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Summary The National Birth Defects Prevention Study enrolled over 3000 infants with nonsyndromic, non-chromosomal congenital heart defects and nearly 4000 infants without heart defects.  Defects included conotruncal, septal, anomalous pulmonary venous return, atrioventricular septal defects, and left- and right-sided obstructive defects.  Mothers of case and control infants were asked whether or not they had smoked during the peri-conceptual period which the authors had defined as 1 month before the pregnancy through the first trimester.  The authors also sought to evaluate environmental exposure.   Infants of mothers who smoked were more likely to be premature and low birth weight.  Further, women who smoked at any point during the pregnancy were more likely to have children with septal defects than women who did not smoke.  The association was stronger for women who were heavy smokers compared with occasional smokers.  The relationship was independent of other known prenatal factors including vitamin use, alcohol, and maternal age.  There was no increased risk of congenital heart defects in the group of mothers who had only environmental exposure to tobacco smoke. 

Summary The purpose of the study was to examine the effects of a multicomponent School Nutrition Policy Initiative (SNPI) on the prevention of overweight and obesity among children in grades 4-6 over a two year period. The study was conducted in ten schools in Philadelphia that were randomly assigned as intervention or control schools.  In the interventions schools, the following took place: 1) staff were trained ten hours per year in nutrition, 2) students received fifty hours of food and nutrition education per year, 3) all foods sold and served were changed to meet nutritional standards based on Dietary Guidelines for Americans, and 4) nutrition educators educated family members.  Results showed that 7.5% of students in intervention schools versus 14.9% in control schools became overweight (P<0.05).  The effect on the prevalence of overweight was particularly effective for black students (P<0.05).  However, there was no difference in the prevalence of obesity.  This will probably require a more targeted approach.

Summary In this cross sectional study of 44 obese and 22 non-obese children, investigators measured casual (i.e. measured in office) blood pressure, ambulatory BP (ABP) and left ventricular mass (LVM) in prepubertal obese and lean children. Mean 24-hour systolic BP, diastolic BP, and LVM were all significantly higher in obese subjects, with nearly 50% of obese subjects demonstrating hypertension on ambulatory monitoring. Surprisingly, 26.2% of obese subjects exhibited masked HTN, defined as elevated ABP in the setting of normal casual BP. In addition, casual measurement of BP missed 55% of hypertension cases detected by ABPM. Only 24-hour systolic BP by ABP was significantly correlated with LVM. LVM is correlated with cardiovascular disease in adults and may be a first indicator of end organ damage, suggesting that obese children, even while relatively young, may have clinically significant hypertension that may not be picked up by routine screening.

Summary Pediatric residents often do not have formal training in end-of-life issues, including palliative care. Pediatric Residents at Johns Hopkins were asked to voluntarily participate in a survey about their experiences. The response rate was 50%. These residents had up to 7 hours of formal training in end-of-life issues per year. Residents reported taking care of a mean of 4.7 children at the time of death, and reported being present for a mean of 3.5 discussions on limiting care. Most of these discussions occurred in a NICU or PICU, through which PGY-1 residents did not rotate. 85% of residents had provided symptom control at the end of life, but only 35% of residents had declared a patient dead. Only 33% of residents reported formal training in declaring a patient dead. Of PGY-3 residents, 82% had completed a death certificate, with only 33% reporting having formal instruction on how to complete a death certificate. All residents across all years reported discussing a patient after death, but less than half of PGY-3 residents had attended a funeral or wake, or had contact with a patient's family after death. This study shows that pediatric residents have limited contact and experience with patients who are dying. Moreover, they report limited instruction in end-of-life issues. This small, single-center study could lead to a larger survey of pediatric residency programs to determine what type of training would be useful in end of life issues.

