Research

The objective of this study was to investigate the incidence of adverse effects including kernicterus, developmental delay, autism, cerebral palsy, and hearing loss in infants with elevated bilirubin levels compared with infants without significant hyperbilirubinemia. In order to test their hypothesis, the authors conducted a population-based cohort study that included newborns >= 35 weeks gestational age who were born in Canada between 1994 and 2000. The infants were divided into three groups: (1) moderate hyperbilriubinemia (13.5-19 mg/dl), (2) severe hyperblirubinemia (>19 mg/dl) and (3) no hyperbilriubinemia. During the study period, there were no reported cases of kernicterus.  There were suggestions of increased incidence of ADHD and autism in the hyperbilirubinemia groups.  No differences were found in the incidence of cerebral palsy, deafness, or developmental delay between groups. The study concluded that the “classic” adverse effects associated with hyperbilirubinemia are no longer seen. However, the authors demonstrate other comorbidities (i.e. autism, ADHD)  They hint that further research in this field should focus on demonstrating causality in order to identify infants who may develop short and long term complications of hyperbilirubinemia.

The objective of the study was to determine risk of SIDS, child abuse and epilepsy/developmental delay after an infant has an ALTE.  A retrospective review over 5 years of first presentation to a tertiary children’s hospital of an ALTE (defined as parental concern for breathing irregularities, color change, altered muscle tone, altered mental status, or abnormal movement that was not explained by a pre-existing condition or alternate diagnosis at presentation) and then follow-up data collected through EDW, state death records, Child and Family Services records, neurology clinic, admissions and ED visits to 20 local hospitals.  471 infants who presented at an average age 66 days were followed for a minimum of 2.6 years, average of 5.1 years.  None died of SIDS. 11% were victims of child abuse (2.2% physical or sexual abuse) of whom 0.4% were identified during initial ALTE work-up and 3.6% within 1 year of ALTE hospitalization.  The rate of child physical abuse, 0.9% is higher than 0.02% what is reported in general pediatric population.  Adverse neurological outcomes developed in 4.9% of patients and led to the death of 0.4% patients.  Initial in-patient evaluation had a low yield of predicting epilepsy.

This article details unintentional injuries in infants 0-12 months old who were treated in emergency departments across the nation between 2001 and 2004 (1,314,000 infants, or 1 infant every 1.5 minutes).  They did not include bites or motor vehicle accidents.  The article’s main point is to show that injuries change over time as developmental milestones are reached.  Overall, falls were the most common unintentional injury for infants of all ages.  In the fall category, the bed was most often the “product” involved; stairs and car seats were also frequent.  They did not distinguish between the child’s crib or bed and someone else’s bed.  The second most common injuries were “struck by or against” and the third were fire or burn injuries.   The other injuries that occurred less frequently than falls changed in distribution as the infants aged.   For example, injuries involving car seats and strollers were most common in infants less than 6 months old.  Also, infant walkers and stairs were more commonly involved between 8 and 12 months of age.  The most common diagnoses as a result of the injuries were contusions and lacerations.  The study was limited because only patients who presented to the hospital were included.  However, the article points out that pediatricians need to discuss upcoming developmental milestones at an infant’s well child check in relation to possible injuries. They must also try to prevent falls at every age involving beds, stairs, and car seats.

This study was a cross-sectional study of 62,000 children ages 5-17 from the 2003-2004 National Survey of Children’s Health.  The sampling was done by telephone.  Interviewers called telephone numbers at random and parents were asked, “Has a doctor of health professional ever told you that your child has attention deficit/hyperactive disorder?”  If the response was yes, then parents were asked whether the child in question was on ADD or ADHD meds.  Measurements of height and weight were also obtained to calculate BMI’s.  Confounders such as age, gender, race, socioeconomic status, depression, anxiety were adjusted for.  Greater than the 95% for BMI was considered overweight.  It was found that individuals with ADD/ADHD who were not on medication had 1.5 x the odds for being overweight.  However,  individuals without ADD/ADHD had odds for being overweight of 1.13.   Finally, individuals with ADD/ADHD who were on medication were at 1.6 x the odds for being underweight.

