Showing papers in "Pediatrics in 1994"

Parents' and Children's Adiposity and Eating Style

Abstract: Objective. To investigate children9s ability to self-regulate energy intake and to determine whether individual differences in the precision of food intake regulation are related to children9s anthropometric measures. We collected information pertaining to parental adiposity and dieting practices, as well as mothers9 child-feeding practices. Of special interest was the degree of control imposed by mothers over their children9s food intake. Our intent was to explore whether these variables might influence children9s regulation of energy intake. Subjects and setting. Seventy-seven 3-5-year-old children who attended a university preschool setting and their parents participated in this experiment. Measurements and main results. Children completed controlled, two-part meals used to estimate their ability to adjust food intake in response to changes in caloric density of the diet. An eating index, reflecting children9s precision in the ability to regulate energy intake, was correlated to children9s anthropometric measures. These correlations provided evidence for a relation between children9s body fat stores and their responsiveness to caloric density cues: Pearson correlation coefficients revealed that children with greater body fat stores were less able to regulate energy intake accurately. The best predictor of children9s ability to regulate energy intake was parental control in the feeding situation: mothers who were more controlling of their children9s food intake had children who showed less ability to self-regulate energy intake (r = -.67, P Conclusions. These findings suggest that the optimal environment for children9s development of self-control of energy intake is that in which parents provide healthy food choices but allow children to assume control of how much they consume.

Parental Monitoring and Peer Influences on Adolescent Substance Use

Abstract: Objective. To examine the joint influences of parental monitoring and peer influence on adolescent substance use over time. Subjects. 6500 adolescents attending six high schools in Wisconsin and northern California. Design. Longitudinal study. Results. Parental monitoring was negatively associated with substance use, whereas the more involved an adolescent9s peers were in substance use, the more likely he or she also was to use drugs and alcohol. Effects of monitoring and peer coercion were strongest for boys and girls at the transition into substance use, rather than at the transition from experimentation to regular use. The effect of parental monitoring on changes in adolescent substance use is mediated not so much by the nature of the adolescent9s peer associates, but by its direct effect on the adolescent. Specifically, poorly monitored adolescents are more likely to use drugs, and drug-using adolescents seek out like-minded friends. Once an adolescent associates with drug-using peers, his or her own substance use approaches their level. Conclusions. Intervention efforts should include both parents and community-level efforts. Parental monitoring is an effective tool both in the prevention of drug use and in the amelioration of drug use.

Practice Parameter: Management of Hyperbilirubinemia in the Healthy Term Newborn

Abstract: Each year approximately 60% of the 4 million newborns in the United States become clinically jaundiced. Many receive various forms of evaluation and treatment. Few issues in neonatal medicine have generated such long-standing controversy as the possible adverse consequences of neonatal jaundice and when to begin treatment. Questions regarding potentially detrimental neurologic effects from elevated serum bilirubin levels prompt continuing concern and debate, particularly with regard to the management of the otherwise healthy term newborn without risk factors for hemolysis. Although most data are based on infants with birth weights ≥2500 g, \"term\" is hereafter defined as 37 completed weeks of gestation. Under certain circumstances, bilirubin may be toxic to the central nervous system and may cause neurologic impairment even in healthy term newborns. Most studies, however, have failed to substantiate significant associations between a specific level of total serum bilirubin (TSB) during nonhemolytic hyperbilirubinemia in term newborns and subsequent IQ or serious neurologic abnormality (including hearing impairment). Other studies have detected subtle differences in outcomes associated with TSB levels, particularly when used in conjunction with albumin binding tests and/or duration of exposure. In almost all published studies, the TSB concentration has been used as a predictor variable for outcome determinations. Factors influencing bilirubin toxicity to the brain cells of newborn infants are complex and incompletely understood; they include those that affect the serum albumin concentration and those that affect the binding of bilirubin to albumin, the penetration of bilirubin into the brain, and the vulnerability of brain cells to the toxic effects of bilirubin.

Infant dietary experience and acceptance of solid foods.

Abstract: Objective. To examine the effects of dietary experience and milk feeding regimen on acceptance of their first vegetable by 4-to 6-month-old infants. Design. Longitudinal study, of 26-days duration, observing infants aged 4 to 6 months at the start of the study. Random assignment to treatments, within-subject control. Setting. General community in a medium-sized mid-western town. Subjects. Thirty-six infants and their mothers. Subjects were solicited through birth records and advertisements in local newspapers. Interventions. Infants were randomly assigned to be fed one vegetable on 10 occasions, either salted or unsalted peas or green beans, for a 10-day period. Outcome measures. Infant intake of the vegetable consumed during the 10-day exposure period; intake of salted and unsalted versions: (1) before the 10-day exposure period, (2) immediately after the exposure period; and (3) after a 1-week period of delay. Intake of a control food was also measured before and after repeated consumption of the vegetable. Adult ratings of the infants9 videotaped responses during test feedings were also obtained before and after the exposure period. Results. After 10 opportunities to consume the vegetable, all infants significantly increased their intake (P Conclusions. Infants increase their acceptance (reflected both in changes in intake and in behavioral response) of a novel food after repeated dietary exposure to that food. Relative to formula-feeding, breast-feeding may facilitate the acceptance of solid foods.

