PEDIATRICS
MAYO
2008
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Decreased Respiratory Compliance in Infants
Less Than or Equal to 32 Weeks' Gestation, Delivered More Than 7 Days After
Antenatal Steroid Therapy
a Division of Neonatology,
Department of Pediatrics
b Department of Public Health and Preventive Medicine, Oregon Health
and Science University, Portland, Oregon
c Division of Neonatal Medicine, Keck School of Medicine, University
of Southern California, Los Angeles, California
OBJECTIVES. Our objective was to compare the
pulmonary function (respiratory compliance) of infants who were 
32 weeks' gestation and delivered >7 days after a single
course of antenatal steroids versus infants who were delivered 1 to
7 days after a single course of antenatal steroids.
METHODS. A prospective cohort study of respiratory
system compliance was conducted of infants 32 weeks' gestation within 72 hours of life and before
surfactant therapy if needed. The study (remote) group was composed
of infants who were treated with antenatal steroids >7 days
before delivery and the comparison group (ideal group) of matched
infants who were treated with antenatal steroids 1 to 7 days before
delivery. Respiratory system compliance was measured with the
single-breath occlusion technique.
RESULTS. Twenty-eight remotely treated infants and 28
ideally treated infants were studied. The remote group had a
significantly lower respiratory system compliance per kilogram and
total respiratory system compliance when compared with the ideal
antenatal steroids group. Within the remote group, infants who
received antenatal steroids 8 to 14 days (n = 10) before
delivery had a significantly higher respiratory system compliance
and a trend to less surfactant need (10% vs 33%) as compared with
infants who received antenatal steroids >14 days (n = 18)
before delivery.
CONCLUSIONS. Infants who were 32 weeks' gestation and remotely treated with antenatal
steroids (average 21 days) had a significantly lower respiratory
compliance compared with matched infants who were ideally treated with
antenatal steroids. We speculate that the lower respiratory system
compliance may reflect the dissipation of beneficial effects of
antenatal steroids on pulmonary function when delivery occurs >7
days after therapy and particularly when therapy is >14 days
before delivery.
Key Words:
antenatal corticosteroids • betamethasone • premature infants • pulmonary
function • respiratory compliance
Abbreviations:
AS—antenatal steroids • RDS—respiratory distress syndrome • Crs—passive
respiratory system compliance • CPAP—continuous positive airway pressure •
PFT—pulmonary function test • CI—confidence interval
Accepted Nov 1, 2007.
[Full Text of McEvoy et al.] [Reprint
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Nurse Opinions and Pulse Oximeter Saturation
Target Limits for Preterm Infants
a Division of Neonatology,
Children's Hospital, Boston, Massachusetts
b Division of Neonatology, Connecticut Children's Medical Center,
Hartford, Connecticut
c Institute for Clinical Research and Health Policy Studies
d Division of Newborn Medicine, Tufts–New England Medical Center,
Boston, Massachusetts
e Department of Neonatology, Beth Israel-Deaconess Medical Center,
Boston, Massachusetts
OBJECTIVE. The objectives of this study were to
compare pulse oximeter saturation limits targeted by nurses for
extremely preterm infants during routine care with nurse opinions
regarding appropriate pulse oximeter saturation limits and with
policy-specified pulse oximeter saturation limits and to identify
factors that influence pulse oximeter saturation limits targeted by
nurses.
METHODS. We surveyed nurses in US NICUs with
neonatal-perinatal fellowships in 2004. Data collected included
pulse oximeter saturation limits targeted by nurses and by NICU
policy when present, nurses' opinions about appropriate pulse
oximeter saturation limits, and NICU and nurse characteristics. Factors
associated with pulse oximeter saturation limits targeted by nurses
were identified with hierarchical linear modeling.
RESULTS. Among those eligible, 2805 (45%) nurses in 59
(60%) NICUs responded. Forty (68%) of 59 NICUs had a policy that
specified a pulse oximeter saturation target range for extremely
preterm infants. Among 1957 nurses at NICUs with policies, 540 (28%)
accurately identified the upper and lower limits of their NICU's policy
and also targeted these values in practice. NICU-specific SDs for
individual nurse target limits were less at NICUs with versus
without a policy for both upper and lower limits. Hierarchical linear
modeling identified presence of pulse oximeter saturation policy,
NICU-specific nurse group opinion, and individual nurse opinion as
factors significantly associated with individual pulse oximeter
saturation target limits. For each percentage point increase in
individual opinion upper limit, the individual target upper limit
increased by 0.41 percentage point at NICUs with a policy compared
with 0.6 percentage point at NICUs with no policy.
CONCLUSIONS. Presence of policy-specified pulse
oximeter saturation limits, nurse group opinion, and individual
nurse opinion were independently associated with individual nurse
pulse oximeter saturation target limits during routine care of extremely
preterm infants. The presence of a policy reduced the influence of
individual nurse opinion on targeted pulse oximeter saturation
limits and reduced variation among nurse target limits within NICUs.
Key Words:
oxygen saturation • prematurity • policy • oxygenation • pulse oximetry • NICU
Abbreviations:
EPI—extremely preterm infant • SpO2—pulse oximeter oxygen saturation
Accepted Nov 1, 2007.
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Community-Based Kangaroo Mother Care to Prevent
Neonatal and Infant Mortality: A Randomized, Controlled Cluster Trial
a Department of Epidemiology,
Columbia University, Mailman School of Public Health, New York, New York
b Health Systems, Johns Hopkins University, Sylhet, Bangladesh
c Mitra and Associates, Dhaka, Bangladesh
d Nutrition Department
e James P. Grant School of Public Health, Bangladesh Rural
Advancement Committee, Dhaka, Bangladesh
f Programs Department, Population Council, Dhaka, Bangladesh
g Gynuity Health Projects, New York, New York
OBJECTIVE. We adapted kangaroo mother care for
immediate postnatal community-based application in rural Bangladesh,
where the incidence of home delivery, low birth weight, and neonatal
and infant mortality is high and neonatal intensive care is unavailable.
This trial tested whether community-based kangaroo mother care reduces
the overall neonatal mortality rate by 27.5%, infant mortality rate
by 25%, and low birth weight neonatal mortality rate by 30%.
METHODS. Half of 42 unions in 2 Bangladesh divisions
with the highest infant mortality rates were randomly assigned to
community-based kangaroo mother care, and half were not. One village
per union was randomly selected proportionate to union population
size. A baseline survey of 39888 eligible consenting women collected
sociodemographic information. Community-based workers were taught to
teach community-based kangaroo mother care to all expectant and
postpartum women in the intervention villages. A total of 4165 live
births were identified and enrolled. Newborns were followed for 30
to 45 days and infants were followed quarterly through their first
birthday to record infant care, feeding, growth, health, and vital
status.
RESULTS. Forty percent overall and 
65% of newborns who died were not weighed at birth, and
missing birth weight was differential by study group. There was no
difference in overall neonatal mortality rate or infant mortality
rate. Except for care seeking, community-based kangaroo mother care
behaviors were more common in the intervention than control group,
but implementation was weak compared with the pilot study.