Summary While osteopenia of prematurity is a well-documented disease process, screening and monitoring protocols vary greatly amongst practitioners. This study surveyed practitioners from 50 different neonatal units (level 2-3) in England, assuming they had more experience in care of infants <32weeks gestational age (the population at greatest risk). Respondents were asked if and how they screen for bone disease, how often they screen, and their criteria for treatment. 72% of respondents contacted actually returned the paper survey. All units employed biochemical tests in screening (notably alkaline phosphatase), as it is the most readily available screen. Only one unit used routine X-ray of wrist to look for osteopenia. The majority of respondents engaged in weekly screening and a few (4), screened every 2 weeks. This provides no data regarding prognosis or efficacy of screening but gives an idea of what the various options are. With such a prevalent disease, there are few studies or guidelines regarding screening and treatment. This study is a first step in that direction by simply looking at what people are already doing. (Submitted by Kathy Wang)

Summary Decisions regarding the initiation of care for premature infants are often controversial at gestational ages less than 25 weeks. Thus, this study was designed to examine additional factors, aside from gestational age, that might have an effect on the likelihood of survival, survival without profound neurodevelopmental impairment, and survival without neurodevelopmental impairment at a corrected age of 18-22 months. The study was a prospective examination of 4,446 infants with gestational ages ranging from 22-25 weeks. Results of this study indicate that for infants who received intensive care, exposure to antenatal corticosteroids, female sex, singleton birth, and higher birth weight were associated with a reduced risk of death or neurodevelopmental impairment. These benefits were similar to those associated with an increase in gestational age of 1 week. This information was then used to develop a web-based tool to estimate the likelihood of a favorable outcome. The study concluded that in addition to gestational age, the following factors should be assessed in predicting outcomes: sex, exposure to antenatal corticosteroids, single versus multiple birth, and birth weight.

Summary A cross sectional analysis was performed on a database of children with complex congenital heart disease from a previous trial (Allopurinol Neurocardiac Protection Trial) in Philadelphia. Children excluded from the trial had a lethal genetic disorder, other congenital malformations, or evidence of end-organ damage prior to surgery. Parents of children involved in the trial were contacted when children were school aged, and were assessed with validated, standard questionnaires. Out of the original 318 neonates involved in the original trial, 145 had survived, were able to be contacted, and agreed to participate in the study. 109 responses were received. Mean age at follow up was 7.9 years and 67% were male. 18% report having repeated a grade. There was a significant increase in the percentage of patients stratified as high-risk for ADHD compared to healthy controls. Teachers reported slightly lower rates, but the increase still retained statistical significance. Up to 49% reported the need for additional classroom support, with 15% in full time special education classrooms. 

Summary This article reported the results of the Continuous Positive Airway Pressure or Intubation at Birth (COIN) trial. Six hundred ten infants born between 25 and 28 weeks gestation were randomized to nasal CPAP or intubation and ventilation at five minutes of life. The primary outcome measured was death or bronchopulmonary dysplasia (defined as need for oxygen at 36 weeks gestational age); notable secondary outcomes included death and the need for oxygen at 28 days and complications including pneumothorax. While the unadjusted odds ratio for the primary outcome measure comparing the CPAP group with the intubation group was 0.80, the results were not statistically significant (95% CI 0.58 to 1.12). At 28 days, however, there was a lower risk of death or need for oxygen therapy in the CPAP group than in the intubation group (odds ratio, 0.63; 95% CI 0.46 to 0.88). The incidence of pneumothorax was nine percent in the CPAP group compared with three percent in the intubation group (p<0.001). Ultimately, 46% of infants in the nasal CPAP group were intubated within the first five days. Of note, the Surfacant Positive Airway Pressure and Pulse Oximetry Trial in Extremely Low Birthweight Infants (SUPPORT) trial will similarly randomize infants to early CPAP or intubation with ventilation and surfactant and look at survival without BPD at 36 weeks gestational age; however, the SUPPORT trial will further look at the difference between managing infants at a higher versus lower percentage of oxygen saturation in blood (85-89% versus 91-95%).

