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THIS MONTH IN ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE: This Month in Archives of Pediatrics & Adolescent Medicine

ARTICLE: Effect of Telephone Calls From Primary Care Practices on Follow-up Visits After Pediatric Emergency Department Visits: Evidence From the Pediatric Emergency Department Links to Primary Care (PEDLPC) Randomized Controlled Trial

Objective To test whether follow-up phone calls to counsel families about pediatric emergency department (PED) use and primary care availability made after an index PED visit would modify subsequent PED use. Design Longitudinal prospective randomized intervention. Setting An urban academic children's hospital. Patients A total of 4246 individuals aged 0 to 21 years from each of 4 participating primary care practices recording an index PED visit from April through December 2005. Intervention Follow-up phone call from the primary care practice within 72 hours of the initial PED visit to counsel about the availability of after-hours advice and when to access the PED. Main Outcome Measures All subsequent visits to primary care practices, PED, pediatric subspecialists, or for inpatient hospitalization during a 365-day follow-up period. Logistic and ordinary least squares regressions estimated unadjusted and adjusted odds ratios of follow-up visits, controlling for covariates. Results Of the 2166 intervention subjects, 816 (37.7%) recorded follow-up PED visits compared with 819 (39.4%) of the 2080 control subjects (P = .26, not significant). The adjusted odds of a follow-up visit being to the PED rather than to another venue was significantly less for intervention than for control subjects (odds ratio, 0.88; confidence interval, 0.82-0.94), indicating decreased intensity of PED use. Conclusion Follow-up phone calls from primary care practices after PED visits counseling patients on the use of primary care and emergency services can modulate subsequent care-seeking behavior and decrease future PED use.

ARTICLE: Access to Pediatric Trauma Care in the United States

Objectives To catalog trauma center resources and estimate access to age-specific trauma care for children younger than 15 years in the United States. Design Cross-sectional study collating information from national, state, and local trauma systems authorities to create a catalog of verified pediatric trauma centers (PTCs) and self-designated "candidate" trauma centers. Access-to-care calculations were estimated using all US block groups and prior validated methods. Setting United States. Patients Children in the US younger than 15 years. Main Outcome Measures The PTC statuses of hospitals in the United States. Percentages of pediatric populations (by state and population density) having access (by ground or air) within 60 minutes to a PTC. Results A total of 170 verified PTCs were identified in 41 states (including the District of Columbia). An estimated 71.5% of pediatric patients were within 60 minutes of a verified PTC by air or ground transport, 43% if ground transportation only was considered. An estimated 17.4 million children did not have access to a PTC within 60 minutes. Access ranged from 22.9% of the population in the most rural areas of the United States to 93.5% in the most urban. The addition of 24 candidate centers increased coverage to 77.4% of the pediatric population being within 60 minutes of a PTC. Conclusions Current pediatric trauma resources vary greatly by state and population density, with many children, particularly in rural areas, underserved. A thorough standardized catalog of verified PTCs is necessary to accurately assess pediatric trauma needs now and to optimize future trauma system planning for children.

ARTICLE: Peace of Mind and Sense of Purpose as Core Existential Issues Among Parents of Children With Cancer

Objective To evaluate issues experienced by parents of children with cancer and factors related to parents' ability to find peace of mind. Design Cross-sectional survey. Setting Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts. Participants One hundred ninety-four parents of children with cancer (response rate, 70%) in the first year of cancer treatment. Main Outcome Measure The Functional Assessment of Chronic Illness Therapy–Spiritual Well-being sense of meaning subscale. Results Principal components analysis of Functional Assessment of Chronic Illness Therapy–Spiritual Well-being sense of meaning subscale responses identified 2 distinct constructs, peace of mind (Cronbach = .83) and sense of purpose (Cronbach = .71). Scores ranged from 1 to 5, with 5 representing the strongest sense of peace or purpose. One hundred forty-seven of 181 parents (81%) scored 4 or higher for questions related to sense of purpose (mean [SD] score, 4.4 [0.6]). Only 44 of 185 parents (24%) had scores in the same range for peace of mind (mean [SD] score, 3.2 [0.9]) (P < .001). In a multivariable logistic regression model, parents had higher peace of mind scores when they also reported that they trusted the oncologist's judgment (odds ratio [OR] = 6.65; 95% confidence interval [CI], 1.47-30.02), that the oncologist had disclosed detailed prognostic information (OR = 2.05; 95% CI, 1.14-3.70), and that the oncologist had provided high-quality information about the cancer (OR = 2.54; 95% CI, 1.11-5.79). Peace of mind was not associated with prognosis (OR = 0.74; 95% CI, 0.41-1.32) or time since diagnosis (OR = 1.00; 95% CI, 0.995-1.003). Conclusions Physicians may be able to facilitate formulation of peace of mind by giving parents high-quality medical information, including prognostic information, and facilitating parents' trust.

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ARTICLE: Screening for Traumatic Exposure and Posttraumatic Stress Symptoms in Adolescents in the War-Affected Eastern Democratic Republic of Congo

Objective To explore adolescent mental health in the eastern Democratic Republic of Congo, scene of a complex emergency since 1996. Design Community cross-sectional data obtained using a cluster sample approach. Setting From November 5, 2007, through February 5, 2008, we assessed 13 secondary schools in 4 selected health zones in the Ituri district. Participants One thousand forty-six adolescents and young adults aged 13 to 21 years completed a self-report questionnaire. Main Exposures War-related traumatic events, posttraumatic stress symptoms, and sociodemographic variables. Main Outcomes Measures The Adolescent Complex Emergency Exposure Scale, specifically designed for this region, screened for exposure to potentially traumatic events, and the Impact of Event Scale–Revised measured symptoms of posttraumatic stress consistent with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. Results Among the 477 girls (45.6%) and 569 boys (54.4%) in the study, 95.0% reported at least 1 traumatic event. On average, adolescents were exposed to 4.71 traumatic events, with higher exposure rates reported in boys, older groups, rural and urban areas, and respondents whose mother or father was dead. Of 990 respondents, 52.2% met symptom criteria for posttraumatic stress disorder. Symptom scores were strongly related to cumulative trauma exposure; however, the strength of this relationship differed slightly across living area groups for girls. Conclusion Adolescents in the eastern Democratic Republic of Congo are highly exposed to political violence, putting them at a considerable risk—mediated by living area and sex—to develop posttraumatic stress symptoms.

ARTICLE: Effect of Maternal Psychopathology on Behavioral Problems in Preschool Children Exposed to Terrorism: Use of Generalized Estimating Equations to Integrate Multiple Informant Reports

Objective To examine whether the number of maternal psychopathologies is associated with increased clinically significant behavioral problems in preschool children exposed to disaster, using child behavior ratings from multiple informants. Design Cross-sectional study. Setting Lower Manhattan, New York, New York. Participants One hundred two preschool child-mother dyads directly exposed to the World Trade Center attacks. Exposures Maternal disorders: 2 (posttraumatic stress disorder [PTSD] and depression), 1 (depression or PTSD), or none. Main Outcome Measures Maternal depression and PTSD were self-reported. Child behavioral problems were rated by mothers and teachers using a standardized behavioral checklist. For each informant, we created separate dichotomous variables that indicated whether the child's behavioral problems were severe enough to be clinically significant. We then used an analytic technique (generalized estimating equations) that integrates the child behavioral problem ratings by the mother and teachers to derive a more reliable indicator of clinically significant child behavioral problems. Results The rate of clinically significant child behavioral problems increased linearly relative to the number of maternal psychopathologies. The number of maternal psychopathologies was associated with a linear increase in functional impairment. Compared with children of mothers without psychopathologies, children of mothers with depression and PTSD were at greater risk for several clinically significant problems, notably, aggressive behavior (relative risk, 13.0), emotionally reactive behavior (11.2), and somatic complaints (10.5). Boys were more likely to have clinically significant behavior problems than were girls. Conclusion Concurrent maternal depression and PTSD was associated with dramatic increases in the rate of clinically significant behavioral problems in preschool children, particularly boys, 3 years after the World Trade Center attacks.

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ARTICLE: HLA-DR4 as a Risk Allele for Autism Acting in Mothers of Probands Possibly During Pregnancy

Objectives To test whether HLA-DR4 acts in the mother, possibly during pregnancy, to contribute to the phenotype of autistic disorder in her fetus. Design Transmission disequilibrium testing in case mothers and maternal grandparents. Setting Previous studies have consistently shown increased frequency of HLA-DR4 in probands with autism and their mothers, but not their fathers. However, this has been documented only in case-control studies and not by a more direct study design to determine whether HLA-DR4 acts in mothers during pregnancy to contribute to autism in their affected offspring. Participants We genotyped for HLA-DR alleles in members of 31 families with parents and maternal grandparents. Probands with autism were tested using the Autism Diagnostic Observation Schedule–Western Psychological Services and Autism Diagnostic Interview, Revised. There was 80% power to detect an odds ratio of 3.6. Participants were all families from New Jersey and were similar in number to earlier studies of autism and HLA-DR4. Outcome Measures Analysis was by standard transmission disequilibrium testing. As a secondary test we examined the possibility of maternal imprinting. Results Significant transmission disequilibrium for HLA-DR4 was seen (odds ratio, 4.67; 95% confidence interval, 1.34-16.24; P = .008) for transmissions from maternal grandparents to mothers of probands, supporting a role for HLA-DR4 as an autism risk factor acting in mothers during pregnancy. Transmission disequilibrium was not seen for HLA-DR4 transmissions from parents to probands or from mothers to probands. Conclusions The HLA-DR4 gene may act in mothers of children with autism during pregnancy to contribute to autism in their offspring. Further studies are required to confirm these findings.

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ARTICLE: Receipt of Special Education Services Following Elementary School Grade Retention

Objective To estimate the proportion of children who receive an Individualized Education Program (IEP) following grade retention in elementary school. Design Longitudinal cohort study. Participants Children retained in kindergarten or first (K/1) grade and third grade, presumably for academic reasons, were followed up through fifth grade. Main Outcome Measure Presence or absence of an IEP. Results A total of 300 children retained in K/1 and 80 retained in third grade were included in the study. Of the K/1 retainees, 68.9% never received an IEP during the subsequent 4 to 5 years; of the third-grade retainees, 72.3% never received an IEP. Kindergarten/first-grade retainees in the highest quintile for socioeconomic status and those with suburban residence were less likely to receive an IEP than retained children in all other socioeconomic status quintiles (adjusted odds ratio, 0.17; 95% confidence interval, 0.05-0.62) and in rural communities (0.16; 0.06-0.44). Among K/1 retainees with persistently low academic achievement in math and reading, as assessed by standardized testing, 38.2% and 29.7%, respectively, never received an IEP. Conclusions Most children retained in K/1 or third grade for academic reasons, including many of those who demonstrated sustained academic difficulties, never received an IEP during elementary school. Further studies are important to elucidate whether retained elementary schoolchildren are being denied their rights to special education services. In the meantime, early-grade retention may provide an opportunity for pediatricians to help families advocate for appropriate special education evaluations for children experiencing school difficulties.

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ARTICLE: Audible Television and Decreased Adult Words, Infant Vocalizations, and Conversational Turns: A Population-Based Study

Objective To test the hypothesis that audible television is associated with decreased parent and child interactions. Design Prospective, population-based observational study. Setting Community. Participants Three hundred twenty-nine 2- to 48-month-old children. Main Exposures Audible television. Children wore a digital recorder on random days for up to 24 months. A software program incorporating automatic speech-identification technology processed the recorded file to analyze the sounds the children were exposed to and the sounds they made. Conditional linear regression was used to determine the association between audible television and the outcomes of interest. Outcome Measures Adult word counts, child vocalizations, and child conversational turns. Results Each hour of audible television was associated with significant reductions in age-adjusted z scores for child vocalizations (linear regression coefficient, –0.26; 95% confidence interval [CI], –0.29 to –0.22), vocalization duration (linear regression coefficient, –0.24; 95% CI, –0.27 to –0.20), and conversational turns (linear regression coefficient, –0.22; 95% CI, –0.25 to –0.19). There were also significant reductions in adult female (linear regression coefficient, –636; 95% CI, –812 to –460) and adult male (linear regression coefficient, –134; 95% CI, –263 to –5) word count. Conclusions Audible television is associated with decreased exposure to discernible human adult speech and decreased child vocalizations. These results may explain the association between infant television exposure and delayed language development.

ARTICLE: Screening for Asymptomatic Chlamydia Infections Among Sexually Active Adolescent Girls During Pediatric Urgent Care

Objective To develop and evaluate an intervention to increase Chlamydia trachomatis (CT) screening among sexually active adolescent girls during pediatric urgent care. Design Ten pediatric clinics were randomly assigned to an intervention (5 clinics) or control group (5 clinics). The proportion of sexually active girls screened for CT was estimated over 18 months (April 2005-September 2006). Setting Large health maintenance organization in northern California. Participants Pediatric clinics providing urgent care services for adolescent girls aged 14 to 18 years. Intervention In the intervention clinics, a team of providers and clinic staff met monthly to redesign their clinic system to improve CT screening during urgent care. Controls received an informational lecture on CT screening. Main Outcome Measures Clinic-specific proportions of sexually active adolescent girls screened for CT. Results The change over time in clinic-specific CT screening rates in urgent care was significantly greater in the intervention group than in the control group (likelihood ratio, 21 = 18.7; P < .001). Between baseline and the fifth intervention period, the proportions of girls screened for CT increased by 15.93% in the intervention group and decreased by 2.13% in the comparison clinics. Conclusions The intervention significantly improved the proportion of adolescent girls screened for CT during urgent care. Despite this success, substantial barriers to screen for CT in urgent care remain. Innovative strategies to provide basic information about CT, other sexually transmitted infections, and pregnancy are greatly needed since many teens are never seen for preventive care in a given year.

ARTICLE: Sports Practice Among Adolescents With Chronic Health Conditions

Objectives To compare the level of sports practice between adolescents with chronic health conditions (CHCs) and control peers and to examine the reasons given by adolescents with CHCs for not practicing any sports in comparison with the control group. Design School survey. Setting Postmandatory schools. Participants A total of 6790 students (3275 females) aged 16 to 20 years, grouped as adolescents with CHCs (355 females, 354 males) and control peers (2920 females, 3161 males). Main Exposure Chronic health condition was defined using a noncategorical approach including adolescents with a chronic disease and/or a physical handicap. Main Outcome Measures Sports practice, barriers to sports practice among individuals not practicing any sports, and biological, psychological, socioeducative, and physical activity characteristics. Results Males with CHCs were less likely than control males to practice sports, whereas no significant difference was observed for females. Chronically ill youth were significantly more likely to report having a CHC as a barrier for not practicing sports. However, the most frequently reported barrier was preference for other activities for males with CHCs and lack of time for control males and for females with and without CHCs. Conclusions Having a CHC seems to influence sports practice among males but not females. We recommend that practitioners dealing with adolescents remember to take into account sports practice as part of the care of young patients with CHCs.

REVIEW ARTICLE: Quality Improvement Strategies for Children With Asthma: A Systematic Review

Objective To evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient pediatric asthma care. Data Sources Cochrane Effective Practice and Organisation of Care Group database (January 1966 to April 2006), MEDLINE (January 1966 to April 2006), Cochrane Consumers and Communication Group database (January 1966 to May 2006), and bibliographies of retrieved articles. Study Selection Randomized controlled trials, controlled before-after trials, or interrupted time series trials of English-language QI evaluations. Interventions Must have included 1 or more QI strategies for the outpatient management of children with asthma. Main Outcome Measures Clinical status (eg, spirometric measures); functional status (eg, days lost from school); and health services use (eg, hospital admissions). Results Seventy-nine studies met inclusion criteria: 69 included at least some component of patient education, self-monitoring, or self-management; 13 included some component of organizational change; and 7 included provider education. Self-management interventions increased symptom-free days by approximately 10 days/y (P = .02) and reduced school absenteeism by about 0.1 day/mo (P = .03). Interventions of provider education and those that incorporated organizational changes were likely to report improvements in medication use. Quality improvement interventions that provided multiple educational sessions, had longer durations, and used combinations of instructional modalities were more likely to result in improvements for patients than interventions lacking these characteristics. Conclusions A variety of QI interventions improve the outcomes and processes of care for children with asthma. Use of similar outcome measures and thorough descriptions of interventions would advance the study of QI for pediatric asthma care.