Prevalence and Health Impact of Developmental Disabilities in US Children

Abstract: Objective. Data from the 1988 National Health Interview Survey—Child Health Supplement were used to examine the prevalence of selected developmental disabilities and their impact among children ages 0 through 17 years. Design. The following conditions, identified through a structured in-person interview with a parent or other adult household member, were examined: deafness or trouble hearing, blindness, epilepsy or seizures, stammering and stuttering, other speech defects, cerebral palsy, delay in growth or development, learning disabilities, and emotional or behavioral problems. The impact was defined by measures of perceived health status, school performance and attendance, and health care utilization. Results. Seventeen percent of children in the United States were reported to have ever had a developmental disability. The prevalence of the individual disabilities ranged from 0.2% for cerebral palsy to 6.5% for learning disabilities. These conditions taken together had a substantial impact on the health and educational functioning of affected children: 1.5 times more doctor visits, 3.5 times more hospital-days, twice the number of school-days lost, and a 2.5-fold increase in the likelihood of repeating a grade in school compared with children without these conditions. The extent of this impact was much greater among children with multiple disabilities or with either cerebral palsy, epilepsy or seizures, delays in growth and development, or emotional or behavioral problems. The impact on school performance was most pronounced for children reported to have learning disabilities. Conclusions. Future research efforts should be focused on ways to reduce the impact of these developmental disabilities on quality of life.

Association of Pulmonary Inflammation and Increased Microvascular Permeability During the Development of Bronchopulmonary Dysplasia: A Sequential Analysis of Inflammatory Mediators in Respiratory Fluids of High-Risk Preterm Neonates

Abstract: Objectives. Bronchopulmonary dysplasia (BPD) of preterm neonates is associated with an increased recruitment of inflammatory cells into the airways. To evaluate further the role of inflammation in the pathogenesis of BPD, tracheobronchial aspirate fluid of neonates with birth weight Methods. Tracheobronchial aspirate fluid was assessed for chemotactic activity, neutrophil cell count, concentrations of elastase-α1-proteinase inhibitor and activity of free elastase, concentrations of chemoattractants (complement component C5-derived anaphylatoxin, leukotrien B 4 , interleukin-8), and albumin concentrations as well as α 1 -proteinase inhibitor activity. The secretory component for immunoglobulin A was used as reference protein. Only specimens without evidence of microbiological colonization were studied. Results. In neonates with prolonged respiratory disease (BPD-risk neonates, n = 24, fraction of inspired oxygen ≥ 0.3 and/or peak inspiratory pressure ≥ 16 cm H 2 O at day 10 postnatal age, birth weight 892 ± 36 g, gestational age 27.2 ± 0.3 weeks) chemotactic activity, cell count, concentrations of the chemoattractants complement component C5-derived anaphylatoxin, leukotriene B 4 , interleukin-8, as well as levels of elastase-α 1 -proteinase inhibitor were significantly higher at day 10 and/or day 15 of postnatal age compared with neonates without chronic pulmonary disease (total n = 35; day 10, n = 11; day 15, n = 8). There was no difference in free elastolytic activity. Concentrations of albumin as well as α 1 -proteinase inhibitor activity were higher in BPD-risk patients on day 15, indicating an increased pulmonary leak. Conclusion. We conclude that preterm neonates at risk for the development of BPD show an enhanced inflammatory reaction in the lungs and an associated increase in pulmonary microvascular permeability. We speculate that inflammation may play an important role in the pathogenesis of BPD.

Suicidal attempts among older adolescents: prevalence and co-occurrence with psychiatric disorders

Abstract: The prevalence of suicidal attempts and ideation and the co-occurrence of attempts with psychiatric disorders were examined in a community sample of 1710 older adolescents. Structured interviews using rigorous diagnostic criteria were conducted in two annual assessments. Lifetime prevalence of attempts was 7.1% and ideation was 21.1%. Almost 90% of those who attempted also evidenced suicidal ideation. Suicide attempts occurred in conjunction with depressive, substance use, and disruptive behavior disorder but not with panic disorders. Results indicate that risk factors for an attempt are the following: being female, from a home without a father, poor education of the father, previous attempts, suicidal ideation, and mental disorders.

Epidemiology of physician-diagnosed allergic rhinitis in childhood.

Abstract: Objective. To investigate the natural history of and risk factors for allergic rhinitis in the first 6 years of life. Methods. Parents of 747 healthy children followed from birth completed a questionnaire when the child was 6 years old. Data were obtained regarding physician-diagnosed allergic rhinitis (PDAR), associated symptoms, and age at onset. Risk-factor data were taken from earlier questionnaires, and data regarding immunoglobulin E (IgE) and skin-test reactivity were obtained at age 6. Results. By the age of 6, 42% of children had PDAR. Children whose rhinitis began in the first year of life had more respiratory symptoms at age 6 and were more likely to have a diagnosis of asthma. Early introduction of foods or formula, heavy maternal cigarette smoking in the first year of life, and higher IgE, as well as parental allergic disorders, were associated with early development of rhinitis. Risk factors for PDAR that remained significant in a multivanate model included maternal history of physician-diagnosed allergy (odds ratio: 2.2, 95% confidence interval: 1.35-3.54), asthma in the child (4.06, 2.06-7.99), and IgE greater than 100 IU/mL at age 6 (1.93, 1.18-3.17). The odds for atopic as opposed to nonatopic PDAR were significantly higher only among those with high IgE and those who had dogs. Conclusion. Allergic rhinitis developing in the first years of life is an early manifestation of an atopic predisposition, which may be triggered by early environmental exposures.