CONCLUSIONS. The extensive missing birth weight and
its potential bias render the evidence insufficient to justify
implementing community-based kangaroo mother care. Additional
experimental research ensuring baseline comparability of mortality,
adequate kangaroo mother care implementation, and birth weight
assessment is necessary to clarify the effect of community-based
kangaroo mother care on survival.
Key Words:
birth weight • kangaroo care • neonatal survival
Abbreviations:
LBW—low birth weight • KMC—kangaroo mother care • STS—skin-to-skin • IMR—infant
mortality rate • BRAC—Bangladesh Rural Advancement Committee •
CKMC—community-based kangaroo mother care • NMR—neonatal mortality rate •
BINP—Bangladesh Integrated Nutrition Programme • NNP—National Nutrition
Programme • GEE—generalized estimating equations • DSMB—data safety and
monitoring board • CI—confidence interval • OR—odds ratio
Accepted Nov 5, 2007.
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Quality of Life in Children With Heart Disease
as Perceived by Children and Parents
a Department of Pediatric
Cardiology, Children's Hospital Medical Center, Cincinnati, Ohio
Departments of b Psychology
c Pediatrics
d Architecture, Texas A&M University, College Station, Texas
OBJECTIVES. The aims of this study were to
evaluate and compare the parent-reported and self-reported quality
of life of children who have cardiovascular disease with the healthy
pediatric population across age groups and to determine the
relationship between perceived quality of life and severity of
cardiovascular disease.
METHODS. The Pediatric Quality of Life Inventory
(PedsQL) Generic Core Scales and Cardiac Module were administered to
475 families including 347 children with cardiovascular disease
during a pediatric cardiology outpatient visit. The PedsQL scores
reported by children with cardiovascular disease and their parents
were compared with pediatric population norms. The relationship
between Pediatric Quality of Life Inventory scores and patient
characteristics was examined.
RESULTS. By self-report, mean PedsQL scores for
children with cardiovascular disease were significantly lower than
healthy child norms for physical and psychosocial functioning. Psychosocial
quality of life scores were classified as significantly impaired as
reported by 21% of children 
8
years of age. Even among children with less severe cardiovascular
disease, 19.2% reported significantly impaired psychosocial quality
of life. By parental report, overall PedsQL scores were not
significantly different from healthy children except in the teenage
group, and both the 8- to 12-year-old and teenage groups had lower
mean psychosocial quality of life scores than healthy peers. Parent-reported
mean PedsQL scores for both physical and psychosocial quality of
life were significantly lower in children with more severe
cardiovascular disease. Children with more severe cardiovascular
disease reported lower mean scores for physical functioning, but
smaller differences in psychosocial quality of life scores were
observed related to disease severity.
CONCLUSIONS. Overall, children with cardiovascular
disease perceived lower quality of life than healthy children across
all age groups. As perceived by parents, overall quality of life was
not significantly different in young children with cardiovascular disease,
but children with more severe cardiovascular disease have worse
physical and psychosocial quality of life. One in 5 children with
cardiovascular disease perceives impaired psychosocial functioning,
including children with mild disease severity.
Key Words:
quality of life • congenital heart disease • psychosocial outcomes
Abbreviations:
CVD—cardiovascular disease • QoL—quality of life • WHO—World Health
Organization • PedsQL—Pediatric Quality of Life Inventory • SES—socioeconomic
status
Accepted Oct 19,
2007.
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Prenatal Exposure to Maternal Infections and
Epilepsy in Childhood: A Population-Based Cohort Study
a Departments of aEpidemiology
c General Practice, Institute of Public Health, University of
Aarhus, Aarhus, Denmark
b Shanghai Institute of Planned Parenthood Research, Shanghai, China
d Department of Neurology and Department of Clinical Pharmacology,
Aarhus University Hospital, Aarhus, Denmark
e Pediatric Infectious Diseases, Epidemiology and Immunology, Emory
University, Atlanta, Georgia
f Department of Epidemiology, School of Public Health, University of
California at Los Angeles, Los Angeles, California
OBJECTIVE. We estimated the association between
prenatal exposure to maternal infections and the subsequent risk for
epilepsy in childhood.
METHODS. We included 90619 singletons who were born
between September 1997 and June
RESULTS. Children who were exposed to maternal
cystitis, pyelonephritis, diarrhea, coughs, and/or vaginal yeast
infection some maternal infections in prenatal life had an increased
risk for epilepsy. Coughs lasting >1 week were associated with an
increased risk for epilepsy only in the first year of life, as was
vaginal yeast infection only in children who were born preterm. These
associations remained unchanged for children without cerebral palsy,
congenital malformation, or a low Apgar score at 5 minutes.
CONCLUSIONS. Prenatal exposure to some maternal
infections was associated with an increased risk for epilepsy in
childhood.
Key Words:
epilepsy • infection • prenatal • pregnancy • cohort studies • etiology
Abbreviations:
DNBC—Danish National Birth Cohort • ICD-10—International Classification of
Diseases, 10th Revision • IRR—incidence rate ratio • CI—confidence interval
Accepted Oct 12,
2007.
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Spectrum of Medium-Chain Acyl-CoA Dehydrogenase
Deficiency Detected by Newborn Screening
a Department of Pediatrics,
New England Newborn Screening Program, University of Massachusetts Medical
School, Jamaica Plain, Massachusetts
b Department of Pediatrics, University of Cincinnati College of
Medicine, Cincinnati, Ohio
c Department of Pediatrics, Children's Hospital Boston, Boston,
Massachusetts
d Department of Neurology, Massachusetts General Hospital, Boston,
Massachusetts
OBJECTIVE. Our goal was to describe the
clinical spectrum of medium-chain acyl-CoA dehydrogenase deficiency
detected by routine newborn screening and assess factors associated
with elevations of octanoylcarnitine in newborns and characteristics
associated with adverse clinical consequences of medium-chain
acyl-CoA dehydrogenase deficiency.
METHODS. The first 47 medium-chain acyl-CoA
dehydrogenase deficiency cases detected by the New England Newborn
Screening Program were classified according to initial and follow-up
octanoylcarnitine values, octanoylcarnitine-decanoylcarnitine ratios,
medium-chain acyl-CoA dehydrogenase genotype, follow-up biochemical
parameters, and feeding by breast milk or formula.
RESULTS. All 20 patients who were homozygous for 985A
G had high initial octanoylcarnitine values (7.0–36.8 µM) and
octanoylcarnitine-decanoylcarnitine ratios (7.0–14.5), whereas
the 27 patients with 0 to 1 copy of 985AG
exhibited a wide range of octanoylcarnitine values (0.5–28.6 µM)
and octanoylcarnitine-decanoylcarnitine ratios (0.8–12.7). Initial
newborn octanoylcarnitine values decreased by days 5 to 8, but the
octanoylcarnitine-decanoylcarnitine ratio generally remained stable.
