Showing papers in "Pediatrics in 2000"

Early Intervention and Language Development in Children Who Are Deaf and Hard of Hearing

Abstract: Objective. The primary purpose of this study was to examine the relationship between age of enrollment in intervention and language outcomes at 5 years of age in a group of deaf and hard-of-hearing children. Method. Vocabulary skills at 5 years of age were examined in a group of 112 children with hearing loss who were enrolled at various ages in a comprehensive intervention program. Verbal reasoning skills were explored in a subgroup of 80 of these children. Participants were evaluated using the Peabody Picture Vocabulary Test and a criterion-referenced measure, the Preschool Language Assessment Instrument, administered individually by professionals skilled in assessing children with hearing loss. A rating scale was developed to characterize the level of family involvement in the intervention program for children in the study. Results. A statistically significant negative correlation was found between age of enrollment and language outcomes at 5 years of age. Children who were enrolled earliest (eg, by 11 months of age) demonstrated significantly better vocabulary and verbal reasoning skills at 5 years of age than did later-enrolled children. Regardless of degree of hearing loss, early-enrolled children achieved scores on these measures that approximated those of their hearing peers. In an attempt to understand the relationships among performance and factors, such as age of enrollment, family involvement, degree of hearing loss, and nonverbal intelligence, multiple regression models were applied to the data. The analyses revealed that only 2 of these factors explained a significant amount of the variance in language scores obtained at 5 years of age: family involvement and age of enrollment. Surprisingly, family involvement explained the most variance after controlling for the influence of the other factors ( r = .615; F change = 58.70), underscoring the importance of this variable. Age of enrollment also contributed significantly to explained variance after accounting for the other variables in the regression ( r = −.452; F change = 19.24). Importantly, there were interactions between the factors of family involvement and age of enrollment that influenced outcomes. Early enrollment was of benefit to children across all levels of family involvement. However, the most successful children in this study were those with high levels of family involvement who were enrolled early in intervention services. Late-identified children whose families were described as limited or average in involvement scored >2 standard deviations below their hearing peers at 5 years of age. Even in the best of circumstances (eg, early enrollment paired with high levels of family involvement), the children in this study scored within the low average range in abstract verbal reasoning compared with hearing peers, reflecting qualitative language differences in these groups of children. Conclusions. Consistent with the findings of Yoshinaga-Itano et al, 1 significantly better language scores were associated with early enrollment in intervention. High levels of family involvement correlated with positive language outcomes, and, conversely, limited family involvement was associated with significant child language delays at 5 years of age, especially when enrollment in intervention was late. The results suggest that success is achieved when early identification is paired with early interventions that actively involve families.

Childhood Obesity and Self-Esteem

Abstract: Background. Although childhood obe- sity may have detrimental consequences for childhood self-esteem, the prevalence and magnitude of this prob- lem is controversial. In addition, the social and emotional effects of decreased self-esteem in obese children are unknown. Methods. A total of 1520 children, 9 to 10 years of age, born to mothers in the National Longitudinal Survey of Youth were studied. Comprehensive demographic data including race and family income were available in 97% of the cohort. Self-esteem was measured using Self- Perception Profile for Children. The 4-year follow-up Self-Perception Profile for Children scores were avail- able in 79% of the children. Obesity was defined as a body mass index greater than the 95th percentile for age and gender. Additional data include a self-administered questionnaire at 13 to 14 years of age concerning emo- tional well being, smoking, and alcohol consumption. Data were stratified by race and gender. The data were weighted to reflect a nationally representative sample of children born to mothers 17 to 28 years of age. Results. Scholastic and global self-esteem scores were not significantly different among 9- to 10-year-old obese and nonobese children. However, over the 4-year period, obese Hispanic females and obese white females showed significantly decreased levels of global self- esteem compared with nonobese Hispanic females and nonobese white females, respectively. Mild decreases in self-esteem also were observed in obese boys compared with nonobese boys. As a result, by 13 to 14 years of age, significantly lower levels of self-esteem were observed in obese boys, obese Hispanic girls, and obese white girls compared with their nonobese counterparts. Decreasing levels of self-esteem in obese children were associated with significantly increased rates of sadness, loneliness, and nervousness compared with obese children whose self-esteem increased or remained unchanged. In addi- tion, obese children with decreasing levels of self-esteem over the 4-year period were more likely to smoke and drink alcohol compared with obese children whose self- esteem increased or remained unchanged. Conclusion. Obese Hispanic and white females dem- onstrate significantly lower levels of self-esteem by early adolescence. In addition, obese children with decreasing levels of self-esteem demonstrate significantly higher rates of sadness, loneliness, and nervousness and are more likely to engage in high-risk behaviors such as smoking or con- suming alcohol. Pediatrics 2000;105(1). URL: http://www.

Neurodevelopmental and Functional Outcomes of Extremely Low Birth Weight Infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993–1994

Abstract: Objectives. The purposes of this study were to report the neurodevelopmental, neurosensory, and functional outcomes of 1151 extremely low birth weight (401–1000 g) survivors cared for in the 12 participating centers of the National Institute of Child Health and Human Development Neonatal Research Network, and to identify medical, social, and environmental factors associated with these outcomes. Study Design. A multicenter cohort study in which surviving extremely low birth weight infants born in 1993 and 1994 underwent neurodevelopmental, neurosensory, and functional assessment at 18 to 22 months9 corrected age. Data regarding pregnancy and neonatal outcome were collected prospectively. Socioeconomic status and a detailed interim medical history were obtained at the time of the assessment. Logistic regression models were used to identify maternal and neonatal risk factors for poor neurodevelopmental outcome. Results. Of the 1480 infants alive at 18 months of age, 1151 (78%) were evaluated. Study characteristics included a mean birth weight of 796 ± 135 g, mean gestation (best obstetric dates) 26 ± 2 weeks, and 47% male. Birth weight distributions of infants included 15 infants at 401 to 500 g; 94 at 501 to 600 g; 208 at 601 to 700 g; 237 at 701 to 800 g; 290 at 801 to 900 g; and 307 at 901 to 1000 g. Twenty-five percent of the children had an abnormal neurologic examination, 37% had a Bayley II Mental Developmental Index Conclusion. ELBW infants are at significant risk of neurologic abnormalities, developmental delays, and functional delays at 18 to 22 months9 corrected age.

Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder

Abstract: This clinical practice guideline provides recommendations for the assessment and diagnosis of school-aged children with attention-deficit/hyperactivity disorder (ADHD). This guideline, the first of 2 sets of guidelines to provide recommendations on this condition, is intended for use by primary care clinicians working in primary care settings. The second set of guidelines will address the issue of treatment of children with ADHD. The Committee on Quality Improvement of the American Academy of Pediatrics selected a committee composed of pediatricians and other experts in the fields of neurology, psychology, child psychiatry, development, and education, as well as experts from epidemiology and pediatric practice. In addition, this panel consists of experts in education and family practice. The panel worked with Technical Resources International, Washington, DC, under the auspices of the Agency for Healthcare Research and Quality, to develop the evidence base of literature on this topic. The resulting evidence report was used to formulate recommendations for evaluation of the child with ADHD. Major issues contained within the guideline address child and family assessment; school assessment, including the use of various rating scales; and conditions seen frequently among children with ADHD. Information is also included on the use of current diagnostic coding strategies. The deliberations of the committee were informed by a systematic review of evidence about prevalence, coexisting conditions, and diagnostic tests. Committee decisions were made by consensus where definitive evidence was not available. The committee report underwent review by sections of the American Academy of Pediatrics and external organizations before approval by the Board of Directors. The guideline contains the following recommendations for diagnosis of ADHD: 1) in a child 6 to 12 years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD; 2) the diagnosis of ADHD requires that a child meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria; 3) the assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment; 4) the assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment, and associated conditions; 5) evaluation of the child with ADHD should include assessment for associated (coexisting) conditions; and 6) other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of other coexisting conditions (eg, learning disabilities and mental retardation). This clinical practice guideline is not intended as a sole source of guidance in the evaluation of children with ADHD. Rather, it is designed to assist primary care clinicians by providing a framework for diagnostic decisionmaking. It is not intended to replace clinical judgment or to establish a protocol for all children with this condition and may not provide the only appropriate approach to this problem.

Determinants of Adolescent Physical Activity and Inactivity Patterns

Abstract: Objectives. Despite recognition of the important influence of environmental determinants on physical activity patterns, minimal empirical research has been done to assess the impact of environmental/ contextual determinants of physical activity. This article aims to investigate environmental and sociodemographic determinants of physical activity and inactivity patterns among subpopulations of US adolescents. We define en- vironmental determinants as modifiable factors in the physical environment that impose a direct influence on the opportunity to engage in physical activity. The present research examines environmental and sociode- mographic determinants of physical activity and inactiv- ity with the implication that these findings can point toward societal-level intervention strategies for increas- ing physical activity and decreasing inactivity among adolescents. Study Design and Methodology. The study popula- tion consists of nationally representative data from the 1996 National Longitudinal Study of Adolescent Health on 17 766 US adolescents enrolled in US middle and high schools (including 3933 non-Hispanic blacks, 3148 His- panics, and 1337 Asians). Hours/week of inactivity (TV/ video viewing and video/computer games) and times/ week of moderate to vigorous physical activity were collected by questionnaire. Outcome variables were moderate to vigorous physical activity and inactivity, which were broken into categories (physical activity: 0 -2 times/week, 3- 4 times/week, and >5 times/week; inactiv- ity: 0 -10 hours/week, 11-24 hours/week, and >25 hours/ week). Sociodemographic and environmental correlates of physical activity and inactivity were used as exposure and control variables and included sex, age, urban resi- dence, participation in school physical education pro- gram, use of community recreation center, total reported incidents of serious crime in neighborhood, socioeco- nomic status, ethnicity, generation of residence in the United States, presence of mother/father in household, pregnancy status, work status, in-school status, region, and month of interview. Logistic regression models of high versus low and me- dium physical activity and inactivity were used to investi- gate sex and ethnic interactions in relation to environmen- tal and sociodemographic factors to examine evidence for the potential impact of physical education and recreation programs and sociodemographic factors on physical activ- ity and inactivity patterns. Results. Moderate to vigorous physical activity was lower and inactivity higher for non-Hispanic black and Hispanic adolescents. Participation in school physical education programs was considerably low for these ado- lescents and decreased with age. Participation in daily school physical education (PE) program classes (adjusted odds ratio (AOR): 2.21; confidence interval (CI): 1.82- 2.68) and use of a community recreation center (AOR: 1.75; CI: 1.56 -1.96) were associated with an increased likelihood of engaging in high level moderate to vigor- ous physical activity. Maternal education was inversely associated with high inactivity patterns; for example, having a mother with a graduate or professional degree was associated with an AOR of .61 (CI: .48-.76) for high inactivity. High family income was associated with in- creased moderate to vigorous physical activity (AOR: 1.43; CI: 1.22-1.67) and decreased inactivity (AOR: .70; CI: .59 -.82). High neighborhood serious crime level was as- sociated with a decreased likelihood of falling in the highest category of moderate to vigorous physical activ- ity (AOR: .77; CI: .66 -.91). Conclusions. These results show important associa- tions between modifiable environmental factors, such as participation in school PE and community recreation pro- grams, with activity patterns of adolescents. Despite the marked and significant impact of participation in school PE programs on physical activity patterns of US adoles- cents, few adolescents participated in such school PE programs; only 21.3% of all adolescents participated in 1

The EPICure Study: Outcomes to Discharge From Hospital for Infants Born at the Threshold of Viability

Abstract: Objective. To evaluate the outcome for all infants born before 26 weeks of gestation in the United Kingdom and the Republic of Ireland. This report is of survival and complications up until discharge from hospital. Methodology. A prospective observational study of all births between March 1, 1995 and December 31, 1995 from 20 to 25 weeks of gestation. Results. A total of 4004 births were recorded, and 811 infants were admitted for intensive care. Overall survival was 39% (n 5 314). Male sex, no reported chorioamnio- nitis, no antenatal steroids, persistent bradycardia at 5 minutes, hypothermia, and high Clinical Risk Index for Babies (CRIB) score were all independently associated with death. Of the survivors, 17% had parenchymal cysts and/or hydrocephalus, 14% received treatment for reti- nopathy of prematurity (ROP), and 51% needed supple- mentary oxygen at the expected date of delivery. Failure to administer antenatal steroids and postnatal transfer for intensive care within 24 hours of birth were predic- tive of major scan abnormality; lower gestation was pre- dictive of severe ROP, while being born to a black mother was protective. Being of lower gestation, male sex, tocolysis, low maternal age, neonatal hypothermia, a high CRIB score, and surfactant therapy were all predic- tive of oxygen dependency. Intensive care was provided in 137 units, only 8 of which had >5 survivors. There was no difference in survival between institutions when di- vided into quintiles based on their numbers of extremely preterm births or admissions. Conclusions. This study provides outcome data for this geographically defined cohort; survival and neonatal morbidity are consistent with previous data from the United Kingdom and facilitate comparison with other geographically based data. Pediatrics 2000;106:659 - 671; ex- tremely preterm infant, survival, cerebral ultrasound scan, intraventricular hemorrhage, parenchymal cysts, hydro- cephalus, retinopathy of prematurity, chronic lung disease. ABBREVIATIONS. PMA, postmenstrual age; NNU, neonatal unit; LMP, last menstrual period; EDD, expected date of delivery; ROP, retinopathy of prematurity; CI, confidence interval; HR, heart rate; CRIB, Clinical Risk Index for Babies; RDS, respiratory distress syndrome; IQR, interquartile range; PROM, prolonged rupture of membranes .24 hours; Fio2, fraction of inspired oxygen; PDA, patent ductus arteriosus. T he care of the fetus considered to be at the threshold of viability raises some of the most difficult clinical problems for obstetricians and pediatricians. Advice given to parents needs to be based on reliable contemporary information drawn from appropriate populations. The number of these infants born in an individual unit is small and con- clusions based on their outcome are unreliable. Pub- lished reports derive from a range of populations including those from single tertiary centers with se- lected patients and others based on geographically defined areas. Furthermore, survival and morbidity are defined differently in different studies and show wide variation. For example, since 1990, for infants born at 25 weeks of gestational age, published rates of survival range from 35% to 79% 1,2 and published rates of severe disability range from 12% to 35%. 3,4 The EPICure study was designed to describe sur- vival and health problems for all infants born before 26 completed weeks of gestational age in the United Kingdom and the Republic of Ireland. In this article we describe the progress of these infants during their initial admission for intensive care.