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SPECIAL FEATURE: Picture of the Month--Diagnosis

EDITORIAL: Approaches to Chlamydia Screening: One Size Does Not Fit All

EDITORIAL: The Forgotten Victims of Posttraumatic Stress Disorder

THE PEDIATRIC FORUM: Collaboration With Pediatric Call Centers for Patient Recruitment

CALL FOR PAPERS: Theme Issue on Palliative Care, Dying, and Bereavement

ADVICE FOR PATIENTS: Chlamydia Screening: A Routine Test

Effect of transfusion on the venous blood lactate level in very low-birthweight infants

Relationship between maternal and newborn anthropometric measurements in Sudan

Clinical features of neonatal sepsis caused by resistant Gram-negative bacteria

Survival and late effects on development of patients with infantile brain tumor

Changes in salivary and fecal secretory IgA in infants under different feeding regimens

Effects of formula supplementation in breast-fed infants with failure to thrive

Effect of passive smoking on growth and infection rates of breast-fed and non-breast-fed infants

Role of exercise in the prevention of obesity and hemodynamic abnormalities in adolescents

Parental stress associated with caring for children with Aspergers syndrome or autism

Septic arthritis and acute hematogenous osteomyelitis in childhood at a tertiary hospital in Japan

Acute septic arthritis in children

Clinical impact of altered immunoglobulin levels in HenochSchonlein purpura

Short-term efficacy of tacrolimus ointment and impact on quality of life

Disease pattern and seasonal variation among Japanese expatriate children in Thailand

Dermatological signs in Wilsons disease

Preoperative management for tricuspid regurgitation in hypoplastic left heart syndrome

Plethysmographic lung volumes in children with sighing dyspnea

Early neonatal onset carbamoyl-phosphate synthase 1 deficiency treated with continuous hemodiafiltration and early living-related liver transplantation

Self-limited lupus-like presentation of human parvovirus B19 infection in a 1-year-old girl

Severe concurrent lung infection caused by legionella and mycoplasma in a 3-year-old patient with Down syndrome and tuberous sclerosis

Brain natriuretic peptide levels in Kawasaki disease: A case report

Intractable epilepsy: Expression of substance P in cortical dysplastic neurons

Acute myocardial infarction after Kawasaki disease in an infant: Treatment with coronary artery bypass grafting

Rapidly progressive acute post-streptococcal glomerulonephritis in a child with IgA nephropathy

Benign lymphoid polyposis: Two diffuse cases leading to fatal intestinal ischemia in children

Intestinal obstruction and phenytoin intoxication

Can cranberry juice be a substitute for cefaclor prophylaxis in children with vesicoureteral reflux?

Frequencies of factors of metabolic syndrome at diagnosis in children with T2DM

Value of washed sputum samples in children with lower respiratory tract infections

Announcements

Congenital Adrenal Hyperplasia: Diagnosis, Evaluation, and Management

Attention Artists Ages 5 to 16 Years

Chlamydial Infections in Children and Adolescents

Hypothyroidism in Children

Infections in Child-care Facilities and Schools

Index of Suspicion

Research and Statistics: Reliability and Validity in Pediatric Practice

Visual Diagnosis: Two Infants Who Have Skin Lesions That React to Minor Trauma

Treatment of Kawasaki Disease: Analysis of 27 US Pediatric Hospitals From 2001 to 2006

OBJECTIVES: We sought to analyze trends in admissions and to describe therapies used for acute Kawasaki disease over a 6-year period. METHODS: The Pediatric Health Information System provides patient data including demographic variables, International Classification of Diseases, Ninth Revision codes, and services billed to patients. Patient identifiers enable tracking of medication use in and across multiple admissions within a center. We analyzed data for patients with (1) a diagnosis code for Kawasaki disease, (2) intravenously administered immunoglobulin treatment during hospitalization, and (3) discharge between January 1, 2001, and December 30, 2006, from 27 hospitals contributing complete data over the study period. RESULTS: During the study period, 5197 Kawasaki disease admissions were identified for 4811 patients; numbers increased 32.6% from 2001 (n = 678) to 2006 (n = 899). Retreatment with intravenous immunoglobulin was administered to 712 patients (14.8%) over the study period. Other antiinflammatory therapies included intravenously administered methylprednisolone (5.8%), orally administered prednisone (2.8%), and infliximab (1%). Use of infliximab steadily increased from 0.0% (0 of 678 patients) in 2001 to 2.3% (21 of 899 patients) in 2006. Coronary artery aneurysms were coded for 3.3% of patients. Male patients, patients <1 year of age, and Hispanic patients were significantly more likely to have coding for coronary artery aneurysms. CONCLUSIONS: Our report provides the first large multicenter description of agents used in the treatment of intravenously administered immunoglobulin-resistant Kawasaki disease in the United States. Trends include increased numbers of admissions attributable to Kawasaki disease and increased usage of infliximab.

Continued Impact of Pneumococcal Conjugate Vaccine on Carriage in Young Children

OBJECTIVES: The goals were to assess serial changes in Streptococcus pneumoniae serotypes and antibiotic resistance in young children and to evaluate whether risk factors for carriage have been altered by heptavalent pneumococcal conjugate vaccine (PCV7). METHODS: Nasopharyngeal specimens and questionnaire/medical record data were obtained from children 3 months to <7 years of age in primary care practices in 16 Massachusetts communities during the winter seasons of 2000–2001 and 2003–2004 and in 8 communities in 2006–2007. Antimicrobial susceptibility testing and serotyping were performed with S pneumoniae isolates. RESULTS: We collected 678, 988, and 972 specimens during the sampling periods in 2000–2001, 2003–2004, and 2006–2007, respectively. Carriage of non-PCV7 serotypes increased from 15% to 19% and 29% (P < .001), with vaccine serotypes decreasing to 3% of carried serotypes in 2006–2007. The relative contribution of several non-PCV7 serotypes, including 19A, 35B, and 23A, increased across sampling periods. By 2007, commonly carried serotypes included 19A (16%), 6A (12%), 15B/C (11%), 35B (9%), and 11A (8%), and high-prevalence serotypes seemed to have greater proportions of penicillin nonsusceptibility. In multivariate models, common predictors of pneumococcal carriage, such as child care attendance, upper respiratory tract infection, and the presence of young siblings, persisted. CONCLUSIONS: The virtual disappearance of vaccine serotypes in S pneumoniae carriage has occurred in young children, with rapid replacement with penicillin-nonsusceptible nonvaccine serotypes, particularly 19A and 35B. Except for the age group at highest risk, previous predictors of carriage, such as child care attendance and the presence of young siblings, have not been changed by the vaccine.

Effectiveness of Amoxicillin/Clavulanate Potassium in the Treatment of Acute Bacterial Sinusitis in Children

OBJECTIVE: The role of antibiotic therapy in managing acute bacterial sinusitis (ABS) in children is controversial. The purpose of this study was to determine the effectiveness of high-dose amoxicillin/potassium clavulanate in the treatment of children diagnosed with ABS. METHODS: This was a randomized, double-blind, placebo-controlled study. Children 1 to 10 years of age with a clinical presentation compatible with ABS were eligible for participation. Patients were stratified according to age (<6 or ≥6 years) and clinical severity and randomly assigned to receive either amoxicillin (90 mg/kg) with potassium clavulanate (6.4 mg/kg) or placebo. A symptom survey was performed on days 0, 1, 2, 3, 5, 7, 10, 20, and 30. Patients were examined on day 14. Children's conditions were rated as cured, improved, or failed according to scoring rules. RESULTS: Two thousand one hundred thirty-five children with respiratory complaints were screened for enrollment; 139 (6.5%) had ABS. Fifty-eight patients were enrolled, and 56 were randomly assigned. The mean age was 66 ± 30 months. Fifty (89%) patients presented with persistent symptoms, and 6 (11%) presented with nonpersistent symptoms. In 24 (43%) children, the illness was classified as mild, whereas in the remaining 32 (57%) children it was severe. Of the 28 children who received the antibiotic, 14 (50%) were cured, 4 (14%) were improved, 4 (14%) experienced treatment failure, and 6 (21%) withdrew. Of the 28 children who received placebo, 4 (14%) were cured, 5 (18%) improved, and 19 (68%) experienced treatment failure. Children receiving the antibiotic were more likely to be cured (50% vs 14%) and less likely to have treatment failure (14% vs 68%) than children receiving the placebo. CONCLUSIONS: ABS is a common complication of viral upper respiratory infections. Amoxicillin/potassium clavulanate results in significantly more cures and fewer failures than placebo, according to parental report of time to resolution of clinical symptoms.

Headache in Young Children in the Emergency Department: Use of Computed Tomography

OBJECTIVE: The goal was to determine whether computed tomographic (CT) scans led to better acute care of young children with headache presenting the emergency department (ED). METHODS: We examined the records of 364 children 2 to 5 years of age who presented with headache to a large urban ED between July 1, 2003, and June 30, 2006. By reviewing initial history and examination findings, we first identified patients with secondary headaches (ie, with readily identifiable explanations such as ventriculoperitoneal shunts, known brain tumors, or acute illnesses, such as viral syndromes, fever, probable meningitis, or trauma). Charts for the remaining patients were reviewed for headache history, neurologic examination findings, laboratory and neuroimaging results, final diagnosis, and disposition. RESULTS: On the basis of initial history and physical examination results, 306 children (84%) had secondary headaches. For 72% of those children, acute febrile illnesses and viral respiratory syndromes accounted for the headaches. Among the 58 children (16%) who had no recognized central nervous system disease or systemic illness at presentation, 28% had CT scans performed. Of those, 1 scan yielded abnormal results, showing a brainstem glioma; the patient demonstrated abnormal neurologic examination findings on the day of presentation. For 15 (94%) of 16 patients, the CT scans did not contribute to diagnosis or management. For 59% of children with apparently primary headaches, no family history was recorded. CONCLUSION: For young children presenting to the ED with headache but normal neurologic examination findings and nonworrying history, CT scans seldom lead to diagnosis or contribute to immediate management.

Urinary Tract Infections in 1- to 3-Month-Old Infants: Ambulatory Treatment With Intravenous Antibiotics

OBJECTIVE: The goal was to examine the feasibility of outpatient management for 1- to 3-month-old infants with febrile urinary tract infections. METHODS: A cohort study was performed with all children 30 to 90 days of age who were evaluated for presumed febrile urinary tract infections in the emergency department of a tertiary-care pediatric hospital between January 1, 2005, and September 30, 2007. Patients were treated with intravenously administered antibiotics as outpatients in a day treatment center unless they met exclusion criteria, in which case they were hospitalized. RESULTS: Of 118 infants included in the study, 67 (56.8%) were admitted to the day treatment center and 51 (43.2%) were hospitalized. The median age of day treatment center patients was 66 days (range: 33–85 days). The diagnosis of urinary tract infection was confirmed for 86.6% of patients treated in the day treatment center. Escherichia coli was identified in 84.5% of urine cultures; 98.3% of isolates were sensitive to gentamicin. Six blood cultures (10.3%) yielded positive results, 5 of them for E coli. Treatment with intravenously administered antibiotics in the day treatment center lasted a mean of 2.7 days. The mean number of visits, including appointments for voiding cystourethrography, was 2.9 visits. The rate of parental compliance with day treatment center visits was 98.3%. Intravenous access problems were seen in 8.6% of cases. Successful treatment in the day treatment center (defined as attendance at all visits, normalization of temperature within 48 hours, negative control urine and blood culture results, if cultures were performed, and absence of hospitalization from the day treatment center) was obtained for 86.2% of patients with confirmed urinary tract infections. CONCLUSIONS: Ambulatory treatment of infants 30 to 90 days of age with febrile urinary tract infections by using short-term, intravenous antibiotic therapy at a day treatment center is feasible.

Functional Status Scale: New Pediatric Outcome Measure

OBJECTIVE: The goal was to create a functional status outcome measure for large outcome studies that is well defined, quantitative, rapid, reliable, minimally dependent on subjective assessments, and applicable to hospitalized pediatric patients across a wide range of ages and inpatient environments. METHODS: Functional Status Scale (FSS) domains of functioning included mental status, sensory functioning, communication, motor functioning, feeding, and respiratory status, categorized from normal (score = 1) to very severe dysfunction (score = 5). The Adaptive Behavior Assessment System II (ABAS II) established construct validity and calibration within domains. Seven institutions provided PICU patients within 24 hours before or after PICU discharge, high-risk non-PICU patients within 24 hours after admission, and technology-dependent children. Primary care nurses completed the ABAS II. Statistical analyses were performed. RESULTS: A total of 836 children, with a mean FSS score of 10.3 (SD: 4.4), were studied. Eighteen percent had the minimal possible FSS score of 6, 44% had FSS scores of ≥10, 14% had FSS scores of ≥15, and 6% had FSS scores of ≥20. Each FSS domain was associated with mean ABAS II scores (P < .0001). Cells in each domain were collapsed and reweighted, which improved correlations with ABAS II scores (P < .001 for improvements). Discrimination was very good for moderate and severe dysfunction (ABAS II categories) and improved with FSS weighting. Intraclass correlations of original and weighted total FSS scores were 0.95 and 0.94, respectively. CONCLUSIONS: The FSS met our objectives and is well suited for large outcome studies.

Age-Related Renal Parenchymal Lesions in Children With First Febrile Urinary Tract Infections

OBJECTIVE: The aim of this study was to define the association between age and the occurrence of acute pyelonephritis and renal scars. METHODS: Between 1999 and 2002, all children 0 to 14 years of age consecutively seen with a first febrile urinary tract infection were enrolled in the study. 99mTc-Dimercaptosuccinic acid renal scintigraphy was performed within 5 days after admission for the detection of renal parenchymal involvement. The presence of vesicoureteral reflux was assessed by using cystography performed 1 month after the infection. If the acute scan results were abnormal, then follow-up 99mTc-dimercaptosuccinic acid scanning was performed after 6 months, to assess the frequency of scars. RESULTS: A total of 316 children were enrolled in the study (190 children <1 year, 99 children 1–4 years, and 27 children 5–14 years of age). 99mTc-Dimercaptosuccinic acid scintigraphy revealed that 59% of the children had renal involvement in the acute phase of infection. The frequency of kidney involvement in infants <1 year of age (49%) was significantly lower than that in children 1 to 4 years of age (73%) and >5 years of age (81%). Of the 187 children with positive acute 99mTc-dimercaptosuccinic acid scan results, 123 underwent repeat scintigraphy after 6 months. Renal scars were found for 28% of children <1 year, 37% of children 1 to 4 years, and 53% of children 5 to 14 years of age. No significant differences in the frequency of scars and the presence or absence of vesicoureteral reflux were noted. CONCLUSIONS: Our findings confirm that acute pyelonephritis and subsequent renal scarring occur only in some children with first febrile urinary tract infections. Children <1 year of age with febrile urinary tract infections have a lower risk of parenchymal localization of infection and renal scarring.

Clinical Predictors of Pneumonia Among Children With Wheezing

OBJECTIVE: The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting. METHODS: A prospective cohort study was performed with children ≤21 years of age who were evaluated in the ED, were found to have wheezing on examination, and had chest radiography performed because of possible pneumonia. Historical features and examination findings were collected by treating physicians before knowledge of the chest radiograph results. Chest radiographs were read independently by 2 blinded radiologists. RESULTS: A total of 526 patients met the inclusion criteria; the median age was 1.9 years (interquartile range: 0.7–4.5 years), and 36% were hospitalized. A history of wheezing was present for 247 patients (47%). Twenty-six patients (4.9% [95% confidence interval [CI]: 3.3–7.3]) had radiographic pneumonia. History of fever at home (positive likelihood ratio [LR]: 1.39 [95% CI: 1.13–1.70]), history of abdominal pain (positive LR: 2.85 [95% CI: 1.08–7.54]), triage temperature of ≥38°C (positive LR: 2.03 [95% CI: 1.34–3.07]), maximal temperature in the ED of ≥38°C (positive LR: 1.92 [95% CI: 1.48–2.49]), and triage oxygen saturation of <92% (positive LR: 3.06 [95% CI: 1.15–8.16]) were associated with increased risk of pneumonia. Among afebrile children (temperature of <38°C) with wheezing, the rate of pneumonia was very low (2.2% [95% CI: 1.0–4.7]). CONCLUSIONS: Radiographic pneumonia among children with wheezing is uncommon. Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged.