The objective of this study was to determine whether patients’ families’ violence-prevention behaviors would be affected by their primary care practitioner’s use of a violence-prevention clinical intervention during the routine well-child examination.  In this cluster-randomized, controlled trial (2002–2006), 137 Pediatric Research in Office Settings practices were randomly assigned and initiated patient recruitment for either an office-based violence-prevention intervention or a control group (educational handout on literacy promotion provided). Primary caregivers of children who were aged 2 to 11 years and presented for a well-child visit were surveyed at baseline and 1 and 6 months.  Practitioners were trained to (1) review a parent pre-visit summary regarding patient-family behavior and parental concern about media use, discipline strategies, and children’s exposure to firearms, (2) counsel using brief principles of motivational interviewing, (3) identify and provide local agency resources for anger and behavior management when indicated, and (4) instruct patient-families on use of tangible tools (minute timers to monitor media time/timeouts and firearm cable locks to store firearms more safely where children live or play). Main outcomes were change over time in self-reported media use <120 minutes per day, use of timeouts, and use of firearm cable locks.  Generalized estimating equation analysis revealed a significant effect at 6 months for decreased media use and safer firearm storage. The intervention group compared with the control group showed an increase in limiting media use to <120 minutes per day. There was no significant effect for timeout use. There was a substantial increase in storing firearms with cable locks for the intervention group vs. a decrease for the control group.  An important limitation is data were collected by self-report which may have been biased toward socially desirable reporting.  Still, the study concludes well-child visits provide an arena for effective preventive innovations, at least with regards to decreased media exposure and increased safe firearm storage.

This is a key, practical article to read for developmental education.  Even for budding intensivists, it’s helpful to read to be conversant on relevant discussions in pediatric culture.  If nothing else out of the 30 plus pages, it is helpful to look at the clinical algorithm.  The current standard of care is to screen for autism by: 1) listening for parental concerns, 2) listening to other childcare provider concerns (i.e. daycare), or 3) looking for red flags during our visits: observed stereotyped behaviors, poor eye contact, inability to indicate desires, etc.  The AAP recommends a formal screen for autism on the 18 and 24 month visits (though we may be getting a feel for autism by the 12 and 15 mo visits) and/or a formal screen if the patient is at least 18 months and at least one of the red flags is evident.  There are a lot of screening tools available (as noted on the table), but I find choosing ones that are easy and available, such as the CHAT or M-CHAT are helpful (Download: www.autismresearchcentre.com/tests/chat_test.asp ).  If results are concerning on the screen, a more formal ASD screen as well as audiologic assessment and referral to early intervention/early childhood are indicated.

The objective of this study was to use a national sample of children born in 2001 to determine the rate of eligibility for Part C Early Intervention, the rate of access to care for developmental delay and factors associated with access to care including poverty, race and health insurance status.  Part C Early Intervention provides services for children under the age of 3 with developmental delay defined by known delay or established risk conditions (ex. low birth weight).  This study determined that 13% of children at 9 and 24 months were determined to be eligible for Part C which is higher than the previously estimated national average of 2%.  Children below the poverty line were more likely to have delays and be eligible for Part C than kids living above the poverty line. However, only 10% of kids who met criteria for Part C actually received services.  Black children were half as likely as white children to receive service, and black families were less satisfied with their experience.  Poverty did not play a role in receiving services, as those in poverty were as likely to receive service as those not in poverty.  Health insurance was not statistically significant which may be due to the fact that Part C is available regardless of insurance status. Access also varies greatly from county to county and more studies are needed to determine how to equalize eligibility and care from state to state.

This review is an update for the US Preventive Services Task Force on universal newborn hearing screening to detect moderate-to-severe permanent, bilateral congenital hearing loss. They focused on 3 key questions: (1) Among infants identified by universal screening who would not be identified by targeted screening, does initiating treatment before 6 months of age improve language and communication outcomes? (2) Compared with targeted screening, does universal screening increase the chance that treatment will be initiated by 6 months of age for infants at average risk or for those at high risk? (3) What are the adverse effects of screening and early treatment? The only significant adverse effect found related with hearing screens was that cochlear implants have been associated with higher risks for bacterial meningitis in young children.  The study concluded that children with hearing loss who had universal newborn hearing screening had better receptive language at 8 years of age but not better expressive language or speech. Infants identified with hearing loss through universal screening have significantly earlier referral, diagnosis, and treatment than those identified in other ways.

With increasing rates of obesity, HTN, type 2 diabetes and cardiovascular disease in older children and adults, the AAP sought to update its recommendations on screening for cholesterol in childhood.  A population approach to diet (total fat <30% and sat. fat <10% of calories) and activity should be recommended to all children >=2yo.  A more intensive individualized approach should be applied to those at high risk (obese, family hx CVD or dyslipidemia, metabolic syndrome, etc), considering pharmacologic therapy when diet fails.  High risk children should be screened between 2 and 10yo with a fasting lipid profile.  For patients >8yo with LDL >190 (or >160 with famhx), pharmacologic intervention with a cholesterol-absorption inhibitor (i.e. ezetimibe) or statin should be considered.  Niacin was discouraged.  The statement also includes a table of age/gender-based norms of lipid levels similar to that used for BP and BMI.  (<=75th%  acceptable, >95th elevated)

