April 2012, VOLUME 129 / ISSUE 4 - مركز مديريت دانش بيماريهاي كودكان

پنجشنبه 4 بهمن 1403 - 22 رجب 1446

English | فارسی

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شما اینجا هستید صفحه اصلیApril 2012, VOLUME 129 / ISSUE 4

مطالب آموزشی

April 2012, VOLUME 129 / ISSUE 4

· Abstract 1 of 63Pediatrics Digest

· Abstract 2 of 63Pediatrics Perspective

· Abstract 3 of 63Article

Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years

OBJECTIVES: Examine statistical effects of sleep-disordered breathing (SDB) symptom trajectories from 6 months to 7 years on subsequent behavior.

METHODS: Parents in the Avon Longitudinal Study of Parents and Children reported on children’s snoring, mouth breathing, and witnessed apnea at ≥2 surveys at 6, 18, 30, 42, 57, and 69 months, and completed the Strengths and Difficulties Questionnaire at 4 (n = 9140) and 7 (n = 8098) years. Cluster analysis produced 5 “Early” (6–42 months) and “Later” (6–69 months) symptom trajectories (“clusters”). Adverse behavioral outcomes were defined by top 10th percentiles on Strengths and Difficulties Questionnaire total and subscales, at 4 and 7 years, in multivariable logistic regression models.

RESULTS: The SDB clusters predicted ≈20% to 100% increased odds of problematic behavior, controlling for 15 potential confounders. Early trajectories predicted problematic behavior at 7 years equally well as at 4 years. In Later trajectories, the “Worst Case” cluster, with peak symptoms at 30 months that abated thereafter, nonetheless at 7 years predicted hyperactivity (1.85 [1.30–2.63]), and conduct (1.60 [1.18–2.16]) and peer difficulties (1.37 [1.04–1.80]), whereas a “Later Symptom” cluster predicted emotional difficulties (1.65 [1.21–2.07]) and hyperactivity (1.88 [1.42–2.49]) . The 2 clusters with peak symptoms before 18 months that resolve thereafter still predicted 40% to 50% increased odds of behavior problems at 7 years.

CONCLUSIONS: In this large, population-based, longitudinal study, early-life SDB symptoms had strong, persistent statistical effects on subsequent behavior in childhood. Findings suggest that SDB symptoms may require attention as early as the first year of life.

KEY WORDS

sleep-disordered breathing

behavior

longitudinal

Accepted November 22, 2011.

· Abstract 4 of 63Article

Clinic-Integrated Behavioral Intervention for Families of Youth With Type 1 Diabetes: Randomized Clinical Trial

OBJECTIVE: To test the effect on diabetes management outcomes of a low-intensity, clinic-integrated behavioral intervention for families of youth with type 1 diabetes.

METHODS: Families (n = 390) obtaining care for type 1 diabetes participated in a 2-year randomized clinical trial of a clinic-integrated behavioral intervention designed to improve family diabetes management practices. Measurement of hemoglobin A1c, the primary outcome, was obtained at each clinic visit and analyzed centrally. Blood glucose meter data were downloaded at each visit. Adherence was assessed by using a semistructured interview at baseline, mid-study, and follow-up. Analyses included 2-sample t tests at predefined time intervals and mixed-effect linear-quadratic models to assess for difference in change in outcomes across the study duration.

RESULTS: A significant overall intervention effect on change in glycemic control from baseline was observed at the 24-month interval (P = .03). The mixed-effect model showed a significant intervention by age interaction (P < .001). Among participants aged 12 to 14, a significant effect on glycemic control was observed (P = .009 for change from baseline to 24-month interval; P = .035 for mixed-effect model across study duration), but there was no effect among those aged 9 to 11. There was no intervention effect on child or parent report of adherence; however, associations of change in adherence with change in glycemic control were weak.

CONCLUSIONS: This clinic-integrated behavioral intervention was effective in preventing the deterioration in glycemic control evident during adolescence, offering a potential model for integrating medical and behavioral sciences in clinical care.

KEY WORDS

type 1 diabetes

children

adolescents

adherence

behavioral intervention

glycemic control

Accepted November 22, 2011.

· Abstract 5 of 63Article

Development of a Pragmatic Measure for Evaluating and Optimizing Rapid Response Systems

OBJECTIVES: Standard metrics for evaluating rapid response systems (RRSs) include cardiac and respiratory arrest rates. These events are rare in children; therefore, years of data are needed to evaluate the impact of RRSs with sufficient statistical power. We aimed to develop a valid, pragmatic measure for evaluating and optimizing RRSs over shorter periods of time.

METHODS: We reviewed 724 medical emergency team and 56 code-blue team activations in a children’s hospital between February 2010 and February 2011. We defined events resulting in ICU transfer and noninvasive ventilation, intubation, or vasopressor infusion within 12 hours as “critical deterioration.” By using in-hospital mortality as the gold standard, we evaluated the test characteristics and validity of this proximate outcome metric compared with a national benchmark for cardiac and respiratory arrest rates, the Child Health Corporation of America Codes Outside the ICU Whole System Measure.

RESULTS: Critical deterioration (1.52 per 1000 non-ICU patient-days) was more than eightfold more common than the Child Health Corporation of America measure of cardiac and respiratory arrests (0.18 per 1000 non-ICU patient-days) and was associated with >13-fold increased risk of in-hospital death. The critical deterioration metric demonstrated both criterion and construct validity.

CONCLUSIONS: The critical deterioration rate is a valid, pragmatic proximate outcome associated with in-hospital mortality. It has great potential for complementing existing patient safety measures for evaluating RRS performance.

KEY WORDS

child

critical illness

early warning score

hospital rapid response team

medical emergency team

physiologic monitoring

mortality

Accepted November 25, 2011.

· Abstract 6 of 63Article

Mental Health Difficulties in Children With Developmental Coordination Disorder

OBJECTIVE: To explore the associations between probable developmental coordination disorder (DCD) defined at age 7 years and mental health difficulties at age 9 to 10 years.

METHODS: We analyzed of prospectively collected data (N = 6902) from the Avon Longitudinal Study of Parents and Children. “Probable” DCD was defined by using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria as those children below the 15th centile of the Avon Longitudinal Study of Parents and Children Coordination Test, with functional limitations in activities of daily living or handwriting, excluding children with neurologic difficulties or an IQ <70. Mental health was measured by using the child-reported Short Moods and Feelings Questionnaire and the parent-reported Strengths and Difficulties Questionnaire. Multiple logistic regression models, with the use of multiple imputation to account for missing data, assessed the associations between probable DCD and mental health difficulties. Adjustments were made for environmental confounding factors, and potential mediating factors such as verbal IQ, associated developmental traits, bullying, self-esteem, and friendships.

RESULTS: Children with probable DCD (N = 346) had an increased odds of self-reported depression, odds ratio: 2.08 (95% confidence interval: 1.36–3.19) and parent-reported mental health difficulties odds ratio: 4.23 (95% confidence interval: 3.10–5.77). The odds of mental health difficulties significantly decreased after accounting for verbal IQ, social communication, bullying, and self-esteem.

CONCLUSIONS: Children with probable DCD had an increased risk of mental health difficulties that, in part, were mediated through associated developmental difficulties, low verbal IQ, poor self-esteem, and bullying. Prevention and treatment of mental health difficulties should be a key element of intervention for children with DCD.

KEY WORDS

developmental coordination disorder

DCD

child development

depression

mental health

child behavior

ALSPAC

developmental disabilities

Accepted November 29, 2011.

· Abstract 7 of 63Article

Motor Coordination and Psychosocial Correlates in a Normative Adolescent Sample

OBJECTIVES: Previous research has revealed an important relationship between motor coordination difficulties and internalizing problems such as anxiety and depressive symptoms. However, further research is needed to understand the potential mediating factors in this relationship. The aim of the current study was to examine whether the association between motor coordination and emotional functioning is mediated by self-perceptions in a normative sample of adolescents.

METHODS: Participants included 93 adolescents aged 12 to 16 years. The Movement Assessment Battery for Children–2 provided 2 indicators of motor coordination; the Mood and Feelings Questionnaire and Spence Children’s Anxiety Scale provided 2 indicators of emotional functioning; and the Self-Description Questionnaire–II provided 6 indicators for self-perceived competence.

RESULTS: Structural equation modeling revealed that motor coordination affects emotional functioning via self-perceptions.

CONCLUSIONS: These results suggest that the relationship between motor coordination and emotional functioning in adolescents from a normative sample may be understood in terms of a mechanism by which motor coordination has an indirect impact on emotional outcomes through various self-perception domains. These findings have important implications for increasing awareness and developing appropriate treatment programs for motor coordination and emotional difficulties.

KEY WORDS

adolescents

anxious symptoms

depressive symptoms

motor coordination

normative sample

self-perceptions

Accepted November 29, 2011.

· Abstract 8 of 63Article

Decline in Infantile Hypertrophic Pyloric Stenosis in Germany in 2000–2008

BACKGROUND AND OBJECTIVE: The incidence of infantile hypertrophic pyloric stenosis (IHPS) is highly variable over time and geographic regions. A decline in IHPS incidence was recently reported in Sweden, the United States, Denmark, and Scotland. In Sweden, the IHPS decline seemed to be concurrent with a declining incidence in sudden infant death syndrome (SIDS), which suggested a common cause; the latter was attributed to campaigns against the prone sleeping position. We investigated the time course of the IHPS incidence in all German federal states (N = 16) between 2000 and 2008. We examined correlations between the IHPS incidence and the SIDS incidence.

METHODS: Data were extracted from the public report of health (Gesundheitsberichterstattung des Bundes). We collected the numbers of IHPS (International Classification of Diseases, 10th Revision [ICD-10], code 40.0), SIDS (ICD-10, R95), and live births (LB; male/female) in each federal state for 2000–2008.

RESULTS: The IHPS incidence declined in Germany from 2000 (3.2086/1000 LB [range: 1.67–5.33]) to 2008 (2.0175/1000 LB [1.74–3.72]; P = .005). The recorded incidence was highly variable in different federal states and over time. The SIDS incidence also declined during the same time period (2000, median: 0.759/1000 LB [interquartile range: 0.54–1.029]; 2008, median: 0.416/1000 LB [interquartile range: 0.285–0.6485]; P = .0255). However, the SIDS regional distribution was different from that of IHPS.