Among 985AG
homozygotes, breastfed newborns had higher initial octanoylcarnitine
values than newborns who received formula. Adverse events occurred
in 5 children, 4 985AG
homozygotes and 1 compound heterozygote with a very high initial octanoylcarnitine:
2 survived severe neonatal hypoglycemia, 1 survived a severe
hypoglycemic episode at 15 months of age, and 2 died as a result of
medium-chain acyl-CoA dehydrogenase deficiency at ages 11 and 33
months.
CONCLUSION. Newborn screening for medium-chain
acyl-CoA dehydrogenase deficiency has detected cases with a wide
range of genotypes and biochemical abnormalities. Although most
children do well, adverse outcomes have not been entirely avoided. Assessment
of potential risk and determination of appropriate treatment remain
a challenge.
Key Words:
newborn screening • metabolic disorders • fatty acid oxidation defects
Abbreviations:
MCAD—medium-chain acyl-CoA dehydrogenase • C8—octanoylcarnitine •
PCR—polymerase chain reaction • C10—decanoylcarnitine
Accepted Oct 12,
2007.
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Neonatal Respiratory Failure: A 12-Month
Clinical Epidemiologic Study From 2004 to 2005 in China
a Department of Neonatology,
Children's Hospital of Fudan University, Shanghai, China
b Department of Neonatology, Provincial Children's Hospital,
Shijiazhuang, Hebei, China
c Department of Neonatology, Quanzhou Women and Children's Hospital,
Quanzhou, Fujian, China
d Department of Neonatology, Xi'An Children's Hospital, Xi'An, Shaanxi,
China
e Department of Neonatology, Children's Hospital of Chongqing
Medical University, Chongqing, China
f Department of Neonatology, Provincial Maternity Hospital, Fuzhou,
Fujian, China
g Department of Neonatology, Suzhou Women and Children's Health
Center, Suzhou, Jiangsu, China
h Division of Neonatology, Department of Pediatrics, Yuying
Children's Hospital of Wenzhou Medical College, Wenzhou, Zhejiang, China
i Department of Neonatology, Provincial Maternity Hospital, Wuhan,
Hubei, China
j Department of Neonatology, Provincial Maternity Hospital, Xi'An,
Shaanxi, China
k Department of Intensive Care, Shenzhen Children's Hospital,
Shenzhen, Guangdong, China
OBJECTIVES. In the past decade, neonatal
special care services in China have been established, during which
time various therapies for neonatal respiratory failure have been
introduced. The objective of this study was to investigate the
incidence, management, outcome, and cost of neonatal respiratory
failure treated by mechanical ventilation in 23 tertiary NICUs of
major hospitals in southeastern and midwestern China.
METHODS. Data were collected over 12 consecutive
months from 2004 to 2005 for neonates with neonatal respiratory
failure. Eligible infants were those who required endotracheal
intubation and mechanical ventilation and/or nasal continuous
positive airway pressure for at least 24 hours and infants who died
within 24 hours of ventilation during their first 7 days of life. Data
characterized demographics, antenatal and perinatal history, illness
severity score, primary disease, respiratory care, complications, survival,
and clinical burden.
RESULTS. From a total of 13070 NICU admissions, there
were 1722 (13.2%) cases of neonatal respiratory failure with
respiratory distress syndrome, pneumonia/sepsis, and meconium
aspiration syndrome as major causes. For infants who survived until
discharge, the median length of ventilation was 70 hours. Overall,
in-hospital mortality for neonatal respiratory failure was 32.1%.
Logistic regressions showed that lower gestational age, vaginal
delivery, fetal distress before delivery, presence of a major
anomaly, and high severity score in preterm infants were associated
with an increased risk for death. In term and postterm infants, only
the presence of a major anomaly and a high severity score were significant
risk factors for death. Mean length and cost of stay in hospital
were 19.2 ± 14.6 days and 14966 ± 13465 Yuan in the survivors.
CONCLUSIONS. Neonatal respiratory failure in the NICU
of the provincial cities of China has high mortality and cost that
are linked to geographic variability, a male predominance, and low
proportion of very preterm infants, characteristic of sociocultural confounding
background.
Key Words:
epidemiology • neonatal respiratory failure • mortality • incidence •
mechanical ventilation • respiratory therapy • neonatal intensive care
Abbreviations:
NRF—neonatal respiratory failure • CMV—conventional mechanical ventilation •
HFV—high-frequency ventilation • nCPAP—nasal continuous positive airway
pressure • SNAPPE-II—score for neonatal acute physiology perinatal extension II
• GA—gestational age • CLD—chronic lung disease • ROP—retinopathy of
prematurity • OR—odds ratio • CI—confidence interval • RDS—respiratory distress
syndrome • MAS—meconium aspiration syndrome • TT—transient tachypnea •
LOV—length of ventilation • LOS—length of stay • ELBW—extremely low birth
weight • VLBW—very low birth weight
Accepted Oct 9, 2007.
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Trends in Intussusception Hospitalizations
Among US Infants, 1993–2004: Implications for Monitoring the Safety of the New
Rotavirus Vaccination Program
a Division of Viral Diseases,
Epidemiology Branch, National Center for Immunizations and Respiratory
Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
b Laboratory of Infectious Diseases, National Institute of Allergy
and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
c Fogarty International Center, National Institutes of Health,
Bethesda, Maryland
d Center for Delivery, Organization and Markets, Agency for
Healthcare Research and Quality, Rockville, Maryland
OBJECTIVES. In
METHODS. By using the Healthcare Cost and Utilization
Project's State Inpatient Database that captures US hospital
discharges from 16 states representing 49% of the birth cohort
during 1993–2004 and from 35 states representing 85% of the birth
cohort in 2002–2004, we examined hospitalizations among infants
(<12 months of age) with an International Classification of
Disease, Ninth Revision, Clinical Modification code for
intussusception (560.0). Incidence rates were calculated by using
census data, and rate ratios with 95% confidence intervals were
calculated by using Poisson regression data.
RESULTS. Annual intussusception hospitalization rates
declined 25% from 1993 to 2004 but have remained stable at 35 cases per 100000 infants since 2000. Rates were very low
for infants younger than 9 weeks (<5 per 100000) then increased
rapidly, peaking at 62
per 100000 at 26 to 29 weeks, before declining gradually to 26 per
100000 at 52 weeks. Compared with rates among non-Hispanic white
infants (27 per 100000), rates were greater among non-Hispanic black
infants (37 per 100000) and Hispanic infants (45 per 100000); however,
rates did not differ by race/ethnicity for infants who were younger
than 16 weeks.
CONCLUSIONS. This assessment of US hospitalizations
provides up-to-date and nationally representative prevaccine rates of
intussusception. Because rates varied almost 12-fold by week of
age and to a lesser extent by race/ethnicity during the age of
vaccination, adjusting baseline rates to reflect the demographics of
the vaccinated population will be crucial for assessing risk for
intussusception after rotavirus vaccination.