Poorer behavioral and developmental outcome more than 10 years after treatment for iron deficiency in infancy.

Abstract: Objective. To determine the long-term effects of iron deficiency in infancy. Design. Longitudinal follow-up study of children who had been tested and treated for iron deficiency as infants. Setting. Periurban community near San Jose, Costa Rica. Participants. Of the original 191 participants, 87% were reevaluated at 11 to 14 years old (average age: 12.3 years). The children were free of iron deficiency and growing normally by US standards. Those who had chronic, severe iron deficiency in infancy ( n = 48) were compared with those who had good iron status before and/or after iron therapy in infancy ( n = 114). Outcome Measures. Comprehensive set of cognitive, socioemotional, and motor tests and measures of school functioning. Results. Children who had severe, chronic iron deficiency in infancy scored lower on measures of mental and motor functioning. After control for background factors, differences remained statistically significant in arithmetic achievement and written expression, motor functioning, and some specific cognitive processes (spatial memory, selective recall, and tachistoscopic threshold). More of the formerly iron-deficient children had repeated a grade and/or been referred for special services or tutoring. Their parents and teachers rated their behavior as more problematic in several areas, agreeing in increased concerns about anxiety/depression, social problems, and attention problems. Conclusions. Severe, chronic iron deficiency in infancy identifies children who continue at developmental and behavioral risk >10 years after iron treatment.

Year 2000 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs

Abstract: The Joint Committee on Infant Hearing (JCIH) endorses early detection of, and intervention for infants with hearing loss (early hearing detection and intervention, [EHDI]) through integrated, interdisciplinary state and national systems of universal newborn hearing screening (UNHS), evaluation, and family-centered intervention. The goal of EHDI is to maximize linguistic and communicative competence and literacy development for children who are hard of hearing or deaf. Without appropriate opportunities to learn language, children who are hard of hearing or deaf will fall behind their hearing peers in language, cognition, and social-emotional development. Such delays may result in lower educational and employment levels in adulthood (Gallaudet University Center for Assessment and Demographic Study, 1998). Thus, all infants' hearing should be screened using objective, physiologic measures to identify those with congenital or neonatal onset hearing loss. Audiologic evaluation and medical evaluations should be in progress before 3 months of age. Infants with confirmed hearing loss should receive intervention before 6 months of age from health care and education professionals with expertise in hearing loss and deafness in infants and young children. Regardless of prior hearing screening outcomes, all infants who demonstrate risk indicators for delayed onset or progressive hearing loss should receive ongoing audiologic and medical monitoring for 3 years and at appropriate intervals thereafter to ensure prompt identification and intervention (American Speech-Language-Hearing Association [ASHA], 1997). EHDI systems should guarantee seamless transitions for infants and their families through this process. Appropriate early intervention programs are family-centered, interdisciplinary, culturally competent, and build on informed choice for families (Baker-Hawkins and Easterbrooks, 1994). To achieve informed decision-making, families should have access to professional, educational, and consumer organizations; and they should have opportunities to interact with adults and children who are hard of hearing and deaf (Ogden, 1996; Thompson, 1994). Families should have access to general information on …

Accuracy of teen and parental reports of obesity and body mass index.

Abstract: Objectives. Adolescent obesity is becoming an increasing public health problem. This study determines: 1) differences in teen and parental report of obesity, 2) amount of misclassification using body mass index (BMI) from self-reported versus measured height and weight as an indicator of obesity, and 3) whether misclassification varies by gender and socioeconomic status. Design. Weighted data from 15 483 baseline (T1) youth and parental interviews from the National Longitudinal Study of Adolescent Health were used. Seventy-four percent of teens were reinterviewed 1 year later (T2). Parents reported socioeconomic status indicators and whether their teen was obese. Teens reported height, weight, and weight perception. BMI was calculated from both self-reported height and weight at T1 and T2 and from measured height and weight at T2. Those with a BMI ≥95% corrected for age and gender were considered obese. Results. At T1, nearly one half of teens (47%) reporting they were very overweight were not obese by BMI. For teens obese by BMI, 19.6% were reported to be obese by both parent and teen, 6.4% by teen only, 29.9% by parent only, and 44.2% by neither teen nor parent. For those with persistent obesity, teen and/or parental report failed to identify more than one third (34%) as obese; 23.4% were identified by both teen and parent report, 5.4% by teen report only, and 37.2% by parent only. At T2, the correlation between BMI calculated from self-reported versus measured height and weight for the overall population was very strong (r = .92). Specificity of obesity status based on self-reported BMI, compared with obesity status based on measured BMI was .996; sensitivity, .722; positive predictive value, .860; and negative predictive value, .978. Overall, 3.8% of teens were misclassified using self-report measures. Girls were no more likely than boys to be misclassified as obese using BMI from self-reported height and weight. Conclusions. Parental report is a better indicator of obesity than teen report of weight status, but parental and teen reports are both poor predictors of adolescent obesity. Using BMI based on self-reported height and weight correctly classified 96% as to obesity status. Thus, studies can use self-reported height and weight to understand teen obesity and its correlates/sequelae.

Pediatric Deaths Attributable to Complex Chronic Conditions: A Population-Based Study of Washington State, 1980–1997

Abstract: Objectives. Advances in medical technology and public health are changing the causes and patterns of pediatric mortality. To better inform health care planning for dying children, we sought to determine if an increasing proportion of pediatric deaths were attributable to an underlying complex chronic condition (CCC), what the typical age of CCC-associated deaths was, and whether this age was increasing. Design. Population-based retrospective cohort from 1980 to 1997, compiled from Washington State annual censuses and death certificates of children 0 to 18 years old. Main Outcome Measures. For each of 9 categories of CCCs, the counts of death, mortality rates, and ages of death. Results. Nearly one-quarter of the 21 617 child deaths during this period were attributable to a CCC. Death rates for the sudden infant death syndrome (SIDS), CCCs, and all other causes each declined, but less so for CCCs. Among infants who died because of causes other than injury or SIDS, 31% of the remaining deaths were attributable to a CCC in 1980 and 41% by 1997; for deaths in children 1 year of age and older, CCCs were cited in 53% in 1980, versus 58% in 1997. The median age of death for all CCCs was 4 months 9 days, with substantial differences among CCCs. No overall change in the age of death between 1980 to 1997 was found (nonparametric trend test). Conclusions. CCCs account for an increasing proportion of child deaths. The majority of these deaths occur during infancy, but the typical age varies by cause. These findings should help shape the design of support care services offered to children dying with chronic conditions and their families.

International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines.

Abstract: The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC. As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for: * Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway. * Preventing heat loss: Hyperthermia should be avoided. * Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO(2) detection can be useful in the secondary confirmation of endotracheal intubation. * Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse. * Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available. * Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate.