Summary In this equivalency trial, 2037 Pakistani children aged 3-59 months with severe pneumonia (lower chest indrawing with or without rapid breathing as per World Health Organization classification) were randomized to undergo hospitalization and intravenous ampicillin for 48 hours followed by oral amoxicillin for three days or to home-based treatment with oral amoxicillin for five days. Children with very severe pneumonia, penicillin allergy, recent hospitalization, persistent vomiting, asthma, history of recurrent wheeze, or whose respiratory status improved with inhaled bronchodilator were excluded. The primary outcome measured was treatment failure by day six, defined as clinical deterioration, inability to take oral medication due to vomiting, persistent fever, or death. There were 87 treatment failures in the hospitalized group and 77 in the ambulatory group (risk difference 1.1%, 95% CI 1.3 to 1.5). Additional analyses to assess whether imbalances between the treatment groups in reported history of diarrhea, vomiting, wheezing, or previous antibiotic use did not affect the finding of equivalence. Four children in the hospitalized group and one in the ambulatory group died; in all cases, treatment failure was declared and the antibiotic had been changed before death. Interestingly, young infancy (aged 3-5 months), being underweight for age, and very fast breathing were predictive of treatment failure while being breastfed at presentation was found to be protective. The results suggest that in children with WHO-defined severe pneumonia, home treatment with high-dose amoxicillin is equivalent to the current recommendations of hospitalization and parenteral antibiotics.

Summary The authors of this study created a decision analysis to compare a 2- versus 3-diagnostic criteria strategy for the definitive diagnosis of otitis media, as well as to compare both prior to a watch and wait strategy. The three criteria to diagnose otitis as determined by the 2004 AAP guidelines are 1) recent onset of symptoms, 2) middle ear inflammation and/or otalgia, and 3) presence of middle ear effusion. Depending on age and the certainty of diagnosis, and the severity of illness, the AAP recommends either treating with antibiotics or observation. NHANES data were used to estimate the number of visits for acute otitis media yearly, as well as further complications such as mastoiditis and other outcomes such as antibiotic use, sick days, mild adverse drug events, and number needed to treat/avoided sick day. Children were stratified according to age: 2-<6months, 6-24months, >24months. Their statistical analysis revealed that using a 3 criteria strategy does decrease antibiotic use in all age groups as compared to the 2 criteria strategy. However, in children <24 months of age, the number needed to treat to decrease one sick day is <1.4, where in children >24 months, 6.6 children need to be treated to decrease one sick day. The conclusion is that the burden to the parents and society for the sick days taken might not outweigh the benefit of antibiotic use in the young children with new symptoms and a red ear. The major study limitation was that it was a model assumption using probabilities to determine their data, not a true representation of consecutive patients presenting to a primary care physician.

Summary Propofol is an ideal sedative for short procedures and imaging studies in pediatrics. It has quick onset and short duration with no lingering after-effects and no life-threatening side effects. This study from Minnesota described a sedation program run by pediatric intensivists at a children's hospital, using propofol for MRI's, lumbar punctures, and endoscopies. The incidence of side effects was very low. The most common was transient hypotension in 30% (defined as a drop of >25 mm Hg from baseline systolic BP); very rarely did these events require fluid resuscitation. The most fearsome side effect, the need for positive pressure ventilation, was seen in 27 of the 7304 cases, and all of those patients were predicted by an abnormal "airway score" that all patients were screened with. This score took into account snoring, obesity, history of lung/heart disease, or craniofacial malformations. Two patients required intubation, both of whom were former preemies with chronic lung disease/BPD. In a controlled setting with ICU supervision, this large-scale study shows that propofol can be used with minimal side effects if patients with abnormal airways are carefully screened and excluded. 

Summary This study, done in Utah, sent a survey to 368 pediatricians to get their opinions about the hospitalist model. Nearly half of community physicians felt that inpatient care was an inefficient use of their time, but 90% of them thought that turning over their inpatient duties to a hospitalist would decrease patient satisfaction. Hospital-based general pediatricians felt similarly, but were more likely to respond that hospitalists improved the quality of inpatient care (68% versus 49% for community doctors). The other major concern of community pediatricians was impaired communication; 60% felt that it would be worse. A major upside to hospital medicine seems to be dedicated housestaff education, but only 58% of community pediatricians felt that the hospitalist model improved teaching. In summation, there is still considerable skepticism about the efficacy and potential improvements that a hospitalist system can provide. However, many community pediatricians may label it a necessary evil, given their time constraints to see enough patients to keep their practices economically viable.