CONCLUSIONS: The IHPS incidence declined by ∼38% nationwide. A parallel decline in SIDS displayed a different pattern in regional distribution; thus, a common cause was unlikely. The regional differences indicated that etiologic factors remained unresolved.

KEY WORDS

epidemiology

infantile hypertrophic pyloric stenosis

SIDS

Accepted November 23, 2011.

· Abstract 9 of 63Article

Impact of Rotavirus Vaccine on Diarrhea-Associated Disease Burden Among American Indian and Alaska Native Children

OBJECTIVE: Beginning in 2006, the Indian Health Service (IHS) began rotavirus vaccination of American Indian and Alaska Native (AI/AN) infants. To assess vaccine impact, we examined trends in IHS diarrhea-associated hospitalization and outpatient visits among AI/AN children in the pre- and postrotavirus vaccine era.

METHODS: Diarrhea-associated hospitalizations and outpatient visits among AI/AN children <5 years of age during 2001 through 2010 were examined by gender, age group, and region for prevaccine years 2001–2006 and postvaccine years 2008, 2009, and 2010. To account for secular declining trends observed in prevaccine years, expected diarrhea-associated hospitalization and outpatient rates for postvaccine years were generated by using Poisson regression analysis of the 2001–2006 annual rates.

RESULTS: Coverage with at least 1 dose of rotavirus vaccine among AI/AN infants aged 3 to 5 months in the first half of 2008, 2009, and 2010 ranged from 48% to 80% in various IHS regions. The prevaccine average annual diarrhea-associated hospitalization rates among AI/AN children <5 years of age was 63 per 10 000 persons (range: 57–75 per 10 000), and declined to 39, 31, and 27 per 10 000 in 2008, 2009, and 2010, respectively. Observed 2008, 2009, and 2010 rates were 24%, 37%, and 44% lower than expected rates, respectively. Decreases in diarrhea-associated hospitalizations and outpatient visits were observed in all IHS regions.

CONCLUSIONS: Diarrhea-associated hospitalization and outpatient visit rates among AI/AN children have declined after implementation of rotavirus vaccination in AI/AN populations.

KEY WORDS

rotavirus

American Indian

Alaska Native

children

infants

Accepted December 13, 2011.

· Abstract 10 of 63Article

Methicillin-Resistant and Susceptible Staphylococcus aureus Bacteremia and Meningitis in Preterm Infants

BACKGROUND: Data are limited on the impact of methicillin-resistant Staphylococcus aureus (MRSA) on morbidity and mortality among very low birth weight (VLBW) infants with S aureus (SA) bacteremia and/or meningitis (B/M).

METHODS: Neonatal data for VLBW infants (birth weight 401–1500 g) born January 1, 2006, to December 31, 2008, who received care at centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network were collected prospectively. Early-onset (≤72 hours after birth) and late-onset (>72 hours) infections were defined by blood or cerebrospinal fluid cultures and antibiotic treatment of ≥5 days (or death <5 days with intent to treat). Outcomes were compared for infants with MRSA versus methicillin-susceptible S aureus (MSSA) B/M.

RESULTS: Of 8444 infants who survived >3 days, 316 (3.7%) had SA B/M. Eighty-eight had MRSA (1% of all infants, 28% of infants with SA); 228 had MSSA (2.7% of all infants, 72% of infants with SA). No infant had both MRSA and MSSA B/M. Ninety-nine percent of MRSA infections were late-onset. The percent of infants with MRSA varied by center (P < .001) with 9 of 20 centers reporting no cases. Need for mechanical ventilation, diagnosis of respiratory distress syndrome, necrotizing enterocolitis, and other morbidities did not differ between infants with MRSA and MSSA. Mortality was high with both MRSA (23 of 88, 26%) and MSSA (55 of 228, 24%).

CONCLUSIONS: Few VLBW infants had SA B/M. The 1% with MRSA had morbidity and mortality rates similar to infants with MSSA. Practices should provide equal focus on prevention and management of both MRSA and MSSA infections among VLBW infants.

KEY WORDS

Staphylococcus aureus

methicillin resistant

infant

newborn

Accepted December 1, 2011.

· Abstract 11 of 63Article

Rising National Prevalence of Life-Limiting Conditions in Children in England

BACKGROUND: Life-limiting conditions (LLCs) describe diseases with no reasonable hope of cure that will ultimately be fatal. For children with these diseases, palliative care services should be available but few data are available to estimate the burden of these conditions.

METHODS: Children (0–19 years) with LLCs were identified within an English Hospital Episode Statistics dataset (2000/2001–2009/2010) by applying a customized coding framework of the International Classification of Diseases, 10th Revision, disease codes. Prevalence per 10 000 population (0–19 years) was calculated by age, diagnostic group, ethnicity, deprivation, and region for each year.

RESULTS: The Hospital Episode Statistics extract contained 175 286 individuals with 1 or more LLCs of which congenital anomalies were the most common (31%). Prevalence increased over 10 years from 25 to 32 per 10 000 population. Prevalence in the South Asian (48 per 10 000); black (42 per 10 000); and Chinese, mixed, and “other” (31 per 10 000) populations were statistically significantly higher compared with the white population (27 per 10 000). Prevalence shows an inverse J-shaped relationship with 5 categories of deprivation, with the highest prevalence in the most deprived areas and the lowest in the second least deprived.

CONCLUSIONS: In 2010, the prevalence of LLCs in children in England was double the previously reported estimates and had increased annually in all areas over the past decade. This clearly identifies an escalating need for specialist pediatric palliative care services. When planning services for these increasing needs, the excess prevalence in ethnic minority groups, especially in deprived areas, needs to be considered.

KEY WORDS

life-limiting conditions

palliative care

HES

ethnicity

deprivation

Accepted November 29, 2011.

· Abstract 12 of 63Article

Congruence of Reproductive Concerns Among Adolescents With Cancer and Parents: Pilot Testing an Adapted Instrument

OBJECTIVE: To identify whether a health-related quality of life (HRQoL) instrument intended to capture reproductive concerns is sensitive and appropriate for adolescent patients with cancer.

METHODS: Pilot testing was completed by administering a 10-item instrument designed to identify reproductive concerns of female adolescent patients with cancer aged 12–18. Parents were also asked to predict their daughters’ responses. Fourteen patients and parents participated. The main outcome measures were language, relevance, accuracy, sensitivity, and missing content regarding the HRQoL instrument. Two pediatric hospitals and 1 local support group for patients and survivors served as the setting for this study.

RESULTS: The majority of parents provided inaccurate predictions of their daughters’ responses regarding their reproductive concerns. Overall, parents underestimated their daughters’ concerns because the majority of adolescents reported a strong desire for future parenthood whereas parents expected their daughters to be satisfied with survivorship.

CONCLUSIONS: Adolescent patients with cancer have strong reproductive concerns; however, this may not be captured on current HRQoL instruments and may be further neglected due to parents’ unawareness. Discussions should be encouraged with adolescent patients before beginning treatment regarding their concerns and values about parenting in the future and cannot rely on parent-proxy reports.

KEY WORDS

adolescent

cancer

congruence

fertility

reproduction

Accepted December 6, 2011.

· Abstract 13 of 63Article

Parental Psychological Well-Being and Behavioral Outcome of Very Low Birth Weight Infants at 3 Years

OBJECTIVE: The purpose was to explore whether poor parental psychological well-being is associated with behavioral problems of very low birth weight (VLBW, ≤1500 g) infants at 3 years of age.

METHODS: In this prospective cohort study, 189 VLBW preterm infants born between January 2001 and December 2006 at the Turku University Hospital, Finland, were followed. Validated questionnaires (Beck Depression Inventory, Parenting Stress Index, and Sense of Coherence Scale) were mailed to the parents when their children were 2 years corrected age. A total of 140 parents evaluated the behavior of the child at 3 years by filling out the Child Behavior Checklist.

RESULTS: There were significant associations between most of the measures of parental symptoms of depression, parenting stress, and sense of coherence and the behavioral outcome of the VLBW infants. The concomitant symptoms of both parents were associated with more problematic child behavior.

CONCLUSIONS: Parents report more behavioral and emotional problems in VLBW children at age 3 if they themselves have had symptoms of depression, parenting stress, or weak sense of coherence 1 year earlier. The new finding of this study was to show the significance of the father’s psychological well-being on the behavioral development of a preterm child.

KEY WORDS

depression

distress

parenting stress

preterm

sense of coherence

Accepted November 30, 2011.

· Abstract 14 of 63Article

Hospital Variation in Nitric Oxide Use for Premature Infants

OBJECTIVE: To describe inter-center hospital variation in inhaled nitric oxide (iNO) administration to infants born prior to 34 weeks' gestation at US children's hospitals.

METHODS: This was a retrospective cohort study using the Pediatric Health Information System to determine the frequency, age at first administration, and length of iNO use among 22 699 consecutive first admissions of unique <34 weeks’ gestation infants admitted to 37 children’s hospitals from January 1, 2007, through December 31, 2010.

RESULTS: A total of 1644 (7.2%) infants received iNO during their hospitalization, with substantial variation in iNO use between hospitals (range across hospitals: 0.5%–26.2%; P < .001). The age at which iNO was started varied by hospital (mean: 20.0 days; range: 6.0–65.1 days, P < .001), as did the duration of therapy (mean: 13.1 days; range: 1.0–31.1 days; P < .001). Preterm infants who received iNO were less likely to survive (36.3% mortality vs 8.3%; odds ratio: 6.27; P < .001). The association between the use of iNO and mortality persists in propensity score–adjusted analyses controlling for demographic factors and diagnoses associated with the use of iNO (odds ratio: 3.79; P < .0001).

CONCLUSIONS: iNO practice patterns in preterm infants varied widely among institutions. Infants who received iNO were less likely to survive, suggesting that iNO is used in infants already at high risk of death. Adherence to National Institutes of Health consensus guidelines may decrease variation in iNO use.

KEY WORDS

nitric oxide

practice variation

prematurity

Accepted December 13, 2011.

· Abstract 15 of 63Article

The Outcome of ELBW Infants Treated With NCPAP and InSurE in a Resource-Limited Institution

BACKGROUND AND OBJECTIVE: Nasal continuous positive airway pressure (NCPAP) plus intubation, surfactant, and extubation (InSurE) with the option of back-up ventilation for those infants for whom noninvasive ventilatory support failed resulted in a significant increase in survival in extremely low birth weight (ELBW) infants. The authors sought to determine the outcome of ELBW infants treated with NCPAP and InSurE in a neonatal high care ward with limited back-up ventilation.