Activity, Dietary Intake, and Weight Changes in a Longitudinal Study of Preadolescent and Adolescent Boys and Girls

Abstract: Objective. To examine the role of physical activity, inactivity, and dietary patterns on annual weight changes among preadolescents and adolescents, taking growth and development into account. Study Design. We studied a cohort of 6149 girls and 4620 boys from all over the United States who were 9 to 14 years old in 1996. All returned questionnaires in the fall of 1996 and a year later in 1997. Each child provided his or her current height and weight and a detailed assessment of typical past-year dietary intakes, physical activities, and recreational inactivities (TV, videos/VCR, and video/computer games). Methods. Our hypotheses were that physical activity and dietary fiber intake are negatively correlated with annual changes in adiposity and that recreational inactivity (TV/videos/games), caloric intake, and dietary fat intake are positively correlated with annual changes in adiposity. Separately for boys and girls, we performed regression analysis of 1-year change in body mass index (BMI; kg/m 2 ). All hypothesized factors were in the model simultaneously with several adjustment factors. Results. Larger increases in BMI from 1996 to 1997 were among girls who reported higher caloric intakes (.0061 ± .0026 kg/m 2 per 100 kcal/day; β ± standard error), less physical activity (−.0284 ± .0142 kg/m 2 /hour/day) and more time with TV/videos/games (.0372 ± .0106 kg/m 2 /hour/day) during the year between the 2 BMI assessments. Larger BMI increases were among boys who reported more time with TV/videos/games (.0384 ± .0101) during the year. For both boys and girls, a larger rise in caloric intake from 1996 to 1997 predicted larger BMI increases (girls: .0059 ± .0027 kg/m 2 per increase of 100 kcal/day; boys: .0082 ± .0030). No significant associations were noted for energy-adjusted dietary fat or fiber. Conclusions. For both boys and girls, a 1-year increase in BMI was larger in those who reported more time with TV/videos/games during the year between the 2 BMI measurements, and in those who reported that their caloric intakes increased more from 1 year to the next. Larger year-to-year increases in BMI were also seen among girls who reported higher caloric intakes and less physical activity during the year between the 2 BMI measurements. Although the magnitudes of these estimated effects were small, their cumulative effects, year after year during adolescence, would produce substantial gains in body weight. Strategies to prevent excessive caloric intakes, to decrease time with TV/videos/games, and to increase physical activity would be promising as a means to prevent obesity.

Delivery Room Management of the Apparently Vigorous Meconium-stained Neonate: Results of the Multicenter, International Collaborative Trial

Abstract: Objective. Disagreement exists concerning the appropriate delivery room management of the airway of vigorous meconium-stained infants. Some suggest a universal approach to intubation and suctioning of the airway in all such neonates, whereas others advocate a selective approach. We performed this investigation: 1) to assess whether intubation and suctioning of apparently vigorous, meconium-stained neonates would reduce the incidence of meconium aspiration syndrome (MAS); and 2) to determine the frequency of complications from delivery room intubation and suctioning of such infants. Methods. Inclusion criteria included: 1) gestational age ≥37 weeks; 2) birth through meconium-stained amniotic fluid of any consistency; and 3) apparent vigor immediately after birth. Subjects were randomized to be intubated and suctioned (INT) or to expectant management (EXP). Primary outcome measures included: 1) the incidence of respiratory distress, including MAS, and 2) the incidence of complications from intubation. Results. A total of 2094 neonates were enrolled from 12 participating centers (1051 INT and 1043 EXP). Meconium-stained amniotic fluid consistency was similar in both groups. Of the 149 (7.1%) infants that subsequently demonstrated respiratory distress, 62 (3.0%) had MAS and 87 (4.2%) had findings attributed to other disorders. There were no significant differences between groups in the occurrence of MAS (INT = 3.2%; EXP = 2.7%) or in the development of other respiratory disorders (INT = 3.8%; EXP = 4.5%). Of 1098 successfully intubated infants, 42 (3.8%) had a total of 51 complications of the procedure. In all cases, the complications were mild and transient in nature. Conclusions. Compared with expectant management, intubation and suctioning of the apparently vigorous meconium-stained infant does not result in a decreased incidence of MAS or other respiratory disorders. Complications of intubation are infrequent and short-lived.

Supplemental therapeutic oxygen for prethreshold retinopathy of prematurity (STOP-ROP), a randomized, controlled trial. I: Primary outcomes

Abstract: Objective. To determine the efficacy and safety of supplemental therapeutic oxygen for infants with prethreshold retinopathy of prematurity (ROP) to reduce the probability of progression to threshold ROP and the need for peripheral retinal ablation. Methods. Premature infants with confirmed pre- threshold ROP in at least 1 eye and median pulse oxim- etry <94% saturation were randomized to a conventional oxygen arm with pulse oximetry targeted at 89% to 94% saturation or a supplemental arm with pulse oximetry targeted at 96% to 99% saturation, for at least 2 weeks, and until both eyes were at study endpoints. Certified examiners masked to treatment assignment conducted weekly eye examinations until each study eye reached ophthalmic endpoint. An adverse ophthalmic endpoint for an infant was defined as reaching threshold criteria for laser or cryotherapy in at least 1 study eye. A favor- able ophthalmic endpoint was regression of the ROP into zone III for at least 2 consecutive weekly examinations or full retinal vascularization. At 3 months after the due date of the infant, ophthalmic findings, pulmonary sta- tus, growth, and interim illnesses were again recorded. Results. Six hundred forty-nine infants (325 conven- tional and 324 supplemental) were enrolled from 30 cen- ters over 5 years. Five hundred ninety-seven (92.0%) in- fants attained known ophthalmic endpoints, and 600 (92%) completed the ophthalmic 3-month assessment. The rate of progression to threshold in at least 1 eye was 48% in the conventional arm and 41% in the supplemen- tal arm. After adjustment for baseline ROP severity stra- tum, plus disease, race, and gestational age, the odds ratio (supplemental vs conventional) for progression was .72 (95% confidence interval: .52, 1.01). Final structural status of all study eyes at 3 months of corrected age showed similar rates of severe sequelae in both treatment arms: retinal detachments or folds (4.4% conventional vs 4.1% supplemental), and macular ectopia (3.9% conven- tional vs 3.9% supplemental). Within the prespecified ROP severity strata, ROP progression rates were lower with supplemental oxygen than with conventional oxy- gen, but the differences were not statistically significant. A post hoc subgroup analysis of plus disease (dilated and tortuous vessels in at least 2 quadrants of the posterior pole) suggested that infants without plus disease may be more responsive to supplemental therapy (46% progres- sion in the conventional arm vs 32% in the supplemental arm) than infants with plus disease (52% progression in

Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds.

Abstract: The definition of clinically significant hypoglycemia remains one of the most confused and contentious issues in contemporary neonatology. In this article, some of the reasons for these contentions are discussed. Pragmatic recommendations for operational thresholds, ie, blood glucose levels at which clinical interventions should be considered, are offered in light of current knowledge to aid health care providers in neonatal medicine. Future areas of research to resolve some of these issues are also presented.