This article was a summary of the current information on and treatment recommendations for insect allergy in children, especially compared to adults. Reactions were categorized into large local reactions (greater than 5 inches), cutaneous systemic reactions (hives) and systemic, or generalized, reactions. In general, boys are more likely to have an insect allergy than girls. Overall, though, children have less severe reactions to insect bites than do adults: children have more frequent large local reactions and less frequent systemic reactions.  Very few children (estimated 3%) who have large local reactions or hives develop systemic reactions with subsequent bites.  This supports the recommendation to not treat or test children with a history of hives secondary to an insect bite.  While few children have systemic reactions, like anaphylaxis, those who do, remain at risk for a generalized reaction for 10-20 years. Retrospectively, children who are treated with venom immunotherapy have a smaller chance of having a subsequent systemic reaction.  Relapse in children treated with venom immunotherapy appears to be 5-10%; all relapse reactions are described as mild.  Currently, venom immunotherapy, usually for 3-5 years, is only recommended for patients with systemic reactions to insect bites.  Skin testing and RAST testing are the two methods used to test children with systemic reactions; the former, however, does not have great sensitivity. Therefore, an evaluation might require both tests for diagnosis.

The field of genetic disease is changing with the understanding of disease pathways. One example of this is the advent of using angiotensin II receptor blockers (ARB's) for the treatment of aortic root dilation in patients with Marfan's Syndrome. The defect with Marfan's syndrome is in a gene that codes for a connective tissue protein known as fibrillin-1. Fibrillin-1 deficiency increases production of transforming growth factor beta (TGF-B), thought to be one of the producers of the Marfan phenotype and reason for the aortic root dilation, the main cause of premature death.  ARB therapy can decrease levels of TGF-B in mice and was used in this trial on 18 pediatric patients (average 6.5 year olds) to monitor the size of aortic root over the next 4 years. ARB therapy (losartan in 17 patients and irbesartan in 1 patient significantly decreased aortic root diameter expansion from 3.54mm a year to 0.46mm a year. Although a small study it is helping lay the ground work for exploration of better studies and drugs to decrease aortic root complications in patients with Marfan syndrome and cast hope on treatment possibilities for single gene genetic disorders.

This study is limited, as it is retrospective, non-randomized, and observational. The study population is small and had severe aortic root enlargement prior to the initiation of treatment. The decision to initiate therapy was not made in a formal or consistent manner. Nevertheless, this study does lend early support to ARBs as important components in the management of aortic dilation in Marfan’s patients.

The purpose of this article is to assess to long term clinical outcome of a population of athletes with marked repolarization abnormalities on a 12-lead electrocardiogram.  Since 1982, the Italian government has required that athletes participating in officially sanctioned sports activity be required to undergo preparticipation monitoring and screening consisting of a medical history, physical exam, 12 lead ECG, and 2-D echocardiogram.  The study was a case-controlled trial that retrospectively compared the outcome of athletes with an abnormal ECG (T-waves > or equal 2 mm in at least three leads) who had no apparent heart disease by history, physical, or echocardiogram.  6% of athletes with abnormal ECG's eventually went on to develop cardiomyopathies, while none in the normal ECG population went on to develop cardiomyopathies of suffer cardiac events over an average period of 9 years.  The study makes a rather convincing argument that there may be something to be learned from paying attention to subtle abnormalities on an ECG in an otherwise healthy individual.  The jury is still out, however, on whether an ECG would be an appropriate screening test for healthy individuals.

The objective of this study is to evaluate the effects of giving heliox or oxygen in combination with nasal CPAP in infants with severe refractory acute RSV bronchiolits admitted to the PICU.   This prospective, observational single- center crossover study included 12 patients  (1 month- 2 yo) diagnosed with severe RSV bronchiolitis clinically and with enzyme-linked assay of nasal secretions to detect RSV.  They were allocated sequentially to begin treatment with either 1)heliox (70% heliox, 30%O2) with nCPAP or 2) O2 nCPAP for 30 minutes each; each patient received both treatments.   All patients had previously been treated with nebulized epinephrine (3mg/dose) and heliox via NRB mask for greater than 1 hour.  Exclusion criteria consisted of the presence of chronic lung disease.  Measurements of O2 saturation, respiratory rate, Modified Wood's Clinical Asthma Score and transcutaneous pCO2 were measured before, 30 minutes, 6 and 8 hours after treatments.  The study found that all values improved with both heliox and O2 with nCPAP, with greater improvements from baseline with heliox after 30 minutes and concluded that the use of heliox may help to avoid intubation.  There were no adverse effects noted in the 12 patients.  Limits of the study include its' small size and lack of blinding.