Key Words:
intussusception • rotavirus vaccine • vaccine safety monitoring
Abbreviations:
VAERS—Vaccine Adverse Event Reporting System • SID—State Inpatient Database •
HCUP—Healthcare Cost and Utilization Project • AHRQ—Agency for Healthcare
Research and Quality • ICD-9-CM—International Classification of Disease,
Ninth Revision, Clinical Modification • RR—rate ratio • CI—confidence
interval
Accepted Oct 8, 2007.
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Percutaneously Inserted Central Catheter for
Total Parenteral Nutrition in Neonates: Complications Rates Related to Upper
Versus Lower Extremity Insertion
a Division of
Neonatal-Perinatal Medicine, Department of Pediatrics, University of
California, School of Medicine, Irvine, California
b Division of Pediatric Radiology, Department of Radiology,
University of California, School of Medicine, Irvine, California
OBJECTIVE. The objective of this study was to
compare the complication rates of upper versus lower extremity
percutaneously inserted central catheters used for total parenteral
nutrition in neonates.
METHODS. During a 48-month study period, 396 neonates
were identified as having had percutaneously inserted central venous
catheters. A total of 370 catheters were inserted from the upper and
107 from the lower extremity. Data retrieved and analyzed were birth
weight, gestational age, age at placement, duration in place, duration
of total parenteral nutrition, type of infusates, catheter-related bloodstream
infection, phlebitis, leakage, occlusion, necrotizing enterocolitis,
intraventricular hemorrhage, serum creatinine, liver function tests,
and length of hospitalization.
RESULTS. The median birth weight and gestational age
were
CONCLUSION. Lower extremity percutaneously inserted
central venous catheters had lower rates of catheter-related
bloodstream infection, longer time to first complication, and lower
cholestasis despite longer duration of total parenteral nutrition. When
possible, lower extremity inserted catheters should be used for
the administration of total parenteral nutrition.
Key Words:
PICC • CRBSI • septicemia • TPN • cholestasis
Abbreviations:
TPN—total parenteral nutrition • PICC—percutaneously inserted central catheter
• CRBSI—catheter-related bloodstream infection
Accepted Sep 27,
2007.
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Quality of General Movements Is Related to
White Matter Pathology in Very Preterm Infants
a Victorian Infant Brain
Studies, Murdoch Childrens Research Institute, Melbourne, Australia
Departments of b Paediatrics
c Obstetrics and Gynaecology
g Howard Florey Institute, University of Melbourne, Melbourne,
Australia
d Division of Newborn Services, Royal Women's Hospital, Melbourne,
Australia
e Queensland Cerebral Palsy and Rehabilitation Research Centre,
University of Queensland, Brisbane, Australia
f Department of Pediatrics, Neurology, and Radiology, St Louis
Children's Hospital, Washington University, St Louis, Missouri
OBJECTIVE. Preterm infants are at an increased
risk for abnormalities of general movements, which predict
subsequent poor neurodevelopmental outcome. The cerebral lesion that
predisposes the preterm infant to abnormal general movements remains
unknown. The objective of this study was to determine the association
between MRI-defined cerebral abnormalities and general movements at
1 and 3 months' corrected age in infants who were born very preterm.
METHODS. Eighty-six preterm infants (<30 weeks'
gestation) were prospectively recruited and underwent brain MRI at
term-equivalent age to investigate the relationship between
qualitative white and gray matter pathology and abnormality of
general movements. Standardized videotaped recordings of general
movements were obtained at 1 and 3 months postterm (±1 week) and
scored without knowledge of the MRI findings. At 1 month corrected
age, general movements of a writhing character were classified as
normal or abnormal (poor repertoire, cramped synchronized, or
chaotic). At 3 months' corrected age, fidgety general movements were
classified as present or absent.
RESULTS. At 1 month, 53 (62%) infants had abnormal
general movements, 46 of whom had poor repertoire general movements
and 7 of whom had cramped synchronized general movements. At 3
months, 23 (25%) infants had absent fidgety movements. At both 1 and
3 months of age, consistently abnormal general movement
classifications were related to increasing white matter abnormality
on MRI. In contrast, there were no significant relationships between
general movement classifications and gray matter abnormalities, either
individually or in total.
CONCLUSION. The significant relationships between
general movements at 1 and 3 months and cerebral white matter
abnormalities on MRI in the very preterm infant support the concept
that abnormal general movements reflect white matter injury.
Key Words:
developmental follow-up • magnetic resonance • neuromotor outcome • preterm
infants
Abbreviations: GM—general movement •
IVH—intraventricular hemorrhage • PVL—periventricular leukomalacia
Accepted Oct 1, 2007.
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Nasal Continuous Positive Airway Pressure With
Heliox Versus Air Oxygen in Infants With Acute Bronchiolitis: A Crossover Study
Pediatric Emergency and Critical Care Division,
Department of Pediatrics, Complejo Hospitalario Universitario de Santiago,
Santiago de Compostela, Spain; Department of Pediatrics, School of Medicine,
University of Santiago de Compostela, Santiago de Compostela, Spain
OBJECTIVE. The purpose of this work was to
evaluate the effects of administering either heliox or air oxygen in
combination with nasal continuous positive airway pressure in
infants with refractory bronchiolitis.
PATIENT AND METHODS. We conducted a prospective,
interventional, single-center, crossover study in a teaching
hospital including infants 1 month to 2 years of age, consecutively
admitted to the PICU from February 2004 to February 2005 for
treatment of severe acute bronchiolitis unresponsive to therapy. Patients
with a clinical score (Modified Wood's Clinical Asthma Score) of
>5, arterial oxygen saturation of <92%, or transcutaneous CO2
pressure of >50 mmHg despite supportive therapy, nebulized L-epinephrine,
and heliox therapy through a nonrebreathing reservoir face mask were
eligible. During the study period, 40 infants with bronchiolitis
were admitted to the PICU; 12 fulfilled inclusion criteria. A
predetermined balanced sequential allocation to either 30 minutes of
treatment with nasal continuous positive airway pressure with heliox
or to air-oxygen nasal continuous positive airway pressure was
performed. Measurements were taken at baseline and after 30 minutes
of each treatment.
RESULTS. Baseline mean values were as follows: nasal
continuous positive airway pressure of 7.2 cmH2O;
clinical score of 7.7 points; transcutaneous CO2 pressure
of 61.6 mmHg; and arterial oxygen saturation of 88.6%, with the
fraction of inspired oxygen at 35.4%. Clinical score, transcutaneous
CO2 pressure, and arterial oxygen saturation improved
during the study time with both heliox-nasal continuous positive
airway pressure and air-oxygen-nasal continuous positive airway
pressure: after 1 hour, the clinical score fell 1.7 points,
transcutaneous CO2 pressure decreased 8.2 mmHg, and
arterial oxygen saturation increased by 7.7%. Improvement in
clinical score was double with heliox-nasal continuous positive airway
pressure compared with the air-oxygen-nasal continuous positive
airway pressure (2.12 vs 1.08 points), and the fall in the
transcutaneous CO2 pressure was greater with heliox-nasal continuous
positive airway pressure compared with air-oxygen-nasal continuous
positive airway pressure (9.7 vs
CONCLUSIONS. Nasal continuous positive airway pressure
improves the clinical score and the CO2 elimination of
infants with refractory bronchiolitis. These positive effects are
significantly enhanced when nasal continuous positive airway pressure
is combined with heliox instead of air oxygen. Both techniques are
noninvasive, seem safe, and may reduce the need for endotracheal
intubation.
