before delivery and the comparison group (ideal group) of matched infants who were treated with antenatal steroids 1 to 7 days before delivery. Respiratory system compliance was measured with the single-breath occlusion technique.
RESULTS. Twenty-eight remotely treated infants and 28 ideally treated infants were studied. The remote group had a significantly lower respiratory system compliance per kilogram and total respiratory system compliance when compared with the ideal antenatal steroids group. Within the remote group, infants who received antenatal steroids 8 to 14 days (n = 10) before delivery had a significantly higher respiratory system compliance and a trend to less surfactant need (10% vs 33%) as compared with infants who received antenatal steroids >14 days (n = 18) before delivery.
CONCLUSIONS. Infants who were ≤32 weeks' gestation and remotely treated with antenatal steroids (average 21 days) had a significantly lower respiratory compliance compared with matched infants who were ideally treated with antenatal steroids. We speculate that the lower respiratory system compliance may reflect the dissipation of beneficial effects of antenatal steroids on pulmonary function when delivery occurs >7 days after therapy and particularly when therapy is >14 days before delivery.
]]>METHODS. We surveyed nurses in US NICUs with neonatal-perinatal fellowships in 2004. Data collected included pulse oximeter saturation limits targeted by nurses and by NICU policy when present, nurses' opinions about appropriate pulse oximeter saturation limits, and NICU and nurse characteristics. Factors associated with pulse oximeter saturation limits targeted by nurses were identified with hierarchical linear modeling.
RESULTS. Among those eligible, 2805 (45%) nurses in 59 (60%) NICUs responded. Forty (68%) of 59 NICUs had a policy that specified a pulse oximeter saturation target range for extremely preterm infants. Among 1957 nurses at NICUs with policies, 540 (28%) accurately identified the upper and lower limits of their NICU's policy and also targeted these values in practice. NICU-specific SDs for individual nurse target limits were less at NICUs with versus without a policy for both upper and lower limits. Hierarchical linear modeling identified presence of pulse oximeter saturation policy, NICU-specific nurse group opinion, and individual nurse opinion as factors significantly associated with individual pulse oximeter saturation target limits. For each percentage point increase in individual opinion upper limit, the individual target upper limit increased by 0.41 percentage point at NICUs with a policy compared with 0.6 percentage point at NICUs with no policy.
CONCLUSIONS. Presence of policy-specified pulse oximeter saturation limits, nurse group opinion, and individual nurse opinion were independently associated with individual nurse pulse oximeter saturation target limits during routine care of extremely preterm infants. The presence of a policy reduced the influence of individual nurse opinion on targeted pulse oximeter saturation limits and reduced variation among nurse target limits within NICUs.
]]>METHODS. Half of 42 unions in 2 Bangladesh divisions with the highest infant mortality rates were randomly assigned to community-based kangaroo mother care, and half were not. One village per union was randomly selected proportionate to union population size. A baseline survey of 39888 eligible consenting women collected sociodemographic information. Community-based workers were taught to teach community-based kangaroo mother care to all expectant and postpartum women in the intervention villages. A total of 4165 live births were identified and enrolled. Newborns were followed for 30 to 45 days and infants were followed quarterly through their first birthday to record infant care, feeding, growth, health, and vital status.
RESULTS. Forty percent overall and ~65% of newborns who died were not weighed at birth, and missing birth weight was differential by study group. There was no difference in overall neonatal mortality rate or infant mortality rate. Except for care seeking, community-based kangaroo mother care behaviors were more common in the intervention than control group, but implementation was weak compared with the pilot study.
CONCLUSIONS. The extensive missing birth weight and its potential bias render the evidence insufficient to justify implementing community-based kangaroo mother care. Additional experimental research ensuring baseline comparability of mortality, adequate kangaroo mother care implementation, and birth weight assessment is necessary to clarify the effect of community-based kangaroo mother care on survival.