Palliative care for children

Abstract: This statement presents an integrated model for providing palliative care for children living with a life-threatening or terminal condition. Advice on the development of a palliative care plan and on working with parents and children is also provided. Barriers to the provision of effective pediatric palliative care and potential solutions are identified. The American Academy of Pediatrics recommends the development and broad availability of pediatric palliative care services based on child-specific guidelines and standards. Such services will require widely distributed and effective palliative care education of pediatric health care professionals. The Academy offers guidance on responding to requests for hastening death, but does not support the practice of physician-assisted suicide or euthanasia for children. ABBREVIATION. AAP, American Academy of Pediatrics. In modern society, we expect children to outlive their parents. However, 53 000 children in the United States die every year from trauma, lethal congenital conditions, extreme prematurity, heritable disorders, or acquired illness.1 The causes of death in children are substantially different from the causes of death in adults; thus, palliative care guidelines that are appropriate for adults are often inappropriate for children. For children living with lifethreatening or terminal conditions, medical professionals are obligated to ensure that medical technology is used only when the benefits for the child outweigh the burdens. An infant or child will benefit from palliative care when no treatment has been shown to alter substantially the expected progression toward death. Palliative care seeks to enhance quality of life in the face of an ultimately terminal condition. Palliative treatments focus on the relief of symptoms (eg, pain, dyspnea) and conditions (eg, loneliness) that cause distress and detract from the child’s enjoyment of life. It also seeks to ensure that bereaved families are able to remain functional and intact. Hospice care refers to a package of palliative care services (including, for example, durable medical equipment, and both diagnostic and therapeutic interventions), generally provided at a limited per diem rate by a multidisciplinary group of physicians, nurses, and other personnel, such as chaplains, health aides, and bereavement counselors. Palliative care includes the control of pain and other symptoms and addresses the psychological, social, or spiritual problems of children (and their families) living with life-threatening or terminal conditions.2,3 The goal of palliative care is the achievement of the best quality of life for patients and their families, consistent with their values, regardless of the location of the patient.4 The American Academy of Pediatrics (AAP) has previously addressed the limitation or withdrawal of life-sustaining medical treatment.5–7 Specific strategies for palliative management of pain, dyspnea, agitation, nausea, vomiting, seizures, depression, anxiety, grief, and other symptoms can be found in other sources.8–11 PRINCIPLES FOR PALLIATIVE CARE The AAP calls for the development of clinical policies and minimum standards that promote the welfare of infants and children living with life-threatening or terminal conditions and their families, with the goal of providing equitable and effective support for curative, life-prolonging, and palliative care.12 The following principles serve as the foundation for an integrated model of palliative care. Respect for the Dignity of Patients and Families The provision of palliative care for children includes sensitivity to and respect for the child’s and family’s wishes. In consultation with the child’s parent or guardian, the plan of care incorporates respect for the terminally ill child’s preferences concerning testing, monitoring, and treatment. Consistent with this principle of respect, information about palliative care should be readily available and parents may choose to initiate a referral to a pediatric palliative care program. The needs of families must be attended to both during the illness and after the child’s death to improve their ability to survive the ordeal intact. Access to Competent and Compassionate Palliative

Maternal perceptions of overweight preschool children.

Abstract: Context. Childhood obesity is a major public health problem, and prevention efforts should begin early in life and involve parents. Objective. To determine what factors are associated with mothers9 failure to perceive when their preschool children are overweight. Design. Cross-sectional survey. Settings. Offices of private pediatricians and clinics of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Participants. Six hundred twenty-two mothers with children 23 to 60 months of age. Main Outcome Measures. Maternal demographic variables, maternal self-reported height and weight, and children9s measured height and weight. Mothers were asked whether they considered themselves or their children overweight. Results. Forty-five percent of mothers had low education (high school degree or less) and 55% had high education (some college or more). Obesity (body mass index: ≥30 kg/m2) was more common in the low education group of mothers (30% vs 17%), and their children tended to be more overweight (weight-for-height percentile: ≥90th; 19% vs 14%). Ninety-five percent of obese mothers believed that they were overweight, with no difference between education groups. However, 79% of mothers failed to perceive their overweight child as overweight. Among the 99 mothers with overweight children, low maternal education was associated with a failure to perceive their children as overweight after adjusting for low family income (≤185% of poverty), maternal obesity, age, and smoking plus the child9s age, race, and gender (adjusted odds ratio: 6.2; 95% confidence interval: 1.7–22.5). Conclusions. Obesity was more common in mothers with less education as well as in their children. Nearly all of the obese mothers regarded themselves as overweight. However, the majority of mothers did not view their overweight children as overweight, and this misperception was more common in mothers with less education. Childhood obesity prevention efforts are unlikely to be successful without a better understanding of how mothers perceive the problem of overweight in their preschool children.

Adverse sedation events in pediatrics: analysis of medications used for sedation.

Abstract: Objectives. To perform a systematic investigation of medications associated with adverse sedation events in pediatric patients using critical incident analysis of case reports. Methods. One hundred eighteen case reports from the adverse drug reporting system of the Food and Drug Administration, the US Pharmacopoeia, and the results of a survey of pediatric specialists were used. Outcome measures were death, permanent neurologic injury, prolonged hospitalization without injury, and no harm. The overall results of the critical incident analysis are reported elsewhere. The current investigation specifically examined the relationship between outcome and medications: individual and classes of drugs, routes of administration, drug combinations and interactions, medication errors and overdoses, patterns of drug use, practitioners, and venues of sedation. Results. Ninety-five incidents fulfilled study criteria and all 4 reviewers agreed on causation; 60 resulted in death or permanent neurologic injury. Review of adverse sedation events indicated that there was no relationship between outcome and drug class (opioids; benzodiazepines; barbiturates; sedatives; antihistamines; and local, intravenous, or inhalation anesthetics) or route of administration (oral, rectal, nasal, intramuscular, intravenous, local infiltration, and inhalation). Negative outcomes (death and permanent neurologic injury) were often associated with drug overdose (n = 28). Some drug overdoses were attributable to prescription/transcription errors, although none of 39 overdoses in 34 patients seemed to be a decimal point error. Negative outcomes were also associated with drug combinations and interactions. The use of 3 or more sedating medications compared with 1 or 2 medications was strongly associated with adverse outcomes (18/20 vs 7/70). Nitrous oxide in combination with any other class of sedating medication was frequently associated with adverse outcomes (9/10). Dental specialists had the greatest frequency of negative outcomes associated with the use of 3 or more sedating medications. Adverse events occurred despite drugs being administered within acceptable dosing limits. Negative outcomes were also associated with drugs administered by nonmedically trained personnel and drugs administered at home. Some injuries occurred on the way to a facility after administration of sedatives at home; some took place in automobiles or at home after discharge from medical supervision. Deaths and injuries after discharge from medical supervision were associated with the use of medications with long half-lives (chloral hydrate, pentobarbital, promazine, promethazine, and chlorpromazine). Conclusions. Adverse sedation events were frequently associated with drug overdoses and drug interactions, particularly when 3 or more drugs were used. Adverse outcome was associated with all routes of drug administration and all classes of medication, even those (such as chloral hydrate) thought to have minimal effect on respiration. Patients receiving medications with long plasma half-lives may benefit from a prolonged period of postsedation observation. Adverse events occurred when sedative medications were administered outside the safety net of medical supervision. Uniform monitoring and training standards should be instituted regardless of the subspecialty or venue of practice. Standards of care, scope of practice, resource management, and reimbursement for sedation should be based on the depth of sedation achieved (ie, the degree of vigilance and resuscitation skills required) rather than on the drug class, route of drug administration, practitioner, or venue.