METHODS: Three hundred eighteen inborn infants with birth weight 500–1000 g and gestational age ≥25 weeks who were admitted to the neonatal high care ward were included in this observational study. InSurE was administered to infants with respiratory distress syndrome on NCPAP who had severe in-drawing and recession, apneic spells, or an Fio₂ >0.4 within 1 hour of birth.

RESULTS: Two hundred twelve (68.6%) infants could be treated with NCPAP only and 97 (31.4%) required InSurE. Seventeen infants were admitted to the NICU; 90%, 87%, and 74.8% of the infants survived until day 3, 7, and discharge, respectively. Only 2 infants developed a pneumothorax and 2 had chronic lung disease. Seventy-nine percent of the infants of ≥750 g or >26 weeks’ gestation survived to discharge compared with 56% and 60% of the infants of <750 g or ≤26 weeks’ gestation, respectively. Maternal antenatal steroid administration contributed significantly to the survival of the infants (P = 0.0017, odds ratio 2.7, 95% confidence interval 1.44–5.07).

CONCLUSIONS: The use of NCPAP and InSurE in a neonatal high care ward with limited resources can improve the survival of ELBW infants. Maternal antenatal steroid administration contributed significantly to survival.

KEY WORDS

ELBW infant

NCPAP

InSurE

limited resources

survival

Accepted December 12, 2011.

· Abstract 16 of 63Article

Effect on Infant Illness of Maternal Supplementation With 400 000 IU Vs 200 000 IU of Vitamin A

BACKGROUND AND OBJECTIVE: Postpartum vitamin A supplementation is a strategy used to combat vitamin A deficiency and seems to reduce maternal/infant morbidity and mortality. However, studies have shown that a dose of 200 000 IU (World Health Organization [WHO] protocol) does not seem to provide adequate retinol levels in maternal breast milk, infant serum, and infant tissue. The objective of this study was to compare the effect of postpartum maternal supplementation with 400 000 IU (International Vitamin A Consultative Group protocol) compared with 200 000 IU of vitamin A on infant morbidity.

METHODS: This was a randomized controlled, triple-blinded clinical trial conducted at 2 public maternity hospitals in Recife in northeastern Brazil. There were 276 mother–child pairs that were allocated to 2 treatment groups: 400 000 IU or 200 000 IU of vitamin A. They were followed up for >6 months to evaluate infant morbidity.

RESULTS: Fever (rate ratio [RR]: 0.92 [95% confidence interval (CI): 0.75–1.14]), diarrhea (RR: 0.96 [95% CI: 0.72–1.28]), otitis (RR: 0.94 [95% CI: 0.48–1.85]), acute respiratory infection (RR: 1.03 [95% CI: 0.88–1.21]), the need for intravenous rehydration (RR: 2.08 [95% CI: 0.64–2.07]), and the use of antibiotic treatment (RR: 0.80 [95% CI: 0.43–1.47]) did not differ significantly between the 2 treatment groups.

CONCLUSIONS: Our findings suggest that postpartum maternal supplementation with 400 000 IU of vitamin A does not provide any additional benefits in the reduction of illness in children aged <6 months; therefore, we do not support the proposal to increase the standard vitamin A dose in the existing WHO protocol.

KEY WORDS

illness

infants

northeast Brazil

randomized clinical trial

vitamin A supplementation

Accepted November 25, 2011.

· Abstract 17 of 63Article

Immune Status in Very Preterm Neonates

OBJECTIVES: Preterm neonates are at increased risk of sepsis compared with those born at term. We investigated immune status at birth and early neonatal life in very preterm neonates and its association with short-term outcomes.

METHODS: Prospective observational study conducted at a university hospital recruiting 113 preterm neonates (23–32 weeks) and 78 controls. Monocyte major histocompatibility complex (MHC) class II expression, serum, and ex vivo lipopolysaccharide stimulated levels of six cytokines (tumor necrosis factor α, interleukin (IL)-1β, IL-6, IL-8, IL-10, and IL-12p70) were measured in umbilical cord blood and over the first 7 days. The presence of neonatal sepsis and histologic chorioamnionitis was recorded.

RESULTS: Prematurity (preterm labor and preterm premature rupture of membranes cohorts), neonatal sepsis, and histologic chorioamnionitis were associated with significant reduction in monocyte MHC class II expression. Neonates who had evidence of subsequent protracted sepsis had low levels of MHC class II expression at birth. Serial monocyte MHC class II expression revealed a fall by day 2, in all preterm neonates, with the degree being influenced by both prematurity and sepsis, and incomplete recovery by day 7, suggesting immunoparalysis in preterm premature rupture of membranes and preterm labor cohorts. Whole blood lipopolysaccharide stimulation assay showed significantly lower tumor necrosis factor α, values in preterm neonates who subsequently developed sepsis indicating a degree of immunoparalysis.

CONCLUSIONS: Our data support the concept that fetal exposure to inflammation before preterm delivery leads to subsequent endotoxin hyporesponsiveness (immunoparalysis), which increases the risk of subsequent sepsis and associated organ dysfunction.

KEY WORDS

preterm delivery

cytokines

immune response

sepsis

inflammation

Accepted December 7, 2011.

· Abstract 18 of 63Article

Barriers to Conducting Advance Care Discussions for Children With Life-Threatening Conditions

BACKGROUND AND OBJECTIVE: Advance care discussions (ACD) occur infrequently or are initiated late in the course of illness. Although data exist regarding barriers to ACD among the care of adult patients, few pediatric data exist. The goal of this study was to identify barriers to conducting ACD for children with life-threatening conditions.

METHODS: Physicians and nurses from practice settings where advance care planning typically takes place were surveyed to collect data regarding their attitudes and behaviors regarding ACD.

RESULTS: A total of 266 providers responded to the survey: 107 physicians and 159 nurses (54% response rate). The top 3 barriers were: unrealistic parent expectations, differences between clinician and patient/parent understanding of prognosis, and lack of parent readiness to have the discussion. Nurses identified lack of importance to clinicians (P = .006) and ethical considerations (P < .001) as impediments more often than physicians. Conversely, physicians believed that not knowing the right thing to say (P = .006) was more often a barrier. There are also perceived differences among specialties. Cardiac ICU providers were more likely to report unrealistic clinician expectations (P < .001) and differences between clinician and patient/parent understanding of prognosis (P = .014) as common barriers to conducting ACD. Finally, 71% of all clinicians believed that ACD happen too late in the patient’s clinical course.

CONCLUSIONS: Clinicians perceive parent prognostic understanding and attitudes as the most common barriers to conducting ACD. Educational interventions aimed at improving clinician knowledge, attitudes, and skills in addressing these barriers may help health care providers overcome perceived barriers.

KEY WORDS

advance care planning

barriers

end-of-life

Accepted November 28, 2011.

· Abstract 19 of 63Article

Shifts in BMI Category and Associated Cardiometabolic Risk: Prospective Results From HEALTHY Study

OBJECTIVES: To evaluate shifts across BMI categories and associated changes in cardiometabolic risk factors over 2.5 years in an ethnically diverse middle school sample.

METHODS: As part of HEALTHY, a multisite school-based study designed to mitigate risk for type 2 diabetes, 3993 children participated in health screenings at the start of sixth and end of eighth grades. Assessments included anthropometric measures, blood pressure, and glucose, insulin, and lipids. Students were classified as underweight, healthy weight, overweight, obese, or severely obese. Mixed models controlling for school intervention status and covariates were used to evaluate shifts in BMI category over time and the relation between these shifts and changes in risk factors.

RESULTS: At baseline, students averaged 11.3 (±0.6) years; 47.6% were boys, 59.6% were Hispanic, and 49.8% were overweight or obese. Shifts in BMI category over time were common. For example, 35.7% of youth who were overweight moved to the healthy weight range, but 13% in the healthy weight range became overweight. BMI shifts were not associated with school intervention condition, household education, or youth gender, race/ethnicity, pubertal status, or changes in height. Increases in BMI category were associated with worsening of cardiometabolic risk factors, and decreases were associated with improvements. Boys who increased BMI category were more vulnerable to negative risk factor changes than girls.

CONCLUSIONS: There are substantial shifts across BMI categories during middle school that are associated with clinically meaningful changes in cardiometabolic risk factors. Programs to promote decreases in BMI and prevent increases are clearly warranted.

KEY WORDS

obesity

overweight

obesity trends

BMI

glucose

insulin

blood pressure

lipids

Accepted December 12, 2011.

· Abstract 20 of 63Article

Cerebral Palsy Among Asian Ethnic Subgroups

OBJECTIVE: Asians have a reduced risk for cerebral palsy (CP) compared with whites. We examined whether individual Asian subgroups have a reduced risk of CP and whether differences in sociodemographic factors explain disparities in CP prevalence.

METHODS: In a retrospective cohort of 629 542 Asian and 2 109 550 white births in California from 1991 to 2001, we identified all children who qualified for services from the California Department of Health Services on the basis of CP. Asians were categorized as East Asian (Chinese, Japanese, Koreans), Filipino, Indian, Pacific Islander (Guamanians, Hawaiians, and Pacific Islanders), Samoan, or Southeast Asian (Cambodian, Laotian, Thai, Vietnamese).

RESULTS: Overall, CP prevalence was lower in Asians than whites (1.09 vs 1.36 per 1000; relative risk = 0.80, 95% confidence interval [CI] = 0.74–0.87) and ranged from 0.61/1000 in Thai children to 2.08/1000 in Samoan children. Several Asian subgroups had low risk profiles with respect to maternal age, educational attainment, and birth weight. However, after we adjusted for maternal age and education, infant gender, and birth weight, the adjusted risk of CP remained lower in East Asians (odds ratio [OR] = 0.75, 95% CI = 0.65–0.87), Filipinos (OR = 0.87, 95% CI = 0.75–0.99), Indians (OR = 0.59, 95% CI = 0.44–0.80), Pacific Islanders (OR = 0.62, 95% CI = 0.40–0.97), and Southeast Asians (OR = 0.68, 95% CI = 0.57–0.82) compared with whites.

CONCLUSIONS: Most Asian national origin subgroups have a lower rate of CP than whites, and this disparity is unexplained. Additional studies that focus on the cause of ethnic disparities in CP may provide new insights into pathogenesis and prevention.

KEY WORDS

cerebral palsy

racial disparity

epidemiology

sociodemographic

Accepted November 30, 2011.