]]>METHODS. The Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales and Cardiac Module were administered to 475 families including 347 children with cardiovascular disease during a pediatric cardiology outpatient visit. The PedsQL scores reported by children with cardiovascular disease and their parents were compared with pediatric population norms. The relationship between Pediatric Quality of Life Inventory scores and patient characteristics was examined.
RESULTS. By self-report, mean PedsQL scores for children with cardiovascular disease were significantly lower than healthy child norms for physical and psychosocial functioning. Psychosocial quality of life scores were classified as significantly impaired as reported by 21% of children ≥8 years of age. Even among children with less severe cardiovascular disease, 19.2% reported significantly impaired psychosocial quality of life. By parental report, overall PedsQL scores were not significantly different from healthy children except in the teenage group, and both the 8- to 12-year-old and teenage groups had lower mean psychosocial quality of life scores than healthy peers. Parent-reported mean PedsQL scores for both physical and psychosocial quality of life were significantly lower in children with more severe cardiovascular disease. Children with more severe cardiovascular disease reported lower mean scores for physical functioning, but smaller differences in psychosocial quality of life scores were observed related to disease severity.
CONCLUSIONS. Overall, children with cardiovascular disease perceived lower quality of life than healthy children across all age groups. As perceived by parents, overall quality of life was not significantly different in young children with cardiovascular disease, but children with more severe cardiovascular disease have worse physical and psychosocial quality of life. One in 5 children with cardiovascular disease perceives impaired psychosocial functioning, including children with mild disease severity.
]]>METHODS. A prospective observational study, using a before-and-after design, was conducted at a tertiary care pediatric hospital in Canada between March 2005 and August 2006. The appropriateness of all hospital days for all admissions was evaluated by a nurse trained in using a utilization review tool. This tool classifies hospital days as "qualified" or "nonqualified" on the basis of the nature of the inpatient services that are used. Reasons for nonqualified days were classified. The intervention consisted of (1) weekly feedback to attending physicians of which patients were nonqualified and (2) dissemination of summary reports to attending physicians. Comparisons were made between the preintervention (March 2005 to August 2005) and intervention (March 2006 to August 2006) phases.
RESULTS. The intervention was associated with a significantly lower risk of inappropriate hospital days. Of the 7246 hospital days in the 6-month intervention phase, 2413 (33%) were nonqualified versus 3859 (47%) of 8228 hospital days in the 6-month preintervention phase. A total of 7.35 hospital days would have to be reviewed, combined with weekly feedback, to prevent 1 nonqualified hospital day. The 48-hour readmission rate in the intervention phase and preintervention phase was 1.0% and 1.6%, respectively. The proportion of nonqualified days to total hospital days that were attributable to "finishing intravenous antibiotics," "awaiting tests," "providing nutrition," "observation only," "tapering treatment," and "teaching" decreased significantly, whereas the "lack of an alternate level of care" increased significantly.
CONCLUSIONS. An audit-and-feedback intervention directed at attending physicians was associated with a lower risk of inappropriate hospital days without an increase in the readmission rate. The utilization review tool also identified processes that impact on inappropriate hospital days.
]]>METHODS. Standard cost/benefit and cost-effectiveness analysis methods were used. Intervention costs were measured as program costs estimated to be incurred by the US government, which funds SunWise, using 3 funding scenarios. Health outcomes were measured as skin cancer cases and premature mortalities averted and quality-adjusted life-years saved. These health outcomes were modeled using an effectiveness evaluation of SunWise based on pretest and posttest surveys administered to students who participated in the program and the Environmental Protection Agency's peer-reviewed Atmospheric and Health Effects Framework model. Costs averted were measured as direct medical costs and costs of productivity losses averted as a result of SunWise. Net benefits were measured as the difference between costs averted and program costs.