Influenza Virus Infection and the Risk of Serious Bacterial Infections in Young Febrile Infants

OBJECTIVE: We aimed to determine the risk of SBIs in febrile infants with influenza virus infections and compare this risk with that of febrile infants without influenza infections. PATIENTS AND METHODS: We conducted a multicenter, prospective, cross-sectional study during 3 consecutive influenza seasons. All febrile infants ≤60 days of age evaluated at any of 5 participating pediatric EDs between October and March of 1998 through 2001 were eligible. We determined influenza virus status by rapid antigen detection. We evaluated infants with blood, urine, cerebrospinal fluid, and stool cultures. Urinary tract infection (UTI) was defined by single-pathogen growth of either ≥5 x 104 colony-forming units per mL or ≥104 colony-forming units per mL in association with a positive urinalysis. Bacteremia, bacterial meningitis, and bacterial enteritis were defined by growth of a known bacterial pathogen. SBI was defined as any of the 4 above-mentioned bacterial infections. RESULTS: During the 3-year study period, 1091 infants were enrolled. A total of 844 (77.4%) infants were tested for the influenza virus, of whom 123 (14.3%) tested positive. SBI status was determined in 809 (95.9%) of the 844 infants. Overall, 95 (11.7%) of the 809 infants tested for influenza virus had an SBI. Infants with influenza infections had a significantly lower prevalence of SBI (2.5%) and UTI (2.4%) when compared with infants who tested negative for the influenza virus. Although there were no cases of bacteremia, meningitis, or enteritis in the influenza-positive group, the differences between the 2 groups for these individual infections were not statistically significant. CONCLUSIONS: Febrile infants ≤60 days of age with influenza infections are at significantly lower risk of SBIs than febrile infants who are influenza-negative. Nevertheless, the rate of UTI remains appreciable in febrile, influenza-positive infants.

The Use of Internet-Based Technology to Tailor Well-Child Care Encounters

OBJECTIVE: The goal was to evaluate the feasibility and acceptance of a new model for well-child care (WCC) in a large health maintenance organization. METHODS: We designed a new model of WCC that engages families in Internet-based developmental and behavioral screening, allows for review of the results before the visit, and allows for selection of the appropriate visit type (e-visit, e-visit with brief provider visit, or extended encounter). The new model was pilot-tested in 2 practices within a large health maintenance organization. Seven providers and 70 parents participated in the study. Parents and providers were surveyed regarding their experience and satisfaction with the encounter. RESULTS: Seventy-five percent of parents thought that the online previsit assessment improved or very much improved the WCC visit. However, 12% of parents found the online assessment somewhat or very difficult to use. All of the parents found the e-visit or the e-visit with brief provider visit acceptable or very acceptable, compared with a standard WCC visit. All 7 providers thought that use of the new model helped focus the visit and that they would continue or definitely continue to use the model. CONCLUSIONS: We demonstrated the feasibility of a new model of WCC that engaged parents in previsit assessment and used alternative visit types to tailor care to the needs of the family. Future research will be needed to examine the impact of this model on important WCC outcomes.

Pediatric Specialized Transport Teams Are Associated With Improved Outcomes

OBJECTIVE: The goal was to test the hypothesis that interfacility transport performed by a pediatric critical care specialized team, compared with nonspecialized teams, would be associated with improved survival rates and fewer unplanned events during the transport process. METHODS: A single-center, prospective, cohort study was performed between January 2001 and September 2002. A total of 1085 infants and children at referral community hospitals with requests for retrieval by the Children's Hospital of Pittsburgh transport team were studied; 1021(94%) were transported by a specialty team and 64 (6%) by nonspecialized teams. Unplanned events during the transport process and 28-day mortality rates were assessed. RESULTS: Unplanned events occurred for 55 patients (5%) and were more common among patients transported by nonspecialized teams (61% vs 1.5%). Airway-related events were most common, followed by cardiopulmonary arrest, sustained hypotension, and loss of crucial intravenous access. After adjustment for illness severity, only the use of a nonspecialized team was independently associated with an unplanned event, and death was more common among patients transported by nonspecialized teams (23% vs 9%). CONCLUSION: Transport of critically ill children to a pediatric tertiary care center can be conducted more safely with a pediatric critical care specialized team than with teams lacking specific training and expertise in pediatric critical care and pediatric transport medicine.

Premarital Sexual Intercourse Among Adolescents in an Asian Country: Multilevel Ecological Factors

OBJECTIVE: The goal was to assess personal and environmental factors associated with premarital sex among adolescents. METHODS: We conducted a case-control study. Between 2006 and 2008, we recruited 500 adolescents who reported having engaged in voluntary sex for most recent sex. Five hundred control subjects were matched for age, gender, and ethnicity. RESULTS: Independently significant factors for premarital sex among boys were pornography viewing (adjusted odds ratio [OR]: 5.82 [95% confidence interval [CI]: 2.34–14.43]), lack of confidence to resist peer pressure (OR: 3.84 [95% CI: 2.27–6.50]), perception that more than one half of their friends had engaged in sex (OR: 3.37 [95% CI: 1.92–5.92]), permissiveness regarding premarital sex (OR: 3.41 [95% CI: 2.10–5.55]), involvement in gang activities (OR: 3.45 [95% CI: 1.66–7.15]), drinking (OR: 1.77 [95% CI: 1.07–2.94]), smoking (OR: 1.91 [95% CI: 1.14–3.20]), and living in low-cost housing (OR: 3.25 [95% CI: 1.64–6.43]). For girls, additional factors were previous sexual abuse (OR: 7.81 [95% CI: 2.50–24.41]) and dropping out of school (OR: 2.72 [95% CI: 1.32–5.61]), and stronger associations were found for lack of confidence to resist peer pressure (OR: 5.56 [95% CI: 2.94–10.53]) and permissiveness regarding premarital sex (OR: 6.25 [95% CI: 3.30–11.83]). Exposure to persons with HIV/AIDS or sexually transmitted infections in the media was negatively associated with sex for boys (OR: 0.27 [95% CI: 0.16–0.45]) and girls (OR: 0.24 [95% CI: 0.13–0.47]). CONCLUSION: Sex education programs for adolescents must address social, media, and pornographic influences and incorporate skills to negotiate sexual abstinence.

What Is the Correct Depth of Chest Compression for Infants and Children? A Radiological Study

OBJECTIVE: For infant and child resuscitation, current basic life support guidelines recommend a compression depth of one third to one half of the anteroposterior chest diameter. This study was conducted to assess the actual compression depths in infants and children when current guidelines are strictly followed. PATIENTS AND METHODS: Chest computed tomography scans of 36 infants (<1 year old) and 38 children (1–8 years old) were reviewed. Patient demographic data were collected from medical records. Measurements of the anteroposterior diameter from chest computed tomography scans were taken from the anterior skin at either the internipple line or the middle of the lower half of the sternum, perpendicular to the skin on the posterior thorax. RESULTS: In the infant group (25 boys, 11 girls), the mean age was 3.6 months. In the child-age group (21 boys, 17 girls), the mean age was 4.0 years. Compression depths were 3.4 to 5.1 cm in the infant group and 4.4 to 6.6 cm in the child group when current guidelines were followed. There was no difference in compression depths measured at internipple line versus in the lower half of the sternum. The intrathoracic structures observed beneath these 2 suggested that compression landmarks were similar. CONCLUSIONS: Radiological assessment of infants' and children's chests indicates similar or higher compression depths for infants and children versus the recommended compression depths for adults (3.8–5.1 cm) according to current guidelines. More evidence is needed to guide the proper depth of chest compression in pediatric populations.

Nocturnal Enuresis and Overweight Are Associated With Obstructive Sleep Apnea

OBJECTIVE: The objective of this study was to examine the relationship of obstructive sleep apnea (OSA), body weight (BMI percentage [BMI%]), and monosymptomatic nocturnal enuresis (MNE) in children. METHODS: A case-control study design was used. All children were 5 to 15 years of age; case patients were recruited from a comprehensive sleep disorders center (n = 149), and control subjects were recruited from a general pediatric practice in the same catchment area (n = 139). Case patients were subject to overnight polysomnograms and grouped into apnea severity categories (minimal, mild, moderate, or severe) on the basis of respiratory disturbance index and minimum arterial oxygen saturation levels. Data for all children included age; gender; height; weight; and history of MNE, snoring, diabetes, nasal allergies, and/or enlarged tonsils. BMI% was used to group children into weight categories as suggested by the Centers for Disease Control and Prevention (underweight, normal weight, at risk for overweight, and overweight). Two age groupings were created (5–10 years and 11–15 years). Descriptive statistics provided the prevalence of OSA, weight category, and MNE among case patients and control subjects. Cross-tabulations examined the relationship of severity of OSA with weight categories and MNE, stratified by age and gender. A series of logistic regression models explored the interrelationship of the grouping variables. RESULTS: A large majority (79.9%) of control subjects were at risk for overweight, and a large majority (80.0%) of children with MNE also had some degree of OSA. Logistic regression demonstrated that both MNE (odds ratio: 5.29) and overweight (odds ratio 4.16) were significantly associated with OSA but not with each other. CONCLUSIONS: Overweight and MNE are associated with OSA but not with each other. OSA should be considered in overweight children with MNE, especially when they display other symptoms of OSA or fail to respond to standard MNE treatment programs.

Early Resuscitation of Children With Moderate-to-Severe Traumatic Brain Injury

OBJECTIVES: Traumatic brain injury is a leading cause of death and disability in children. Guidelines have been established to prevent secondary brain injury caused by hypotension or hypoxia. The purpose of this study was to identify the prevalence, monitoring, and treatment of hypotension and hypoxia during "early" (prehospital and emergency department) care and to evaluate their relationship to vital status and neurologic outcomes at hospital discharge. METHODS: This was a retrospective study of 299 children with moderate-to-severe traumatic brain injury presenting to a level 1 pediatric trauma center. We recorded vital signs and medical provider response to hypotension and/or hypoxia during all portions of early care. RESULTS: Blood pressure (31%) and oxygenation (34%) were not recorded during some portion of "early care." Documented hypotension occurred in 118 children (39%). An attempt to treat documented hypotension was made in 48% (57 of 118 children). After adjusting for severity of illness, children who did not receive an attempt to treat hypotension had an increased odds of death of 3.4 and were 3.7 times more likely to suffer disability compared with treated hypotensive children. Documented hypoxia occurred in 131 children (44%). An attempt to treat hypoxia was made in 92% (121 of 131 children). Untreated hypoxia was not significantly associated with death or disability, except in the setting of hypotension. CONCLUSIONS: Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved outcomes.

Maternal Perception of Weight Status and Health Risks Associated With Obesity in Children

OBJECTIVE: To examine factors associated with the maternal perception of the weight status in related and unrelated children and to examine whether associated health risks for children's physical and mental health are recognized. PATIENTS AND METHODS: Two hundred nineteen mothers with children between 3 and 6 years of age took part in this study. The participating mothers were recruited from inpatient clinics and kindergartens. Parents were presented with 9 silhouettes representing different age- and gender-specific BMI percentiles. Demographic and weight-related variables were assessed with regard to their influence on the accuracy of the maternal weight estimation in general and for their own child. RESULTS: Of the participating mothers, 64.5% identified the overweight silhouettes of preschool-aged children correctly. However, only 48.8% of the mothers identified the overweight silhouettes associated with an increased risk for physical health problems, and 38.7% identified the silhouettes associated with an increased mental health risk. Mothers with a lower educational background were more likely to misclassify the overweight silhouettes and underestimate the associated health problems. For their own child, only 40.3% of the mothers chose silhouettes that were in agreement with the objective weight status of their child. This underestimation was associated with a higher maternal and child weight status but not with a general inability to identify the weight status of children. CONCLUSIONS: Identifying unrelated overweight silhouettes is influenced by maternal education level, whereas estimating their own child's weight status is influenced by the weight status of the mother and the child. Hence, feedback on the child's risk to become overweight is necessary to increase maternal risk awareness and willingness to take part in prevention programs.

Epinephrine Auto-injectors: Is Needle Length Adequate for Delivery of Epinephrine Intramuscularly?

OBJECTIVE: Studies show that intramuscular epinephrine results in peak plasma concentrations of epinephrine faster than the subcutaneous route, and therefore, epinephrine is recommended to be administered intramuscularly. The objective of this study was to determine if the needle length on epinephrine auto-injectors is adequate to deliver epinephrine intramuscularly in children. METHODS: Patients between the ages of 1 and 12 years who presented to a children's hospital were enrolled in the study. Ultrasound was used to determine the depth from the skin to the vastus lateralis muscle. The patient's body mass index was recorded. The data were analyzed using simple descriptive statistics, and logistic regression was used to identify variables that might predict whether or not the needle length was exceeded. RESULTS: A total of 256 children were enrolled. Of these, 158 children weighed less than 30 kilograms and would be prescribed the 0.15mg epinephrine auto-injector. Nineteen of these children (12%) had a skin to muscle surface distance of >1/2'' and would not receive epinephrine intramuscularly from current auto-injectors. There were 98 children weighing ≥30 kilograms who would receive the 0.3 mg epinephrine auto-injector. Of these 98 children, a total of 29 (30%) had a skin to muscle surface distance of >5/8'' and would not receive epinephrine intramuscularly. CONCLUSION: The needle on epinephrine auto-injectors is not long enough to reach the muscle in a significant number of children. Increasing the needle length on the auto-injectors would increase the likelihood that more children receive epinephrine by the recommended intramuscular route.

Estimation of Optimal CPR Chest Compression Depth in Children by Using Computer Tomography

OBJECTIVE: Pediatric consensus-driven cardiopulmonary resuscitation guidelines target chest compression (CC) depths of one third to one half anterior-posterior (AP) chest depth. Estimates for this target as assessed by computed tomography (CT) measurements of internal and external AP chest dimensions could direct future pediatric cardiopulmonary resuscitation guidelines. METHODS: A total of 280 consecutive chest CT scans in permuted blocks of 20 for each of 14 age divisions between 0 and 8 years were reconstructed and analyzed. External and internal AP depths were measured at midsternum, and residual chest depth was calculated at simulated one-third and one-half AP compressions. RESULTS: After a simulated compression calculation, one-half external AP depth CC would result in residual internal depth of <10 mm for 94% (263 of 280) of children 3 months to 8 years. For a one-third external AP CC, only 0.4% (1 of 280) of children 3 months to 8 years had a calculated residual internal chest depth <10 mm. CONCLUSIONS: By using CT reconstruction estimates of chest dimensions across the developmental spectrum from 0 to 8 years of age, we demonstrated that a simulated CC targeting approximately one-third external AP chest depth seems radiographically appropriate for children aged 3 months to 8 years, whereas simulated CC targeting approximately one-half external AP chest depth seems radiographically to be too deep, resulting in residual internal chest depth of <10 mm for most patients of this age.

Do Stimulants Protect Against Psychiatric Disorders in Youth With ADHD? A 10-Year Follow-up Study

OBJECTIVE: Little is known about the effect of stimulant treatment in youth with attention-deficit/hyperactivity disorder (ADHD) on the subsequent development of comorbid psychiatric disorders. We tested the association between stimulant treatment and the subsequent development of psychiatric comorbidity in a longitudinal sample of patients with ADHD. METHODS: We conducted a case-control, 10-year prospective follow-up study into young-adult years of youth with ADHD. At baseline, we assessed consecutively referred white male children with (n = 140) and without (n = 120) ADHD, aged 6 to 18 years. At the 10-year follow-up, 112 (80%) and 105 (88%) of the children in the ADHD and control groups, respectively, were reassessed (mean age: 22 years). We examined the association between stimulant treatment in childhood and adolescence and subsequent comorbid disorders and grade retention by using proportional hazards survival models. RESULTS: Of the 112 participants with ADHD, 82 (73%) were previously treated with stimulants. Participants with ADHD who were treated with stimulants were significantly less likely to subsequently develop depressive and anxiety disorders and disruptive behavior and less likely to repeat a grade compared with participants with ADHD who were not treated. CONCLUSIONS: We found evidence that stimulant treatment decreases the risk for subsequent comorbid psychiatric disorders and academic failure in youth with ADHD.