Key Words:
helium-oxygen mixture • bronchiolitis • continuous positive airway pressure •
noninvasive ventilation • respiratory therapy • pediatrics
Abbreviations:
nCPAP—nasal continuous positive airway pressure • AO—air oxygen •
RSV—respiratory syncytial virus • M-WCAS—Modified Wood's Clinical Asthma Score
• satO2—arterial oxygen saturation • tcPCO2—transcutaneous CO2 pressure • FIO2—fraction
of inspired oxygen
Accepted Oct 1, 2007.
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Predictors of Retinochoroiditis in Children
With Congenital Toxoplasmosis: European, Prospective Cohort Study
a Department of Epidemiology
and Population Health, Albert Einstein College of Medicine, Bronx, New York
b Centre for Paediatric Epidemiology and Biostatistics, University
College London Institute of Child Health, London, United Kingdom
c Division of Neonatology and Intensive Care, Department of
Pediatrics, University of Vienna, Vienna, Austria
d Department of Infectious Diseases, Aarhus University Hospital,
Aarhus, Denmark
e Perinatal Infection Unit, Department of Pediatrics, University of
Naples Federico II, Naples, Italy
f Karolinska University Hospital, Huddinge, Stockholm, Sweden
OBJECTIVE. By school age, 20% of children
infected with congenital toxoplasmosis will have 1 retinochoroidal lesion. We determined which children are
most at risk and whether prenatal treatment reduces the risk of
retinochoroiditis to help clinicians decide about treatment and
follow-up.
PATIENTS AND METHODS. We prospectively studied a
cohort of children with congenital toxoplasmosis identified by
prenatal or neonatal screening in 6 European countries. We
determined the effects of prenatal treatment and prognostic markers
soon after birth on the age at first detection of retinochoroiditis.
RESULTS. Of 281 children with congenital
toxoplasmosis, 50 developed ocular disease, and 17 had recurrent
retinochoroiditis during a median follow-up of 4.1 years. Prenatal
treatment had no significant effect on the age at first or
subsequent lesions. Delayed start of postnatal treatment did not
increase retinochoroiditis, but the analysis lacked power. Older
gestational age at maternal seroconversion was weakly associated
with a reduced risk of retinochoroiditis. The presence of nonocular
clinical manifestations of congenital toxoplasmosis at birth
strongly predicted retinochoroiditis. For 92% (230 of 249) of
children with no retinochoroiditis detected before 4 months of age,
the probability of retinochoroiditis by 4 years was low, whether
clinical manifestations were present or not 8.0%.
CONCLUSIONS. Prenatal treatment did not significantly
reduce the risk of retinochoroiditis in this European cohort. If
children have no retinochoroiditis in early infancy, the low risk of
subsequent ocular disease may not justify postnatal treatment and
repeated ophthalmic assessments during childhood. Controlled trials
are needed to address the lack of evidence for the effectiveness of
postnatal treatment.
Key Words:
congenital toxoplasmosis • retinochoroiditis • prospective cohort • treatment
effectiveness
Abbreviations:
Ig—immunoglobulin • OR—odds ratio • CI—confidence interval • IQR—interquartile
range
Accepted Oct 8, 2007.
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Trends in Bacteremia in the Pre- and
Post-Highly Active Antiretroviral Therapy Era Among HIV-Infected Children in
the US Perinatal AIDS Collaborative Transmission Study (1986–2004)
Division of Infectious Diseases, Departments of a
Pediatrics
b Medicine, Emory University School of Medicine
c Department of Epidemiology, Rollins School of Public Health, Emory
University, Atlanta, Georgia
d Department of Pediatrics, Harlem Hospital Center, New York, New
York
e Department of Pediatrics, University of Maryland, Baltimore,
Maryland
f Department of Pediatrics, University of Medicine and Dentistry,
Newark, New Jersey
g Division of HIV/AIDS Prevention, National Center for HIV, STD, and
TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
OBJECTIVE. HIV-infected children are at high
risk for bacteremia. Highly active antiretroviral therapy has
reduced rates of opportunistic infections; less is known about its
effect on pediatric bacteremia rates. Thus, we sought to determine
its impact on bacteremia incidence in HIV-infected children.
METHODS. Children born during 1986–1998 were followed
until
RESULTS. Among 364 children, 68 had 118 documented
bacteremias, 97 before and 21 after January 1, 1997. Streptococcus
pneumoniae constituted 56 (58%) pre–and 13 (62%) post–highly
active antiretroviral therapy cases. The incidence rate ratio of
bacteremias comparing post–versus pre–highly active antiretroviral
therapy was 0.3 overall and 0.2, 0.2, and 0.4 among children aged 0
to 24, 25 to 48, and 49 to 72 months, respectively. Kaplan-Meier
analysis for time to first bacteremia in children born during the pre–highly
active antiretroviral therapy compared with the post–highly active
antiretroviral therapy era revealed that 69% and 94%, respectively, remained
bacteremia free at a median follow-up of 6 years. The Cox
proportional hazards model also showed a significant reduction of
bacteremias in the post–highly active antiretroviral therapy era,
even after controlling for gender and race. Among children <6
years of age, those who experienced bacteremia had faster temporal
CD4% decline than those who never had bacteremia. Survival analysis
revealed that HIV-infected children with bacteremia experienced
higher overall mortality when controlling for gender, race, and
clinic site.
CONCLUSIONS. A significant decrease in bacteremia
incidence and a prolongation in the time to first bacteremia
incident were seen in the post–highly active antiretroviral therapy
era. Children with a steeper decline of CD4 T cells were more likely
to develop bacteremia. Children who experienced bacteremia had an
associated higher mortality than their bacteremia-free counterparts.
Key Words:
pediatric HIV/AIDS • bacteremia incidence • HAART
Abbreviations:
OI—opportunistic infection • IVIG—intravenous immunoglobulin • PACTS—Perinatal
AIDS Collaborative Transmission Study • CDC—Centers for Disease Control and
Prevention • HOPE—HIV Follow-up of Perinatally Exposed Children •
TMP-SMX—trimethoprim-sulfamethoxazole • CI—confidence interval
Accepted Oct 11,
2007.