Children as victims of violence: A national survey

Abstract: OBJECTIVE. The goal of this study was to gain a more comprehensive perspective on the scope, variety, and consequences of child victimization, which has been obscured by a fragmentation into specific problems like sexual abuse or kidnapping. METHODS. Two thousand children aged 10 to 16 years were interviewed in a national telephone survey of children. RESULTS. In the previous year, a quarter of the children had experienced a completed victimization, one in eight had experienced an injury, and one in a hundred required medical attention as a result. Nonfamily physical assaults were the most numerous. Contact sexual abuse occurred to 3.2% of girls and 0.6% of boys. There were also substantial numbers of incidents of attempted kidnappings and violence directed to children's genitals. CONCLUSION. The victimization of children occurs to a greater extent than has been previously reported and is poorly represented in official statistics. IMPLICATION. The authors argue for a more comprehensive interest in children's victimization including better national statistics about the problem. Language: en

Belief in the law of small numbers

Abstract: Misconceptions of chance are not limited to naive subjects. A study of the statistical intuitions of experienced research psychologists revealed a lingering belief in what might be called the "law of small numbers," according to which even small samples are highly representative of the populations from which they are drawn. The responses of these investigators reflected the expectation that a valid hypothesis about a population will be represented by a statistically significant result in a sample—with little regard for its size. As a consequence the researchers put too much faith in the results of small samples and grossly overestimated the replicability of such results. In the actual conduct of research, this bias leads to the selection of samples of inadequate size and to overinterpretation of findings.

Febrile infants at low risk for serious bacterial infection - An appraisal of the Rochester criteria and implications for management

Abstract: Objective. Prospective studies were conducted to test the hypothesis that infants unlikely to have serious bacterial infections (SBI) can be accurately identified by low risk criteria. Methods. Febrile infants (rectal T ≥ 38°C) ≤60 days of age were considered at low risk for SBI if they met the following criteria: 1) appear well; 2) were previously healthy; 3) have no focal infection; 4) have WBC count 5.0-15.0 x 109 cells/L (5000-15 000/mm3), band form count≤ 1.5 x 109 cells/L (≤1500/mm3), ≤10 WBC per high power field on microscopic examination of spun urine sediment, and ≤5 WBC per high power field on microscopic examination of a stool smear (if diarrhea). The recommended evaluation included the culture of specimens of blood, cerebrospinal fluid, and urine for bacteria. Outcomes were determined. The negative predictive values of the low risk criteria for SBI and bacteremia were calculated. Results. Of 1057 eligible infants, 931 were well appearing, and, of these, 437 met the remaining low risk criteria. Five low risk infants had SBI including two infants with bacteremia. The negative predictive value of the low risk criteria was 98.9% (95% confidence interval, 97.2% to 99.6%) for SBI, and 99.5% (95% confidence interval, 98.2% to 99.9%) for bacteremia. Conclusions. These data confirm the ability of the low risk criteria to identify infants unlikely to have SBI. Infants who meet the low risk criteria can be carefully observed without administering antimicrobial agents.

The use of alternative medicine by children

Abstract: Objective. Alternative medicine (AM) is of growing interest to the general public. Although several studies have been published concerning its use in adults, the use by children is less well known. The purpose of this study is to determine the frequency with which alternative medicine is employed in a pediatric population that also uses conventional medicine. A second goal is to investigate the sociodemographic factors that influence the choice of these forms of therapy. Methods. Parents of children consulting the general outpatient clinic of a university hospital completed a self-administered questionnaire asking about previous use of AM for themselves or their children. Results. Based on 1911 completed questionnaires, 208 children (11%) previously consulted one or more AM practitioners. Chiropractic, homeopathy, naturopathy, and acupuncture together accounted for 84% of use. Children who used AM differed significantly from those who only used conventional medicine in that they were older than the nonusers, their mothers were better educated, and their parents also tended to use AM. Conclusion. The findings indicate that AM is an aspect of child health care that no longer can be ignored. Being aware of these practices will enable physicians to discuss alternative therapies with parents in order to ensure the continuity of essential conventional treatments.

Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life

Abstract: OBJECTIVE: To examine, during the 3rd and 4th years of life, the health, development, rates of child maltreatment, and living conditions of children who had been enrolled in a randomized trial of nurse home visitation during pregnancy and first 2 years of their lives. DESIGN: Prospective follow-up of families who had been randomly assigned to nurse-visited and comparison conditions. SETTING: Study conducted in semirural community in upstate New York. Families dispersed among 14 other states during 2-year period after children's second birthdays. PARTICIPANTS: Four hundred women were recruited through a health department antepartum clinic and offices of private obstetricians and were registered before 30th week of pregnancy. All women had no previous live births and 85% were either teenaged (< 18 years at registration), unmarried, or from Hollingshead social classes IV or V. Analysis focused on whites, who comprised 89% of sample. INTERVENTION: Nurse home visitation from pregnancy through second year of the child's life. MAIN RESULTS: There were no treatment differences in the rates of child abuse and neglect or children's intellectual functioning from 25 to 48 months of age. Nurse-visited children, nevertheless, lived in homes with fewer hazards for children; they had 40% fewer injuries and ingestions and 45% fewer behavioral and parental coping problems noted in the physician record; and they made 35% fewer visits to the emergency department than did children in the comparison group. Nurse-visited mothers were observed to be more involved with and to punish their children to a greater extent than were mothers in the comparison group. The functional meaning of punishment differed between the nurse-visited and comparison families. CONCLUSIONS: The program does have enduring effects on certain aspects of parental caregiving, safety of the home, and children's use of the health care system, but it may be necessary to extend the length of the program for families at highest risk to produce lasting reductions in child abuse and neglect.