Adverse Sedation Events in Pediatrics: A Critical Incident Analysis of Contributing Factors

Abstract: Objective. Factors that contribute to adverse sedation events in children undergoing procedures were examined using the technique of critical incident analysis. Methodology. We developed a database that consists of descriptions of adverse sedation events derived from the Food and Drug Administration9s adverse drug event reporting system, from the US Pharmacopeia, and from a survey of pediatric specialists. One hundred eighteen reports were reviewed for factors that may have contributed to the adverse sedation event. The outcome, ranging in severity from death to no harm, was noted. Individual reports were first examined separately by 4 physicians trained in pediatric anesthesiology, pediatric critical care medicine, or pediatric emergency medicine. Only reports for which all 4 reviewers agreed on the contributing factors and outcome were included in the final analysis. Results. Of the 95 incidents with consensus agreement on the contributing factors, 51 resulted in death, 9 in permanent neurologic injury, 21 in prolonged hospitalization without injury, and in 14 there was no harm. Patients receiving sedation in nonhospital-based settings compared with hospital-based settings were older and healthier. The venue of sedation was not associated with the incidence of presenting respiratory events (eg, desaturation, apnea, laryngospasm, ∼80% in each venue) but more cardiac arrests occurred as the second (53.6% vs 14%) and third events (25% vs 7%) in nonhospital-based facilities. Inadequate resuscitation was rated as being a determinant of adverse outcome more frequently in nonhospital-based events (57.1% vs 2.3%). Death and permanent neurologic injury occurred more frequently in nonhospital-based facilities (92.8% vs 37.2%). Successful outcome (prolonged hospitalization without injury or no harm) was associated with the use of pulse oximetry compared with a lack of any documented monitoring that was associated with unsuccessful outcome (death or permanent neurologic injury). In addition, pulse oximetry monitoring of patients sedated in hospitals was uniformly associated with successful outcomes whereas in the nonhospital-based venue, 4 out of 5 suffered adverse outcomes. Adverse outcomes despite the benefit of an early warning regarding oxygenation likely reflect lack of skill in assessment and in the use of appropriate interventions, ie, a failure to rescue the patient. Conclusions. This study—a critical incident analysis—identifies several features associated with adverse sedation events and poor outcome. There were differences in outcomes for venue: adverse outcomes (permanent neurologic injury or death) occurred more frequently in a nonhospital-based facility, whereas successful outcomes (prolonged hospitalization or no harm) occurred more frequently in a hospital-based setting. Inadequate resuscitation was more often associated with a nonhospital-based setting. Inadequate and inconsistent physiologic monitoring (particularly failure to use or respond appropriately to pulse oximetry) was another major factor contributing to poor outcome in all venues. Other issues rated by the reviewers were: inadequate presedation medical evaluation, lack of an independent observer, medication errors, and inadequate recovery procedures. Uniform, specialty-independent guidelines for monitoring children during and after sedation are essential. Age and size-appropriate equipment and medications for resuscitation should be immediately available regardless of the location where the child is sedated. All health care providers who sedate children, regardless of practice venue, should have advanced airway assessment and management training and be skilled in the resuscitation of infants and children so that they can successfully rescue their patient should an adverse sedation event occur.

Cerebral intravascular oxygenation correlates with mean arterial pressure in critically ill premature infants.

Abstract: Objectives. Premature infants experience brain injury, ie, germinal matrix–intraventricular hemorrhage (GMH-IVH) and periventricular leukomalacia (PVL), in considerable part because of disturbances in cerebral blood flow (CBF). Because such infants are susceptible to major fluctuations in mean arterial blood pressure (MAP), impaired cerebrovascular autoregulation would increase the likelihood for the changes in CBF that could result in GMH-IVH and PVL. The objectives of this study were to determine whether a state of impaired cerebrovascular autoregulation could be identified reliably and conveniently at the bedside, the frequency of any such impairment, and the relation of the impairment to the subsequent occurrence of severe GMH-IVH and PVL. Patients and Methods. To monitor the cerebral circulation continuously and noninvasively, we used near-infrared spectroscopy (NIRS) to determine quantitative changes in cerebral concentrations of oxygenated hemoglobin (HbO2) and deoxygenated hemoglobin (Hb) from the first hours of life. Our previous experimental study showed a strong correlation between a measure of cerebral intravascular oxygenation (HbD), ie, HbD = HbO2 − Hb, determined by NIRS, and volemic CBF, determined by radioactive microspheres. We studied 32 very low birth weight premature infants (gestational age: 23–31 weeks; birth weight: 605-1870 g) requiring mechanical ventilation, supplemental oxygen, and invasive blood pressure monitoring by NIRS from 1 to 3 days of age. MAP measured by arterial catheter pressure transducer and arterial oxygen saturation measured by pulse oximetry were recorded simultaneously. The relationship of MAP to HbD was quantitated by coherence analysis. Results. Concordant changes (coherence scores >.5) in HbD and MAP, consistent with impaired cerebrovascular autoregulation, were observed in 17 of the 32 infants (53%). Eight of the 17 infants (47%) developed severe GMH-IVH or PVL or both. Of the 15 infants with apparently intact autoregulation, ie, coherence scores .5. Conclusions. We conclude that NIRS can be used in a noninvasive manner at the bedside to identify premature infants with impaired cerebrovascular autoregulation, that this impairment is relatively common in such infants, and that the presence of this impairment is associated with a high likelihood of occurrence of severe GMH-IVH/PVL.

Persistent pulmonary hypertension of the newborn in the era before nitric oxide: practice variation and outcomes.

Abstract: Objectives. In the era before widespread use of inhaled nitric oxide, to determine the prevalence of persistent pulmonary hypertension (PPHN) in a multicenter cohort, demographic descriptors of the population, treatments used, the outcomes of those treatments, and variation in practice among centers. Study Design. A total of 385 neonates who received ≥50% inspired oxygen and/or mechanical ventilation and had documented evidence of PPHN (2D echocardiogram or preductal or postductal oxygen difference) were tracked from admission at 12 Level III neonatal intensive care units. Demographics, treatments, and outcomes were documented. Results. The prevalence of PPHN was 1.9 per 1000 live births (based on 71 558 inborns) with a wide variation observed among centers (.43–6.82 per 1000 live births). Neonates with PPHN were admitted to the Level III neonatal intensive care units at a mean of 12 hours of age (standard deviation: 19 hours). Wide variations in the use of all treatments studied were found at the centers. Hyperventilation was used in 65% overall but centers ranged from 33% to 92%, and continuous infusion of alkali was used in 75% overall, with a range of 27% to 93% of neonates. Other frequently used treatments included sedation (94%; range: 77%–100%), paralysis (73%; range: 33%–98%), and inotrope administration (84%; range: 46%–100%). Vasodilator drugs, primarily tolazoline, were used in 39% (range: 13%–81%) of neonates. Despite the wide variation in practice, there was no significant difference in mortality among centers. Mortality was 11% (range: 4%–33%). No specific therapy was clearly associated with a reduction in mortality. To determine whether the therapies were equivalent, neonates treated with hyperventilation were compared with those treated with alkali infusion. Hyperventilation reduced the risk of extracorporeal membrane oxygenation without increasing the use of oxygen at 28 days of age. In contrast, the use of alkali infusion was associated with increased use of extracorporeal membrane oxygenation (odds ratio: 5.03, compared with those treated with hyperventilation) and an increased use of oxygen at 28 days of age. Conclusions. Hyperventilation and alkali infusion are not equivalent in their outcomes in neonates with PPHN. Randomized trials are needed to evaluate the role of these common therapies.