This article was based on a cohort study performed at La Raza National Medical Center in Mexico City that followed twenty pediatric patients with a a histopathologic diagnosis of hemangiomas.  Patients were treated were treated with interferon-alpha-2b and followed for response over several years.  Inclusion criteria included having a hemangioma located in a site that endangered an organ's functions or threatened the patient's life and having failed previous treatments.  Of the 20 patients involved in the study, all had failed prior corticosteroid therapy and several had failed additional therapies including copper mesh, embolization and ligation of vessels.  An excellent response, defined as 50% or more reduction of tumor size at 6 months of treatment was observed in 17 of the 20 patients.  A moderate response, defined as less than 50% of tumor reduction at 6 months of treatment, was observed in 1 of the 20 patients, and poor response was observed in 2 of the 20 patients.  The study authors conclude that interferon-alpha-2b may be an effective option for treating steroid-resistant hemangiomas that may be threatening to organ function or to a patient's life.

For children undergoing painful or anxiety-provoking procedures in the ER, adequate sedation is important.  It can reduce emotional trauma and allow ease of the procedure.  The benzodiazepine midazolam is an amnestic and anxiolytic agent.  Intranasal midazolam (INM) is seen as appealing in the ER because it achieves rapid CSF levels, prevents need for IV access, and avoids pain associated with IM injections.  Efficacy and safety of INM were examined in this retrospective study.  It reviewed 205 children ages 1-60 months who received INM sedation via a Mucosal Atomizer Device in a Pediatric ED from April 1-June 30, 2005.  The most common indication for sedation was laceration repair (89%).  The majority of patients (62%) were NPO for 4 hours.  A degree of sedation (DOS) scoring system was used (1=no sedative effect, 2=anxiolysis, 3=conscious-moderate sedation), based on the patient’s behavior before, during and after the procedure.  Seventy-nine percent of patients given INM alone were assigned a DOS score; 66% received a DOS score of 2, 29% a DOS score of 1, and the remaining 5% given a DOS score of 3.  While 5% of patients did require additional sedation to complete their procedure, 95% of patients did not.  Besides nasal irritation and bad taste, no adverse effects were recorded for children who received INM alone.  Limitations include its retrospective design, the subjectivity of DOS scores, and limited participants to determine efficacy.  The authors concluded that INM is efficacious for minor procedures without adverse effects, despite relatively short fasting times.

The goal of this study was to evaluate whether the use of sexual assault nurse examiners (SANEs) in a pediatric ED (PED) improves the medical care of pediatric and adolescent sexual assault victims.  Medical records of patients who presented to an urban PED with a history of sexual assault and required forensic evaluation (rape kit) from December 2004 to December 2006 were reviewed in a retrospective, blinded fashion for the following documentation: (1) genitourinary (GU) examination and if a GU injury was present; (2) evaluation for sexually transmitted infections (STIs) (gonorrhea and chlamydia), and serologies for hepatitis B and C, HIV, and VDRL; (3) prescription of prophylaxis for STIs, HIV, and pregnancy; (4) evaluation by a PED social worker; and (5) referral to sexual assault crisis services. Patients were grouped as to whether a SANE had been involved in their care.  Of the 114 patients whose medical records were reviewed, 60 had been evaluated by a SANE (SANE+), and 54 patients had not (SANE-); 98% of patients were girls.  Patients evaluated by a SANE were more likely to have the GU examination documented (71% vs. 41%; P= 0.001) and to have GU injury documented (21% vs. 0%; P = 0.024).  Eligible patients were more likely to have testing for gonorrhea and chlamydia (98% vs. 76%; P= 0. 001), and serologies for hepatitis B and C (95% vs. 80%%; P = 0.03) and HIV (93% vs. 72%; P = 0.03) when a SANE had been involved in their care. There were no significant differences between groups with respect to provision of prophylaxis for gonorrhea, chlamydia, or HIV. Significantly more patients were prescribed prophylaxis for pregnancy by a SANE (85% vs. 64%; P = 0.025).  Although there were no significant differences between groups with respect to an evaluation by a PED social worker, significantly more patients in the SANE+ group were referred to the Rape Crisis Center for support and counseling (98% vs. 30%; P= 0.001).  The bottom line is that pediatric victims of sexual assault get better and more complete care when evaluated by a SANE, and having SANEs readily available to patients should be a priority in PEDs.