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Lower Stress Responses After Newborn
Individualized Developmental Care and Assessment Program Care During Eye
Screening Examinations for Retinopathy of Prematurity: A Randomized Study
a Department of Women and
Child Health, Karolinska Institute, Stockholm, Sweden
b Departments of Paediatrics
f Ophtalmology, Lund University, Lund, Sweden
c Winnicott Baby Unit, St Mary's National Health Service Trust,
London, United Kingdom
d Department of Paediatrics, Linköping University, Linköping, Sweden
e Northwick Park Hospital, London, United Kingdom
g Department of Optometry and Visual Science, City University,
London, United Kingdom
OBJECTIVE. Screening examination for
retinopathy of prematurity is distressing and painful. The aim of
the present study was to investigate whether a Newborn
Individualized Developmental Care and Assessment Program
intervention during a retinopathy of prematurity examination results
in less adverse behavioral, pain, and stress responses as compared
with standard care.
METHODS. The first 2 eye examinations in 36 preterm
infants were evaluated. The infants were randomly assigned at the
first eye examination to receive either Newborn Individualized
Developmental Care and Assessment Program care or standard care. At
the second examination, crossover of subject assignment was
performed. The assessments included behavioral responses; recordings
of heart rate, respiration, and oxygenation; pain scores (premature
infant pain profile); and salivary cortisol at defined time points
up to 4 hours after the eye examination. The nursing support given
during the eye examinations (intervention score) were scored using
predefined criteria.
RESULTS. Altogether, 68 examinations were evaluated. Newborn
Individualized Developmental Care and Assessment Program care was
associated with better behavioral scores during the examination but
there was no difference in heart rate, respiratory rate, oxygenation,
or premature infant pain profile score between the 2 care strategies
before or after the eye examination. Salivary cortisol increased
from baseline to 30 minutes after the eye examination independent of
care strategy and decreased significantly between 30 and 60 minutes
when infants were subjected to Newborn Individualized Developmental
Care and Assessment Program care but not after standard care. During
the study period the intervention score for standard care increased
and approached the score for Newborn Individualized Developmental
Care and Assessment Program care at the later eye examinations.
CONCLUSION. A Newborn Individualized Developmental
Care and Assessment Program-based intervention during eye
examination does not decrease pain responses but results in faster
recovery, as measured by lower salivary cortisol 60 minutes after
the examination. The differences were seen despite the influence
from the Newborn Individualized Developmental Care and Assessment Program
intervention on the standard care treatment that occurred during the
study period.
Key Words:
developmental care • eye examination • NIDCAP • pain • preterm infant •
retinopathy of prematurity • stress
Abbreviations:
ROP—retinopathy of prematurity • NIDCAP—Newborn Individualized Developmental
Care and Assessment Program • PMA—postmenstrual age • PIPP—premature infant
pain profile
Accepted Oct 18,
2007.
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Early Intratracheal Instillation of Budesonide
Using Surfactant as a Vehicle to Prevent Chronic Lung Disease in Preterm
Infants: A Pilot Study
a Department of Pediatrics,
College of Medicine
f Research Institute of Chinese Medicine, China Medical University,
Taichung, Taiwan
c Departments of Chemical Engineering
d Chemistry, National Cheng Kung University, Tainan, Taiwan
e National Research Institute of Chinese Medicine, Taipei, Taiwan
g Department of Biotechnology, Asian University, Wufeng, Taiwan
b Department of Pediatrics, John H. Stroger, Jr, Hospital of Cook
County, Chicago, Illinois
OBJECTIVE. Budesonide is an inhaled steroid
with a strong topical effect but with minimal systemic effects; it
has been effectively delivered to animal lungs using surfactant as a
vehicle. The purposes of this study were to determine whether early
intratracheal instillation of budesonide using surfactant as a
vehicle would improve pulmonary status, reduce mortality, and reduce
chronic lung disease morbidity.
PATIENTS AND METHODS. We conducted a prospective,
randomized blind trial in 116 very low birth weight infants (<0.6 shortly after birth: 60 were in the treated group (intratracheal
instillation of a mixture of 0.25 mg/kg of budesonide and 100.00 mg/kg
of survanta, every 8 hours) and 56 were in the control group (100
mg/kg of survanta only, every 8 hours). The end point assessment was
the number of infants who would die or develop chronic lung disease
at 36 weeks’ postconceptional age.
RESULTS. Infants in the treatment group required
significantly lower mean airway pressure on day 1 and day 3 and had
significantly lower oxygen index and PCO2 during the first 3 days than infants in
the control group. More infants were extubated in the treatment group
than controls at 1 and 2 weeks. The combined outcome of deaths or
chronic lung disease was significantly lower in the treatment group
than in the control group (19 of 60 vs 34 of 56). No clinically
significant adverse effects were observed during the study.
CONCLUSIONS. This pilot study indicated that early
postnatal intratracheal instillation of budesonide using surfactant
as vehicle significantly improved the combined outcome of death
or chronic lung disease in small premature infants without causing immediate
adverse effects. The results are encouraging, and a large sample
multicenter trial is warranted.
Key Words:
budesonide • survanta • chronic lung disease
Abbreviations:
CLD—chronic lung disease • RDS—respiratory distress syndrome • FIO2—fractional
inspired oxygen • CPAP—continuous positive airway pressure • IMV—intermittent
mandatory ventilation • AUC—area under the plasma concentration-time curve •
MAP—mean airway pressure • OI—oxygen index
Accepted Nov 14,
2007.
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Decreased Full Breastfeeding, Altered
Practices, Perceptions, and Infant Weight Change of Prepregnant Obese Women: A
Need for Extra Support
a Multidisciplinary
Pediatrics–Child Nutrition
c Maternity
d INSERM Clinical Investigation Center, Centre Hospitalier
Universitaire de Poitiers, Poitiers, France
b EA 3813, Laboratoire Adaptation Physiologique aux Activités
Physiques, Université de Poitiers, Poitiers, France
OBJECTIVE. The purpose of this work was to
compare breastfeeding practices, perceptions, and infant weight
change of prepregnant obese versus normal-weight mothers in the
first 3 months postpartum.
PATIENTS AND METHODS. For the prospective case-control
study, obese mothers (prepregnant BMI 30 kg/m2) were matched with normal-weight mothers
(18.5 prepregnant
BMI < 25 kg/m2) according to initial infant feeding,
parity, maternal age, ethnicity, and education. Participants
completed an oral questionnaire in the hospital and a telephone
interview at 1 and 3 months postpartum.
RESULTS. Of 1432 mothers who had given birth at a
university hospital in France, 10% were obese. Breastfeeding
initiation was lower for obese (48%) versus normal-weight (64%)
mothers. A total of 111 of 141 obese mothers were paired with 111
normal-weight mothers. Infant birth weight was similar for newborns
of obese and normal-weight mothers. Among mothers who initiated breastfeeding,
infant weight gain from 0 to 1 month was lower in breastfed infants
of obese mothers compared to normal-weight mothers. Obese mothers
were less likely to maintain full breastfeeding at 1 month and 3
months. The percentage of mothers breastfeeding to any extent did
not differ between obese and reference women. Obese mothers more
often felt uncomfortable breastfeeding in public at 3 months. Fewer
obese mothers perceived that their milk supply was sufficient at 1
month and 3 months. Despite greater breastfeeding difficulties,
obese mothers were less likely to seek support for breastfeeding in
the first 3 months postpartum.