RESULTS. Economic analysis indicated that if the SunWise School Program continues through 2015 at current funding levels, then it should avert >50 premature deaths, nearly 11000 skin cancer cases, and 960 quality-adjusted life-years (undiscounted) among its participants. For every dollar invested in SunWise, between approximately $2 and $4 in medical care costs and productivity losses are saved, depending on the funding scenario.
CONCLUSIONS. From a cost/benefit and cost-effectiveness perspective, it is worthwhile to educate children about sun safety; small to modest behavioral impacts may result in significant reductions in skin cancer incidence and mortality.
]]>METHODS. Ten hospitals enrolled 191 infants who were born at <37 weeks' gestational age at 56 to 60 days' chronological age. Infants were randomly assigned to a group that received diphtheria-tetanus-acellular pertussis immunization (n = 93) or a control group that did not (n = 98). Recording monitors were used continuously during the next 48 hours to document prolonged apnea and prolonged bradycardia. The presence and number of episodes during the 48-hour period were compared between groups by using 2 and t tests.
RESULTS. In the diphtheria-tetanus-acellular pertussis group, 16.1% experienced at least 1 episode of prolonged apnea compared with 20.4% of control infants. One or more prolonged bradycardia events occurred in 58.1% of immunized infants and 56.1% of the control infants. The frequency of episodes was not significantly different between groups. The immunization group and the control group each had an average of 0.5 episodes of prolonged apnea. The mean number of prolonged bradycardia episodes was 2.6 in the immunization group and 2.7 in the control group.
CONCLUSIONS. Preterm infants who received diphtheria-tetanus-acellular pertussis at 2 months after birth were no more likely to experience prolonged apnea and bradycardia than were control infants. This study supports the American Academy of Pediatrics recommendation regarding diphtheria-tetanus-acellular pertussis immunization at 2 months of age for preterm infants.
]]>METHODS. To identify genetic factors that might contribute to variations in mumps vaccine–induced immune responses, we performed HLA genotyping in a group of 346 healthy schoolchildren (12–18 years of age) who previously received 2 doses of live mumps vaccine. Single-nucleotide polymorphisms (minor allele frequency of >5%) in cytokine and cytokine receptor genes were genotyped for a subset of 118 children.
RESULTS. Median values for mumps-specific antibody titers and lymphoproliferative stimulation indices were 729 IU/mL and 4.8, respectively. Girls demonstrated significantly higher mumps antibody titers than boys, indicating gender-linked genetic differences in humoral immune response. Significant associations were found between the HLA-DQB1*0303 alleles and lower mumps-specific antibody titers. An interesting finding was the association of several HLA class II alleles with mumps-specific lymphoproliferation. Alleles of the DRB1 (*0101, *0301, *0801, *1001, *1201, and *1302), DQA1 (*0101, *0105, *0401, and *0501), and DQB1 (*0201, *0402, and *0501) loci were associated with significant variations in lymphoproliferative immune responses to mumps vaccine. Additional associations were observed with single-nucleotide polymorphisms in the interleukin-10RA, interleukin-12RB1, and interleukin-12RB2 cytokine receptor genes. Minor alleles for 4 single-nucleotide polymorphisms within interleukin-10RA and interleukin-12RB genes were associated with variations in humoral and cellular immune responses to mumps vaccination.
CONCLUSIONS. These data suggest the important role of HLA and immunoregulatory cytokine receptor gene polymorphisms in explaining variations in mumps vaccine–induced immune responses.
]]>METHODS. We included 90619 singletons who were born between September 1997 and June 2003 in the Danish National Birth Cohort and followed them up to December 2005. Information on maternal infections during pregnancy (cystitis, pyelonephritis, diarrhea, coughs lasting >1 week, vaginal yeast infection, genital herpes, venereal warts, and herpes labialis) was prospectively reported by mothers in 2 computer-assisted telephone interviews in early and midgestation; information on maternal cystitis and pyelonephritis during late period of pregnancy was also collected in a third interview after birth. Children who received a diagnosis of epilepsy as inpatients or outpatients were retrieved from the Danish National Hospital Register. We identified 646 children with a diagnosis of epilepsy during up to 8 years of follow-up time. Cox proportional hazards regression models were used to estimate incidence rate ratio and 95% confidence interval.