As part of a randomized controlled trial designed to assess effectiveness of tobacco cessation intervention delivered in the pediatric ED, the authors report the acceptability to parents and staff of providing said intervention in the acute setting.  Parents recruited to the larger study were randomly assigned to usual care or intervention consisting of a practitioner asking the parent about motivation to quit, advising the parent of options for assistance, and then faxing a referral to the Ohio Tobacco Quitline on behalf of the parent.  Parents of moderately to severely ill children were excluded even if the illness was possibly tobacco-related. Acceptability was assessed via baseline surveys completed by the parent and the staff member caring for the child in the ED.  Of parents, 90% agreed that the ED “is a good place to give advice about smoking” and most in the intervention group felt it provided useful information.  Of ED staff, 97% agreed that the ED is an appropriate setting to screen parents for tobacco use and 90% agreed that it was likewise a good place to advise parents about smoking cessation.  Only 7 of 230 providers felt the intervention interfered with patient care.  Preliminary results from the larger study indicate that Quitline follow-up rate was significantly below that expected, with only 83% of faxed referrals received, and of those over 60% of participants were unreachable or declined enrollment, with only 6 of 239 parents in the intervention group enrolled in counseling via a Quitline representative at 6 weeks.

The study authors identified cases of diabetes from multiple centers, and the patients identified with type 1 or type 2 diabetes were sent a survey. Respondents to the survey were then invited for a study visit.  The total participants were 2445 of an eligible 7539.   Data was gathered on demographics, hemoglobin A1c and health-related quality of life as measured by the Peds Quality of Life Inventory (PedsQL).  The authors found that a higher PedsQL was associated with Type 1 DM versus Type 2 DM. As well, using an insulin pump, and <= 1 ED visit in 6 months, and no hospitalizations in 6 mos was associated with higher PedsQL score.   Among those with Type 1 DM, there was as significantly lower PedsQL score in older/adolescent females.  Lower PedsQL score was also associated with Medicaid/government-funded insurance and among those with type 2 DM, injections of insulin 3 times or more per day (versus oral medications) was associated with lower PedsQL score.

Conclusions: One major conclusion is that teenage girls with diabetes may need more resources/services to prevent decline in quality of life and/or diabetes control.

Data from the 1960's found the mean age of puberty onset to be between 8 and 13 in girls and between 9.5 and 13.5 in boys. Since this time puberty onset has been decreasing and is now not considered precocious unless before the ages of 6 years in black females and 7 years in all other races. Reasons for earlier puberty include early maternal menarche, low birth weight, obesity, lack of a household father figure, and possible exposure to estrogenic disrupting chemicals. Precocious puberty has an estimated prevalence of 0.2% among girls and 0.05% among boys. The most common reason is the early activation of GnRH which in most cases remains unexplained but can be due to central hypothalamic tumors, brain damage, peripheral gonadal and adrenal tumors, activation of genes involved in the gonadotropic pathway, McCune-Albright syndrome, or exposure to exogenous sex steroids. Work-up includes history and physical, family history, bone age, hormone measurements (estradiol, testosterone, LH, to name some), pelvic or testicular ultrasound scans, and if a concern, brain MRI. Although most unexplained cases (50%) will spontaneously regress on their own some may be due to the above causes and require further work-up and management as thoroughly reviewed in this article.

One problem with organ donation is the opinion within the medical community that it is unlawful to alter the management of a dying patient in order to prepare that patient for organ donation after death.  This especially applies to patients who experience cardiopulmonary arrest after the planned withdrawal of active support in intensive care units.  Non-heart-beating donation requires the delay of ending medical care of a dying patient in order to allow for the preparation and surgical retrieval of donor organs.  It is proposed that in allowing deviation from clinical management, one acts contrary to the patient’s best interest.  Best interest, however, may only be defined in the context of an individual patient.  It encompasses medical, emotional, ethical, social, moral, and welfare considerations.  Familial, spiritual, and religious values practiced by the patient should be reviewed when deciding one’s best interest.  The courts have ruled in support of patients’ wishes and values.  A patient’s expression to be an organ donor exists among these values.  Therefore, a patient’s best interest is served by preparing a patient for organ donation even at the cost of prolonging death. To honor a patient’s best interests requires the medical team to act not only according to what is medically indicated, but also, to explore the patient’s values and make decisions according to that which complies best with them.

The issues of medical ethics that physicians face in sports medicine are as follows: informed consent, third parties, advertising, confidentiality, drug use, and innovative technology.  Within these areas, the physician seeks beneficence, the physician’s obligation to work toward the well-being of their patient above all other goals.  To protect patient autonomy, the physician must inform patients of diagnoses, potential prognoses, and allow the athlete to form an opinion.  Athletes are often persuaded by desire to play, coaching agendas, advertising, and financial interests.  The physician must safeguard the patient’s confidences within the contractual agreements between the physician, player and team.  HIPPA allows physicians to share health information with coaches if the players are under contract with the team.  FERPA permits physicians employed by a school to release health information without the patient’s authorization to school officials who have an educational interest in the information. Physicians should counsel athletes on banned performance-enhancing substance, known to provide an unfair advantage to athletes and potentially cause harmful side effects. The rapid technological advancement of operative techniques, medications, and rehabilitation regimens strains the physician’s ability to rely upon evidence-based medicine when treating injured athletes.  Physicians must evaluate the clinical evidence available for new treatment options and inform patients of the lack of data validating such proposed remedies.  Risks and benefits associated with these treatments must also be discussed so that the injured athlete is able to make a more informed decision. The sports medicine physician must understand ethical standards and direct the care of the athlete accordingly.