Do Clinical Markers of Barotrauma and Oxygen Toxicity Explain Interhospital Variation in Rates of Chronic Lung Disease

Abstract: Objective. To explore the hypothesis that variation in respiratory management among newborn intensive care units (NICUs) explains differences in chronic lung disease (CLD) rates. Design. Case–cohort study. Setting. NICUs at 1 medical center in New York (Babies9 and Children9s Hospital [Babies9]) and 2 in Boston (Beth Israel Hospital and Brigham and Women9s Hospital [Boston]). Study Population. Four hundred fifty-two infants born at 500 to 1500 g birth weight between January 1991 and December 1993, who were enrolled in an epidemiologic study of neonatal intracranial white matter disorders. Case Definition. Supplemental oxygen required at 36 weeks9 postmenstrual age. Results. The prevalence rates of CLD differed substantially between the centers: 4% at Babies9 and 22% at the 2 Boston hospitals, despite similar mortality rates. Initial respiratory management at Boston was more likely than at Babies9 to include mechanical ventilation (75% vs 29%) and surfactant treatment (45% vs 10%). Case and control infants at Babies9 were more likely than were those at Boston to have higher partial pressure of carbon dioxide and lower pH values on arterial blood gases. However, measures of oxygenation and ventilator settings among case and control infants were similar at the 2 medical centers in time-oriented logistic regression analyses. In multivariate logistic regression analyses, the initiation of mechanical ventilation was associated with increased risk of CLD: after adjusting for other potential confounding factors, the odds ratios for mechanical ventilation were 13.4 on day of birth, 9.6 on days 1 to 3, and 6.3 on days 4 to 7. Among ventilated infants, CLD risk was elevated for maximum peak inspiratory pressure >25 and maximum fraction of inspired oxygen = 1.0 on the day of birth, lowest peak inspiratory pressure >20 and maximum partial pressure of carbon dioxide >50 on days 1 to 3, and lowest white blood count Conclusion. In multivariate analyses, a number of specific measures of respiratory care practice during the first postnatal week were associated with the risk of a very low birth weight infant developing CLD. However, after adjusting for baseline risk, most of the increased risk of CLD among very low birth weight infants hospitalized at 2 Boston NICUs, compared with those at Babies9 Hospital, was explained simply by the initiation of mechanical ventilation.

Nocturnal Pulse Oximetry as an Abbreviated Testing Modality for Pediatric Obstructive Sleep Apnea

Abstract: Objective. To determine the utility of pulse oximetry for diagnosis of obstructive sleep apnea (OSA) in children. Methods. We performed a cross-sectional study of 349 patients referred to a pediatric sleep laboratory for possible OSA. A mixed/obstructive apnea/hypopnea index (MOAHI) greater than or equal to 1 on nocturnal polysomnography (PSG) defined OSA. A sleep laboratory physician read nocturnal oximetry trend and event graphs, blinded to clinical and polysomnographic results. Likelihood ratios were used to determine the change in probability of having OSA before and after oximetry results were known. Results. Of 349 patients, 210 (60%) had OSA as defined polysomnographically. Oximetry trend graphs were classified as positive for OSA in 93 and negative or inconclusive in 256 patients. Of the 93 oximetry results read as positive, PSG confirmed OSA in 90 patients. A positive oximetry trend graph had a likelihood ratio of 19.4, increasing the probability of having OSA from 60% to 97%. The median MOAHI of children with a positive oximetry result was 16.4 (7.5, 30.2). The 3 false-positive oximetry results were all in the subgroup of 92 children who had diagnoses other than adenotonsillar hypertrophy that might have affected breathing during sleep. A negative or inconclusive oximetry result had a likelihood ratio of .58, decreasing the probability of having OSA from 60% to 47%. Interobserver reliability for oximetry readings was very good to excellent (κ = .80). Conclusions. In the setting of a child suspected of having OSA, a positive nocturnal oximetry trend graph has at least a 97% positive predictive value. Oximetry could: 1) be the definitive diagnostic test for straightforward OSA attributable to adenotonsillar hypertrophy in children older than 12 months of age, or 2) quickly and inexpensively identify children with a history suggesting sleep-disordered breathing who would require PSG to elucidate the type and severity. A negative oximetry result cannot be used to rule out OSA.

Do parents understand immunizations? A national telephone survey.

Abstract: Background. Immunization may now be undervalued because vaccines have largely eliminated the threat of serious infectious diseases in childhood. As the incidence of vaccine-preventable diseases has declined, concern about vaccine safety has increased. Significant erosion of public confidence in vaccine safety could lead to reduced immunization rates and a resurgence of vaccine-preventable diseases. Objective and Methods. To assess parents9 understanding of vaccine-preventable diseases, vaccines, immunization practices, and policies, we conducted a telephone survey in the United States with a nationally representative sample (n = 1600) of parents with children ≤6 years of age, and expectant parents in April and May 1999. Results. Eighty-seven percent of respondents deemed immunization an extremely important action that parents can take to keep their children well. Although respondents9 overall rating of immunization safety was high, a substantial minority held important misconceptions. For example, 25% believed that their child9s immune system could become weakened as a result of too many immunizations, and 23% believed that children get more immunizations than are good for them. Children9s health care providers were cited as the most important source of information on immunizations. Conclusions. Although the majority of parents understand the benefits of immunization and support its use, many parents have important misconceptions that could erode their confidence in vaccines. A systematic educational effort addressing common misconceptions is needed to ensure informed immunization decision-making. Physicians, nurses, and other providers of primary care have a unique opportunity to educate parents because parents see them as the most important source of information about immunizations. vaccination, immunization, pediatric, safety, health beliefs.

The Unmet Health Needs of America's Children

Abstract: Objective. Unmet need for health care is a critical indicator of access problems. Among children, unmet need for care has special significance inasmuch as the failure to obtain treatment can affect health status and functioning in the near- and long-term. The purpose of this study was to present current prevalence estimates and descriptive characteristics of children with unmet health needs using nationally representative household survey data. Methods. We analyzed 4 years of National Health Interview Survey data spanning 1993 through 1996. Our analysis included 97 206 children Results. Overall, 7.3% (4.7 million) of US children experienced at least 1 unmet health care need. Dental care was the most prevalent unmet need. After adjustment for confounding factors, near-poor and poor children were both about 3 times more likely to have an unmet need as nonpoor children (adjusted odds ratio [95% confidence interval] = 2.89 [2.52, 3.32], 3.0 [2.53, 3.56], respectively). Uninsured children were also about 3 times more likely to have an unmet need as privately insured children (adjusted odds ratio [95% confidence interval] = 2.92 [2.58, 3.32]). Conclusions. Despite the nation9s great wealth, unmet health needs remain prevalent among US children. A combined public policy that addresses financial and nonfinancial barriers to care is required to reduce the prevalence of unmet need for health care.