RESULTS. Children who were exposed to maternal cystitis, pyelonephritis, diarrhea, coughs, and/or vaginal yeast infection some maternal infections in prenatal life had an increased risk for epilepsy. Coughs lasting >1 week were associated with an increased risk for epilepsy only in the first year of life, as was vaginal yeast infection only in children who were born preterm. These associations remained unchanged for children without cerebral palsy, congenital malformation, or a low Apgar score at 5 minutes.
CONCLUSIONS. Prenatal exposure to some maternal infections was associated with an increased risk for epilepsy in childhood.
]]>METHODS. The first 47 medium-chain acyl-CoA dehydrogenase deficiency cases detected by the New England Newborn Screening Program were classified according to initial and follow-up octanoylcarnitine values, octanoylcarnitine-decanoylcarnitine ratios, medium-chain acyl-CoA dehydrogenase genotype, follow-up biochemical parameters, and feeding by breast milk or formula.
RESULTS. All 20 patients who were homozygous for 985A->G had high initial octanoylcarnitine values (7.0–36.8 µM) and octanoylcarnitine-decanoylcarnitine ratios (7.0–14.5), whereas the 27 patients with 0 to 1 copy of 985A->G exhibited a wide range of octanoylcarnitine values (0.5–28.6 µM) and octanoylcarnitine-decanoylcarnitine ratios (0.8–12.7). Initial newborn octanoylcarnitine values decreased by days 5 to 8, but the octanoylcarnitine-decanoylcarnitine ratio generally remained stable. Among 985A->G homozygotes, breastfed newborns had higher initial octanoylcarnitine values than newborns who received formula. Adverse events occurred in 5 children, 4 985A->G homozygotes and 1 compound heterozygote with a very high initial octanoylcarnitine: 2 survived severe neonatal hypoglycemia, 1 survived a severe hypoglycemic episode at 15 months of age, and 2 died as a result of medium-chain acyl-CoA dehydrogenase deficiency at ages 11 and 33 months.
CONCLUSION. Newborn screening for medium-chain acyl-CoA dehydrogenase deficiency has detected cases with a wide range of genotypes and biochemical abnormalities. Although most children do well, adverse outcomes have not been entirely avoided. Assessment of potential risk and determination of appropriate treatment remain a challenge.
]]>METHODS. Data were collected over 12 consecutive months from 2004 to 2005 for neonates with neonatal respiratory failure. Eligible infants were those who required endotracheal intubation and mechanical ventilation and/or nasal continuous positive airway pressure for at least 24 hours and infants who died within 24 hours of ventilation during their first 7 days of life. Data characterized demographics, antenatal and perinatal history, illness severity score, primary disease, respiratory care, complications, survival, and clinical burden.
RESULTS. From a total of 13070 NICU admissions, there were 1722 (13.2%) cases of neonatal respiratory failure with respiratory distress syndrome, pneumonia/sepsis, and meconium aspiration syndrome as major causes. For infants who survived until discharge, the median length of ventilation was 70 hours. Overall, in-hospital mortality for neonatal respiratory failure was 32.1%. Logistic regressions showed that lower gestational age, vaginal delivery, fetal distress before delivery, presence of a major anomaly, and high severity score in preterm infants were associated with an increased risk for death. In term and postterm infants, only the presence of a major anomaly and a high severity score were significant risk factors for death. Mean length and cost of stay in hospital were 19.2 ± 14.6 days and 14966 ± 13465 Yuan in the survivors.
CONCLUSIONS. Neonatal respiratory failure in the NICU of the provincial cities of China has high mortality and cost that are linked to geographic variability, a male predominance, and low proportion of very preterm infants, characteristic of sociocultural confounding background.
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