Cardiac Safety of Methylphenidate Versus Amphetamine Salts in the Treatment of ADHD

OBJECTIVES: Safety concerns about central nervous system stimulants for the treatment of attention-deficit/hyperactivity disorder (ADHD) include adverse cardiac effects. This study aimed to compare the risk for cardiac events in users of methylphenidate and amphetamine salts. METHODS: A retrospective cohort design using claims data from the Florida Medicaid fee-for-service program representing a total of 2131953 children and adolescents was used. The analysis included all beneficiaries who were between 3 and 20 years of age, enrolled between July 1994 and June 2004, had at least 1 physician diagnosis of ADHD and were newly started on methylphenidate or amphetamine salts. Each month of follow-up was classified according to stimulant use into current use or former use. We defined cardiac events as first emergency department (ED) visit for cardiac disease or symptoms. Risk between current users of methylphenidate versus amphetamine salts and former users of drugs in these categories was compared by using a time-dependent Cox proportional hazard model that adjusted for differences in gender; race; age; year of the index date; disability; congenital anomalies; history of circulatory disease; history of hospital admission; and use of antidepressants, antipsychotics, and bronchodilators. RESULTS: A total of 456 youth visited the ED for cardiac reasons during 52783 years of follow-up. After adjustment for differences in covariates, the risk for cardiac ED visits was similar among current users of methylphenidate or amphetamines. Periods of former use had a similar risk between youth with an exposure history to methylphenidate or amphetamine. CONCLUSION: Exposure to methylphenidate and amphetamines salts showed similar risk for cardiac ED visits. Additional population-based studies that address manifestation of serious heart disease, especially after long-term use, dosage comparisons, and interactions with preexisting cardiac risk factors are needed to inform psychiatric treatment decisions.

Epidemiology of Sexually Transmitted Infections in Suspected Child Victims of Sexual Assault

OBJECTIVE: The objective of this study was to describe the epidemiology of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Treponema pallidum, HIV, and herpes simplex virus type 2 (HSV-2) infection diagnosed by culture or by serologic or microscopic tests and by nucleic acid amplification tests in children who are evaluated for sexual victimization. METHODS: Children aged 0 to 13 years, evaluated for sexual victimization, who required sexually transmissible infection (STI) testing were enrolled at 4 US tertiary referral centers. Specimens for N gonorrhoeae and C trachomatis cultures, wet mounts for detection of T vaginalis, and serologic tests for syphilis and HIV were collected and processed according to study sites' protocols. Nucleic acid amplification tests for C trachomatis and N gonorrhoeae and serologic tests for HSV-2 were performed blinded to other data. RESULTS: Of 536 children enrolled, 485 were female. C trachomatis was detected in 15 (3.1%) and N gonorrhoeae in 16 (3.3%) girls. T vaginalis was identified in 5 (5.9%) of 85 girls by wet mount, 1 (0.3%) of 384 children had a positive serologic screen for syphilis, and 0 of 384 had serologic evidence of HIV infection. Of 12 girls who had a specimen for HSV-2 culture, 5 (41.7%) had a positive result; 7 (2.5%) of 283 had antibody evidence of HSV-2 infection. Overall, 40 (8.2%) of 485 girls and 0 of 51 boys (P = .02) had ≥1 STI. Girls with vaginal discharge were more likely to test positive for an STI (13 [24.5%] of 53) than other girls (27 [6.3%] of 432; prevalence ratio = 3.9; P < .001), although 10 girls with STIs had normal physical examinations. Most girls (27 [67.5%]) with a confirmed STI had normal or nonspecific findings on anogenital examination. CONCLUSIONS: The prevalence of each STI among sexually victimized children is <10%, even when highly sensitive detection methods are used. Most children with STIs have normal or nonspecific findings on physical examination.

Health Status and Behavioral Outcomes for Youth Who Anticipate a High Likelihood of Early Death

OBJECTIVE: The relationship between adolescents' perceived risk for dying and their involvement in risk behaviors is unknown. We sought to determine the proportion of US youth who anticipate a high likelihood of early mortality and relationships with health status and risk behaviors over time. METHODS: We analyzed data from times 1 (1995), 2 (1996), and 3 (2001–2002) of the National Longitudinal Study of Adolescent Health, a nationally representative sample of youth in grades 7 through 12. The relationship between perceived risk for premature mortality and health behaviors/outcomes was assessed by using bivariate and multivariate analyses. RESULTS: At time 1, 14.7% of the 20594 respondents reported at least a 50/50 chance that they would not live to age 35. In adjusted models, illicit drug use, suicide attempt, fight-related injury, police arrest, unsafe sexual activity, and a diagnosis of HIV/AIDS predicted early death perception at time 2, time 3, or both (adjusted odds ratios: 1.26–5.12). Conversely, perceived early mortality at time 1 predicted each of these behaviors and outcomes, except illicit drug use, at time 2 or time 3, most strongly a diagnosis of HIV/AIDS (adjusted odds ratios: 7.13 [95% confidence interval: 2.50–20.36]). CONCLUSIONS: Adolescent involvement in risk behaviors predicted a belief in premature mortality 1 and 7 years later. Reciprocally, adolescents' perceived risk for early death predicted serious health outcomes, notably a diagnosis of HIV/AIDS in young adulthood. Given its frequency and influence on behavior and health, adolescents' perceived risk for early death should be incorporated into psychosocial assessments and interviews.

Incidence and Outcomes of Pediatric Acute Lung Injury

OBJECTIVE: This population-based, prospective, cohort study was designed to determine the population incidence and outcomes of pediatric acute lung injury. METHODS: Between 1999 and 2000, 1 year of screening was performed at all hospitals admitting critically ill children in King County, Washington. County residents 0.5 to 15 years of age who required invasive (through endotracheal tube or tracheostomy) or noninvasive (through full face mask) mechanical ventilation, regardless of the duration of mechanical ventilation, were screened. From this population, children meeting North American-European Consensus Conference acute lung injury criteria were eligible for enrollment. Postoperative patients who received mechanical ventilation for <24 hours were excluded. Data collected included the presence of predefined cardiac conditions, demographic and physiological data, duration of mechanical ventilation, and deaths. US Census population figures were used to estimate incidence. Associations between outcomes and subgroups identified a priori were assessed. RESULTS: Thirty-nine children met the criteria for acute lung injury, resulting in a calculated incidence of 12.8 cases per 100000 person-years. Severe sepsis (with pneumonia as the infection focus) was the most common risk factor. The median 24-hour Pediatric Risk of Mortality III score was 9.0, and the mean ± SD was 11.7 ± 7.5. The hospital mortality rate was 18%, lower than that reported previously for pediatric acute lung injury. There were no statistically significant associations between age, gender, or risk factors and outcomes. CONCLUSIONS: We present the first population-based estimate of pediatric acute lung injury incidence in the United States. Population incidence and mortality rates are lower than those for adult acute lung injury. Low mortality rates in pediatric acute lung injury may necessitate clinical trial outcome measures other than death.

Risk Factors for Persistent Fatigue With Significant School Absence in Children and Adolescents

OBJECTIVE: To assess children and adolescents with severe fatigue who are referred to pediatricians and to examine whether factors can be identified at their first visit that predict worse outcomes at 1 year. METHODS: Ninety-one patients, aged 8 to 18 years completed questionnaires about sleep, somatic symptoms, physical activity, and fatigue. They were reassessed 12 months later. Measurements at baseline and outcome were analyzed by using univariable logistic regression with persistent, severe fatigue (yes/no) and persistent school absence (yes/no) as dependent variables and baseline scores as independent variables. RESULTS: After 12 months, 50.6% of the children and adolescents showed improvement; 29.1% had persistent fatigue, and 20.3% had persistent fatigue with significant school absence. Factors associated with the poorest outcome were sleep problems (odds ratio [OR]: 1.4 [95% confidence interval (CI): 1.1–1.8]), initial fatigue score (OR: 1.1 [95% CI: 1.0–1.2]), somatic complaints such as hot and cold spells (OR: 1.9 [95% CI: 1.2–3.0]), blurred vision (OR: 2.1 [95% CI: 1.1–4.0]), pain in arms and legs (OR: 2.0 [95% CI: 1.0–3.2]), back pain (OR: 1.8 [95% CI: 1.0–3.2]), constipation (OR: 1.7 [95% CI: 1.0–2.7]), and memory deficits (OR: 1.8 [95% CI: 1.0–3.2]). Resolved fatigue was associated with male gender (OR: 5.0 [95% CI: 1.6–15.5]) and a physically active lifestyle (OR: 1.3 [95% CI: 1.1–1.5]). CONCLUSIONS: Assessment of predictive factors at the first visit enables the pediatrician to identify those patients with severe fatigue who are at risk of a poor outcome. Female gender, poor sleep quality, physically inactive lifestyle, and specific somatic complaints were important predictive factors.

Cancer Risk Among Children With Very Low Birth Weights

OBJECTIVE: The risk of hepatoblastoma is strongly increased among children with very low birth weight (<1500 g). Because data on very low birth weight and other childhood cancers are sparse, we examined the risk of malignancy with very low birth weight in a large data set. METHODS: We combined case-control data sets created by linking the cancer and birth registries of California, Minnesota, New York, Texas, and Washington states, which included 17672 children diagnosed as having cancer at 0 to 14 years of age and 57966 randomly selected control subjects. Unconditional logistic regression analysis was used to examine the association of cancer with very low birth weight and moderately low birth weight (1500–1999 g and 2000–2499 g, respectively), compared with moderate/high birth weight (≥2500 g), with adjustment for gender, gestational age, birth order, plurality, maternal age, maternal race, state, and year of birth. RESULTS: Most childhood cancers were not associated with low birth weights. However, retinoblastomas and gliomas other than astrocytomas and ependymomas were possibly associated with very low birth weight. The risk of other gliomas was also increased among children weighing 1500 to 1999 g at birth. CONCLUSIONS: These data suggested no association between most cancers and very low birth weight, with the exception of the known association of hepatoblastoma and possibly moderately increased risks of other gliomas and retinoblastoma, which may warrant confirmation.

Paternal Depressive Symptoms During Pregnancy Are Related to Excessive Infant Crying

OBJECTIVE: Excessive infant crying, or infantile colic, is a common and often stress-inducing problem for parents that can ultimately result in child abuse. From previous research it is known that maternal depression is related to excessive crying, but so far little is known about the influence of paternal depression. METHODS: In a prospective, population-based study, we obtained information on both maternal and paternal depressive symptoms at 20 weeks of pregnancy by using the Brief Symptom Inventory. Parental depressive symptoms were related to excessive crying in 4426 two-month-old infants. The definition of excessive crying was based on the widely used Wessel's criteria (ie, crying >3 hours for >3 days in the past week). RESULTS: After adjustment for depressive symptoms of the mother and relevant confounders, we found a 1.29 (95% confidence interval: 1.09–1.52) higher risk of excessive infant crying per SD of paternal depressive symptoms. CONCLUSIONS: Our findings indicate that paternal depressive symptoms during pregnancy might be a risk factor for excessive infant crying. This finding could be related to genetic transmission, interaction of a father with lasting depressive symptoms with the infant, or related indirectly through contextual stressors such as marital, familial, or economic distress.

State and Regional Variation in Regulations Related to Feeding Infants in Child Care

OBJECTIVE: The purpose of this study was to compare state and regional variation in infant feeding regulations for child care facilities and to compare these regulations to national standards. METHODS: We reviewed regulations for child care for all US states and Washington, DC, and examined patterns according to type of facility and geographic region. We compared state regulations with national standards for feeding infants in child care. The standards included were: (1) infants are fed according to a feeding plan from a parent or physician; (2) breastfeeding is supported by the child care facility; (3) no solid food is given before 6 months of age; (4) infants are fed on demand; (5) infants are fed by a consistent caregiver; (6) infants are held while feeding; (7) infants cannot carry or sleep with a bottle; (8) caregivers cannot feed >1 infant at a time; (9) no cow's milk is given to children <12 months of age; (10) whole cow's milk is required for children 12 to 24 months of age; and (11) no solid food is fed in a bottle. RESULTS: The mean number of regulations for states was 2.8 (SD: 1.6) for centers and 2.0 (SD: 1.3) for family child care homes. No state had regulations for all 11 standards for centers; only Delaware had regulations for 10 of the 11 standards. For family child care homes, Ohio had regulations for 5 of the 11 standards, the most of any state. States in the South had the greatest mean number of regulations for centers (3.3) and family child care homes (2.2), and the West had the fewest (2.3 and 1.9, respectively). CONCLUSIONS: Many states lacked infant feeding regulations. Encouraging states to meet best-practice national standards helps ensure that all child care facilities engage in appropriate and healthful infant feeding practices.

Convalescent Care of Infants in the Neonatal Intensive Care Unit in Community Hospitals: Risk or Benefit?

OBJECTIVE: To compare very low birth weight (VLBW) infants transported to a community hospital (CH) before discharge with infants who received convalescent care in a regional-referral NICU (RR-NICU) on 4 parameters: health indicators at the time of hospital discharge, health care use during the 4 months after discharge to home, parent satisfaction with hospital care, and cost of hospitalization. PATIENTS AND METHODS: VLBW infants cared for in 2 RR-NICUs during 2004–2006 were enrolled in the study. One RR-NICU transfers infants to a CH for convalescent care and the other discharges infants directly home. Infants were followed prospectively. Information was gathered from medical charts, parent interviews, and hospital business offices. RESULTS: A total of 255 VLBW infants were enrolled in the study, and 148 were transferred to 15 CHs. Nineteen percent of transferred infants were readmitted to a higher level of care before discharge from the hospital. Preventative health measures and screening examinations were more frequently missed, readmission within 2 weeks of discharge from the hospital was more frequent, parents were less satisfied with hospital care, and duration of hospitalization was 12 days longer, although not statistically different, if infants were transferred to a CH for convalescence rather than discharged from the RR-NICU. Total hospital charges did not differ significantly between the groups. CONCLUSION: Transfer of infants to a CH from an RR-NICU for convalescent care has become routine but may place infants at risk. Our study indicates room for improvement by both CHs and RR-NICUs in the care of transferred VLBW infants.

Unimpaired Outcomes for Extremely Low Birth Weight Infants at 18 to 22 Months

OBJECTIVE: The goal was to identify, among extremely low birth weight (≤1000 g) live births, the proportion of infants who were unimpaired at 18 to 22 months of corrected age. METHODS: Unimpaired outcome was defined as Bayley Scales of Infant Development II scores of ≥85, normal neurologic examination findings, and normal vision, hearing, swallowing, and walking. Outcomes were determined for 5250 (86%) of 6090 extremely low birth weight inborn infants. RESULTS: Of the 5250 infants whose outcomes were known at 18 months, 850 (16%) were unimpaired, 1153 (22%) had mild impairments, 1147 (22%) had moderate/severe neurodevelopmental impairments, and 2100 (40%) had died. Unimpaired survival rates varied according to birth weight, from <1% for infants ≤500 g to 24% for infants 901 to 1000 g. The regression model to predict unimpaired survival versus death or impairment for live births (N = 5250) indicated that 25.3% of the variance was derived from infant factors present at birth, including female gender, higher birth weight, singleton birth. The regression model to predict unimpaired survival for discharged infants indicated that most of the variance was derived from combined effects of major neonatal morbidities, neonatal interventions, and maternal demographic features (15.7%) and only 8.5% was derived from infant factors present at birth. CONCLUSIONS: Although <1% of live-born infants of ≤500 g survive free of impairment at 18 months, this increases to almost 24% for infants of 901 to 1000 g. Female gender, singleton birth, higher birth weight, absence of neonatal morbidities, private health insurance, and white race increase the likelihood of unimpaired status.

Conflicts About End-of-Life Decisions in NICUs in the Netherlands

OBJECTIVE: To determine the frequency and background of conflicts about neonatal end-of-life (EoL) decisions. METHODS: We reviewed the medical files of 359 newborns who had died during 1 year in the 10 Dutch NICUs and identified 150 deaths that were preceded by an EoL decision on the basis of the child's poor prognosis. The attending neonatologists of 147 of the 150 newborns were interviewed to obtain details about the decision-making process. RESULTS: EoL decisions about infants with a poor prognosis were initiated mainly by the physician, who subsequently involved the parents. Conflicts between parents and the medical team occurred in 18 of 147 cases and were mostly about the child's poor neurologic prognosis. Conflicts within the team occurred in 6 of 147 cases and concerned the uncertainty of the prognosis. In the event of conflict, the EoL decision was postponed. Consensus was reached by calling additional meetings, performing additional diagnostic tests, or obtaining a second opinion. The chief causes of conflict encountered by the physicians were religious convictions that forbade withdrawal of life-sustaining treatment and poor communication between the parents and the team. CONCLUSIONS: The parents were involved in all EoL decision-making processes, and consensus was ultimately reached in all cases. Conflicts within the team occurred in 4% of the cases and between the team and the parents in 12% of the cases. The conflicts were resolved by postponing the EoL decision until consensus was achieved.