· Abstract 21 of 63Article

The National Perinatal Hepatitis B Prevention Program, 1994–2008

OBJECTIVE: To determine the trends and outcomes of the national Perinatal Hepatitis B Prevention Program (PHBPP) for infants born from 1994 to 2008.

METHODS: PHBPPs in state and city public health jurisdictions annually submitted program outcome reports to the Centers for Disease Control and Prevention. The annual number of births to hepatitis B surface antigen (HBsAg)-positive women was estimated and used to evaluate the percentage of PHBPP-identified HBsAg-positive pregnant women. PHBPP reports were used to assess program objectives achieved, and infant outcomes by 12 to 24 months of age.

RESULTS: From 1994 to 2008, the estimated number of annual births to HBsAg-positive women increased from 19 208 to 25 600 (P < .001). The annual number of PHBPP-managed infants increased (P < .001), comprising 40.8% to 50.5% of the estimated number. On average, 94.4% of PHBPP-managed infants received hepatitis B immunoglobulin and hepatitis B vaccine within 1 day of birth. The percentage of infants who completed the vaccine series by age 12 months decreased from 86.0% to 77.7% (P = .004), but the percentage who received postvaccination testing increased from 25.1% to 56.0% (P < .001). Incidence of chronic hepatitis B virus infection among tested infants decreased from 2.1% in 1999 to 0.8% in 2008 (P = .001).

CONCLUSIONS: The PHBPP achieved substantial progress in preventing perinatal hepatitis B virus infection in the United States, despite an increasing number of at-risk infants. Significant gaps remain in identifying HBsAg-positive pregnant women, and completing management and assessment of their infants to ensure prevention of perinatal hepatitis B virus transmission.

KEY WORDS

hepatitis B

immunization programs

infant

newborn diseases

infectious disease transmission

pregnancy complications

infectious

United States

Accepted December 14, 2011.

· Abstract 22 of 63Article

Implications of Childhood Autism for Parental Employment and Earnings

OBJECTIVE: To examine changes in parental labor force participation, hours of work, and annual earnings associated with childhood autism spectrum disorders (ASD).

METHODS: We used the 2002–2008 Medical Expenditure Panel Survey to examine parental labor market outcomes of children with ASD relative to children with another health limitation and children without health limitations. A logit model was used to estimate parental labor force participation. A tobit model was used to estimate parental hours of work and earnings.

RESULTS: On average, mothers of children with ASD earn 35% ($7189) less than the mothers of children with another health limitation and 56% ($14 755) less than the mothers of children with no health limitation. They are 6% less likely to be employed and work 7 hours less per week, on average, than mothers of children with no health limitation. There were no statistically significant differences in fathers’ labor market outcomes across 3 groups. On average, children with ASD are 9% less likely to have both parents working. Family earnings of children with ASD are 21% ($10 416) less than those of children with another health limitation and 28% ($17 763) less than those of children with no health limitation. Family weekly hours of work are an average of 5 hours less than those of children with no health limitation.

CONCLUSIONS: Families of children with ASD face significant economic burden. Given the substantial health care expenses associated with ASD, the economic impact of having lower income in addition to these expenses is substantial. It is essential to design universal health care and workplace policies that recognize the full impact of autism.

KEY WORDS

autism

developmental disabilities

family impact

economic burden

Accepted December 15, 2011.

· Abstract 23 of 63Article

Pharmacy Communication to Adolescents and Their Physicians Regarding Access to Emergency Contraception

OBJECTIVE: Emergency contraception (EC) is an effective pregnancy prevention strategy. EC is available without a prescription to those aged 17 years or older. The objective of this study was to assess the accuracy of information provided to adolescents and their physicians when they telephone pharmacies to inquire about EC.

METHODS: By using standardized scripts, female callers telephoned 943 pharmacies in 5 US cities posing as 17-year-old adolescents or as physicians calling on behalf of their 17-year-old patients. McNemar tests were used to compare outcomes between adolescent and physician callers.

RESULTS: Seven hundred fifty-nine pharmacies (80%) indicated to adolescent callers, and 766 (81%) to physician callers, that EC was available on the day of the call. However, 145 pharmacies (19%) incorrectly told the adolescent callers that it would be impossible to obtain EC under any circumstances, compared with 23 pharmacies (3%) for physician callers. Pharmacies conveyed the correct age to dispense EC without a prescription in 431 adolescent calls (57%) and 466 physician calls (61%). Compared with physician callers, adolescent callers were put on hold more often (54% vs 26%) and spoke to self-identified pharmacists less often (3% vs 12%, P < .0001). When EC was not available, 36% and 33% of pharmacies called by adolescents and physicians respectively offered no additional suggestions on how to obtain it.

CONCLUSIONS: Most pharmacies report having EC in stock. However, misinformation regarding who can take EC, and at what age it is available without a prescription, is common. Such misinformation may create barriers to timely access.

KEY WORDS

adolescent medicine

adolescent pregnancy

adolescent sexual behavior

adolescents

contraceptive agents

Accepted January 23, 2012.

· Abstract 24 of 63Article

Risk Factor Changes for Sudden Infant Death Syndrome After Initiation of Back-to-Sleep Campaign

OBJECTIVE: To test the hypothesis that the profile of sudden infant death syndrome (SIDS) changed after the Back-to-Sleep (BTS) campaign initiation, document prevalence and patterns of multiple risks, and determine the age profile of risk factors.

METHODS: The San Diego SIDS/Sudden Unexplained Death in Childhood Research Project recorded risk factors for 568 SIDS deaths from 1991 to 2008 based upon standardized death scene investigations and autopsies. Risks were divided into intrinsic (eg, male gender) and extrinsic (eg, prone sleep).

RESULTS: Between 1991–1993 and 1996–2008, the percentage of SIDS infants found prone decreased from 84.0% to 48.5% (P < .001), bed-sharing increased from 19.2% to 37.9% (P < .001), especially among infants <2 months (29.0% vs 63.8%), prematurity rate increased from 20.0% to 29.0% (P = .05), whereas symptoms of upper respiratory tract infection decreased from 46.6% to 24.8% (P < .001). Ninety-nine percent of SIDS infants had at least 1 risk factor, 57% had at least 2 extrinsic and 1 intrinsic risk factor, and only 5% had no extrinsic risk. The average number of risks per SIDS infant did not change after initiation of the BTS campaign.

CONCLUSIONS: SIDS infants in the BTS era show more variation in risk factors. There was a consistently high prevalence of both intrinsic and especially extrinsic risks both before and during the Back-to-Sleep era. Risk reduction campaigns emphasizing the importance of avoiding multiple and simultaneous SIDS risks are essential to prevent SIDS, including among infants who may already be vulnerable.

KEY WORDS

triple-risk model

brainstem

prone sleep

bed-sharing

serotonin

maternal smoking

Accepted December 14, 2011.

· Abstract 25 of 63Article

Tight Glycemic Control With Insulin in Hyperglycemic Preterm Babies: A Randomized Controlled Trial

OBJECTIVE: The optimal treatment of neonatal hyperglycemia is unclear. The aim of this trial was to determine whether tight glycemic control with insulin improves growth in hyperglycemic preterm infants, without increasing the incidence of hypoglycemia.

METHODS: Randomized, controlled, nonblinded trial of 88 infants born at <30 weeks’ gestation or <1500 g who developed hyperglycemia (2 consecutive blood glucose concentrations (BGC) >8.5 mmol/L, 4 hours apart) and were randomly assigned to tight glycemic control with insulin (target BGC 4–6 mmol/L, “tight” group) or standard practice (restrictive guidelines for starting insulin, target BGC 8–10 mmol/L, “control” group). The primary outcome was linear growth rate to 36 weeks’ postmenstrual age.

RESULTS: Eighty-eight infants were randomly assigned (tight group n = 43; control group n = 45). Infants in the tight group had a lesser lower leg growth rate (P < .05), but greater head circumference growth (P < .0005) and greater weight gain (P < .001) to 36 weeks’ postmenstrual age than control infants. Tight group infants had lower daily BGC (median [interquartile range] 5.7 [4.8–6.7] vs 6.5 [5.1–8.2] mmol/L, P < .001) and greater incidence of hypoglycemia (BGC <2.6 mmol/L) (25/43 vs 12/45, P < .01) than controls. There were no significant differences in nutritional intake, or in the incidences of mortality or morbidity.

CONCLUSIONS: Tight glycemic control with insulin in hyperglycemic preterm infants increases weight gain and head growth, but at the expense of reduced linear growth and increased risk of hypoglycemia. The balance of risks and benefits of insulin treatment in hyperglycemic preterm neonates remains uncertain.

KEY WORDS

preterm infant

very low birth weight

hyperglycemia

growth

tight glycemic control

hypoglycemia

insulin

Accepted December 13, 2011.

· Abstract 26 of 63Article

Accuracy and Usefulness of the HEDIS Childhood Immunization Measures

OBJECTIVE: With the use of Centers for Disease Control and Prevention (CDC) immunization recommendations as the gold standard, our objectives were to measure the accuracy (“is this child up-to-date on immunizations?”) and usefulness (“is this child due for catch-up immunizations?”) of the Healthcare Effectiveness Data and Information Set (HEDIS) childhood immunization measures.

METHODS: For children aged 24 to 35 months from the 2009 National Immunization Survey, we assessed the accuracy and usefulness of the HEDIS childhood immunization measures for 6 individual immunizations and a composite.

RESULTS: A total of 12 096 children met all inclusion criteria and composed the study sample. The HEDIS measures had >90% accuracy when compared with the CDC gold standard for each of the 6 immunizations (range, 94.3%–99.7%) and the composite (93.8%). The HEDIS measure was least accurate for hepatitis B and pneumococcal conjugate immunizations. The proportion of children for which the HEDIS measure yielded a nonuseful result (ie, an incorrect answer to the question, “is this child due for catch-up immunization?”) ranged from 0.33% (varicella) to 5.96% (pneumococcal conjugate). The most important predictor of HEDIS measure accuracy and usefulness was the CDC-recommended number of immunizations due at age 2 years; children with zero or all immunizations due were the most likely to be correctly classified.

CONCLUSIONS: HEDIS childhood immunization measures are, on the whole, accurate and useful. Certain immunizations (eg, hepatitis B, pneumococcal conjugate) and children (eg, those with a single overdue immunization), however, are more prone to HEDIS misclassification.

KEY WORDS

immunizations

quality indicators

health care surveys

Accepted December 14, 2011.