This review is based on a literature search of MEDLINE and EMBASE to gather information on antiretroviral adherence measurement techniques, adherence estimates, and clinical correlates in low and middle income countries based on World Bank criteria. Only 17 studies met search criteria. The methods employed to measure adherence included self-reporting, caregiver reporting, pill count, and direct observation therapy.  Only one study employed a validation strategy by testing serum levels of medications. No studies correlated clinical outcomes or viral load to compliance. Estimates of adherence ranged from 49%-100% with 76% of studies reporting greater than 75% adherence. They highlight certain predictors of poor adherence including low socioeconomic status, poor education, medication regimen, conflict between child and caregiver, and lack of disclosure of child's HIV status. The authors conclude that though methods vary from country to country and study to study, the adherence rates are significantly higher than those reported in higher income countries which have been less than 75% consistently. Though this is an intriguing conclusion, the authors never clarify why this may be the case or even offer analysis of the higher-income country studies.  Other glaring omissions include the absence of analysis of the size of the 17 studies compared , the ages of children involved, or the setting of the care given. This review does however highlight the topic of compliance as a whole and the lack of standardized protocols and validation methods in the literature thus far. In particular they note that caregiver estimates of compliance were consistently higher than self-reporting, suggesting an important bias.

Although Kawasaki Disease is highly responsive to IVIG, 10-20% of patients will have a persistent fever after one dose.  These patients are at increased risk for development of coronary artery abnormalities. If they can be identified on presentation, additional or more aggressive therapies can be tried early in the course of illness when prevention of coronary artery damage might still be possible.  The authors of study noted a marked increase in the 2006 incidence of IVIG-resistant KD in San Diego County to 38%, without any corresponding change to either the patients’ clinical presentation or to the IVIG product administered.  In a retrospective review of 362 children at two clinical sites, the authors identified four patient characteristics that were independent predictors of IVIG-resistance: illness day at diagnosis, percent bands on CBC, GGT level, and  age-adjusted Hgb level.  A scoring system to predict IVIG-resistant patients based on these characteristics had a sensitivity of 73% and specificity of 62%.

This study sought to develop a clinical tool that can be used to identify children with serious bacterial infection (SBI).  Patients were febrile children without source, aged 7 days to 36 months.  All children had a urine analysis and culture, blood culture, CBC, CRP, and procalcitonin level drawn.  Fifty-four of the 202 children included in the study (27%) were found to have SBI.  Infections included 7 patients with bacteremia, 40 with pyeloneprhitits, 5 with lobar pulmonary consolidation, 1 with retropharyngeal abscess, and 1 with mastoiditis.  Procalcitonin level, CRP, and positive urine dipstick were found to be the only statistically significant predictors of SBI. The authors then developed a scoring system based on the three aforementioned predictive variables associated with SBI, assigning two points for procalcitonin (PCT) greater than 0.5 ng/ml and four points for PCT above 2 ng/ml, as well as two points for CRP above 40 mg/L and four points for CRP above 100 mg/L.  One point was assigned for urine dipstick with positive nitrite or leukocyte esterase.   Using this scoring system, a laboratory score of greater than or equal to three had a sensitivity of 94% and specificity of 81%, as well as a positive predictive value of 64% and a negative predictive value of 98% in predicting SBI.  The authors conclude that if the laboratory score developed in their study acts as an accurate predictor of SBI, it may considerably diminish the use of antibiotics in treating children with benign infections.

The objective of this study is to compare immediate extubation versus delayed extubation after 36 hours in ELBW infants.  It is a prospective, unmasked RCT evaluating 86 infants between 24-27 wkGA; 44 patients receiving immediate extubation after meeting extubation criteria (vent rate < 30, PIP<15 cmH2O, FiO2<30%) and 42 being extubated after 36 hours of meeting extubation criteria. The same protocol was used in all patients in the delivery room, in transfer and in the NICU.  Exclusion criteria included a lethal congenital abnormality or abnormalities requiring specific ventilatory support, severe hypoxemia and refractory CV collapse.  Primary outcome measured was extubation failure within 7 days after initial extubation.  The study ceased after 2 years as there was no statistical difference between the two groups in regards to extubation failure. The study did find that total NICU stay and total ventilatory support duration showed improvement in the delayed extubation group, while there was no difference in rates of BPD at 36wks and mortality.  The study concludes that there was no difference in extubation failures between delayed versus immediate extubation and hypothesizes that the results may suggest delayed extubation provides alveolar stabilization and preserved lung development or function.