Preventive Dental Care for Young, Medicaid-Insured Children in Washington State

BACKGROUND: Children from low-income families face barriers to preventive dental care (PDC) and are disproportionately affected by dental caries. The Access to the Baby and Childhood Dentistry (ABCD) program of Washington State is targeted to Medicaid-insured children <6 years of age to improve their access to PDC. OBJECTIVES: To test the hypothesis that residing in an ABCD county improves the likelihood of receiving PDC and, to compare PDC use among young, Medicaid-insured children in Washington to national statistics. METHODS: We extracted 2003 Washington Medicaid dental claims for continuously enrolled children ≤6 years of age. Multivariable analysis was performed to identify variables independently associated with ≥1 preventive dental visit (PDV) in 2003. For national comparison, we used the 2003 Medical Expenditure Panel Survey (MEPS). RESULTS: Among Medicaid-insured children ≤6 yrs of age from WA counties with ABCD program, 45% had at least 1 PDV compared with 36% from non-ABCD counties (P < .001) and 37% of US children with continuous private insurance (P < .001). There were significantly higher adjusted odds of a PDV for children from ABCD counties relative to non-ABCD counties (odds ratio: 1.30 [95% confidence interval: 1.05–1.60]). CONCLUSIONS: We confirmed our hypothesis that residing in an ABCD county was associated with a higher likelihood of having ≥1 PDV in 2003. We also found that significantly more children in established ABCD counties received PDC compared with privately insured US children. These findings provide additional evidence that the ABCD program reduces disparities in dental care access among young, Medicaid-insured children in Washington and point to the importance of expanding the ABCD program to other states.

Are Outcomes and Care Processes for Preterm Neonates Influenced by Health Insurance Status?

OBJECTIVE: The purpose of this work was to compare the processes of care and to evaluate outcomes of premature neonates delivered to women with Medicaid managed care versus private insurance. DESIGN/METHODS: All of the infants born at <37 weeks' gestation between January 2001 and August 2005 in the ParadigmHealth database were included in these analyses (n = 24151). Infants were categorized by maternal health insurance status as private insurance or Medicaid managed care and analyzed for differences in demographic data and length of stay. For survivors, differences in respiratory care, nutritional, and maturational milestones were assessed. In addition, age to wean to open crib, weight gain, home oxygen, and apnea monitor use were compared. Adverse outcomes, including necrotizing enterocolitis, sepsis, severe intraventricular hemorrhage, severe retinopathy of prematurity, bronchopulmonary dysplasia, apnea, and mortality, were compared. Statistical tests used were Students t test, 2, and Kruskall-Wallis test. Multiple logistic regression was performed after controlling for demographic variables. RESULTS: Of the 24151 infants studied, 19046 (78.9%) had private insurance, and 5105 (21.1%) had Medicaid managed care. There were no differences in gestational age at birth; however, Medicaid managed care infants had lower birth weight, lower Apgar score at 5 minutes, increased incidence of necrotizing enterocolitis and bacterial sepsis, and longer length of stay. Of the surviving infants, more neonates with private insurance went home on oxygen and apnea monitors despite no differences found in the incidences of apnea or bronchopulmonary dysplasia between the groups. There were no differences in processes of care for feeding and respiratory milestones, but infants with Medicaid managed care weaned to an open crib later and had greater overall weight gain compared with infants with private insurance. CONCLUSIONS: We speculate that, in addition to the known impact of insurance status on well-being at birth, Medicaid managed care is independently associated with adverse neonatal outcomes in preterm infants, as well as differences in neonatal intensive care discharge processes.

Morbidities and Hospital Resource Use During the First 3 Years of Life Among Very Preterm Infants

OBJECTIVE: The objective of this study was to determine how the use of hospital resources during the first 3 years of life was associated with prematurity-related morbidity in very preterm infants (gestational age of <32 weeks or birth weight of <1501 g). METHODS: The study was a retrospective, national register study including all very preterm infants born alive in Finland between 2000 and 2003 (N = 2148). Infants who died before the age of 3 years (n = 264) or who had missing register data (n = 88) were excluded from the study. The relationship between 6 morbidity groups and the need for hospital care during the first 3 years of life was studied by using a negative binomial model. RESULTS: A total of 66.2% of the infants did not have any of the morbidities studied. Infants who were subsequently diagnosed as having cerebral palsy (6.1% of the study group), later obstructive airway disease (20.0%), hearing loss (2.5%), visual disturbances or blindness (3.8%), or other ophthalmologic problems (13.4%) had initial hospital stays that were a mean of 7, 8, 12, 17, and 3 days longer, respectively, than those for infants without these conditions. All morbidity groups were associated with increased numbers of hospital visits during either the second or third year of life, compared with infants without these morbidities. The need for hospitalizations and outpatient hospital care decreased with postnatal age for infants with later morbidities and for infants without later morbidities. CONCLUSIONS: Most very preterm infants born in Finland survived without severe morbidities and required relatively little hospital care after the initial discharge. However, those with later morbidities had a long initial length of stay and more readmissions and outpatient visits during the 3-year follow-up period.

Prenatal Growth and Early Postnatal Influences on Adult Motor Cortical Excitability

OBJECTIVE: Suboptimal prenatal growth may adversely influence motor neurophysiologic development and predispose the individual to greater risk of neurodegenerative disorders in later life. We investigated the influences of prenatal growth and the postnatal environment on motor cortical function in young adults. METHODS: Transcranial magnetic stimulation was used to construct corticospinal stimulus-response curves for 35 young adults (mean age: 28 ± 0.5 years; 19 males) born ≥37weeks' gestation. Birth weight centile was calculated relative to maternal size, parity, ethnicity, gender, and gestation. Handgrip strength and dexterity were measured separately. Regression analyses assessed the influence of prenatal (birth weight centile and gestation) and postnatal (socioeconomic indices and maternal education) factors on corticospinal parameters, strength, and dexterity scores. RESULTS: Lower birth weight was associated with increased interhemispheric asymmetry in motor threshold and increased cortical stimulus-response curve slope. A shorter gestation predicted a larger area under this curve in the right hand. High motor threshold was predicted by greater environmental adversity in early postnatal life, but not by prenatal factors. Higher birth weight centile and lower motor threshold were associated with greater educational achievement. CONCLUSIONS: Poor in utero growth and mild prematurity are associated with altered corticospinal excitability in adulthood. An early postnatal environment with less early postnatal socioeconomic disadvantage and having a mother with a completed high school education partly ameliorates this. While altered cortical development has some functional consequences already evident in early adulthood, it may have a later, additional adverse impact on aging-related changes in motor function.

Movie Character Smoking and Adolescent Smoking: Who Matters More, Good Guys or Bad Guys?

OBJECTIVE: To assess the association between smoking onset and exposure to movie smoking according to character type. METHODS: A longitudinal, random-digit-dial telephone survey of 6522 US adolescents was performed with movie exposure assessed at 4 time points over 24 months. Adolescents were asked whether they had seen a random subsample of recently released movies, for which we identified smoking by major characters and type of portrayal (divided into negative, positive, and mixed/neutral categories). Multivariate hazard regression analysis was used to assess the independent effects of these exposures on the odds of trying smoking. RESULTS: By the 24-month follow-up survey, 15.9% of baseline never-smokers had tried smoking. Within the sample of movies, 3848 major characters were identified, of whom 69% were male. Smokers represented 22.8% of 518 negative characters, 13.7% of 2486 positive characters, and 21.1% of 844 mixed/neutral characters. Analysis of the crude relationship showed that episodes of negative character smoking exposure had the strongest influence on smoking initiation. However, because most characters were portrayed as positive, exposure to this category was greatest. When the full population effect of each exposure was modeled, each type of character smoking independently affected smoking onset. There was an interaction between negative character smoking and sensation-seeking with stronger response for adolescents lower in sensation-seeking. CONCLUSIONS: Character smoking predicts adolescent smoking initiation regardless of character type, which demonstrates the importance of limiting exposure to all movie smoking. Negative character portrayals of smoking have stronger impact on low risk-taking adolescents, undercutting the argument that greater exposure is a marker for adolescent risk-taking behavior.

Intrapartum Antibiotic Exposure and Early Neonatal, Morbidity, and Mortality in Africa

BACKGROUND: Infants born to women who receive intrapartum antibiotics may have higher rates of infectious morbidity and mortality than unexposed infants. OBJECTIVE: Our goal was to determine the association of maternal intrapartum antibiotics and early neonatal morbidity and mortality. METHODS: We performed secondary analysis of data from a multisite randomized, placebo-controlled clinical trial of antibiotics to prevent chorioamnionitis-associated mother-to-child transmission of HIV-1 and preterm birth in sub-Saharan Africa. Early neonatal morbidity and mortality were analyzed. In an intention-to-treat (ITT) analysis, infants born to women randomly assigned to antibiotics or placebo were compared. In addition, non-ITT analysis was performed because some women received nonstudy antibiotics for various clinical indications. RESULTS: Overall, 2659 pregnant women were randomly assigned. Of these, 2466 HIV-1–infected and HIV-1–uninfected women delivered 2413 live born and 84 stillborn infants. In the ITT analysis, there were no significant associations between exposure to antibiotics and early neonatal outcomes. Non-ITT analyses showed more illness at birth (11.2% vs 8.6%, P = .03) and more admissions to the special care infant unit (12.6% vs 9.8%, P = .04) among infants exposed to maternal intrapartum antibiotics than among unexposed infants. Additional analyses revealed greater early neonatal morbidity and mortality among infants of mothers who received nonstudy antibiotics than of mothers who received study antibiotics. CONCLUSIONS: There is no association between intrapartum exposure to antibiotics and early neonatal morbidity or mortality. The associations observed in non-ITT analyses are most likely the result of women with peripartum illnesses being more likely to receive nonstudy antibiotics.

Primary Care Follow-up Plans for Adolescents With Substance Use Problems

OBJECTIVE: Primary care visits provide an opportunity to screen adolescents for substance use and offer early intervention, but little is known about follow-up plans. The objective of this study was to determine recommendations by PCPs and assess the relationship between their diagnostic impressions of substance use severity and plans for intervention. METHODS: Data were collected through a prospective observational study conducted at 7 primary care practices in New England. Patients aged 12 to 18 years completed an interview, which included sociodemographic characteristics and the CRAFFT substance abuse screen. PCPs received screen results, noted their diagnostic impression of participants' substance use severity, and recorded follow-up plans. Follow-up plans other than "periodic screening" alone were defined as "active intervention." We examined the relationship of provider impressions with follow-up recommendations by using the 2 test. RESULTS: For 2034 adolescents, PCPs recommended no plan for 369 patients, periodic screening for 1557 patients, a return visit for 98 patients, and referral to counseling for 44 patients. PCPs' diagnostic impressions identified 97 (4.8%) patients with problem use and 19 (0.01%) patients with abuse or dependence. Recommendations for active intervention were more likely with patients' higher severity of use. However, 1 in 5 patients thought to have problem use did not receive a recommendation for an active intervention. Parent notification was planned for only 13 patients. CONCLUSIONS: When concerned about substance use, PCPs recommend a return visit to their office more than twice as often as referral to counseling, and rarely planned to engage parents. PCPs need enhanced training and strategies for delivery of office-based interventions.

Should a Head-Injured Child Receive a Head CT Scan? A Systematic Review of Clinical Prediction Rules

CONTEXT: Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty. OBJECTIVE: To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury. METHODS: Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used. RESULTS: A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (≥11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required ≤56% to undergo CT). Four of the 8 rules were applicable to children with minor head injury (Glasgow coma score ≥13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance. CONCLUSIONS: Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.

Parental Confidence in Making Overweight-Related Behavior Changes

BACKGROUND: Confidence is an important construct for behavioral change; higher levels of confidence, or self-efficacy, increase the likelihood that a person will change a health behavior even when faced with obstacles. OBJECTIVE: To identify parent, child, and clinician characteristics associated with higher parental confidence in their ability to make overweight-related behavior changes for their family. METHODS: We interviewed 446 parents of children, aged 2 to 12 years, with a BMI of ≥85th percentile and surveyed their pediatric clinicians (N = 75). The main outcome was parental confidence in their ability to make overweight-related behavior changes. We derived a continuous parental confidence score from 6 questions (Cronbach's = 0.72) regarding parental confidence in limiting television viewing, removing televisions from children's bedrooms, reducing fast-food intake, reducing sugar-sweetened beverage intake, increasing physical activity, and improving overall eating patterns for their family. We used multiple linear regression to predict the effects of parent, child, and clinician characteristics on the parents' confidence scores. RESULTS: The mean (SD) score on the parental confidence scale was 13.0 (3.5), and the range was 0.0 to 24.0. In multivariable analyses, parents who said their clinicians assessed their confidence (41%; β = 0.73 [95% confidence interval: 0.04–1.42]) or who said that their clinicians assessed their readiness to change (35%; β =0.80 [95% confidence interval: 0.10–1.49]) reported higher levels of confidence compared with parents whose clinicians did not assess confidence or readiness to change. CONCLUSIONS: Clinician assessment of parental confidence and readiness to change was associated with higher parent confidence in making changes to keep their child from being overweight.

Pathways to Approval of Pediatric Cardiac Devices in the United States: Challenges and Solutions

Patients treated by pediatric interventional cardiologists and cardiac surgeons often have unmet medical device needs that pose a challenge to the current regulatory evaluation and approval process in the United States. In this report we review current US Food and Drug Administration regulatory processes, review some unique aspects of pediatric cardiology and cardiac surgery that pose challenges to these processes, and discuss possible alternate pathways to cardiac device evaluation and approval for children. Children deserve to benefit from new and refined cardiac devices and technology designed explicitly for their conditions.

Impact of Electronic Health Record-Based Alerts on Influenza Vaccination for Children With Asthma

OBJECTIVE: The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma. METHODS: A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had >80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices. RESULTS: A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.3% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (≥11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits. CONCLUSIONS: Clinical alerts were associated with only modest improvements in influenza vaccination rates.

Assessing the Functional Status of Hospitalized Children

Equipment for Ambulances

Effects of Oseltamivir on Influenza-Related Complications in Children With Chronic Medical Conditions

OBJECTIVE: This study investigated the influence of oseltamivir on influenza-related complications and hospitalizations for children and adolescents, 1 to 17 years of age, with chronic medical conditions or neurologic or neuromuscular disease. METHODS: In a retrospective study, outcomes for patients who were given oseltamivir within 1 day after influenza diagnosis were compared with those for patients who received no antiviral therapy. Anonymous data from MarketScan databases (Thomson Reuters, Cambridge, MA) were used to identify patients from 6 influenza seasons between 2000 and 2006. The study outcomes were frequencies of pneumonia, respiratory illnesses other than pneumonia, otitis media, and hospitalization. RESULTS: Oseltamivir was prescribed for 1634 patients according to the study criteria, and 3721 patients received no antiviral therapy for their influenza. After adjustment for demographic and medical history variables, oseltamivir was associated with significant reductions in the risks of respiratory illnesses other than pneumonia, otitis media and its complications, and all-cause hospitalization in the 14 days after influenza diagnosis. Analyses for 30 days after influenza diagnosis also showed significant risk reductions for respiratory illnesses other than pneumonia, otitis media and its complications, and all-cause hospitalization with oseltamivir. CONCLUSION: When it was prescribed at influenza diagnosis, oseltamivir was associated with reduced risks of influenza-related complications and hospitalizations for children and adolescents at high risk of influenza complications.

Effect of a High-Flow Open Nasal Cannula System on Obstructive Sleep Apnea in Children

OBJECTIVE: Obstructive sleep apnea syndrome in children is associated with significant morbidity. Continuous positive airway pressure (CPAP) treats obstructive apnea in children, but is impeded by low adherence. We, therefore, sought to assess the effect of warm humidified air delivered through an open nasal cannula (treatment with nasal insufflation [TNI]) on obstructive sleep apnea in children with and without adenotonsillectomy. METHODS: Twelve participants (age: 10 ± 1 years; BMI: 35 ± 14 kg/m2), with obstructive apnea-hypopnea syndrome ranging from mild to severe (2–36 events per hour) were administered 20 L/min of air through a nasal cannula. Standard sleep architecture, sleep-disordered breathing, and arousal indexes were assessed at baseline, on TNI, and on CPAP. Additional measures of the percentage of time with inspiratory flow limitation, respiratory rate, and inspiratory duty cycle were assessed at baseline and on TNI. RESULTS: TNI reduced the amount of inspiratory flow limitation, which led to a decrease in respiratory rate and inspiratory duty cycle. TNI improved oxygen stores and decreased arousals, which decreased the occurrence of obstructive apnea from 11 ± 3 to 5 ± 2 events per hour (P < .01). In the majority of children, the reduction in the apnea-hypopnea index on TNI was comparable to that on CPAP. CONCLUSIONS: TNI offers an alternative to therapy to CPAP in children with mild-to-severe sleep apnea. Additional studies will be needed to determine the efficacy of this novel form of therapy.

Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents

OBJECTIVE: The goal was to characterize prospectively the course and outcome of chronic fatigue syndrome in adolescents during a 2-year period after infectious mononucleosis. METHODS: A total of 301 adolescents (12–18 years of age) with infectious mononucleosis were identified and screened for nonrecovery 6 months after infectious mononucleosis by using a telephone screening interview. Nonrecovered adolescents underwent a medical evaluation, with follow-up screening 12 and 24 months after infectious mononucleosis. After blind review, final diagnoses of chronic fatigue syndrome at 6, 12, and 24 months were made by using established pediatric criteria. RESULTS: Six, 12, and 24 months after infectious mononucleosis, 13%, 7%, and 4% of adolescents, respectively, met the criteria for chronic fatigue syndrome. Most individuals recovered with time; only 2 adolescents with chronic fatigue syndrome at 24 months seemed to have recovered or had an explanation for chronic fatigue at 12 months but then were reclassified as having chronic fatigue syndrome at 24 months. All 13 adolescents with chronic fatigue syndrome 24 months after infectious mononucleosis were female and, on average, they reported greater fatigue severity at 12 months. Reported use of steroid therapy during the acute phase of infectious mononucleosis did not increase the risk of developing chronic fatigue syndrome. CONCLUSIONS: Infectious mononucleosis may be a risk factor for chronic fatigue syndrome in adolescents. Female gender and greater fatigue severity, but not reported steroid use during the acute illness, were associated with the development of chronic fatigue syndrome in adolescents. Additional research is needed to determine other predictors of persistent fatigue after infectious mononucleosis.

Low-Income Parents' Views on the Redesign of Well-Child Care

OBJECTIVE: To examine the perspectives of low-income parents on redesigning well-child care (WCC) for children aged 0 to 3 years, focusing on possible changes in 3 major domains: providers, locations, and formats. METHODS: Eight focus groups (4 English and 4 Spanish) were conducted with 56 parents of children aged 6 months to 5 years, recruited through a federally qualified health center. Discussions were recorded, transcribed, and analyzed by using the constant comparative method of qualitative analysis. RESULTS: Parents were mostly mothers (91%), nonwhite (64% Latino, 16% black), and <30 years of age (66%) and had an annual household income of <$35000 (96%). Parents reported substantial problems with WCC, focusing largely on limited provider access (especially with respect to scheduling and transportation) and inadequate behavioral/developmental services. Most parents endorsed nonphysician providers and alternative locations and formats as desirable adjuncts to usual physician-provided, clinic-based WCC. Nonphysician providers were viewed as potentially more expert in behavioral/developmental issues than physicians and more attentive to parent-provider relationships. Some alternative locations for care (especially home and day care visits) were viewed as creating essential context for providers and dramatically improving family convenience. Alternative locations whose sole advantage was convenience (eg, retail-based clinics), however, were viewed more skeptically. Among alternative formats, group visits in particular were seen as empowering, turning parents into informal providers through mutual sharing of behavioral/developmental advice and experiences. CONCLUSIONS: Low-income parents of young children identified major inadequacies in their WCC experiences. To address these problems, they endorsed a number of innovative reforms that merit additional investigation for feasibility and effectiveness.

Early Nasal Continuous Positive Airway Pressure and Necrotizing Enterocolitis in Preterm Infants

BACKGROUND: The use of early nasal continuous positive airway pressure (ENCPAP) as the mode of initial respiratory support for very low birth weight (VLBW) infants has been increasing. The impact of CPAP and oxygen on gut mucosa and perfusion in premature infants is not known. The relation between ENCPAP and necrotizing enterocolitis (NEC) has not been adequately addressed. OBJECTIVE: To evaluate if the use of an individualized respiratory management strategy encouraging the use of ENCPAP is associated with an increased risk of NEC, and to determine risk factors for NEC in premature infants supported by CPAP. METHODS: A retrospective analysis was conducted on VLBW infants (birth weight < 1500 g) managed at 2 institutions that use an ENCPAP respiratory management strategy for premature infants. Data on the use of oxygen and mode of ventilatory support were collected during the first 3 days of life. Diagnosis of NEC was used as the dependent variable in a logistic regression model. Birth weight, gender, prenatal steroid use, mode of respiratory support (CPAP versus ventilator) and fraction of inspired oxygen, umbilical artery catheter placement, partial pressure of oxygen, patent ductus arteriosus, early sepsis, hospital, and delivery room management (ENCPAP versus initial intubation) were controlled for in the model. RESULTS: Data on 343 premature infants were collected for this study. Mean birth weight was 999 ± 289 g and gestational age was 28 ± 2.6 weeks. The majority of patients were managed with ENCPAP, with only 13% of patients intubated in the delivery room. The overall incidence of NEC was 7% (n = 24). The exposure to ENCPAP did not increase the risk for NEC compared with the use of a ventilator. CONCLUSIONS. The risk of NEC in VLBW premature infants was not increased by the use of ENCPAP. Initial respiratory support with ENCPAP seems to be a safe alternative to routine intubation and mechanical ventilation in premature infants.

Intravenous Lipid and Bilirubin-Albumin Binding Variables in Premature Infants

BACKGROUND: The lipid intake at which a significant bilirubin-displacing effect occurs as a function of gestational age (GA) is unclear. OBJECTIVE: To determine the effect of gradual increase in IL intake from 1.5 to 3 g/kg per day on bilirubin-albumin binding variables as a function of GA in premature infants with indirect hyperbilirubinemia. METHODS: Infants of 24 to 33 weeks' gestation at birth who received IL (20% Intralipid [Fresenius Kabi, Uppsala, Sweden]) doses of 1.5, 2, 2.5, and 3 g/kg per day over 4 consecutive days were prospectively evaluated. The blood samples were drawn twice at least 8 hours apart on each IL intake to measure total serum bilirubin and free bilirubin by the peroxidase test. The highest free bilirubin on each IL intake, the corresponding total serum bilirubin, and serum albumin were used to calculate the bilirubin/albumin binding constant or binding affinity. RESULTS: Sixty-two infants (median GA: 28 weeks) were studied during the first 10 days of life. None of the subjects had culture-proven sepsis, had triglyceride levels of >2.05 mmol/L, or were receiving steroids. Infants were grouped in 2-week GA intervals. The cumulative frequency of elevated free bilirubin concentration (≥90th percentile or Bf ≥ 32 nmol/L) as a function of IL intake was inversely related to GA and was significantly different among 2-week GA groups. There was significant decrease in binding affinity and increase in free bilirubin concentration with higher IL intake for ≤28 week but not for >28 week GA groups. CONCLUSIONS: The IL intake may be associated with a significant fall in the binding affinity of bilirubin for plasma protein and a concomitant increase in free bilirubin concentration in premature infants. The lipid intake at which this occurs depends on GA.

Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma

OBJECTIVE: To explore the relationship between sleep-disordered breathing (SDB) and behavioral problems among inner-city children with asthma. METHODS: We examined data for 194 children (aged 4–10 years) who were enrolled in a school-based asthma intervention program (response rate: 72%). SDB was assessed by using the Sleep-Related Breathing Disorder Questionnaire that contains 3 subscales: snoring, sleepiness, and attention/hyperactivity. For the current study, we modified the Sleep-Related Breathing Disorder Questionnaire by removing the 6 attention/hyperactivity items. A sleep score of >0.33 was considered indicative of SDB. To assess behavior, caregivers completed the Behavior Problem Index (BPI), which includes 8 behavioral subdomains. We conducted bivariate analyses and multiple linear regression to determine the association of SDB with BPI scores. RESULTS: The majority of children (mean age: 8.2 years) were male (56%), black (66%), and insured by Medicaid (73%). Overall, 33% of the children experienced SDB. In bivariate analyses, children with SDB had significantly higher (worse) behavior scores compared with children without SDB on total BPI (13.7 vs 8.8) and the subdomains externalizing (9.4 vs 6.3), internalizing (4.4 vs 2.5), anxious/depressed (2.4 vs 1.3), headstrong (3.2 vs 2.1), antisocial (2.3 vs 1.7), hyperactive (3.0 vs 1.8), peer conflict (0.74 vs 0.43), and immature (2.0 vs 1.5). In multiple regression models adjusting for several important covariates, SDB remained significantly associated with total BPI scores and externalizing, internalizing, anxious/depressed, headstrong, and hyperactive behaviors. Results were consistent across SDB subscales (snoring, sleepiness). CONCLUSIONS: We found that poor sleep was independently associated with behavior problems in a large proportion of urban children with asthma. Systematic screening for SDB in this high-risk population might help to identify children who would benefit from additional intervention.

Side Effects of Methylphenidate in Childhood Cancer Survivors: A Randomized Placebo-Controlled Trial

OBJECTIVES: To investigate the frequency and severity of side effects of methylphenidate among childhood survivors of acute lymphoblastic leukemia and brain tumors and identify predictors of higher adverse effect levels. METHODS: Childhood cancer survivors (N = 103) identified as having attention and learning problems completed a randomized, double-blind, 3-week, home-crossover trial of placebo, low-dose methylphenidate (0.3 mg/kg; 10 mg twice daily maximum) and moderate-dose methylphenidate (0.6 mg/kg; 20 mg twice daily maximum). Caregivers completed the Barkley Side Effects Rating Scale (SERS) at baseline and each week during the medication trial. Siblings of cancer survivors (N = 49) were recruited as a healthy comparison group. RESULTS: There was a significantly higher number and severity of symptoms endorsed on the SERS when patients were taking moderate dose compared with placebo or low dose, but not low dose compared with placebo. The number of side effects endorsed on the SERS was significantly lower during all 3 home-crossover weeks (placebo, low dose, moderate dose) when compared with baseline symptom scores. The severity of side effects was also significantly lower, compared with baseline screening, during placebo and low-dose weeks but not moderate-dose weeks. Both the number and severity of symptoms endorsed at baseline were significantly higher for patients compared with siblings. Female gender and lower IQ were associated with higher adverse effect levels. CONCLUSIONS: Methylphenidate is generally well tolerated by childhood cancer survivors. There is a subgroup at increased risk for side effects that may need to be closely monitored or prescribed a lower medication dose. The seemingly paradoxical findings of increased "side effects" at baseline must be considered when monitoring side effects and designing clinical trials.

Delivery Indications at Late-Preterm Gestations and Infant Mortality Rates in the United States

OBJECTIVE: The rate of preterm births has been increasing in the United States, especially for births 34 to 36 weeks of gestation (late preterm), which now constitute 71% of all preterm births. The causes for these trends remain unclear. We characterized the delivery indications for late preterm births and their potential impact on neonatal and infant mortality rates. PATIENTS AND METHODS: Using the 2001 US Birth Cohort Linked birth/death files of 3 483 496 singleton births, we categorized delivery indications as follows: (1) maternal medical conditions; (2) obstetric complications; (3) major congenital anomalies; (4) isolated spontaneous labor: vaginal delivery without induction and without associated medical/obstetric factors; and (5) no recorded indication. RESULTS: Of the 292 627 late-preterm births, the first 4 categories (those with indications and isolated spontaneous labor) accounted for 76.8%. The remaining 23.2% (67 909) were classified as deliveries with no recorded indication. Factors significantly increasing the chance of no recorded indication were older maternal age; non-Hispanic, white mother; ≥13 years of education; Southern, Midwestern, and Western region; multiparity; or previous infant with a ≥4000-g birth weight. The neonatal and infant mortality rates were significantly higher among deliveries with no recorded indication compared with deliveries secondary to isolated spontaneous labor but lower compared with deliveries with an obstetric indication or congenital anomaly. CONCLUSIONS: A total of 23% of late preterm births had no recorded indication for delivery noted on birth certificates. Patient factors may be playing a role in these deliveries. It is concerning that these infants had higher mortality rates compared with those born after spontaneous labor at similar gestational ages. Given the excess risk of mortality, patients and providers need to discuss the risks of delivering a preterm infant in the absence of medical indications at 34 to 36 weeks.

Apolipoprotein E Genotype Modifies the Risk of Behavior Problems After Infant Cardiac Surgery

OBJECTIVE: The goal was to evaluate polymorphisms of the APOE gene as modifiers of neurobehavioral outcomes for preschool-aged children with congenital heart defects, after cardiac surgery. METHODS: A prospective observational study with neurodevelopmental evaluation between the fourth and fifth birthdays was performed. Attention and behavioral skills were assessed through parental report. RESULTS: Parents of 380 children completed the neurobehavioral measures. Child Behavior Checklist scores for the pervasive developmental problem scale were in the at-risk or clinically significant range for 15% of the cohort, compared with 9% for the normative data (P < .00001). Attention problem scores were in the at-risk or clinically significant range for 12% of the cohort, compared with 7% for the normative data (P = .0002). The Attention-Deficit/Hyperactivity Disorder Rating Scale-IV, Preschool Version, was completed for 378 children; 30% scored in the clinically significant range for inattention and 22% for impulsivity. After adjustment for covariates, the APOE 2 allele was significantly associated with higher scores (worse problems) for multiple Child Behavior Checklist indices, including somatic complaints (P = .009), pervasive developmental problems (P = .032), and internalizing problems (P = .009). In each case, the 4 allele was associated with a better outcome. APOE 2 carriers had impaired social skills, compared with 4 carriers (P = .009). CONCLUSIONS: For preschool-aged children with congenital heart defects requiring surgery, parental rating scales showed an increased prevalence of restricted behavior patterns, inattention, and impaired social interactions. The APOE 2 allele was associated with increased behavior problems, impaired social interactions, and restricted behavior patterns.

Functioning at School Age of Moderately Preterm Children Born at 32 to 36 Weeks' Gestational Age

OBJECTIVE: To study outcome of low-risk moderately preterm birth between 32 and 36/7 weeks' gestation. METHODS: 377 Moderately preterm children (M: 34.7, SD: 1.2 complete weeks), without need for neonatal intensive care and without dysmaturity or congenital malformations, were compared with 182 term children and assessed at eight years (M: 8.9, SD: 0.54). School situation, IQ, sustained attention, behavior problems, and attention-deficit/hyperactivity characteristics were studied. RESULTS: Special education was attended by 7.7% of the moderately preterm children, more than twice the rate of 2.8% in the general Dutch population of this age. Additional exploration for two preterm subgroups of 32 to 33 versus 34 to 36 weeks' gestation showed a need for special education in 9.7% versus 7.3% and a significant difference in grade retention for 30% versus 17%, respectively. Of the children attending mainstream primary schools, grade retention was found in 19% of the preterm versus 8% of the comparison children. Adjusting for maternal education, a group difference of 3 points was found in IQ. The preterm children needed more time for the sustained attention task. The preterm children had more behavior problems (specifically internalizing problems with 27% scoring above the borderline cut-off), as well as more attention-deficit/hyperactivity disorder characteristics (specifically attention deficits). CONCLUSIONS: Cognitive and emotional regulation difficulties affect functioning of moderately preterm children, as school problems, a slightly lower IQ, attention and behavioral problems are found when they are compared with term-born children. Identification and monitoring of precursors of these problems at younger age is needed in view of prevention purposes.

Risk Factors Affecting School Readiness in Premature Infants With Respiratory Distress Syndrome

OBJECTIVE: With advances in neonatal care, more children born prematurely are successfully reaching school age. It is unknown how many will be ready for school and what factors affect school readiness. Our objective was to assess readiness of children born prematurely for entry into public school, and determine risk factors associated with lack of school readiness in this population. METHODS: This was a single-center prospective cohort study. Follow- up data were collected for 135 of 167 (81%) surviving premature infants with RDS requiring surfactant-replacement therapy. The children were seen between July 2005 and September 2006 (average age: 5.7 ± 1.0 years) and underwent standardized neurodevelopmental and health assessments and socioeconomic status classification. A 4-level school-readiness score was constructed by using each child's standardized scores on assessments of basic concepts (Bracken School-Readiness Assessment), perceptual skills (Visual-Motor Integration Test), receptive vocabulary (Peabody Picture Vocabulary Test, Third Edition), daily living functional skills (Pediatric Functional Independence Measure), and presence of sensory impairments or autism. Proportional odds models were used to identify risk factors predicting lower school-readiness levels. RESULTS: Mean birth weight was 1016 ± 391 g, and mean gestational age was 27.5 ± 2.6 weeks. Ninety-one (67%) children were school-ready. Using multivariate analysis, male gender, chronic lung disease, and severe intraventricular hemorrhage or periventricular leukomalacia were associated with lower school-readiness levels. However, the most powerful factor determining school-readiness level was low socioeconomic status. CONCLUSION: Interventions targeting neonatal morbidities may be much less effective at improving overall performance at school age compared with the effect of the impoverished social environment.