· Abstract 27 of 63Article

Analgesic Effect of Breast Milk Versus Sucrose for Analgesia During Heel Lance in Late Preterm Infants

OBJECTIVE: The purpose of this trial was to investigate whether breast milk (either breastfed or bottle-fed) has a better analgesic effect than sucrose in newborns born at a postmenstrual age between 32 and 37 weeks.

METHODS: We conducted a randomized controlled trial at a secondary care neonatal unit in the Netherlands on 71 preterm neonates (postmenstrual age at birth 32–37 weeks), undergoing heel lance with an automated piercing device. Newborns were randomly assigned to breast milk (either breastfed or bottle-fed) administered during heel lance or oral sucrose administered before heel lance. We assessed the Premature Infant Pain Profile (PIPP) score (range, 0–21) to investigate whether there was a difference in pain score between neonates receiving breast milk and those receiving sucrose solution.

RESULTS: There was no significant difference in mean PIPP score between neonates receiving breast milk (6.1) and those receiving sucrose (5.5), with a mean difference of 0.6 (95% confidence interval −1.6 to 2.8; P = .58).

CONCLUSIONS: From this study, it cannot be concluded that breast milk has a better analgesic effect than sucrose in late preterm infants. From the results, it follows with 95% confidence that the analgesic effect of breast milk is not >1.6 points better and not > 2.8 points worse on the PIPP scale (SD 3.7) than the analgesic effect of sucrose in late preterm infants.

KEY WORDS

pain

preterm neonates

sucrose

breastfeeding

heel lance

Accepted November 29, 2011.

· Abstract 28 of 63Article

Breast Milk and Glucose for Pain Relief in Preterm Infants: A Noninferiority Randomized Controlled Trial

OBJECTIVE: The study goal was to compare the efficacy of expressed breast milk (EBM) versus 25% glucose on pain responses of late preterm infants during heel lancing.

METHODS: In a noninferiority randomized controlled trial, a total of 113 newborns were randomized to receive EBM (experimental group [EG]) or 25% glucose (control group [CG]) before undergoing heel lancing. The primary outcome was pain intensity (Premature Infant Pain Profile [PIPP]) and a 10% noninferiority margin was established. Secondary outcomes were incidence of cry and percentage of time spent crying and adverse events. Intention-to-treat (ITT) analysis was used.

RESULTS: Groups were similar regarding demographics and clinical characteristics, except for birth weight and weight at data collection day. There were lower pain scores in the CG over 3 minutes after lancing (P < .001). A higher number of infants in the CG had PIPP scores indicative of minimal pain or absence of pain (P = .002 and P = .003 on ITT analysis) at 30 seconds after lancing, and the mean difference in PIPP scores was 3 (95% confidence interval: 1.507–4.483). Lower incidence of cry (P = .001) and shorter duration of crying (P = .014) were observed for CG. Adverse events were benign and self-limited, and there was no significant difference between groups (P = .736 and P = .637 on ITT analysis).

CONCLUSIONS: Results based on PIPP scores and crying time indicate poorer effects of EBM compared with 25% glucose during heel lancing. Additional studies exploring the vol and administration of EBM and its combination with other strategies such as skin-to-skin contact and sucking are necessary.

KEY WORDS

newborn

pain

analgesia

human milk

glucose

Accepted November 29, 2011.

· Abstract 29 of 63Article

Triage Nurse Initiation of Corticosteroids in Pediatric Asthma Is Associated With Improved Emergency Department Efficiency

OBJECTIVE: To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED.

METHODS: A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4. One-to-one periods (physician-initiated and nurse-initiated) were analyzed from September 2009 through May 2010. In both phases, triage nurses initiated bronchodilator therapy before physician assessment, per Pediatric Respiratory Assessment Measure score. We reviewed charts of 644 consecutive children aged 2 to 17 years for the following outcomes: admission rate; times to clinical improvement, steroid receipt, mild status, and discharge; and rate of return ED visit and subsequent admission.

RESULTS: Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1–50; P = .04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36–0.87). Efficiency gains were made in time to steroid receipt (median difference: 44 minutes; 95% CI: 39–50; P < .001), time to mild status (median difference: 51 minutes; 95% CI: 17–84; P = .04), and time to discharge (median difference: 44 minutes; 95% CI: 17–68; P = .02). No differences were found in return visit rate or subsequent admission.

CONCLUSIONS: Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.

KEY WORDS

asthma

pediatrics

emergency department

multidisciplinary teams

medical directive

Accepted December 5, 2011.

· Abstract 30 of 63Article

Prenatal Methamphetamine Exposure and Childhood Behavior Problems at 3 and 5 Years of Age

OBJECTIVE: We evaluated behavior problems in children who were prenatally exposed to methamphetamine (MA) at ages 3 and 5 years.

METHODS: The Infant Development, Environment, and Lifestyle study, a prospective, longitudinal study of prenatal MA exposure and child outcome, enrolled subjects postpartum in Los Angeles, California; Honolulu, Hawaii; Des Moines, Iowa; and Tulsa, Oklahoma. Prenatal exposure was determined by maternal self-report and/or meconium results. Exposed and comparison groups were matched on race, birth weight, public health insurance, and education. Mothers in the comparison group denied use and had a negative meconium screen for amphetamines. Prenatal exposures to tobacco, alcohol, or marijuana occurred in both groups. At ages 3 and 5 years, 330 children (166 exposed and 164 comparison) were assessed for behavior problems by using the caregiver report on the Child Behavior Checklist. General linear mixed models were used to determine the effects of prenatal MA exposure, including heavy exposure (≥3 days per week), age, and the interaction of exposure and age on behavior problems with adjustment for other drugs of abuse and environmental risk factors.

RESULTS: MA exposure was associated with increased emotional reactivity and anxious/depressed problems at both ages and externalizing and attention-deficit/hyperactivity disorder problems by age 5 years. Heavy exposure was related to attention problems and withdrawn behavior at both ages. There were no effects of MA on the internalizing or total behavior problems scales.

CONCLUSIONS: This first report of behavior problems in patients as young as 3 years associated with MA exposure identifies an important public health problem. Continued follow-up can inform the development of preventive intervention programs.

KEY WORDS

amphetamines

behavior disorders/problems

children

methamphetamine

prenatal exposure

Accepted December 16, 2011.

· Abstract 31 of 63Article

Limitations and Opportunities of Transcutaneous Bilirubin Measurements

OBJECTIVE: Although transcutaneous bilirubinometers have existed for over 30 years, the clinical utility of the technique is limited to a screening method for hyperbilirubinemia, rather than a replacement for invasive blood sampling. In this study, we investigate the reason for this limited clinical value and address possibilities for improvement.

METHODS: To obtain better insight into the physiology of bilirubin measurements, we evaluated a transcutaneous bilirubinometer that determines not only the cutaneous bilirubin concentration (TcB) but also the blood volume fraction (BVF) in the investigated skin volume. For 49 neonates (gestational age 30 ± 3.1 weeks, postnatal age 6 [4–10] days) at our NICU, we performed 124 TcB and 55 BVF measurements.

RESULTS: The TcB correlated well with the total serum bilirubin concentration (TSB) (r = 0.88) with an uncertainty of 55 µmol/L. The BVF in the measured skin volume ranged between 0.1% and 0.75%.

CONCLUSIONS: The performance of our bilirubinometer is comparable to existing transcutaneous devices. The limited clinical value of current bilirubinometers can be explained by the low BVF in the skin volume that is probed by these devices. Because the TcB depends for over 99% on the contribution of extravascular bilirubin, it is a physiologically different parameter from the TSB. Hence, the standard method of evaluation that compares the TcB to the TSB is insufficient to fully investigate the clinical value of transcutaneous bilirubinometers, ie, their predictive value for kernicterus. We suggest that the clinical value may be improved considerably by changing either the method of evaluation or the technological design of transcutaneous bilirubinometers.

KEY WORDS

transcutaneous bilirubin measurement

newborn

hyperbilirubinemia

kernicterus

jaundice

Accepted December 1, 2011.

· Abstract 32 of 63Article

Interrater Reliability of Clinical Findings in Children With Possible Appendicitis

OBJECTIVE: Our objective was to determine the interrater reliability of clinical history and physical examination findings in children undergoing evaluation for possible appendicitis in a large, multicenter cohort.

METHODS: We conducted a prospective, multicenter, cross-sectional study of children aged 3–18 years with possible appendicitis. Two clinicians independently evaluated patients and completed structured case report forms within 60 minutes of each other and without knowing the results of diagnostic imaging. We calculated raw agreement and assessed reliability by using the unweighted Cohen κ statistic with 2-sided 95% confidence intervals.

RESULTS: A total of 811 patients had 2 assessments completed, and 599 (74%) had 2 assessments completed within 60 minutes. Seventy-five percent of paired assessments were completed by pediatric emergency physicians. Raw agreement ranged from 64.9% to 92.3% for history variables and 4 of 6 variables had moderate interrater reliability (κ > .4). The highest κ values were noted for duration of pain (κ = .56 [95% confidence intervals .51–.61]) and history of emesis (.84 [.80–.89]). For physical examination variables, raw agreement ranged from 60.9% to 98.7%, with 4 of 8 variables exhibiting moderate reliability. Among physical examination variables, the highest κ values were noted for abdominal pain with walking, jumping, or coughing (.54 [.45–.63]) and presence of any abdominal tenderness on examination (.49 [.19–.80]).

CONCLUSIONS: Interrater reliability of patient history and physical examination variables was generally fair to moderate. Those variables with higher interrater reliability are more appropriate for inclusion in clinical prediction rules in children with possible appendicitis.

KEY WORDS

appendicitis

interrater reliability

clinical prediction rules

Accepted November 29, 2011.

· Abstract 33 of 63Article

A Randomized Controlled Trial of Zinc as Adjuvant Therapy for Severe Pneumonia in Young Children

BACKGROUND AND OBJECTIVE: Diarrhea and pneumonia are the leading causes of illness and death in children <5 years of age. Zinc supplementation is effective for treatment of acute diarrhea and can prevent pneumonia. In this trial, we measured the efficacy of zinc when given to children hospitalized and treated with antibiotics for severe pneumonia.

METHODS: We enrolled 610 children aged 2 to 35 months who presented with severe pneumonia defined by the World Health Organization as cough and/or difficult breathing combined with lower chest indrawing. All children received standard antibiotic treatment and were randomized to receive zinc (10 mg in 2- to 11-month-olds and 20 mg in older children) or placebo daily for up to 14 days. The primary outcome was time to cessation of severe pneumonia.