Low-Dose Indomethacin and Prevention of Intraventricular Hemorrhage: A Multicenter Randomized Trial

Abstract: OBJECTIVES: Parenchymal involvement of intraventricular hemorrhage (IVH) is a major risk factor for neurodevelopmental handicap in very low birth weight neonates. Previous trials have suggested that indomethacin would lower the incidence and severity of IVH in very low birth weight neonates. METHODS: We enrolled 431 neonates of 600- to 1250-g birth weight with no evidence for IVH at 6 to 11 hours of age in a prospective, randomized, placebo-controlled trial to test the hypothesis that low-dose indomethacin (0.1 mg/kg intravenously at 6 to 12 postnatal hours and every 24 hours for two more doses) would lower the incidence and severity of IVH. Serial cranial ultrasound examinations and echocardiographs were performed. RESULTS: There were no differences in the birth weight, gestational age, sex, Apgar scores, and percent of neonates treated with surfactant between the indomethacin and placebo groups. Within the first 5 days, 25 (12%) indomethacin-treated and 40 (18%) placebo-treated neonates developed IVH (P = .03, trend test). Only one indomethacin-treated patient experienced grade 4 IVH compared with 10 placebo-treated neonates (P = .01). Sixteen indomethacin-treated neonates and 29 control neonates died (P = .08); there was a difference favoring indomethacin with respect to survival time (P = .06). Eighty-six percent of all neonates had a patent ductus arteriosus on the first postnatal day; indomethacin was associated with significant ductal closure by the fifth day of life (P < .001). There were no differences in adverse events attributed to indomethacin between the two treatment groups. CONCLUSIONS: Low-dose prophylactic indomethacin significantly lowers the incidence and severity of IVH, particularly the severe form (grade 4 IVH). In addition, indomethacin closes the patent ductus arteriosus and is not associated with significant adverse drug events in very low birth weight neonates.

Examination findings in legally confirmed child sexual abuse: it's normal to be normal

Abstract: Background. Studies of alleged victims of child sexual abuse vary greatly in the reported frequency of physical findings based on differences in definition of abuse and of "findings." This study was designed to determine the frequency of abnormal findings in a population of children with legal confirmation of sexual abuse, using a standardized classification system for colposcopic photographic findings. Methods. Case files and colposcopic photographs of 236 children with perpetrator conviction for sexual abuse, were reviewed. The photos were reviewed blindly by a team member other than the examiner, and specific anatomical findings were noted and classified as normal to abnormal on a scale of 1 to 5. Historical and behavioral information, as well as legal outcome was recorded, and all data entered into a dBase III program. Correlations were sought between abnormal findings and other variables. Results. The mean age of the patients was 9.0 years (range 8 months to 17 years, 11 months), with 63% reporting penile-genital contact. Genital examination findings in girls were normal in 28%, nonspecific in 49%, suspicious in 9%, and abnormal in 14% of cases. Abnormal anal findings were found in only 1% of patients. Using discriminant analysis, the two factors which significantly correlated with the presence of abnormal genital findings in girls were the time since the last incident, and a history of blood being reported at the time of the molest. Conclusions. Abnormal genital findings are not common in sexually abused girls, based on a standardized classification system. More emphasis should be placed on documenting the child9s description of the molestation, and educating prosecutors that, for children alleging abuse: "It9s normal to be normal."

The Relationship Among Television Watching, Physical Activity, and Body Composition of Young Children

Abstract: Purpose. Television watching has been reported to be associated with obesity, resting energy expenditure, and lower daily physical activity among both children and adolescents. However, most of these studies were based on self report or data collected in laboratory settings. This study examined the relationship among observed time of television watching, observed physical activity level and body composition among 3- or 4-year-old children. Methods. African-American (41.4%), Mexican-American (23%), and Anglo-American (35.6%) children (N = 191, males = 90) from the Texas site of the Studies of Child Activity and Nutrition program were observed from 6 to 12 hours per day up to 4 days over 1 year. Activity level each minute of the day was measured with the Children9s Activity Rating Scale (interobserver reliability = .84 ± .001). The interobserver reliability of time of television watching was .96 ± .08. Results. The median of the longest number of consecutive minutes of television watching was 15 (range = 1 to 79). The median percent of minutes of television watching of total observed minutes was 14.8% (0% to 58%) and the median percent of minutes of inside minutes was 17.9% (0% to 80.9%). There were no gender or ethnic differences in time watching television or physical activity during television watching. Physical activity during television watching was lowest during the longest bout of television watching (\l=x_\ = 1.48 ± .28) compared to outside minutes (\l=x_\ = 2.38 ± .21), inside non-television minutes (\l=x_\ = 1.96 ± .13) and inside television minutes (\l=x_\ = 1.65 ± .18). The level of physical activity during television-watching times was highest (P Conclusions. Television watching was weakly negatively correlated with physical activity levels, and physical activity was lower during television-watching than non-television-watching time in this sample of children. Television viewing behavior was not associated with body composition.