Summary Premature infants less than 28 weeks are at greatest risk for oxygen-related morbidity. The personal views of NICU nursing staff regarding appropriate pulse oximetry ranges may be the major determinant of pulse oximetry targets achieved in these infants. These authors conducted an anonymous, Web-based survey of US level III NICU nurses. They queried the nurses on whether there was a SpO2 policy in their NICU, and the specific numbers. They also asked each nurse for the specific upper and lower limits of pulse ox saturation that they felt were appropriate in their own practice. Sixty percent of the eligible NICUs participated in the study. 68% of NICUs had policies specifying pulse oximetry ranges for very premature infants. 45% (2805/ 6251) of eligible nurses at participating NICUs submitted surveys. At NICUs without a policy, SpO2 values for individual target ranges were higher than at NICUs with a policy, and the nurse-specific SDs were lower. 64% of nurses were aware that a policy for SpO2 was present in their NICU. Only 37% of the nurses correctly identified both the upper and lower SpO2 limits specified by their NICU's policy. 28% correctly identified their NICU's policy-specified upper and lower SpO2 limits and also used these target ranges. Nursing opinion has a great impact on the target ranges used for extremely premature infants. Presence of a policy at a NICU has a significant effect on lowering the target pulse oximetry ranges, but even in NICUs with policies, a large number of nurses are unaware of them or are using ranges that differ from these.

Summary Because premature infants are known to desaturate in car seats, they are believed to be at increased risk of death. However, there is no data on the prevalence of seated infant deaths. This study was designed to determine the frequency of sudden deaths in infants in sitting devices and whether premature infants make up a disproportionate number. The authors obtained data from the provincial coroner’s office on all deaths in a ten year period of children <1 year of age that occurred suddenly and unexpectedly. They excluded accidental deaths and deaths in hospitals. They compared those deaths where the infant was seated to the others. The authors found total of 534 sudden unexpected deaths in the time period of interest. When they excluded patients without full data, they had 508 cases (0.60/1000 live births). 17/508 deaths (3.3%) occurred in infants while in a sitting position. The proportion of premature infants was similar in groups. Of the patients who died at <1 month (corrected), six (9.4%) were in the seat group, whereas 11/444 infants >1 month (2.4%) were in the seat group. (RR of 3.80, p = 0.006). The authors conclude that seated SIDS deaths are not particularly common, and that preemies do not account for an excess number. However, they did find an excess of infants of less than 1 month of age dying in a sitting position. The major limitation of this study was the extremely small number of sudden infant deaths in the seated position, which strongly limits the power of sub-group analysis.

Summary Bilious vomiting in a newborn should be considered obstruction until proven otherwise. The authors of this study developed a survey to assess what color different observer groups felt best represented bilious vomiting. The authors developed a questionnaire with eight numbered colors from pale yellow to dark green. Respondents were allowed to check multiple boxes, but they were also asked to indicate which color was the best match for bilious vomit. They sent questionnaires to general practitioners (in the UK), nurses in a special care nursery, midwives, and mothers in mother/toddler groups. The returned responses were divided into yellow and green. 100% of the parents, nurses, and midwives returned the survey. 49% of the general practitioners did. 56% of the parents, 12% of the general practitioners, 10% of the midwives, and 3% of the special care nurses did not pick any of the green colors. The differences between parents and general practitioners and general practitioners and nurses were significant. The authors conclude that there is clearly no consensus on the color of bilious vomiting. They found it worrying that half of the general practitioners thought a yellow color was the best match for bile and a quarter did not think green was bilious at all, even though green vomit is the accepted color of bilious vomiting in the surgical literature.

Summary This article examined data in the Neonatal Research Network to determine prognostic indicators for survival and disability in extremely premature infants. A prospective study of a 4446 infants born between 22 and 25 weeks gestation was used to determine survival, as well as survival with and without severe neurodevelopmental impairment at 18 to 22 months corrected age. Infants who survived without mechanical ventilation were excluded, as well as infants provided no intervention who died. Results demonstrated that the infants who received intensive care (mechanical ventilation) had reduced risk of death and impairment for female sex, antenatal corticosteroids, singleton birth, and higher birth weight (per 100 grams). Each demonstrated risk reductions similar to a 1 week increase in gestational age. This study may impact our future practices in that more than just gestational age should be considered when counseling families and providing life support to extremely premature infants.