The authors reviewed Norway's national registries to evaluate any medical disabilities and the social performance of infants born alive and without congenital anomalies at various preterm intervals between 1967 and 1983.  They then reviewed the databases of the nationalized systems for health insurance and disability services, education, income-taxes, unemployment services, criminal records, and the death registry.  Overall, survival to adulthood varied from 17.8% of 23-27 week preemies to 96.5% of the 34-36 week preemies.  Among survivors, 9% (vs. 0.1% of term infants) developed cerebral palsy, 4.4% (vs. 0.4%) had mental retardation, and 10.6% (vs. 1.7%) received medical disability pension.  The associations of the disabilities correlated inversely to the cohort's gestational age, with decreased prevalence as gestational age approached term delivery.  After excluding those with disabilities, gestational age with birth was also found to be associated education level attained, income, receipt of Social Security benefits, and establishment of family.  There was no correlation between gestational age and unemployment rates or criminal activity.  The authors suggested there may be subtle brain-dysfunction caused by preterm birth resulting in the adverse adult outcomes; however, they acknowledge they may not have accounted for all confounding biological and social factors.

The objective of this prospective study was to determine whether decreased pulmonary surfactant content contributed to postextubation respiratory failure in preterm infants previously diagnosed with RDS. In order to test their hypothesis, the authors included preterm infants who were intubated, received exogenous radiolabeled surfactant, and could not be weaned from the ventilator within 72 hours of life. Tracheal aspirate samples were collected every six to 12 hours before the anticipated extubation. Retrospectively, the infants were divided into 3 groups: extubation failure, extubation success, and not extubated if they could not meet criteria for extubation.  Radiolabeled phosholipid content was determined from the tracheal aspirates among the infants in all three groups. The study showed that infants who had been successfully extubated had increased levels of phospholipids compared with those infants who had failed an attempt at extubation or could not meet criteria for extubation. By measuring phospholipid content, the authors concluded that differences in exogenous surfactant metabolism in preterm neonates caused surfactant deficiency associated with severe respiratory distress.

This retrospective chart review tested the association between the timing of neonatal seizures and the presence of complications during labor and delivery.  Of the 193 infants identified with EEG-confirmed seizures, 40% were preterm (mean 30 weeks GA) and roughly 65% were encephalopathic.  Regression analysis was performed to assess the relationship between seizure timing and intrapartum/neonatal factors such as length of labor, heart rate abnormalities, Apgar scores, metabolic acidosis, inborn/outborn status, gestational maturity, and need for a caesarian section.  No significant associations were found between intrapartum obstetrical factors and neonatal seizures; the lack of an association existed both with and without the presence of an accompanying neonatal encephalopathy.  While limited by a relatively small sample size and historical cohort design, this study is consistent with other recent research that suggests that maternal, placental, and/or fetal medical conditions *before* labor and delivery are more relevant to neonatal outcomes than intrapartum fetal distress or obstetrical events.

The objective of this study was to determine total cholesterol and triglyceride levels while on the Ketogenic Diet, as well as, dietary interventions to lower elevated levels.  The Ketogenic Diet is a high fat, low carb diet used to treat intractable epilepsy.  After being on the diet for at least 3 months, 60% of children were found to have elevated total cholesterol levels >200mg/dl and 20% >300mg/dl.  Dietary modifications were used in half of the participants with elevated levels which included carnitine supplementation, medium-chain triglyceride or polyunsaturated fat substitutions and decreasing the ratio of the fat to carbohydrate load (4:1 to 3:1).  60% of subjects had a decrease in cholesterol level to near or below 200mg/dl with intervention.  The other half of the study received no intervention and was observed to have a 41% had a decrease in total cholesterol after 3 months.  It was determined that no single intervention was more likely to reduce total cholesterol and that the body may be able to metabolize the high fat load associated with the diet better as time progresses.  After analysis, it was determined that the formula-only based Ketogenic Diet, and younger age was less likely to cause hyperlipidemia as opposed to solid food.  There is no evidence at this time that elevated lipid levels while on the diet lead to early atherosclerosis or cardiac disease.