An Estimate of the Prevalence of Asthma and Wheezing Among Inner-City Children

Abstract: OBJECTIVE To estimate the prevalence of asthma and wheezing unassociated with a diagnosis of asthma among inner-city children. DESIGN Cross-sectional survey of a sample of Bronx households. METHODS Random digit dialing telephone survey using parental report. SETTING Bronx County, NY. PARTICIPANTS 662 self-designated heads-of-household who reported for all children 0 through 17 years of age living in their households. MEASUREMENTS Questions from the Child Health Supplement to the 1988 National Health Interview Survey and the International Union Against Tuberculosis and Lung Disease Bronchial Symptoms Questionnaire were used to estimate the prevalence of asthma and wheezing-related illness. RESULTS Information was gathered on 1285 children. Of this sample, 184 (14.3%) were reported to have ever had asthma (cumulative prevalence) and 111 (8.6%) were reported to have asthma in the last 12 months (period prevalence). The asthma period prevalence rate among Bronx children was twice the United States rate (4.3%). Among children 0 through 11 years of age, the prevalence rate was similar for boys and girls, although among children 12 through 17 years of age, asthma was significantly more prevalent among boys. Fifty-four children (4.2%) were reported to have had wheezing in the past 12 months unassociated with a diagnosis of asthma (wheeze only). The cumulative, but not the period, prevalence rate of asthma differed significantly by income and race/ethnicity. The cumulative prevalence was significantly higher among Hispanics and children from the lowest income families. The prevalence of wheeze only (no reported history of asthma) was higher among whites (6.4%) and blacks (5.8%) than Hispanics (2.9%) (P < .1). The reported number of wheezing attacks and the average number of nights per week that sleep was disturbed by wheezing during the past year were similar for those with asthma and those with wheeze only, although severe attacks (wheezing severe enough to limit speech) were significantly more likely among those reported to have asthma (P < .001). The total asthma prevalence (period prevalence of asthma plus wheeze only) was 12.8% and was quite consistent across subgroups. CONCLUSIONS These data suggest that the prevalence of asthma among inner-city children may be substantially higher than the rates for this group estimated from national survey data. Some proportion of the wheeze only group may represent undiagnosed, and thereby undertreated, asthma. Public health efforts directed at reducing asthma morbidity and mortality need to address the possibility that asthma prevalence is higher within inner cities and that a large number of children with asthma may be inadequately diagnosed and treated.

Guidelines on forgoing life-sustaining medical treatment

Abstract: Most children who become ifi, even those with lifothreatening disorders, recover to lead satisfying lives. Nonetheless, the course of disease may at times cause health care professionals and families to consider whether continued treatment truly represents the best option. Sometimes limiting or stopping life support seems most appropriate, especially if treatment only preserves biological existence or if the overall goal of therapy has shifted to the maintenance of comfort. Based on the existing consensus in ethics and law, the following guidelines for professionals caring for children suggest elements in decisions to forgo lifosustaining medical treatment (LSMT). Decisions to withhold or withdraw LSMT may soriously tax the intellectual and emotional reserves of all parties. Patients, families, physicians, and other members of the medical care team should have access to and feel free to use ethics consultants or ethics cornmittees in addition to the other resources on which they usually rely.5’6

Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated?

Abstract: Objective. The aim of this research was to describe the postoperative respiratory complications after tonsillectomy and/or adenoidectomy (T and/or A) in children with obstructive sleep apnea syndrome (OSAS), to define which children are at risk for these complications, and to determine whether continuous positive airway pressure (CPAP) is an effective strategy for dealing with these complications. Methods. The data for this study were gathered through a retrospective chart review of all children 15 years of age or younger with polysomnographically (PSG) proven OSAS who had a T and/or A at Hennepin County Medical Center between January 1985 and September 1992. Particular attention was paid to factors that contributed to the OSAS, postoperative respiratory complications, and intervention strategies for dealing with these complications. Results. The charts of 37 children with OSAS documented by preoperative PSG who later had a T and/or A were reviewed retrospectively. Ten of these children had significant postoperative respiratory compromise secondary to OSAS that prolonged their hospital stay from 1 to 30 days and caused symptoms ranging from O2 desaturation <80% to respiratory failure. These children were younger and had significant associated medical problems that contributed to or resulted from their OSAS in addition to large tonsils and adenoids. The associated medical problems included craniofacial anomalies, hypotonia, morbid obesity, previous upper airway trauma, cor pulmonale, and failure to thrive. The children with postoperative respiratory complications also had more severe apnea on their preoperative PSG. One child had a uvulopalatopharyngoplasty (UPPP) in addition to the T & A. Taken together, the history, physical and neurological examination, and the PSG were able to identify successfully the children who subsequently developed respiratory compromise secondary to OSAS after a T and/or A. Nasal continuous positive airway pressure (CPAP) and bilevel CPAP was used successfully to manage the preoperative and/or postoperative upper airway obstruction in five of these children. Conclusions. Based on these findings, overnight observation is recommended with an apnea monitor and oximeter for patients undergoing a T and/or A who have OSAS and meet any of the following high-risk clinical criteria: (1) 40 and (2) SaO2 nadir <70%; or undergoing a UPPP in addition to the T and/or A. Nasal CPAP/bilevel CPAP can be used to manage the preoperative and/or postoperative upper airway obstruction in patients with OSAS undergoing a T and/or A.