CONCLUSIONS. Pediatricians and health professionals
should recognize that obese mothers have different breastfeeding
practices and perceptions. Extra support and intervention are needed
among obese mothers during prenatal and early postnatal periods so
that their children can benefit from breastfeeding.
Key Words:
growth • infant feeding • lactation • maternal and child health • nutrition
Abbreviations: CHU—Centre Hospitalier
Universitaire
Accepted Nov 13,
2007.
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Prenatal and Postnatal Growth and Cognitive
Abilities at 56 Months of Age: A Longitudinal Study of Infants Born at Term
a Departments of Psychology
c Public Health, University of Helsinki, Helsinki, Finland
b National Public Health Institute, Helsinki, Finland
d Department of Pediatrics, Hospital for Children and Adolescents,
Helsinki University Central Hospital, Helsinki, Finland
e Department of Child Neurology, Hospital for Children and
Adolescents, University of Helsinki, Helsinki, Finland
OBJECTIVE. The aim of the study was to
investigate whether weight, length, BMI (kilograms per meter
squared), and head circumference at birth and their postnatal growth
are associated with cognitive abilities at 56 months of age among
infants born at term.
PATIENTS AND METHODS. Our sample was composed of 1056
Finnish children born at term, (37 to 41 weeks) free of any major
impairments. Weight, length, and head circumference were measured at
birth and at 5, 20, and 56 months of age, and BMI was calculated.
We assessed cognitive abilities by conducting tests of general reasoning,
visual-motor integration, verbal competence, and language
comprehension at 56 months of age.
RESULTS. Firstly, for every 1 SD lower in weight or
BMI at birth, general reasoning and/or visual-motor integration was
>1.20 points lower, and for every 1 SD lower in length or head
circumference at birth, abilities across all of the cognitive
domains were >1.31 points lower. Second, for every 1 SD slower
gain in weight or BMI from birth to 5 months, general reasoning and
visual-motor integration decreased by >0.97 points; for every 1
SD slower gain in length from 5 to 20 months and from 20 to 56
months, respectively, visual-motor integration, and verbal competence
and language comprehension decreased by >1.03 points; and for
every 1 SD slower increase in head circumference from birth to 5
months and from 5 to 20 months, respectively, visual-motor
integration and language comprehension decreased by >1.17 points.
Third, tests for nonlinear relationships revealed that, in some
cases, large body size and faster growth were also associated with
lower scores in cognitive tests.
CONCLUSIONS. Our findings suggest that, even within
the range of children born at term, prenatal and postnatal growth in
body size are associated with individual differences in cognitive
abilities.
Key Words:
birth size • growth • cognitive abilities • postnatal growth • term born
Abbreviations:
UC—unstandard coefficient • CI—confidence interval • IGF—insulin-like growth
factor
Accepted Nov 13,
2007.
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Erythroid Apoptosis in Idiopathic Neonatal
Jaundice
, MDa, 
, MScc,
a Departments of Pediatric
Neonatology
b Pediatric Hematology
c Hematology Laboratory, Dokuz Eylül University Faculty of Medicine,
Izmir, Turkey
OBJECTIVES. The objectives of this study were
to evaluate the contribution of erythroid apoptosis to neonatal
idiopathic pathologic jaundice and to determine whether a
measurement of the erythroid apoptosis value at birth could predict
the development of hyperbilirubinemia during the first 15 days of
life.
PATIENTS AND METHODS. Three groups were defined: group
1 (n = 101), healthy newborns whose erythroid apoptosis value
and serum total bilirubin levels were detected from birth to day
15; group 2 (n = 24), newborns who were hospitalized for jaundice
(serum total bilirubin level: >12.9 mg/dL) without any identifiable
pathologic cause; and group 3 (control group, n = 24), healthy
newborns whose serum total bilirubin levels were 12.9 mg/dL. Erythroid apoptosis value was assessed by flow
cytometry using an annexin-V fluorescein isothiocyanate kit.
RESULTS. In group 1, there was no correlation between
the erythroid apoptosis value and serum total bilirubin levels
obtained at birth and at the fourth and 15th days of life; the
erythrocyte apoptosis value obtained at birth was not significantly
different between the neonates whose serum total bilirubin levels
were >12.9 and 12.9
mg/dL and who had prolonged and nonprolonged jaundice during
follow-up. The erythroid apoptosis value differed significantly
between the newborns in groups 2 and 3. There was no significant
correlation between the erythroid apoptosis value and serum total
bilirubin levels of the infants in groups 2 and 3.
CONCLUSIONS. The erythroid apoptosis value obtained at
birth could not predict the development of hyperbilirubinemia in
neonates, but it was increased significantly in jaundiced neonates whose
serum total bilirubin levels were >12.9 mg/dL. In these infants, increase
in the erythroid apoptosis value may be a result of the toxic effect
of bilirubin or of a protective mechanism of neonates to increase
heme turnover and bilirubin production to diminish oxidative stress.
Key Words:
apoptosis • erythrocyte • jaundice • hyperbilirubinemia • newborn
Abbreviations: STB—serum total bilirubin
Accepted Nov 8, 2007.
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Verbal Autopsy Methods to Ascertain Birth
Asphyxia Deaths in a Community-based Setting in Southern Nepal
a Department of International
Health, International Center for Advancing Neonatal Health, Johns Hopkins
Bloomberg School of Public Health, Baltimore, Maryland
b Nepal Nutrition Intervention Project, Sarlahi, Katmandu, Nepal
c Institute of Medicine, Tribhuvan University, Katmandu, Nepal
OBJECTIVES. The goals of this study were to (1)
develop an approach to ascertain birth asphyxia deaths by using
verbal autopsy data from a community-based setting in Nepal, and (2)
explore variations in birth asphyxia mortality fractions by using
different birth asphyxia case definitions and hierarchical
classifications.
PATIENTS AND METHODS. Data were prospectively
collected during a cluster-randomized, community-based trial of
health interventions on neonatal mortality in Sarlahi, Nepal from
2002 to 2006. To assign cause of death, 4 computer-assigned,
symptom-based asphyxia case definitions; Nepali physician
classification; and our independent review of verbal autopsy open
narratives were used. Various hierarchical classification approaches
to assign cause of death were also explored.
RESULTS. Birth asphyxia specific mortality ranged from
26% to 54%, depending on the computer case definition used. There
was poor agreement between computer and physician classification
of birth asphyxia. By comparing computer results, physician results,
and our independent ascertainment of cause of death, we identified
246 cases of birth asphyxia (32% of neonatal deaths). Allowing for
>1 cause of death, 30% and 42% of asphyxia cases also met
criteria for prematurity and serious infection, respectively. When a
hierarchy was used to assign a single cause of death, the birth
asphyxia proportionate mortality was reduced to 12% when
identification of deaths because of congenital anomalies, prematurity,
and serious infections preceded birth asphyxia.