This study, using the 2005 National Health Interview Survey, sought to estimate the prevalence of asthma in racial minority subgroups that are rarely included in asthma studies.  The data from the survey was analyzed for the prevalence of current asthma, lifetime asthma, and asthma attacks according to race and place of birth while controlling for other demographic and socio-demographic variables.  It found that American Indian/Alaska Native children had both the highest prevalence of current asthma and the highest prevalence of "no health insurance."  It also found that there was a disproportionably high lifetime asthma prevalence in black, AI/AN, and Filipino children.  Also children born in the US were more likely to report current asthma than children now in the US but born out-of-the-country.  There was a wide variation in the Asian American subgroups in asthma prevalence.  In the study, they propose that more information on these groups would be helpful in assessing race as an important risk marker for asthma whether the causes of the differences is due to environment, social issues, culture, or bias in physician diagnosis or in parental reporting of asthma.

This study assessed the use of various factors of a patient's asthma status to determine the adjustment of asthma therapy.  The recently updated national guidelines only assess asthma based on frequency of symptoms and albuterol use as well as the recently added risk category which is determined by acute hospital care.  This cross-sectional study took in these factors as well as other factors that the investigators thought would influence the pediatrician to adjust asthma therapy including whether parents were bothered by the child's asthma status, qualitative changes in symptoms, and wheezing during physical examination.  A random sample of pediatricians was chosen and their opinions on adjusting therapy were assessed by vignettes.  The results showed that pediatricians were significantly more likely to increase treatment in a recently hospitalized patient, a bothered parent, poorly controlled symptoms, or if wheezing was present on physical examination compared to patients with well-controlled symptoms.  In contrast pediatricians were less likely to decrease treatment for a child with well-controlled symptoms and with recent hospitalization or a bothered parent, or a child whose symptoms had worsened since the last doctor visit compared with children with well-controlled symptoms.  This study also found that pediatricians seemed less willing to step down therapy even when indicated by the national guidelines.  The investigators propose that a multidimensional approach to asthma using a clinical easy-to-use tool would be an important addition to the current guidelines in adjusting asthma therapy.

Obstructive sleep apnea (OSA) is a common pediatric disorder, occurring in of 2-3% of all children, peaking between ages 2 and 8 years, with adenotonsillar hypertrophy being the most common etiology. This study attempted to evaluate the effectiveness of intranasal steroids as a treatment for pediatric patients with OSA.

Methods: This was a randomized, double blind, crossover study, enrolling patients ages 6-12 years with snoring and a polysomnogram demonstrating mild OSA. They were randomized to a treatment group, receiving a 6 wk course of intranasal budesonide, and a control group, receiving intranasal saline. All subjects then had a second polysomnogram preformed, and after a 2 wk washout period, were started on a 6 wk course of the treatment they were not receiving in the first phase. They all then received a third polysomnogram at the conclusion.

Results: 62 children were enrolled, 43 of which completed all phases of the study and 19 of which dropped out after the first phase (14 from placebo arm and 5 from treatment arm). 54% of patients in the treatment arm had normalization of their obstructive apnea/hypopnea index, and there were statistically significant improvements in sleep latency and reduction in adenoidal size compared to the placebo arm. These results persisted even at 8 wks following treatment.

Conclusion: This study supports the use of intranasal steroids as a first line agent in mild OSA to improve symptoms and possibly decrease the need for tonsil and adenoidectomy.

This was a cohort study which followed for 7 years children diagnosed with mild-moderate asthma and were enrolled into the Child hood Asthma management Program trial.  They had repeated DEXA scans annually.  Bone mineral accretion was then calculated for boys and girls separately.  It was found that in boys there was a decrease in bone mineral accretion (0.052, 0.049, and 0.046g/cm2 per year and there was a greater risk for osteopenia (10, 14, 21%) for  0, 1-4, and  >5 oral corticosteroid bursts respectively.  However, there was no significant difference in girls.  Inhaled corticosteroid use caused a significant decrease in bone mineral accretion that was not dose dependent.  There was no increased risk for osteopenia.  Again no significant effect was seen in girls.

The researchers in this article aimed to look at associations between single-nucleotide polymorphisms in the B2-adrenergic receptor genes and asthma and wheeze along with smoking exposure. They used odds ratios and confidence intervals to look at joint effects of these polymorphisms in utero and secondhand tobacco smoke exposure on asthma and wheeze outcomes. There were 3,128 children in the study, and along with questionnaires, they were genotyped for specific gene polymorphisms. They found that children homozygous for the Arg16 allele and exposed to in utero maternal smoking were at a three-fold increased risk of wheeze as compared to unexposed children. Secondhand smoking showed similar results. As number of smokers in the household increased, the risk of wheeze increased as well. Other diplotypes looked at did not show a significant association. Basically, there are long-term effects of in utero and postnatal exposure to tobacco smoke in a genetically susceptible group of children and intervention strategies are needed to reduce smoke exposures to children in general, especially those who are genetically susceptible.