The Association of Lung Disease With Cerebral White Matter Abnormalities in Preterm Infants

OBJECTIVE: Preterm infants have a high incidence of neurodevelopmental impairment associated with diffuse cerebral white matter abnormalities and also a high incidence of serious respiratory disease. However, it is unclear if lung disease and brain injury are related, and previous research has been impeded by confounding effects, including prematurity and infection. Using a new approach that permits multivariate statistical analysis, we tested the hypothesis that lung disease is associated with specific white matter abnormalities, detected as reduced fractional anisotropy (FA) in diffusion tensor imaging data. METHODS: Fifty-three preterm infants with no evidence of focal abnormality on conventional MRI were studied at term-equivalent age by using tract-based spatial statistics, an automated observer-independent method for voxelwise analysis of major white matter pathways. RESULTS: In several white matter tracts, FA decreased with a linear relation to the gestational age at birth. Independent of the confounding effects of prematurity and age at scan, respiratory disease was associated with specific white matter abnormalities in preterm infants; those infants receiving mechanical ventilation for >2 days in the perinatal period (n = 10) showed reduced FA in the genu of the corpus callosum, whereas subjects with chronic lung disease (n = 15) displayed a reduction in FA in the left inferior longitudinal fasciculus. CONCLUSION: Independent of the degree of prematurity, respiratory disease is associated with cerebral white matter abnormalities.

Carbon Monoxide is a Significant Mediator of Cardiovascular Status Following Preterm Birth

OBJECTIVE: With male gender as a strong predictor of cardiovascular instability, we hypothesized that gender-specific differences in circulating carbon monoxide levels contributed to dysregulated microvascular function in preterm male infants. METHODS: Infants born at 24 to 34 weeks of gestation (N = 84) were studied in a regional tertiary neonatal unit. Carboxyhemoglobin levels were measured through spectrophotometry in umbilical arterial blood and at 24, 72, and 120 hours after birth. Microvascular blood flow was determined through laser Doppler flowmetry. RESULTS: Carboxyhemoglobin levels demonstrated a strong inverse relationship with gestational age (r = –0.636; P < .001) and were higher in boys (P = .032). Repeated-measures analysis of variance showed a significant decrease in arterial carboxyhemoglobin levels over time (P < .001), with significant between-subjects effects for gestational age (P = .011) and gender (P = .025). Positive correlations with microvascular blood flow at 24 hours of age (r = 0.495; P < .001) and 120 hours of age (r = 0.548; P < .001) were observed. With controlling for gestational age, carboxyhemoglobin levels at 72 hours were greater for infants who died in the first week of life (P = .035). CONCLUSIONS: The gestational age- and gender-specific differences in carboxyhemoglobin levels and the relationship with dysregulated microvascular blood flow, a state related to greater illness severity and hypotension, are novel findings not confined solely to sick preterm infants. Both inducible heme oxygenase-dependent and non–heme oxygenase-dependent pathways may initially play a central role in carbon monoxide production, inducing pathophysiologic processes in a gender-specific manner.

Child Protection Outcomes for Infants of Substance-Using Mothers: A Matched-Cohort Study

OBJECTIVE: Parental drug use is a critical public health issue; it is estimated to be present in up to 80% of referrals to Australian child protection agencies. However, no data regarding the child protection outcomes of infants of substance-using parents exist in Australia, and no comparisons have been made with infants of non–substance-using parents. We assessed differences in substantiated abuse between 2 groups of mothers in Brisbane to quantify this risk. METHODS: Mothers who disclosed opiate, amphetamine, or methadone use between 2000 and 2003 were identified and compared with non–substance-using mothers who were matched for gender and gestational age. All infants were linked to the Department of Child Safety Child Protection Information System database. Child protection outcomes, such as substantiated notifications and entry into foster care, were compared between groups. RESULTS: We studied 119 infants of substance-using mothers and 238 matched infants. Infants of substance-using mothers were more likely to suffer substantiated harm (hazard ratio 13.3 [95% confidence interval 4.6–38.3]) and to enter foster care (hazard ratio 13.3 [95% confidence interval 5.1–34.3]). Infants of mothers using illicit drugs were more likely to suffer substantiated harm and more likely to enter foster care than infants of mothers who were compliant with a methadone program. CONCLUSIONS: Infants of substance-using mothers have much poorer child protection outcomes than infants of non–substance-using mothers. This study adds substantial evidence toward a real association between maternal drug use and child abuse. Greater interagency collaboration is urgently required to reduce this risk.

Cerebral Oxygen Saturation and Extraction in Preterm Infants With Transient Periventricular Echodensities

OBJECTIVE: Our aim was to determine regional cerebral tissue oxygen saturation and fractional tissue oxygen extraction in preterm infants with transient periventricular echodensities. We hypothesized that as a result of reduced cerebral perfusion, regional cerebral tissue oxygen saturation will be lower and fractional tissue oxygen extraction will be higher during the first days after birth. PATIENTS AND METHODS: This was a prospective, observational study of 49 preterm infants (gestational age median: 30.1 weeks [26.0–31.8 weeks]; birth weight median: 1220 g [615–2250 g]). We defined transient periventricular echodensities as echodensities that persisted for >7 days. Regional cerebral tissue oxygen saturation was measured on days 1–5, 8, and 15 after birth. Fractional tissue oxygen extraction was calculated as (transcutaneous arterial oxygen saturation – regional cerebral tissue oxygen saturation)/transcutaneous arterial oxygen saturation. RESULTS: Transient periventricular echodensities were found in 25 of 49 infants. During the first week we found no difference between the 2 groups for cerebral tissue oxygen saturation and fractional tissue oxygen extraction values. On day 15 after birth, cerebral tissue oxygen saturation was lower in preterm infants with transient periventricular echodensities (66%) compared with infants without echodensities (76%) (P = .003). Fractional tissue oxygen extraction in infants with transient periventricular echodensities (0.30) was higher than fractional tissue oxygen extraction in infants without transient periventricular echodensities (0.20) (P < .001). The differences could not be explained by confounding variables. CONCLUSIONS: Persistent transient periventricular echodensities may be associated with increased cerebral oxygen demand after the first week after birth, which is contrary to our hypothesis. Cerebral oxygenation may be involved in the recovery of perinatal white matter damage.

Elevated Cerebral Pressure Passivity Is Associated With Prematurity-Related Intracranial Hemorrhage

OBJECTIVES: Cerebral pressure passivity is common in sick premature infants and may predispose to germinal matrix/intraventricular hemorrhage (GM/IVH), a lesion with potentially serious consequences. We studied the association between the magnitude of cerebral pressure passivity and GM/IVH. PATIENTS AND METHODS: We enrolled infants <32 weeks' gestational age with indwelling mean arterial pressure (MAP) monitoring and excluded infants with known congenital syndromes or antenatal brain injury. We recorded continuous MAP and cerebral near-infrared spectroscopy hemoglobin difference (HbD) signals at 2 Hz for up to 12 hours/day and up to 5 days. Coherence and transfer function analysis between MAP and HbD signals was performed in 3 frequency bands (0.05–0.25, 0.25–0.5, and 0.5–1.0 Hz). Using MAP-HbD gain and clinical variables (including chorioamnionitis, Apgar scores, gestational age, birth weight, neonatal sepsis, and Score for Neonatal Acute Physiology II), we built a logistic regression model that best predicts cranial ultrasound abnormalities. RESULTS: In 88 infants (median gestational age: 26 weeks [range 23–30 weeks]), early cranial ultrasound showed GM/IVH in 31 (37%) and parenchymal echodensities in 10 (12%) infants; late cranial ultrasound showed parenchymal abnormalities in 19 (30%) infants. Low-frequency MAP-HbD gain (highest quartile mean) was significantly associated with early GM/IVH but not other ultrasound findings. The most parsimonious model associated with early GM/IVH included only gestational age and MAP-HbD gain. CONCLUSIONS: This novel cerebrovascular monitoring technique allows quantification of cerebral pressure passivity as MAP-HbD gain in premature infants. High MAP-HbD gain is significantly associated with GM/IVH. Precise temporal and causal relationship between MAP-HbD gain and GM/IVH awaits further study.

Serum Gentamicin Concentrations in Encephalopathic Infants are Not Affected by Therapeutic Hypothermia

OBJECTIVE. Mild hypothermia for 72 hours is neuroprotective in newborns with moderate or severe hypoxic-ischemic encephalopathy. A core temperature of 33.5°C might reduce drug clearance leading to potential toxicity. Gentamicin is nephrotoxic and ototoxic at high serum concentrations. No study has investigated the influence of 72 hours of hypothermia on serum gentamicin concentrations (SGCs) in children of any age. We aimed to compare the SGCs in encephalopathic infants who underwent intensive care with therapeutic hypothermia or normothermia. METHODS. Data were collected retrospectively from 2 NICUs in Bristol, United Kingdom, that offered cooling therapy within clinical trials since 1998. Eligible infants (n = 55) developed grade 2/3 encephalopathy after birth and fulfilled the entry criteria defined in the CoolCap trial. Encephalopathic infants with similar demographic values were either nursed under normothermia or 72 h-hypothermia. Once-daily gentamicin dosage (4–5 mg/kg) was administered, and trough SGC was recorded with corresponding creatinine concentrations. The time and number of omitted drug doses were noted. RESULTS. Mean trough SGC (pre–second dose) and mean plasma creatinine concentrations for both treatment groups were similar (gentamicin: 2.19 ± 1.7 [hypothermia] and 2.30 ± 2.0 [normothermia] mg/L; creatinine: 115.6 ± 42.8 [hypothermia] and 121.0 ± 45.1 [normothermia] µmol/L). Forty percent of the trough SGCs in both groups were above the recommended trough concentration of 2.0 mg/L. A significant correlation (r2 = 0.36) was found between high SGCs and impaired renal function assessed by raised plasma creatinine levels regardless of treatment options. CONCLUSIONS. Our data confirm that impaired renal function is strongly associated with high SGCs. Reduced body temperatures do not affect the clearance of gentamicin.

Triplets Across the First 5 Years: The Discordant Infant at Birth Remains at Developmental Risk

OBJECTIVES: To examine whether the risk posed to infant development by triplet birth persists into childhood and whether growth-discordant triplets are at a particularly high developmental risk. METHODS: Twenty-one sets of triplets were matched with 21 sets of twins and 21 singletons (N = 126) for medical and demographic conditions and were followed from birth to 5 years. At 6, 12, and 24 months, cognitive development was assessed and mother-infant interactions were coded for maternal sensitivity and child social engagement. At 5 years, the children's cognitive development and neuropsychological skills were tested, social engagement was coded from mother-child interactions, and behavior problems were examined. Maternal adjustment was assessed during interviews at 1 and 5 years. RESULTS: Although triplets showed lower cognitive performance at 6, 12, and 24 months as compared with singletons and twins, differences were attenuated by 5 years in both global IQ and executive functions. Similarly, the lower social engagement observed across infancy and the higher internalizing symptoms reported at 2 years for those in the triplet group were no longer found at 5 years. Difficulties in maternal adjustment among mothers of triplets decreased from 1 to 5 years. However, in 65.2% of the initial sample there was a weight discordance of >15% at birth, and the discordant triplets showed poorer cognitive and social development as compared with their siblings across infancy. At 5 years, the discordant children demonstrated lower cognitive and executive functions performance, decreased social engagement, and higher internalizing symptoms as compared with both siblings and peers. CONCLUSIONS: Whereas most triplets catch up after an early developmental delay, the risk for discordant triplets seems to persist into childhood. Such infants, who are at both biological and environmental risk, should receive special and consistent professional care.

Cardiovascular Medication Errors in Children

OBJECTIVES: We sought to describe pediatric cardiovascular medication errors and to determine patients and medications with more-frequently reported and/or more-harmful errors. METHODS: We analyzed cardiovascular medication error reports from 2003–2004 for patients <18 years of age, from the US Pharmacopeia MEDMARX database. Reports were stratified according to harm score (A, near miss; B–D, error, no harm; E–I, harmful error). Proportions of harmful reports were determined according to drug class and age group. "High-risk" drugs were defined as antiarrhythmics, antihypertensives, digoxin, and calcium channel blockers. RESULTS: A total of 147 facilities submitted 821 reports with community hospitals predominating (70%). Mean patient age was 4 years (median: 0.9 years). The most common error locations were NICUs, general care units, PICUs, pediatric units, and inpatient pharmacies. Drug administration, particularly improper dosing, was implicated most commonly. Severity analysis showed 5% "near misses," 91% errors without harm, and 4% harmful errors, with no reported fatalities. A total of 893 medications were cited in 821 reports. Diuretics were cited most frequently, followed by antihypertensives, angiotensin inhibitors, β-adrenergic receptor blockers, digoxin, and calcium channel blockers. Calcium channel blockers, phosphodiesterase inhibitors, antiarrhythmics, and digoxin had the largest proportions of harmful events, although the values were not statistically significantly different from those for other drug classes. Infants <1 year of age accounted for 50% of reports. Proportions of harmful events did not differ according to age. CONCLUSIONS: Infants <1 year of age were most frequently reported in cardiovascular medication errors reaching inpatients, in a national, voluntary, error-reporting database. Proportions of harmful errors were not significantly different by age or cardiovascular medication. Most errors were related to medication administration, largely due to improper dosing.

Trajectories of Receptive Language Development From 3 to 12 Years of Age for Very Preterm Children

OBJECTIVES: The goal was to examine whether indomethacin use, gender, neonatal, and sociodemographic factors predict patterns of receptive language development from 3 to 12 years of age in preterm children. METHODS: A total of 355 children born in 1989–1992 with birth weights of 600 to 1250 g were evaluated at 3, 4.5, 6, 8, and 12 years with the Peabody Picture Vocabulary Test-Revised. Hierarchical growth modeling was used to explore differences in language trajectories. RESULTS: From 3 to 12 years, preterm children displayed catch-up gains on the Peabody Picture Vocabulary Test-Revised. Preterm children started with an average standardized score of 84.1 at 3 years and gained 1.2 points per year across the age period studied. Growth-curve analyses of Peabody Picture Vocabulary Test-Revised raw scores revealed an indomethacin-gender effect on initial scores at 3 years, with preterm boys assigned randomly to receive indomethacin scoring, on average, 4.2 points higher than placebo-treated boys. However, the velocity of receptive vocabulary development from 3 to 12 years did not differ for the treatment groups. Children with severe brain injury demonstrated slower gains in skills over time, compared with those who did not suffer severe brain injury. Significant differences in language trajectories were predicted by maternal education and minority status. CONCLUSION: Although indomethacin yielded an initial benefit for preterm boys, this intervention did not alter the developmental trajectory of receptive language scores. Severe brain injury leads to long-term sequelae in language development, whereas a socioeconomically advantaged environment supports better language development among preterm children.

Teaching by Listening: The Importance of Adult-Child Conversations to Language Development

OBJECTIVE: To test the independent association of adult language input, television viewing, and adult-child conversations on language acquisition among infants and toddlers. METHODS: Two hundred seventy-five families of children aged 2 to 48 months who were representative of the US census were enrolled in a cross-sectional study of the home language environment and child language development (phase 1). Of these, a representative sample of 71 families continued for a longitudinal assessment over 18 months (phase 2). In the cross-sectional sample, language development scores were regressed on adult word count, television viewing, and adult-child conversations, controlling for socioeconomic attributes. In the longitudinal sample, phase 2 language development scores were regressed on phase 1 language development, as well as phase 1 adult word count, television viewing, and adult-child conversations, controlling for socioeconomic attributes. RESULTS: In fully adjusted regressions, the effects of adult word count were significant when included alone but were partially mediated by adult-child conversations. Television viewing when included alone was significant and negative but was fully mediated by the inclusion of adult-child conversations. Adult-child conversations were significant when included alone and retained both significance and magnitude when adult word count and television exposure were included. CONCLUSIONS: Television exposure is not independently associated with child language development when adult-child conversations are controlled. Adult-child conversations are robustly associated with healthy language development. Parents should be encouraged not merely to provide language input to their children through reading or storytelling, but also to engage their children in two-sided conversations.