RESULTS: Zinc recipients recovered marginally faster, but this difference was not statistically significant (hazard ratio = 1.10, 95% CI 0.94–1.30). Similarly, the risk of treatment failure was slightly but not significantly lower in those who received zinc (risk ratio = 0.88 95% CI 0.71–1.10).

CONCLUSIONS: Adjunct treatment with zinc reduced the time to cessation of severe pneumonia and the risk of treatment failure only marginally, if at all, in hospitalized children.

KEY WORDS

zinc

pneumonia

young children

therapeutic

treatment failure

Accepted November 28, 2011.

· Abstract 34 of 63Article

Alcohol Consumption in Movies and Adolescent Binge Drinking in 6 European Countries

OBJECTIVE: The goal of this study was to investigate whether the association between exposure to images of alcohol use in movies and binge drinking among adolescents is independent of cultural context.

METHODS: A cross-sectional survey study in 6 European countries (Germany, Iceland, Italy, Netherlands, Poland, and Scotland) was conducted. A total of 16 551 pupils from 114 public schools with a mean (± SD) age of 13.4 (± 1.18) years participated. By using previously validated methods, exposure to alcohol use in movies was estimated from the 250 top-grossing movies of each country (years 2004−2009). Lifetime binge drinking was the main outcome measure.

RESULTS: Overall, 27% of the sample had consumed >5 drinks on at least 1 occasion in their life. After controlling for age, gender, family affluence, school performance, television screen time, sensation seeking and rebelliousness, and frequency of drinking of peers, parents, and siblings, the adjusted β-coefficient for lifetime binge drinking in the entire sample was 0.12 (95% confidence interval: 0.10−0.14; P < .001). The crude relationship between movie alcohol use exposure and lifetime binge drinking was significant in all countries; after covariate adjustment, the relationship was still significant in 5 of 6 countries. A sensitivity analysis revealed that the association is content specific, as there was no significant association between lifetime binge drinking and exposure to smoking in movies.

CONCLUSIONS: The link between alcohol use in movies and adolescent binge drinking was robust and seems relatively unaffected by cultural contexts.

KEY WORDS

alcohol

Europe

exposure

media

youth

Accepted November 28, 2011.

· Abstract 35 of 63Article

Stair-Related Injuries to Young Children Treated in US Emergency Departments, 1999–2008

OBJECTIVE: The objective of this study was to investigate the epidemiologic characteristics and secular trends of stair-related injuries among children aged <5 years treated in US emergency departments.

METHODS: A retrospective analysis was conducted of data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission from 1999 through 2008 by using sample weights to estimate national numbers and rates of stair-related injuries.

RESULTS: An estimated 931 886 children aged <5 years were treated for stair-related injuries from 1999 through 2008, averaging 93 189 injuries per year and 46.5 injuries per 10 000 population annually. The number of injuries per year decreased significantly by 11.6% from 1999 to 2008. The rate of stair-related injuries also decreased significantly from 53.0 to 42.4 per 10 000 population from 1999 to 2008. Soft tissue injuries accounted for 34.6% of cases. Approximately three-fourths (76.3%) of children had injuries to the head and neck region, and 2.7% of patients were hospitalized. Children who were being carried at the time of injury accounted for 24.5% of injuries among children <1 year and were more than 3 times more likely to be hospitalized than children injured by other mechanisms.

CONCLUSIONS: Stair-related injuries are on the decline but still represent an important source of injury to young children. Increased prevention efforts are needed, including parental education and improved stairway design, to decrease stair-related injuries among young children.

KEY WORDS

stairs

injury

children

falls

prevention

Accepted December 8, 2011.

· Abstract 36 of 63Article

Incidence and Cost of Injury Among Youth in Agricultural Settings, United States, 2001–2006

OBJECTIVE: Estimate the annual US incidence and cost of fatal and nonfatal youth injury in agricultural settings.

METHODS: We used 2001–2006 Childhood Agricultural Injury Survey data to estimate the incidence of nonfatal injury and 2001–2006 Multiple Cause of Death data to estimate the incidence of fatal injury. To estimate the costs for injuries suffered by youth working/living in agricultural settings, we multiplied the number of injuries times published unit costs by body part, nature of injury, and age group.

RESULTS: An average of 26 655 agricultural injury incidents occurred annually to youth (ages 0–19) in the United States during the period 2001–2006 (95% confidence interval [CI]: 24 263–29 046). These injuries cost society an estimated $1.423 billion per year in 2005 dollars (95% CI: $1.333 billion–$1.513 billion). Fatalities alone cost an estimated $420 million per year. Work related injuries annually cost $347 million or 24.4% of the total cost (95% CI: 20.3%–28.5%). Most agricultural youth injuries were not work related.

CONCLUSIONS: We found that, similarly to adult agricultural injuries, youth agricultural injuries tend to be more severe and more costly than nonagricultural injuries. Only 1.4% of injured youth in the United States were hospitalized in 2000, but 14% of youth injured in agriculture were hospitalized in 2001–2006. To address this serious problem, prevention should focus on better controlling both child access to agricultural recreational activities and child assignment to agricultural work tasks that exceed developmental norms.

KEY WORDS

agricultural youth

QALY

occupational

Accepted December 13, 2011.

· Abstract 37 of 63Review Article

Electrocardiogram Screening for Disorders That Cause Sudden Cardiac Death in Asymptomatic Children: A Meta-analysis

BACKGROUND AND OBJECTIVES: Pediatric sudden cardiac death (SCD) occurs in an estimated 0.8 to 6.2 per 100 000 children annually. Screening for cardiac disorders causing SCD in asymptomatic children has public appeal because of its apparent potential to avert tragedy; however, performance of the electrocardiogram (ECG) as a screening tool is unknown. We estimated (1) phenotypic (ECG- or echocardiogram [ECHO]-based) prevalence of selected pediatric disorders associated with SCD, and (2) sensitivity, specificity, and predictive value of ECG, alone or with ECHO.

METHODS: We systematically reviewed literature on hypertrophic cardiomyopathy (HCM), long QT syndrome (LQTS), and Wolff-Parkinson-White syndrome, the 3 most common disorders associated with SCD and detectable by ECG.

RESULTS: We identified and screened 6954 abstracts, yielding 396 articles, and extracted data from 30. Summary phenotypic prevalences per 100 000 asymptomatic children were 45 (95% confidence interval [CI]: 10–79) for HCM, 7 (95% CI: 0–14) for LQTS, and 136 (95% CI: 55–218) for Wolff-Parkinson-White. The areas under the receiver operating characteristic curves for ECG were 0.91 for detecting HCM and 0.92 for LQTS. The negative predictive value of detecting either HCM or LQTS by using ECG was high; however, the positive predictive value varied by different sensitivity and specificity cut-points and the true prevalence of the conditions.

CONCLUSIONS: Results provide an evidence base for evaluating pediatric screening for these disorders. ECG, alone or with ECHO, was a sensitive test for mass screening and negative predictive value was high, but positive predictive value and false-positive rates varied.

KEY WORDS

sudden cardiac death

ECG screening

hypertrophic cardiomyopathy

long QT syndrome

Wolff-Parkinson-White syndrome

Accepted November 22, 2011.

· Abstract 38 of 63Review Article

Nosocomial Rotavirus Infections: A Meta-analysis

BACKGROUND AND OBJECTIVES: Nosocomial rotavirus (nRV) infections represent an important part of rotavirus (RV)-associated morbidity. The incidence of nRV influences the estimated total RV disease burden, an important determinant of cost-effectiveness of RV vaccination programs. Our aim is to summarize the existing evidence and produce reliable estimates of nRV incidence, in pediatric settings in Europe and North America.

METHODS: We searched electronic databases for studies on nRV incidence among pediatric inpatients. To ascertain complete case reporting, only studies describing active nRV surveillance in their methodology were included. Random effects meta-analysis was performed. Meta-regression was used to obtain results adjusted for important study characteristics.

RESULTS: Twenty surveillance studies met the quality criteria for inclusion. The pooled unadjusted nRV incidence was 2.9 per 100 hospitalizations (95% confidence interval [CI]: 1.6–4.4). Incidence was significantly influenced by studies' seasonality-months (RV epidemic season only or year-round) and the age range of included patients. Highest nRV incidence was found for children <2 years of age, hospitalized during the epidemic months (8.1/100 hospitalizations; 95% CI: 6.4–9.9). The adjusted year-round nRV incidence estimate without age restriction was 0.4/100 hospitalizations (95% CI: 0.1–2.1) and 0.7 (95% CI: 0.0–1.8) for children <5 years of age.

CONCLUSIONS: This is the first meta-analysis to summarize results of surveillance studies on nRV incidence. nRV is an important problem among hospitalized infants during the winter months. The lower season and age-adjusted nRV incidence estimate seems more appropriate for application in population-based burden of disease analysis.

KEY WORDS

rotavirus

meta-analysis

systematic review

nosocomial

hospital-acquired

incidence

Accepted November 29, 2011.

· Abstract 39 of 63Review Article

Prenatal and Passive Smoke Exposure and Incidence of Asthma and Wheeze: Systematic Review and Meta-analysis

OBJECTIVES: Exposure to passive smoke is a common and avoidable risk factor for wheeze and asthma in children. Substantial growth in the prospective cohort study evidence base provides an opportunity to generate new and more detailed estimates of the magnitude of the effect. A systematic review and meta-analysis was conducted to provide estimates of the prospective effect of smoking by parents or household members on the risk of wheeze and asthma at different stages of childhood.

METHODS: We systematically searched Medline, Embase, and conference abstracts to identify cohort studies of the incidence of asthma or wheeze in relation to exposure to prenatal or postnatal maternal, paternal, or household smoking in subjects aged up to 18 years old. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by using random effects model.

RESULTS: We identified 79 prospective studies. Exposure to pre- or postnatal passive smoke exposure was associated with a 30% to 70% increased risk of incident wheezing (strongest effect from postnatal maternal smoking on wheeze in children aged ≤2 years, OR = 1.70, 95% CI = 1.24–2.35, 4 studies) and a 21% to 85% increase in incident asthma (strongest effect from prenatal maternal smoking on asthma in children aged ≤2 years, OR = 1.85, 95% CI = 1.35–2.53, 5 studies).

CONCLUSIONS: Building upon previous findings, exposure to passive smoking increases the incidence of wheeze and asthma in children and young people by at least 20%. Preventing parental smoking is crucially important to the prevention of asthma.