Assessing the Health Status of Children Entering Foster Care

Abstract: Objective. Most research on health problems of children in foster care has been cross-sectional, resulting in overselection of children who have been in care long-term and underrepresentation of children who are in care for a short time. Methodology. This paper reports on the health of a large cohort of children who had complete health examinations at the time of entry into foster care in a middle-size city during a 2-year period. Results. Results indicate that >90% of the children had an abnormality in atleast one body system, 25% failed the vision screen, and 15% failed the hearing screen. The children were also lighter and shorter than the norm. Mental health screening revealed that 75% had a family history of mental illness or drug or alcohol abuse. Of children older than 3 years of age, 15% admitted to or were suspect for suicidal ideation and 7% for homicidal ideation. Of the children younger than 5 years of age, 23% had abnormal or suspect results on developmental screening examinations. At the time of entry into foster care, 12% of the children required an antibiotic. More than half needed urgent or nonurgent referrals for medical services and, for children >3 years of age, more than half needed urgent or nonurgent referrals for dental and mental health services. Just 12% of the children required only routine follow-up care. Conclusions. The high prevalence and broad range of health needs of children at the time they enter foster care necessitate the design and implementation of better models of health care delivery for children in foster care.

Parenting Behaviors and the Onset of Smoking and Alcohol Use: A Longitudinal Study

Abstract: Objective To identify which specific parenting behaviors are associated with the onset of alcohol and tobacco use and how they are associated Design Prospective cohort study of two groups of preadolescents surveyed annually, the first group for 4 years, the second for 3 years Setting Two public school districts in Southern California Subjects 1034 fifth graders and 1266 seventh graders began the study after obtaining parental consent to complete surveys in a classroom setting By the last measurement, attrition was 37 and 38% for the two cohorts, respectively Main outcome measures The onset of tobacco or alcohol use in the last month Results Children who reported that parents spent more time with them and communicated with them more frequently had lower onset rates of using alcohol and tobacco in the last month These parental interactions lead to more positive relationships with their children Parental monitoring and positive relations were protective factors for disruptive behavior and the selection of substance-using friends Disruptive behavior increased the odds of adolescents drinking in the last month approximately twofold and of smoking in the last month two to fourfold Conclusions This study provides further evidence that parenting behaviors are significant precursors to adolescent disruptive behavior, vulnerability to peer pressure, and subsequent substance use Parents should be targeted in future substance use prevention programs, before their children reach adolescence

Predicting Adult Stature Without Using Skeletal Age: The Khamis-Roche Method

Abstract: Study objective. To obtain reliable and accurate predictions of adult stature in white American children who are free of disease without using skeletal age. Design. Apply a modification of the Roche-Wainer-Thissen stature prediction model to a sample of white American children. Setting. Longitudinal data (every 6 months) from participants in the Fels Longitudinal Study were used for the development of the stature prediction model. Participants. Residents of Southwest Ohio, 223 white males and 210 white females, at the time of their enrollment into the Fels Longitudinal Study. Measurements and results. The errors of the proposed method, which does not use skeletal age as a predictor variable, are only slightly larger than those for the Roche-Wainer-Thissen method which uses skeletal age as a predictor variable. Conclusions. Adult stature predictions are needed commonly but the current methods are difficult to apply because they require a skeletal age assessed by a modern method. The Khamis-Roche method predicts adult stature in the absence of skeletal age with only a slight deterioration in accuracy and reliability. The applicability of the Khamis-Roche method is limited to white American children without pathologic conditions that alter the potential for growth in stature, but it should be useful for white children who are unusual in stature or in levels of maturity for age.

Prenatal Dexamethasone Treatment in Conjunction with Rescue Therapy of Human Surfactant: A Randomized Placebo-Controlled Multicenter Study

Abstract: OBJECTIVES A placebo-controlled, randomized, double-blind study was performed to determine whether prenatal dexamethasone (DEX) treatment improves the outcome of the preterm infant when exogenous surfactant is available. METHODS 157 pregnant women at five hospitals with threatened preterm delivery and with lengths of gestation < 32 weeks received either DEX (dose 6 mg four times at 12-hour intervals) or placebo (PL). Prenatal treatment was not repeated. Preterm infants received rescue therapy of human surfactant (maximum four doses) if they required ventilatory support and at least 40% oxygen for the treatment of respiratory distress syndrome (RDS). RESULTS Enrolled pregnant women delivered 188 live-born neonates, of whom 79 (DEX 41 and PL 38 neonates) were born 1 to 14 days after the prenatal treatment. Neonates born within 1 to 14 days after the initial DEX treatment had a lower incidence of RDS (DEX, 44%; PL, 79%; P < .01), lower requirements of surfactant (DEX, 22%; PL, 53%; P < .01), shorter duration of ventilatory support (DEX, 2.0 days; PL, 5.3 days; P < .05) and oxygen therapy (DEX, 2.0 days; PL, 7.0 days; P < .01), and a higher neonatal survival without ventilatory support (P < .05) than PL-treated neonates. DEX-treated neonates had higher mean blood pressure than PL-treated neonates during the first 3 days after birth. Among all neonates treated with DEX, there was a lower incidence of intraventricular hemorrhage or periventricular leucomalacia (DEX, 13%; PL, 33%; P < .01). Reduction in the incidence of intraventricular hemorrhage or periventricular leucomalacia in DEX-treated neonates was particularly associated with exogenous human surfactant therapy (DEX+surfactant 10%; PL+surfactant 48%; P < .01). CONCLUSIONS Prenatal DEX treatment combined with exogenous human surfactant therapy in preterm infants decreases pulmonary morbidity and cerebral complications, and increases survival without severe morbidity.