Summary The objective of the study was to look at the data of unintentional injuries in infants <12months of age treated in the ED. The authors did a retrospective analysis of data for infants <12months from the National Electronic Surveillance System-All Injury Program for 2001-2004. The results of the study showed that an estimated 1,314,000 injured infants were treated in US EDs during the 4 year period. The leading cause of nonfatal nonintentional injury for infants was falls, accounting for half of the injuries. The second most common injury was "struck by or against" and the third was fire or burn injuries. The patients were more likely to be male than female. Generally, injury rates increased and hospitalization rates decreased according to month of age. Contusions/abrasions were the leading diagnosis overall for all the infants seen. Bedding was the product most frequently noted as being involved in the injury event at every age except at 2 months and 12 months. Car seats were the most involved at 2 months, and stairs were the most at 12 months. In conclusion, every 1.5 minutes an infant 0-12 months is seen in the ED for a nonfatal nonintentional injury. The infant’s risk of injury is influenced by a combination of social and physical environments and products. Creating a safe environment along with parental knowledge of the developmental milestones is important in the prevention of these injuries.

Summary The authors sought to document the frequency with which pediatric residents encounter end of life issues with patients and how comfortable and prepared residents feel regarding these areas. They sent out the 80 categorical pediatric residents at Johns Hopkins an internet survey with 48 questions dealing with specific aspects of end of life care. 40 residents returned the survey. The specific areas addressed in the survey were being present for a patient's death, participation in or observation of discussions regarding withdrawing or limiting treatment, providing end of life symptom treatment, declaring a patient dead, discussing autopsy with families, completing a death certificate, seeking support after a patient's death, and having follow up contact with the patient's family after the death. Overall, the residents had less experience with death than did residents of the past. However, most residents do have a role in various aspects of end of life care. Despite having the responsibility of providing this care, most residents felt that they received no formal training regarding these issues and felt ill-prepared to provide these services. When residents stated that they had been educated about an aspect of end of life care, it was much more likely to have occurred in an informal manner at the time of the death rather than in a more neutral, less emotionally charged setting.

Summary This was a retrospective case-control study conducted via a chart review which tried to elucidate the frequency and risk factors for deep focus of infection in children who had Staphylococcus aureus bacteremia (SAB). This involved children presenting to Rainbow Babies and Children’s Hospital between January 1992 and June 2006. The primary outcome of the study was the presence of a deep focus of infection as documented by a positive echocardiogram, bone imaging or abdominal imaging. A total of 298 children were included, of whom 58 (19%) had documented evidence of deep-seated infection. 84% of them had an underlying medical condition. Forty-seven of these children had symptoms of a deep seated infection on discovery of a SAB where 11 children (3.7%) had unsuspected deep seated infection. All children who had an unsuspected deep seated infection had either an underlying medical condition or a central venous access. Having a positive culture beyond 1 day was significantly associated with an unsuspected deep seated infection. This is the largest pediatric study of deep-seated infections by SAB reported to date and suggests that further imaging should be reserved for those with one or more of the risk factors. The retrospective nature of this study and the single tertiary care center used in this study limits its ability to be generalizable.

Summary This was a historic case-control study which sought to determine the unique clinical and laboratory features of neonates with and without HSV infection admitted to Texas Children’s Hospital during a 14 year period (1991-2005). This study included all hospitalized neonates (<29days of age at admission ) with laboratory confirmed HSV infection in comparison with a restricted sample of HSV-negative hospitalized neonates (1:4 ratio). Forty HSV-infected neonates and 160 controls were included. Of the 40 with infection, 27.5% were infected with HSV 1. 37.5% had disseminated disease, 37.5% involved the CNS and 25% had skin/eye/mouth disease. Several factors were associated with neonatal HSV infection including maternal primary HSV infection, vaginal delivery, prematurity, cutaneous lesions, seizures, lethargy, temperature instability, elevated hepatic enzymes, and CSF pleocytosis. For neonates without vesicular rash, several factors not classically associated with HSV infection were elucidated including maternal fever, respiratory distress requiring mechanical ventilation, and CSF pleocytosis. These findings might allow for earlier detection of neonatal HSV infection, especially amongst those from a similar patient population. The retrospective nature of this study and the potential selection bias due to the study design limits the study.