KEY WORDS

asthma

wheeze

passive smoking exposure

meta-analysis

Accepted December 1, 2011.

· Abstract 40 of 63Review Article

Language Functions in Preterm-Born Children: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE: Preterm-born children (<37 weeks’ gestation) have higher rates of language function problems compared with term-born children. It is unknown whether these problems decrease, deteriorate, or remain stable over time. The goal of this research was to determine the developmental course of language functions in preterm-born children from 3 to 12 years of age.

METHODS: Computerized databases Embase, PubMed, Web of Knowledge, and PsycInfo were searched for studies published between January 1995 and March 2011 reporting language functions in preterm-born children. Outcome measures were simple language function assessed by using the Peabody Picture Vocabulary Test and complex language function assessed by using the Clinical Evaluation of Language Fundamentals. Pooled effect sizes (in terms of Cohen’s d) and 95% confidence intervals (CI) for simple and complex language functions were calculated by using random-effects models. Meta-regression was conducted with mean difference of effect size as the outcome variable and assessment age as the explanatory variable.

RESULTS: Preterm-born children scored significantly lower compared with term-born children on simple (d = –0.45 [95% CI: –0.59 to –0.30]; P < .001) and on complex (d = –0.62 [95% CI: –0.82 to –0.43]; P < .001) language function tests, even in the absence of major disabilities and independent of social economic status. For complex language function (but not for simple language function), group differences between preterm- and term-born children increased significantly from 3 to 12 years of age (slope = –0.05; P = .03).

CONCLUSIONS: While growing up, preterm-born children have increasing difficulties with complex language function.

KEY WORDS

language development

long-term outcome

meta-analytic methods

premature infants

systematic reviews

Accepted December 9, 2011.

· Abstract 41 of 63State-of-the-Art Review Article

Role of Copy Number Variants in Structural Birth Defects

BACKGROUND AND OBJECTIVE: Human genomes include copy number variants (CNVs), defined as regions with DNA gains or losses. Pathologic CNVs, which are larger and often occur de novo, are increasingly associated with disease. Given advances in genetic testing, namely microarray-based comparative genomic hybridization and single nucleotide polymorphism arrays, previously unidentified genotypic aberrations can now be correlated with phenotypic anomalies. The objective of this study was to conduct a nonsystematic literature review to document the role of CNVs as they relate to isolated structural anomalies of the craniofacial, respiratory, renal, and cardiac systems.

METHODS: All full-length articles in the PubMed database through May 2011 that discussed CNVs and isolated structural defects of the craniofacial, respiratory, renal, and cardiac systems were considered. Search terms queried include CNV, copy number variation, array comparative genomic hybridization, birth defects, craniofacial defects, respiratory defects, renal defects, and congenital heart disease. Reports published in languages other than English and articles regarding CNVs and neurocognitive deficits were not considered.

RESULTS: Evidence supports that putatively pathogenic CNVs occur at an increased frequency in patients with isolated structural birth defects and implicate specific regions of the genome. Through CNV detection, advances have been made in identifying genes and specific loci that underlie isolated birth defects.

CONCLUSIONS: Although limited studies have been published, the promising evidence reviewed here warrants the continued investigation of CNVs in children with isolated structural birth defects. Patient care and genetic counseling stand to improve through a better understanding of CNVs and their effect on disease phenotype.

KEY WORDS

DNA copy number variations

comparative genomic hybridization

congenital abnormalities

craniofacial abnormalities

congenital heart disease

Accepted December 7, 2011.

· Abstract 42 of 63Special Article

Novel Modeling of Reference Values of Cardiovascular Risk Factors in Children Aged 7 to 20 Years

BACKGROUND AND OBJECTIVE: Most of the cardiovascular risk factors strongly associated with obesity and overweight vary with age and gender. However, few reference values are available for healthy European children. Our objective was to establish pediatric reference ranges for waist circumference, systolic and diastolic blood pressures, fasting lipid levels (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides), glucose, and insulin.

METHODS: A representative sample of 1976 healthy French individuals (1004 female participants and 972 male participants) aged 7 to 20 years was used to obtain age- and gender-specific normal ranges for each of the above-listed cardiovascular risk factors, based on the Royston and Wright method.

RESULTS: Mean waist circumference increased with age in both genders and was slightly higher in males than in females. Whereas systolic blood pressure increased gradually with age, with the increase being steeper in males than in females, no gender effect was found for diastolic blood pressure, which was therefore modeled after pooling males and females. Total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglyceride values varied little with age and gender. Glucose and insulin levels revealed pubertal peaks, which were sharper in females than in males, reflecting the normal insulin resistance during puberty.

CONCLUSIONS: These ranges can be used as references for European children to monitor cardiovascular risk factors and to plan interventions and education programs.

KEY WORDS

cardiovascular risk factors

reference range

abdominal adiposity

nutrition

lipids

Accepted November 30, 2011.

· Abstract 43 of 63Special Article

· Abstract 44 of 63Special Article

Behavioral and Social Phenotypes in Boys With 47,XYY Syndrome or 47,XXY Klinefelter Syndrome

OBJECTIVE: To contrast the behavioral and social phenotypes including a screen for autistic behaviors in boys with 47,XYY syndrome (XYY) or 47,XXY Klinefelter syndrome (KS) and controls and investigate the effect of prenatal diagnosis on the phenotype.

METHODS: Patients included 26 boys with 47,XYY, 82 boys with KS, and 50 control boys (ages 4–15 years). Participants and parents completed a physical examination, behavioral questionnaires, and intellectual assessments.

RESULTS: Most boys with XYY or KS had Child Behavior Checklist parental ratings within the normal range. On the Child Behavior Checklist, mean problem behaviors t scores were higher in the XYY versus KS groups for the Problem Behavior, Externalizing, Withdrawn, Thought Problems, and Attention Problems subscales. On the Conners’ Parent Rating Scale–Revised, the XYY versus KS group had increased frequency of hyperactive/impulsive symptoms (P < .006). In addition, 50% and 12% of the XYY and KS groups, respectively, had scores >15 for autism screening from the Social Communication Questionnaire. For the boys with KS, prenatal diagnosis was associated with fewer problem behaviors.

CONCLUSIONS: A subset of the XYY and KS groups had behavioral difficulties that were more severe in the XYY group. These findings could guide clinical practice and inform patients and parents. Boys diagnosed with XYY or KS should receive a comprehensive psychoeducational evaluation and be screened for learning disabilities, attention-deficit/hyperactivity disorder, and autism spectrum disorders.

KEY WORDS

XXY

XYY

Klinefelter syndrome

autism

ADHD

Accepted December 13, 2011.

· Abstract 45 of 63Commentary

· Abstract 46 of 63Commentary

· Abstract 47 of 63Commentary

· Abstract 48 of 63Commentary

· Abstract 49 of 63Quality Report

Improved Outcomes in a Quality Improvement Collaborative for Pediatric Inflammatory Bowel Disease

OBJECTIVES: Unintended variation in the care of patients with Crohn disease (CD) and ulcerative colitis (UC) may prevent achievement of optimal outcomes. We sought to improve chronic care delivery and outcomes for children with inflammatory bowel disease by using network-based quality improvement methods.

METHODS: By using a modified Breakthrough Series collaborative structure, 6 ImproveCareNow Network care centers tested changes in chronic illness care and collected data monthly. We used an interrupted time series design to evaluate the impact of these changes.

RESULTS: Data were available for 843 children with CD and 345 with UC. Changes in care delivery were associated with an increase in the proportion of visits with complete disease classification, measurement of thiopurine methyltransferase (TPMT) before initiation of thiopurines, and patients receiving an initial thiopurine dose appropriate to their TPMT status. These were significant in both populations for all process variables (P < .01) except for measurement of TPMT in CD patients (P = .12). There were significant increases in the proportion of CD (55%–68%) and UC (61%–72%) patients with inactive disease. There was also a significant increase in the proportion of CD patients not taking prednisone (86%–90%). Participating centers varied in the success of achieving these changes.

CONCLUSIONS: Improvements in the outcomes of patients with CD and UC were associated with improvements in the process of chronic illness care. Variation in the success of implementing changes suggests the importance of overcoming organizational factors related to quality improvement success.

KEY WORDS

inflammatory bowel disease

Crohn disease

ulcerative colitis

outcomes

quality

improvement

ImproveCareNow

Accepted October 31, 2011.

· Abstract 50 of 63Quality Report

Utilizing Improvement Science Methods to Improve Physician Compliance With Proper Hand Hygiene

OBJECTIVE: In 2009, The Joint Commission challenged hospitals to reduce the risk of health care–associated infections through hand hygiene compliance. At our hospital, physicians had lower compliance rates than other health care workers, just 68% on general pediatric units. We used improvement methods and reliability science to increase compliance with proper hand hygiene to >95% by inpatient general pediatric teams.

METHODS: Strategies to improve hand hygiene were tested through multiple plan-do-study-act cycles, first by 1 general inpatient medical team and then spread to 4 additional teams. At the start of each rotation, residents completed an educational module and posttest about proper hand hygiene. Team compliance data were displayed daily in the resident conference room. Real-time identification and mitigation of failures by a hand-washing champion encouraged shared accountability. Organizational support ensured access to adequate hand hygiene supplies. The main outcome measure was percent compliance with acceptable hand hygiene, defined as use of an alcohol-based product or hand-washing with soap and turning off the faucet without using fingers or palm. Compliance was defined as acceptable hand hygiene before and after contact with the patient or care environment. Covert bedside observers recorded at least 8 observations of physicians’ compliance per day.

RESULTS: Physician compliance with proper hand hygiene improved to >95% within 6 months and was sustained for 11 months.

CONCLUSIONS: Instituting a hand-washing champion for immediate identification and mitigation of failures was key in sustaining results. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care–associated infections.

KEY WORDS

hand hygiene

handwashing

patient safety

joint commission

health care–associated infections

Accepted November 14, 2011.