Reading ability of parents compared with reading level of pediatric patient education materials.

Abstract: Objectives. To test the reading ability of parents of pediatric outpatients and to compare their reading ability with the ability necessary to read commonly used educational materials; to compare individual reading grade levels with the levels of the last grade completed in school; and to further validate a new literacy screening test designed specifically for medical settings. Design. Prospective survey. Setting. Pediatrics outpatient clinic in a large, public university, teaching hospital. Participants. Three hundred ninety-six parents or other caretakers accompanying pediatric outpatients. Measurements. Demographics and educational status were assessed using a structured interview. Reading ability was tested using the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Wide Range Achievement Test-Revised2. Written educational materials were assessed for readability levels with a computer program (Grammatik IV). Results. The mean score on the REALM for all parents placed them in the seventh to eighth grade reading range, despite the mean self-reported last grade completed in school being 11th grade 5th month. Wide Range Achievement Test-Revised2 scores correlated well with REALM scores (0.82). Eighty percent of 129 written materials from the American Academy of Pediatrics, the Centers for Disease Control, the March of Dimes, pharmaceutical companies, and commercially available baby books required at least a 10th grade reading level. Only 25% of 60 American Academy of Pediatrics items and 19% of all materials tested were written at less than a ninth grade level, and only 2% of all materials were written at less than a seventh grade level. Conclusion. This study demonstrates that parents9 self-reported education level will not accurately indicate their reading ability. Testing is needed to screen at-risk parents for low reading levels. In a public health setting, a significant amount of available parent education materials and instructions require a higher reading level than most parents have achieved. In such settings, all materials probably should be written at less than a high school level if most parents are to be expected to read them. The REALM can easily be used in busy public health clinics to screen parents for reading ability.

Interleukin-6: A Sensitive Parameter for the Early Diagnosis of Neonatal Bacterial Infection

Abstract: Objective Early recognition is important for the successful treatment and outcome of neonatal infections. As interleukin-6 (Il-6) plays a critical role in the induction of C-reactive protein (CRP) synthesis in the liver, it was hypothesized that this cytokine could be detected earlier in blood than the CRP during the course of bacterial infection. Design In a prospective study of 298 newborns who were admitted to the nursery unit, CRP levels, blood cell count with differential, and Il-6 levels were determined at the time of admission and 24 hours after admission. Seventy-six newborns were excluded from the study because of incomplete or incorrect blood sampling. Results The remaining 222 newborns were assigned to one of five groups: 11 newborns with blood culture-positive sepsis (sensitivity of Il-6 on admission 73%), 15 newborns with clinical sepsis (sensitivity of Il-6 on admission 87%), 41 newborns with infection (sensitivity of Il-6 on admission 68%), and 54 newborns without clinical and laboratory evidence of infection (specificity 78%). The remaining 101 newborns were defined as a mixed group because the diagnosis of neonatal infection could not clearly be made. Seventy-five percent of infected newborns had negative Il-6 levels 24 hours after admission. Of the 18 infected newborns with negative Il-6 levels on admission, 10 newborns had elevated CRP levels, suggesting that Il-6 was already negative because of the short half-life of Il-6. Sensitivity of Il-6 in CRP-negative newborns on admission was 100% in newborns with blood culture-positive and clinical sepsis. Il-6 was more sensitive than CRP in infected newborns on admission (73% vs 58%). Conclusion Il-6 is a sensitive parameter for diagnosing neonatal bacterial infection. The combination of CRP and Il-6 seems to be the ideal tool for the early diagnosis of neonatal infection.

Infant Sleep Position and Risk for Sudden Infant Death Syndrome: Report of Meeting Held January 13 and 14, 1994, National Institutes of Health, Bethesda, MD

Abstract: Objective. To evaluate the current knowledge on the relationship between infant sleep position and sudden infant death syndrome (SIDS), and to determine how the information can be used to guide further activities in the United States. Methods. Data from international vital statistics, epidemiologic studies of SIDS risk factors, and studies of outcomes of public health interventions that advocated nonprone sleeping to reduce the risk for SIDS were discussed at a meeting held by the National Institute of Child Health and Human Development (NICHD) with cosponsorship from the National Institute on Deafness and Other Communication Disorders (NIDCD), and the National Center for Health Statistics (NCHS) on January 13, and 14, 1994. Results. Trends in postneonatal mortality and SIDS rates from 1980 through 1992 were evaluated for Australia, Britain, New Zealand, the Netherlands, Norway, Sweden, and the United States. All of the countries that experienced a rapid decline in prone sleeping also had reductions of approximately 50% in their SIDS rates. Postneonatal mortality rates dropped as well, with the reduction in SIDS being the primary contributor to the reported declines. The major behavioral change in all targeted populations was in sleep position. No significant changes were observed in the proportion of parents who smoked cigarettes, or in breast-feeding. Preliminary data from population-based studies showed there were no reported adverse outcomes associated with a change to side or back sleep position, such as an increase in deaths due to aspiration or in apparent life-threatening events. Conclusion. The overwhelming opinion of the assembled experts was that the evidence justified greater effort to reach parents with the American Academy of Pediatrics9 recommendation that healthy infants, when being put down to sleep, be positioned on their side or back.

Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children.

Abstract: Objective. The aim of this prospective study was to compare the clinical value of the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell (WBC) count in diagnosis and follow-up of acute hematogenous osteomyelitis in children. Design. Forty-four children aged 2 weeks to 14 years with bacteriologically confirmed acute hematogenous osteomyelitis were examined. Staphylococcus aureus was responsible in 39 cases (89%), Haemophilus influenzae type b in 3 cases (7%), pneumococcus in 1 case (2%), and a microaerophilic streptococcus in 1 case (2%). ESR was measured at the time of admission and on days 3, 5, 7, 10, 14, 19, and 29 of treatment, and CRP was measured on the same days as ESR but also on days 2, 9, 12, 17, and 23. WBC count was examined at the time of admission and on days 5, 10, 19, and 29. Results. ESR was elevated (≥20 mm/h) initially in 92% of the cases; the mean value was 45 mm/h, and the peak values (mean 58 mm/h) were reached on days 3 to 5. After this the levels slowly returned to normal in approximately 3 weeks (mean 18 days). CRP was elevated (>19 mg/L) at the time of admission in 98% of the cases, the mean value being 71 mg/L. The peak CRP value was reached on day 2 (mean 83 mg/L). The decrease was very rapid, normal values being reached within a week (mean 6.9 days). The WBC count was a poor indicator of acute hematogenous osteomyelitis, since only 35% of the children had leukocytosis (WBCs > 12 x 109/L) at the time of admission. Conclusions. In patients with acute hematogenous osteomyelitis, CRP increased and especially decreased significantly faster than ESR, reflecting the effectiveness of the therapy given and predicting recovery more sensitively than ESR or WBC count.

Ultrasound screening for developmental dysplasia of the hip in the neonate: the effect on treatment rate and prevalence of late cases

Abstract: OBJECTIVE To assess the effect of ultrasound screening on primary diagnosis, management, and prevalence of late cases of developmental dysplasia of the hip (DDH). DESIGN A randomized, controlled trial, including 11,925 newborn infants who were allocated to receive either general, or selective or no ultrasound screening in addition to the clinical examination. In the selectivity screened group only infants with risk factors or clinical findings of DDH received an ultrasound examination. The infants were at least 27 months old at the conclusion of the study. Those with risk factors for DDH had a radiograph examination of the hips at 4.5 months of age. RESULTS The three study groups did not differ in terms of sex distribution or positive Barlow/Ortolani tests. General ultrasound screening resulted in a higher treatment rate than in either the selective or in the no ultrasound screening groups (3.4% vs 2.0% and 1.8%, P < .0001). For infants not subjected to treatment, ultrasound screening resulted in a higher follow-up rate because of nonconclusive early findings (13%, 1.8%, 0%, respectively; P < .0001). The prevalence of late subluxation or dislocation was lower for subjects assigned to general ultrasound screening than for those subjected to selective or no ultrasound screening, but the differences were not statistically significant (0.3, 0.7, 1.3 per 1000, respectively; P = .11, test for trend). CONCLUSION The effect of ultrasound screening in reducing the prevalence of late DDH was at best marginal despite a considerable increase in diagnostic and therapeutic efforts.

Fluoxetine treatment of children and adults with autistic disorder and mental retardation

Abstract: An open trial of pharmacological treatment with fluoxetine, ranging from 20 mg every other day to 80 mg per day, led to a significant improvement in Clinical Global Impressions ratings of Clinical Severity in 15 of 23 subjects with autistic disorder and 10 of 16 subjects with mental retardation Six of 23 patients with autistic disorder and 3 of 16 patients with mental retardation had side effects which significantly interfered with function, consisting predominantly of restlessness, hyperactivity, agitation, decreased appetite, or insomnia Double-blind studies of the efficacy of pharmacological agents that potently inhibit 5-IIT uptake in the treatment of mental retardation coexisting with Axis I psychiatric disorders (especially obsessive-compulsive disorder) and autistic disorder are warranted

Risk Factors for Pneumonia Among Children in a Brazilian Metropolitan Area

Abstract: Objective. To investigate risk factors for pneumonia for infants Design. Hospital-based, case-control study with neighborhood control subjects. Setting. Urban area in southern Brazil. Subjects. Five hundred ten infants with radiologically confirmed pneumonia who were admitted to a pediatric hospital. One age-matched neighborhood control subject was selected for each case. Results. Multiple conditional regression modeling was used to control for confounding, taking into account the hierarchical relationships between risk factors. The incidence of radiologically confirmed pneumonia was associated with low paternal education, the number of persons in the household, young maternal age, attendance at day-care centers, low birth weight and weight-for-age, lack of breast-feeding and of non-milk supplements, and a history of previous pneumonia or wheezing. Day-care center attendance showed the highest risk, with an adjusted odds ratio of 11.75. Conclusions. In addition to continued efforts toward appropriate case management, actions directed against the above risk factors may help prevent the major cause of deaths of children younger than 5 years.