Major Factors Influencing Breastfeeding Rates: Mother's Perception of Father's Attitude and Milk Supply

Abstract: Objective. To determine factors influencing feeding decisions, breastfeeding and/or bottle initiation rates, as well as breastfeeding duration. Setting. A family medicine practice of a 530-bed community-based hospital in northwestern Pennsylvania. Participants. All mothers whose infants received well-child care from birth to 1 year of age. Outcome Measure. A survey of 28 simple questions was developed and mailed to 245 mothers. The survey assessed: 1) demographics, 2) prenatal and postnatal care, 3) sources of breastfeeding information, 4) timing of decision, 5) preference, 6) type of feeding selected, 7) duration of breastfeeding, 8) factors influencing decisions to breastfeed and/or to bottle-feed, and 9) factors that would have encouraged bottle-feeding mothers to breastfeed. Results. The breastfeeding initiation rate was 44.3%. By the time the infant was 6 months old, only 13% of these were still breastfeeding. The decision to breastfeed or to bottle-feed was most often made before pregnancy or during the first trimester. The most common reasons mothers chose breastfeeding included: 1) benefits the infant9s health, 2) naturalness, and 3) emotional bonding with the infant. The most common reasons bottle-feeding was chosen included: 1) mother9s perception of father9s attitude, 2) uncertainty regarding the quantity of breast milk, and 3) return to work. By self-report, factors that would have encouraged bottle-feeding mothers to breastfeed included: 1) more information in prenatal class; 2) more information from TV, magazines, and books; and 3) family support. Conclusions. To overcome obstacles, issues surrounding perceived barriers, such as father9s attitude, quantity of milk, and time constraints, need to be discussed with each parent. To achieve the goal of 75% of breastfeeding mothers, extensive education regarding the benefits must be provided for both parents and optimally the grandmother by physicians, nurses, and the media before pregnancy or within the first trimester.

Skin-to-Skin Contact Is Analgesic in Healthy Newborns

Abstract: Objectives. To determine whether skin-to-skin contact between mothers and their newborns will reduce the pain experienced by the infant during heel lance. Design. A prospective, randomized, controlled trial. Setting. Boston Medical Center, Boston, Massachusetts. Participants. A total of 30 newborn infants were studied. Interventions. Infants were assigned randomly to either being held by their mothers in whole body, skin-to-skin contact or to no intervention (swaddled in crib) during a standard heel lance procedure. Outcome Measures. The effectiveness of the intervention was determined by comparing crying, grimacing, and heart rate differences between contact and control infants during and after blood collection. Results. Crying and grimacing were reduced by 82% and 65%, respectively, from control infant levels during the heel lance procedure. Heart rate also was reduced substantially by contact. Conclusion. Skin-to-skin contact is a remarkably potent intervention against the pain experienced during heel stick in newborns.

Use of the national institutes of health criteria for diagnosis of neurofibromatosis 1 in children.

Abstract: Objective. The National Institutes of Health (NIH) Diagnostic Criteria for neurofibromatosis 1 (NF1) are very useful clinically, but some individuals who are later shown to have NF1 cannot be diagnosed in early childhood using these criteria. The aim of this study is to determine the value of the NIH Diagnostic Criteria for NF1 in early childhood, to determine the age at which diagnosis can confidently be made, and to clarify the age at onset of the cardinal clinical features used in the NIH Diagnostic Criteria. Methods. We studied 1893 NF1 patients under 21 years old from the National Neurofibromatosis Foundation International Database to determine the age at which the features included in the NIH Diagnostic Criteria appear. Results. Approximately 46% of sporadic NF1 cases fail to meet the NIH Diagnostic Criteria by 1 year of age. Nearly all (97%; 95% confidence interval: 94–98) NF1 patients meet the criteria for diagnosis by 8 years old, and all do so by 20 years old. The usual order of appearance of the clinical features listed as NIH criteria is cafe-au-lait macules, axillary freckling, Lisch nodules, and neurofibromas. Symptomatic optic glioma is usually diagnosed by 3 years old, and characteristic osseous lesions are usually apparent within the first year of life. Conclusion. The diagnosis of NF1 cannot always be made in young children using the NIH Diagnostic Criteria. Modification of these criteria may be necessary for children under 8 years old.

Variations in practice and outcomes in the Canadian NICU network: 1996-1997

Abstract: Background. Previous reports of variations in outcomes among neonatal intensive care units (NICUs) examined only specific subpopulations of interest (eg, very low birth weight [VLBW] infants Objectives. We report on current practice and outcomes variations in a population-based national study of Canadian NICUs from January 8, 1996 to October 31, 1997. Method. Information on 20 488 admissions to 17 tertiary level NICUs across Canada was prospectively collected by trained abstractors using a standard manual of operations and definitions. Data were verified and analyzed in concert with a steering committee comprising experienced researchers and neonatologists. Patient information included demographic information, antenatal history, mode of delivery, problems at delivery, status of infant and problems at birth, illness severity (Clinical Risk Index for Babies, Score for Neonatal Acute Physiology, Score for Neonatal Acute Physiology-Version II), therapeutic intensity (Neonatal Therapeutic Intensity Scoring System [NTISS]), selected NICU practices and procedures, use of technology and resources, and selected patient outcomes. Patients were tracked until death or discharge home. Results. The mean number of annual admissions to an NICU was 657, with 26% outborn infants. Fifty-three percent were Conclusion. This study provides population-based information about NICU outcomes. Significant variation in NICU practices and outcomes was observed despite Canada9s universal health insurance system. This national database provides valuable information for planning research, allocating resources, designing health and public policy, and serving as a basis for longitudinal studies of NICU care in Canada.

Neurodevelopmental outcome and lifestyle assessment in school-aged and adolescent children with hypoplastic left heart syndrome.

Abstract: OBJECTIVES The purposes of this study are to describe the quality of life and cognitive function in school-aged children who have undergone staged palliation for hypoplastic left heart syndrome (HLHS), and to identify factors that are predictive of neurodevelopmental outcome in this population. METHODS School-aged survivors with HLHS who had undergone palliative surgery at our institution were identified and mailed a questionnaire to assess subjectively quality of life, school performance, and incidence of medical complications. A subgroup of local patients underwent standardized testing of cognitive function and neurologic examination. These patients were compared with the larger (remote) group of questionnaire respondents to determine whether results may be generalizable to the entire HLHS population. Potential predictors of neurologic and cognitive outcome were tested for their association with test scores using multivariate regression analysis. RESULTS Questionnaire results were obtained from 115 of 138 eligible children (83%; mean age: 9.0 +/- 2.0 years). Standardized testing was performed in 28 of 34 (82%) eligible local patients (mean age: 8.6 +/- 2.1 years). The majority of parents or guardians described their child's health as good (34%) or excellent (45%) and their academic performance as average (42%) or above average (42%). One third of the children, however, were receiving some form of special education. Chronic medication usage was common (64%); the incidence of medical complications was comparable to that previously reported in children with Fontan physiology. Cognitive testing of the local group demonstrated a median full scale IQ of 86 (range: 50-116). Mental retardation (IQ: <70) was noted in 18% of patients. In multivariate analysis, only the occurrence of preoperative seizures predicted lower full scale IQ. CONCLUSIONS Although the majority of school-aged children with HLHS had IQ scores within the normal range, mean performance for this historical cohort of survivors was lower than that in the general population.