· Abstract 51 of 63Case Report

Hypercalcemia in Children Receiving Pharmacologic Doses of Vitamin D

Vitamin D deficiency causes rickets, requiring vitamin D at doses greater than daily dietary intake. Several treatment regimens are found in the literature, with wide dosing ranges, inconsistent monitoring schedules, and lack of age-specific guidelines. We describe 3 children, ages 2 weeks to 2 and 9/12 years, who recently presented to our institution with hypercalcemia and hypervitaminosis D (25-hydroxyvitamin D levels >75 ng/mL), associated with treatment of documented or suspected vitamin D-deficient rickets. The doses of vitamin D used were within accepted guidelines and believed to be safe. The patients required between 6 weeks and 6 months to correct the elevated serum calcium, with time to resolution of hypercalcemia related to age and peak serum calcium, but not to peak 25-hydroxyvitamin D level. With recent widespread use of vitamin D in larger dosages in the general population, we provide evidence that care must be taken when using pharmacologic dosing in small children. With limited dosing guidelines available on a per weight basis, the administration of dosages to infants that are often used in older children and adults has toxic potential, requiring a cautious approach in dose selection and careful follow-up. Dosage recommendations may need to be reassessed, in particular, where follow-up and monitoring may be compromised.

KEY WORDS

hypervitaminosis D

hypercalcemia

rickets

Accepted November 14, 2011.

· Abstract 52 of 63Case Report

Clinical Presentation of Intoxication Due to Synthetic Cannabinoids

Synthetic cannabinoids are relatively novel substances of abuse. The use of these compounds among adolescents and young adults has been increasing, making it important for pediatric providers to be familiar with the presenting signs and symptoms of intoxication. We describe three case presentations of reported synthetic cannabinoid intoxication and provide a brief discussion of these compounds.

KEY WORDS

cannabinoids

intoxication

substance abuse

Spice

Accepted November 14, 2011.

· Abstract 53 of 63Case Report

Late Delirious Behavior With 2009 H1N1 Influenza: Mild Autoimmune-Mediated Encephalitis?

Delirious behavior associated with influenza usually has an onset within a few days after fever and lasts <24 hours. As we encountered several patients with 2009 H1N1 influenza who presented with late-onset and long-standing delirious behavior, we retrospectively evaluated the clinical, radiologic, and laboratory features to elucidate the possible pathophysiology. This information was collected on 5 previously healthy patients (2 boys and 3 girls, aged 10–15 years) with 2009 H1N1 influenza who presented with late onset (>3 days after fever) and long-standing (>48 hours) delirious behavior. Each exhibited mild to moderate drowsiness between the episodes of delirious behavior. Electroencephalography was normal except for 1 patient with high voltage and slow activity bilaterally in the occipital regions. Brain MRI was normal. The outcome was excellent with no neurologic sequel in 4 of the 5 patients. In all 5 patients, autoantibodies against N-methyl-D-aspartate type glutamate receptor were elevated or positive in cerebrospinal fluid or serum; the autoantibody levels normalized in the 3 patients who had follow-up studies. This study indicates that 2009 H1N1 influenza has a tendency to cause late-onset and long-standing delirious behavior, at least in Japanese children. Mild autoimmune-mediated encephalitis should be considered as an underlying cause.

KEY WORDS

2009 H1N1 influenza

delirium

anti-NMDA-type GluR antibodies

Accepted November 17, 2011.

· Abstract 54 of 63Case Report

Recognizing and Managing Eczematous Id Reactions to Molluscum Contagiosum Virus in Children

Molluscum contagiosum (MC) is a self-limiting cutaneous viral eruption that is very common in children. MC infection can trigger an eczematous reaction around molluscum papules known as a hypersensitivity or an id reaction. In addition, a hypersensitivity reaction can occasionally occur at sites distant from the primary molluscum papules. These eczematous reactions are often asymptomatic or minimally pruritic. We believe that id reactions represent an immunologically mediated host response to MC virus and a harbinger of regression. Therefore, these reactions often do not require treatment other than emollients. Moreover, topical steroids or immunomodulators may suppress this process and potentiate the spread of the primary MC infection. However, in symptomatic patients, treatment should not be withheld and short-course treatments of topical corticosteroids may be used. In this case series, we describe 3 cases of hypersensitivity reactions in otherwise healthy children with MC. We hope that our report will make clinicians more aware of this common eczematous response to MC and will improve the management and counseling of these patients and their parents.

KEY WORDS

id reaction

molluscum dermatitis

molluscum contagiosum

Accepted November 14, 2011.

· Abstract 55 of 63Case Report

Neonatal Liver Cirrhosis Without Iron Overload Caused by Gestational Alloimmune Liver Disease

Gestational alloimmune liver disease has emerged as the major cause of antenatal liver injury and failure. It usually manifests as neonatal liver failure with hepatic and extrahepatic iron overload, a clinical presentation called neonatal hemochromatosis. We report on a newborn in whom fetal hepatomegaly was detected during pregnancy and who presented at birth with liver cirrhosis and mild liver dysfunction. Liver biopsy showed the absence of iron overload but strong immunostaining of hepatocytes for the C5b-9 complex, the terminal complement cascade neoantigen occurring specifically during complement activation by the immunoglobulin G-mediated classic pathway, which established the alloimmune nature of the hepatocyte injury. The infant survived with no specific therapy, and follow-up until 36 months showed progressive normalization of all liver parameters. This case report expands the recognized clinical spectrum of congenital alloimmune liver disease to include neonatal liver disease and cirrhosis, even in the absence of siderosis. Such a diagnosis is of utmost importance regarding the necessity for immunotherapy in further pregnancies to avoid recurrence of alloimmune injury.

KEY WORDS

cirrhosis

gestational alloimmune disease

membrane attack complex

neonatal hemochromatosis

Accepted November 2, 2011.

· Abstract 56 of 63Case Report

Blue Rubber Bleb Nevus Syndrome: Successful Treatment With Sirolimus

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder with characteristic vascular malformations of the skin, gastrointestinal system, and, less often, other organ systems. The characteristic cutaneous lesions consist of deep-blue, soft, rubbery blebs, which are easily compressible. The most serious complication is abundant gastrointestinal bleeding. We describe the case of an 8-year-old girl with diagnosed BRBNS who had multiple venous malformations all over her body, importantly, throughout the gastrointestinal tract, mouth, esophagus, stomach, small bowel, and colon. She presented with recurrent massive gastrointestinal bleeding and soft tissue hematoma despite prednisolone and α-interferon therapy. We started low-dose sirolimus as an antiangiogenic agent. The vascular masses were reduced rapidly and there was no gastrointestinal bleeding and muscular hematoma after sirolimus therapy. There was no drug adverse reaction at 20-month follow-up. To the best of our knowledge, this is the first report related to the use of sirolimus in a patient with BRBNS.

KEY WORDS

gastrointestinal bleeding

hemangiomatosis

sirolimus

blue rubber bleb nevus syndrome

Accepted November 17, 2011.

· Abstract 57 of 63From the American Academy of PediatricsClinical Report

Strategies for Prevention of Health Care–Associated Infections in the NICU

Health care–associated infections in the NICU result in increased morbidity and mortality, prolonged lengths of stay, and increased medical costs. Neonates are at high risk of acquiring health care–associated infections because of impaired host-defense mechanisms, limited amounts of protective endogenous flora on skin and mucosal surfaces at time of birth, reduced barrier function of their skin, use of invasive procedures and devices, and frequent exposure to broad-spectrum antibiotic agents. This clinical report reviews management and prevention of health care–associated infections in newborn infants.

KEY WORDS

health care–associated infection

nosocomial infection

neonatal ICU

NICU

antibiotics

neonate

newborn

· Abstract 58 of 63From the American Academy of PediatricsPolicy Statement

Pediatric Sudden Cardiac Arrest

Pediatric sudden cardiac arrest (SCA), which can cause sudden cardiac death if not treated within minutes, has a profound effect on everyone: children, parents, family members, communities, and health care providers. Preventing the tragedy of pediatric SCA, defined as the abrupt and unexpected loss of heart function, remains a concern to all. The goal of this statement is to increase the knowledge of pediatricians (including primary care providers and specialists) of the incidence of pediatric SCA, the spectrum of causes of pediatric SCA, disease-specific presentations, the role of patient and family screening, the rapidly evolving role of genetic testing, and finally, important aspects of secondary SCA prevention. This statement is not intended to address sudden infant death syndrome or sudden unexplained death syndrome, nor will specific treatment of individual cardiac conditions be discussed. This statement has been endorsed by the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society.

KEY WORDS

syncope

cardiovascular disease

long QT

cardiomyopathy

athlete

heart disease

· Abstract 59 of 63From the American Academy of PediatricsPolicy Statement

· Abstract 60 of 63From the American Academy of PediatricsTechnical Report

Epidemiology and Diagnosis of Health Care–Associated Infections in the NICU

Health care−associated infections in the NICU are a major clinical problem resulting in increased morbidity and mortality, prolonged length of hospital stays, and increased medical costs. Neonates are at high risk for health care−associated infections because of impaired host defense mechanisms, limited amounts of protective endogenous flora on skin and mucosal surfaces at time of birth, reduced barrier function of neonatal skin, the use of invasive procedures and devices, and frequent exposure to broad-spectrum antibiotics. This statement will review the epidemiology and diagnosis of health care−associated infections in newborn infants.

KEY WORDS

antibiotics

health care−associated infection

neonate

newborn

NICU

nosocomial infection

· Abstract 61 of 63From the American Academy of PediatricsStatement of Endorsement

· Abstract 62 of 63From the American Academy of PediatricsStatement of Endorsementt

· Abstract 63 of 63From the American Academy of PediatricsClinical Report

Medical Staff Appointment and Delineation of Pediatric Privileges in Hospitals

The review and verification of credentials and the granting of clinical privileges are required of every hospital to ensure that members of the medical staff are competent and qualified to provide specified levels of patient care. The credentialing process involves the following: (1) assessment of the professional and personal background of each practitioner seeking privileges; (2) assignment of privileges appropriate for the clinician’s training and experience; (3) ongoing monitoring of the professional activities of each staff member; and (4) periodic reappointment to the medical staff on the basis of objectively measured performance. We examine the essential elements of a credentials review for initial and renewed medical staff appointments along with suggested criteria for the delineation of clinical privileges. Sample forms for the delineation of privileges can be found on the American Academy of Pediatrics Committee on Hospital Care Web site (http://www.aap.org/visit/cmte19.htm). Because of differences among individual hospitals, no 1 method for credentialing is universally applicable. The medical staff of each hospital must, therefore, establish its own process based on the general principles reviewed in this report. The issues of medical staff membership and credentialing have become very complex, and institutions and medical staffs are vulnerable to legal action. Consequently, it is advisable for hospitals and medical staffs to obtain expert legal advice when medical staff bylaws are constructed or revised.

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میلادی:23 ژانویه 2025

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