Maternal Allopurinol During Fetal Hypoxia Lowers Cord Blood Levels of the Brain Injury Marker S-100B

BACKGROUND: Fetal hypoxia is an important determinant of neonatal encephalopathy caused by birth asphyxia, in which hypoxia-induced free radical formation plays an important role. HYPOTHESIS: Maternal treatment with allopurinol, will cross the placenta during fetal hypoxia (primary outcome) and reduce S-100B and free radical formation (secondary outcome). METHODS: In a randomized, double-blind feasibility study, 53 pregnant women in labor (54 fetuses) with a gestational age of >36 weeks and fetal hypoxia, as indicated by abnormal/nonreassuring fetal heart rate tracing or fetal scalp pH of <7.20, received 500 mg of allopurinol or placebo intravenously. Severity of fetal hypoxia, brain damage and free radical formation were assessed by arterial cord blood lactate, S-100B and non-protein-bound-iron concentrations, respectively. At birth, maternal and cord blood concentrations of allopurinol and its active metabolite oxypurinol were determined. RESULTS: Allopurinol and oxypurinol concentrations were within the therapeutic range in the mother (allopurinol > 2 mg/L and/or oxypurinol > 4 mg/L) but not always in arterial cord blood. We therefore created 3 groups: a placebo (n = 27), therapeutic allopurinol (n = 15), and subtherapeutic allopurinol group (n = 12). Cord lactate concentration did not differ, but S-100B was significantly lower in the therapeutic allopurinol group compared with the placebo and subtherapeutic allopurinol groups (P < .01). Fewer therapeutic allopurinol cord samples had measurable non–protein-bound iron concentrations compared with placebo (P < .01). CONCLUSIONS: Maternal allopurinol/oxypurinol crosses the placenta during fetal hypoxia. In fetuses/newborns with therapeutic allopurinol/oxypurinol concentrations in cord blood, lower plasma levels of the brain injury marker protein S-100B were detected. A larger allopurinol trial in compromised fetuses at term seems warranted. The allopurinol dosage must be adjusted to achieve therapeutic fetal allopurinol/oxypurinol concentrations.

Improved Outcomes Associated With Medical Home Implementation in Pediatric Primary Care

OBJECTIVE: The medical home model with its emphasis on planned care, care coordination, family-centered approaches, and quality provides an attractive concept construct for primary care redesign. Studies of medical home components have shown increased quality and reduced costs, but the medical home model as a whole has not been studied systematically. This study tested the hypothesis that increased medical homeness in primary care practice is associated with decreased utilization of health services and increased patient satisfaction. METHODS: Forty-three primary care practices were identified through 7 health plans in 5 states. Using the Medical Home Index (MHI), each practice's implementation of medical home concepts "medical homeness" was measured. Health plans provided the previous year's utilization data for children with 6 chronic conditions. The plans identified 42 children in each practice with these chronic conditions and surveyed their families regarding satisfaction with care and burden of illness. RESULTS: Higher MHI scores and higher subdomain scores for organizational capacity, care coordination, and chronic-condition management were associated with significantly fewer hospitalizations. Higher chronic-condition management scores were associated with lower emergency department use. Family survey data yielded no recognizable trends with respect to the medical home measurement. CONCLUSIONS: Developing an evidence base for the value of the primary care medical home has importance for providers, payers, policy makers, and consumers. Reducing hospitalizations through enhanced primary care provides a potential case for new reimbursement strategies supporting medical home services such as care coordination. Larger-scale studies are needed to further develop/examine these relationships.

Improving Clinical Quality Indicators Through Electronic Health Records: It Takes More Than Just a Reminder

Ethnicity Matters in the Assessment and Treatment of Children's Pain

Speed Isn't Everything in Pediatric Medical Transport

The Association of High-Magnitude Cerebral Passivity and Intraventricular Hemorrhage in Premature Infants

Optimizing Early Development and Understanding Trajectories of Resiliency After Extreme Prematurity

Pediatrics Print Edition Is Redesigned to Better Meet Your Needs

Role of the Pediatrician in Youth Violence Prevention

Youth violence continues to be a serious threat to the health of children and adolescents in the United States. It is crucial that pediatricians clearly define their role and develop the appropriate skills to address this threat effectively. From a clinical perspective, pediatricians should become familiar with Connected Kids: Safe, Strong, Secure, the American Academy of Pediatrics' primary care violence prevention protocol. Using this material, practices can incorporate preventive education, screening for risk, and linkages to community-based counseling and treatment resources. As advocates, pediatricians may bring newly developed information regarding key risk factors such as exposure to firearms, teen dating violence, and bullying to the attention of local and national policy makers. This policy statement refines the developing role of pediatricians in youth violence prevention and emphasizes the importance of this issue in the strategic agenda of the American Academy of Pediatrics.

Using Personal Health Records to Improve the Quality of Health Care for Children

A personal health record (PHR) is a repository of information from multiple contributors (eg, patient, family, guardians, physicians, and other health care professionals) regarding the health of an individual. The development of electronic PHRs presents new opportunities and challenges to the practice of pediatrics. This policy statement provides recommendations for actions that pediatricians can take to support the development and use of PHRs for children. Pediatric health care professionals must become actively involved in developing and adopting PHRs and PHR systems. The American Academy of Pediatrics supports development of: educational programs for families and clinicians on effective and efficient use of PHRs; incentives to facilitate PHR use and maintenance; and child- and adolescent-friendly standards for PHR content, portability, security, and privacy. Properly designed PHR systems for pediatric care can empower patients. PHRs can improve access to health information, improve coordination of preventive health and health maintenance activities, and support emergency and disaster management activities. PHRs provide support for the medical home for all children, including those with special health care needs and those in foster care. PHRs can also provide information to serve as the basis for pediatric quality improvement efforts. For PHRs to be adopted sufficiently to realize these benefits, we must determine how best to support their development and adoption. Privacy and security issues, especially with regard to children and adolescents, must be addressed.

The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care

Pediatric primary care clinicians have unique opportunities and a growing sense of responsibility to prevent and address mental health and substance abuse problems in the medical home. In this report, the American Academy of Pediatrics proposes competencies requisite for providing mental health and substance abuse services in pediatric primary care settings and recommends steps toward achieving them. Achievement of the competencies proposed in this statement is a goal, not a current expectation. It will require innovations in residency training and continuing medical education, as well as a commitment by the individual clinician to pursue, over time, educational strategies suited to his or her learning style and skill level. System enhancements, such as collaborative relationships with mental health specialists and changes in the financing of mental health care, must precede enhancements in clinical practice. For this reason, the proposed competencies begin with knowledge and skills for systems-based practice. The proposed competencies overlap those of mental health specialists in some areas; for example, they include the knowledge and skills to care for children with attention-deficit/hyperactivity disorder, anxiety, depression, and substance abuse and to recognize psychiatric and social emergencies. In other areas, the competencies reflect the uniqueness of the primary care clinician's role: building resilience in all children; promoting healthy lifestyles; preventing or mitigating mental health and substance abuse problems; identifying risk factors and emerging mental health problems in children and their families; and partnering with families, schools, agencies, and mental health specialists to plan assessment and care. Proposed interpersonal and communication skills reflect the primary care clinician's critical role in overcoming barriers (perceived and/or experienced by children and families) to seeking help for mental health and substance abuse concerns.

Antenatal Counseling Regarding Resuscitation at an Extremely Low Gestational Age

The anticipated delivery of an extremely low gestational age infant raises difficult questions for all involved, including whether to initiate resuscitation after delivery. Each institution caring for women at risk of delivering extremely preterm infants should provide comprehensive and consistent guidelines for antenatal counseling. Parents should be provided the most accurate prognosis possible on the basis of all the factors known to affect outcome for a particular case. Although it is not feasible to have specific criteria for when the initiation of resuscitation should or should not be offered, the following general guidelines are suggested. If the physicians involved believe there is no chance for survival, resuscitation is not indicated and should not be initiated. When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference. Finally, if a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued. Whenever resuscitation is considered an option, a qualified individual, preferably a neonatologist, should be involved and should be present in the delivery room to manage this complex situation. Comfort care should be provided for all infants for whom resuscitation is not initiated or is not successful.

Expert Witness Participation in Civil and Criminal Proceedings

The interests of the public and both the medical and legal professions are best served when scientifically sound and unbiased expert witness testimony is readily available in civil and criminal proceedings. As members of the medical community, patient advocates, and private citizens, pediatricians have ethical and professional obligations to assist in the administration of justice. The American Academy of Pediatrics believes that the adoption of the recommendations outlined in this statement will improve the quality of medical expert witness testimony in legal proceedings and, thereby, increase the probability of achieving outcomes that are fair, honest, and equitable. Strategies for enforcing guidance and promoting oversight of expert witnesses are proposed.

CLINICAL PROFILE AND HOME MANAGEMENT OF SICKLE CELL-RELATED PAIN: The Enugu (Nigeria) Experience

THE BENEFIT OF ATG IN IMMUNOSUPPRESSIVE THERAPY OF CHILDREN WITH MODERATE APLASTIC ANEMIA

RHABDOMYOSARCOMA OF THE EXTREMITIES: A Focus on Tumors Arising in the Hand and Foot

INCIDENCE OF PRIMARY CENTRAL NERVOUS SYSTEM TUMORS AMONG CHILDREN IN BELGRADE (SERBIA), 1991-2004

PANEL REACTIVE ANTIBODY IN THALASSEMIC SERUM INHIBITS PROLIFERATION AND DIFFERENTIATION OF CORD BLOOD CD34 + CELLS IN VITRO

ALLOGENEIC STEM CELL TRANSPLANTATION FOR MYELODYSPLASTIC SYNDROMES IN CHILDREN: A Report from the Spanish Working Party for Blood and Marrow Transplantation in Children (GETMON)

SEVERE HYPOCHROMIC MICROCYTIC ANEMIA IN A PATIENT WITH CONGENITAL ATRANSFERRINEMIA

EFFECT OF SOMATOSTATIN ANALOGUE OCTREOTIDE IN MEDULLOBLASTOMA IN XENOGRAFT AND CELL CULTURE STUDY

SUCCESSFUL TREATMENT OF KASABACH-MERRITT SYNDROME WITH VINCRISTINE AND DIAGNOSIS OF THE HEMANGIOMA USING THREE-DIMENSIONAL IMAGING

A NOVEL L218P MUTATION IN NADH-CYTOCHROME B5 REDUCTASE ASSOCIATED WITH TYPE I RECESSIVE CONGENITAL METHEMOGLOBINEMIA

PLASMA HEPARANASE AS A SIGNIFICANT MARKER OF TREATMENT RESPONSE IN CHILDREN WITH HODGKIN LYMPHOMA: Pilot Study

ALLOGENEIC CORD BLOOD TRANSPLANTATION IN CHILDREN WITH HEMATOLOGICAL MALIGNANCIES: A Long-Term Follow-Up Single-Center Study

EXTRA-OSSEOUS EWING SARCOMA

BONE MARROW TRANSPLANTATION OR HYDROXYUREA FOR SICKLE CELL ANEMIA: Long-Term Effects on Semen Variables and Hormone Profiles

ANTIBODY TITRATION AND IMMUNE RESPONSE OF IRANIAN β-THALASSEMIC PATIENTS TO HEPATITIS B VIRUSE VACCINE (BOOSTER EFFECT)

GROWTH STATUS IN CHILDREN AND ADOLESCENTS WITH SICKLE CELL DISEASE

CD10 AND CD34 EXPRESSION IN CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA IN MOROCCO: Clinical Relevance and Outcome

HEPATITIS G VIRUS INFECTION IN MULTITRANSFUSED EGYPTIAN CHILDREN

TRENDS IN SURVIVAL AFTER CHILDHOOD CANCER IN SLOVENIA BETWEEN 1957 AND 2007

SPERM CRYOPRESERVATION PRACTICES AMONG ADOLESCENT CANCER PATIENTS AT RISK FOR INFERTILITY

SPONTANEOUS THROMBOSIS OF HEPATIC ANEURYSMS IN AN INFANT WITH WISKOTT-ALDRICH SYNDROME

MULTIPLE CHROMOSOME ABNORMALITIES IN THE PLEURAL FLUID OF A PATIENT WITH RECURRENT EWING SARCOMA

THROMBOLYTICS FOR HYPERACUTE STROKE IN CHILDREN

HEMORHEOLOGICAL PARAMETERS IN CHILDREN WITH IRON-DEFICIENCY ANEMIA AND THE ALTERATIONS IN THESE PARAMETERS IN RESPONSE TO IRON REPLACEMENT

HAPLOIDENTICAL HEMATOPOIETIC STEM CELL TRANSPLANTATION IN CHILD HEMATOLOGIC MALIGNANCIES WITH G-CSF-MOBILIZED MARROW GRAFTS WITHOUT T-CELL DEPLETION: A Single-Center Report of 45 Cases

HYPEREOSINOPHILIC SYNDROME IN CHILDHOOD: Clinical and Molecular Features of Two Cases

THE CASE OF A 1-YEAR-OLD GIRL WITH HEREDITARY HYPERFERRITINEMIA CATARACT SYNDROME

ANAPLASTIC LARGE CELL LYMPHOMA WITH PRIMARY INVOLVEMENT OF SKELETAL MUSCLE: A Rare Case Report and Review of the Literature

POLAND SYNDROME WITH INTRACRANIAL GERM CELL TUMOR IN A CHILD

RHABDOMYOLYSIS DUE TO Escherichia coli SEPSIS IN THREE PEDIATRIC PATIENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA

PARVOVIRUS B19-INDUCED PERSISTENT PURE RED CELL APLASIA IN A CHILD WITH T-CELL IMMUNODEFICIENCY

ALTERED IRON METABOLISM IN CHILDREN WITH HUMAN IMMUNODEFICIENCY VIRUS DISEASE

ACUTE LYMPHOBLASTIC LEUKEMIA SECONDARY TO CHEMORADIOTHERAPY FOR PERIVASCULAR EPITHELIOID CELL TUMOR OF UTERUS

CHOOSING THERAPY FOR ADOLESCENT FEMALES WITH CANCER: Fertility Should Matter

RELAPSE OF PRIMITIVE MEDIASTINAL LYMPHOMA AS A MYELOID MASS FOLLOWING BEAM AUTOLOGOUS TRANSPLANT AND SUBSEQUENT REFRACTORINESS TO MATCHED UNRELATED UMBILICAL CORD BLOOD ALLOGRAFT

TRANSFORMATION OF MYELODYSPLASTIC SYNDROME TO T-CELL ACUTE LYMPHOBLASTIC LEUKEMIA IN A YOUNG ADULT

DIFFERENTIAL microRNA EXPRESSION IN CHILDHOOD B-CELL PRECURSOR ACUTE LYMPHOBLASTIC LEUKEMIA

INCIDENCE OF AND RISK FACTORS FOR CHILDHOOD THROMBOSIS: A Single-Center Experience in Ankara, Turkey

UNDULANT COURSE OF AFP: A Sign of Tumor Activation or Not?

IS THE TREATMENT FOR CHILDHOOD SOLID TUMORS ASSOCIATED WITH LOWER BONE MASS THAN THAT FOR LEUKEMIA AND HODGKIN DISEASE?

EXPRESSION OF PTEN AND SHP1, INVESTIGATED FROM TISSUE MICROARRAYS IN PEDIATRIC ACUTE LYMPHOBLASTIC, LEUKEMIA

COEXISTENCE OF SYMPTOMATIC IRON-DEFICIENCY ANEMIA AND DUODENAL NODULAR LYMPHOID HYPERPLASIA DUE TO GIARDIASIS: Case Report

BONE FRACTURE: An Unusual Presentation of Acute Megakaryoblastic Leukemia

SUCCESSFUL USE OF TERBUTALINE IN PERSISTENT PRIAPISM IN A 12-YEAR-OLD BOY WITH CHRONIC MYELOID LEUKEMIA

WT1 (WILMS TUMOR 1) PEPTIDE IMMUNOTHERAPY FOR CHILDHOOD RHABDOMYOSARCOMA: A Case Report

INVASIVE ASPERGILLOSIS OF THE SMALL BOWEL IN AN INFANT WITH ACUTE MYELOID LEUKEMIA AND INTESTINAL OBSTRUCTION

SAFETY OF HEMATOPOIETIC STEM CELL TRANSPLANTATION IN CHILDREN LESS THAN THREE YEARS OF AGE

PLASMA NATRIURETIC PEPTIDES LEVELS AND ECHOCARDIOGRAPHIC FINDINGS IN LATE SUBCLINICAL ANTHRACYCLINE TOXICITY

MTHFR 677CT And 1298AC POLYMORPHISMS IN CHILDREN WITH DOWN SYNDROME AND ACUTE MYELOID LEUKEMIA IN BRAZIL

RESPONSE TO RITUXIMAB AND PREDNISOLONE FOR OPSOCLONUS-MYOCLONUS-ATAXIA SYNDROME IN A CHILD WITH GANGLIONEUROBLASTOMA