CONCLUSIONS. The use of various verbal autopsy
definitions and hierarchical approaches to assign cause of death may
substantially affect estimates of birth asphyxia-specific mortality
and analyses of risk factors. Verbal autopsy methods need to be
standardized and validated to generate accurate global estimates to
direct policy and resource allocation in low-middle–income
countries.
Key Words:
asphyxia • neonatal mortality • newborn • Nepal • verbal autopsy
Abbreviations:
BA—birth asphyxia • WHO—World Health Organization • CHERG—Child Health
Epidemiology Research Group • NWS—Nepal Newborn Washing Study • NNIPS—Nepal
Nutrition Intervention Project • LMP—last menstrual period
Accepted Jan 18,
2008.
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Risk Factors for Neonatal Mortality Due to
Birth Asphyxia in Southern Nepal: A Prospective, Community-Based Cohort Study
a Department of International
Health, International Center for Advancing Neonatal Health, Johns Hopkins
Bloomberg School of Public Health, Baltimore, Maryland
b Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal
c Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
OBJECTIVE. Our goal was to identify antepartum,
intrapartum, and infant risk factors for birth asphyxia mortality in
a rural, low-resource, population-based cohort in southern Nepal.
PATIENTS AND METHODS. Data were collected
prospectively during a cluster-randomized, community-based trial
evaluating the impact of newborn skin and umbilical cord cleansing
on neonatal mortality and morbidity in Sarlahi, Nepal. A total of
23662 newborn infants were enrolled between September 2002 and
January 2006. Multivariable regression modeling was performed to
determine adjusted relative risk estimates of birth asphyxia
mortality for antepartum, intrapartum, and infant risk factors.
RESULTS. Birth asphyxia deaths (9.7/1000.0 live
births) accounted for 30% of neonatal mortality. Antepartum risk
factors for birth asphyxia mortality included low paternal
education, Madeshi ethnicity, and primiparity. Facility delivery;
maternal fever; maternal swelling of the face, hands, or feet; and
multiple births were significant intrapartum risk factors for birth
asphyxia mortality. Premature infants (<37 weeks) were at higher
risk, and the combination of maternal fever and prematurity resulted
in a 7-fold elevation in risk for birth asphyxia mortality compared to
term infants of afebrile mothers.
CONCLUSIONS. Maternal infections, prematurity, and
multiple births are important risk factors for birth asphyxia mortality
in the low-resource, community-based setting. Low socioeconomic status
is highly associated with birth asphyxia, and the mechanisms leading
to mortality need to be elucidated. The interaction between maternal
infections and prematurity may be an important target for future
community-based interventions to reduce the global impact of birth
asphyxia on neonatal mortality.
Key Words:
asphyxia neonatorum • risk factors • mortality • neonatal • Nepal
Abbreviations:
RR—relative risk • CI—confidence interval • OR—odds ratio • IL—interleukin
Accepted Aug 31,
2007.
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Achievement of Targeted Saturation Values in
Extremely Low Gestational Age Neonates Resuscitated With Low or High Oxygen
Concentrations: A Prospective, Randomized Trial
a Neonatalogy Service,
b Neonatalogy Service, University Clinical Hospital San Carlos,
Complutense University, Madrid, Spain
OBJECTIVE. Extremely low gestational age
neonates have very low oxygen saturation in utero and an immature
antioxidant defense system. Abrupt increases in oxygen saturation
after birth may cause oxidative stress. We compared achievement of a
targeted oxygen saturation of 85% at 10 minutes of life when
resuscitation was initiated with low or high fractions of inspired
oxygen and levels were adjusted according to preductal pulse oxygen
saturation values.
METHODS. A prospective, randomized, clinical trial was
performed in 2 level III neonatal referral units. Patients of 28 weeks of gestation who required active resuscitation were
randomly assigned to the low-oxygen group (fraction of inspired
oxygen: 30%) or the high-oxygen group (fraction of inspired oxygen:
90%). Every 60 to 90 seconds, the fraction of inspired oxygen was
increased in 10% steps if bradycardia occurred (<100 beats per
minute) or was decreased in similar steps if pulse oxygen saturation
reached values of >85%. Preductal pulse oxygen saturation was
continuously monitored.
RESULTS. The fraction of inspired oxygen in the
low-oxygen group was increased stepwise to 45% and that in the
high-oxygen group was reduced to 45% to reach a stable pulse oxygen
saturation of 85%
at 5 to 7 minutes in both groups. No differences in oxygen saturation
in minute-to-minute registers were found independent of the initial
fraction of inspired oxygen used 4 minutes after cord clamping. No
differences in mortality rates in the early neonatal period were
detected.
CONCLUSIONS. Resuscitation can be safely initiated for
extremely low gestational age neonates with a low fraction of
inspired oxygen (30%),
which then should be adjusted to the infant's needs, reducing the
oxygen load to the neonate.
Key Words:
oxygen • resuscitation • pulse oximeter • extremely low gestational age neonate
• fetal to neonatal transition
Abbreviations: SpO2—arterial
oxygen by pulse oximetry • HR—heart rate • CPAP—continuous positive airway
pressure • FIO2—fraction of inspired oxygen
Accepted Sep 20,
2007.
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Pulse Oxygen Saturation Levels and Arterial
Oxygen Tension Values in Newborns Receiving Oxygen Therapy in the Neonatal
Intensive Care Unit: Is 85% to 93% an Acceptable Range?
a Division of
Neonatal-Perinatal Medicine, Emory University, Atlanta, Georgia
b Mid-Atlantic Neonatology Associates and Atlantic Neonatal Research
Institute, Morristown Memorial Hospital, Morristown, New Jersey
c Department of Pediatrics, University of the North, Barranquilla,
Colombia
d Pediatrix Medical Group, Neonatology, Dallas, Texas
OBJECTIVE. Our aim was to define the
relationship of PaO2 and pulse oxygen saturation values during routine clinical
practice and to evaluate whether pulse oxygen saturation values
between 85% and 93% were associated with PaO2 levels of <40 mmHg.
METHODS. Prospective comparison of PaO2 and
pulse oxygen saturation values in 7 NICUs at sea level in 2
countries was performed. The PaO2 measurements were obtained from indwelling
arterial catheters; simultaneous pulse oxygen saturation values were
recorded if the pulse oxygen saturation values changed <1% before,
during, and after the arterial gas sample was obtained.
RESULTS. We evaluated 976 paired PaO2/pulse
oxygen saturation values in 122 neonates. Of the 976 samples, 176
(18%) from infants breathing room air had a mean pulse oxygen
saturation of 93.9 ± 4.3% and a median of 95.5%. The analysis of 800
samples from infants breathing supplemental oxygen revealed that,
when pulse oxygen saturation values were 85% to 93%, the mean PaO2 was 56 ± 14.7 mmHg and the median 54 mmHg. At this pulse oxygen
saturation level, 86.8% of the samples had PaO2 values of 40 to 80 mmHg, 8.6% had
values of <40 mmHg, and 4.6% had values of >80 mmHg. When the
pulse oxygen saturation values were >93%, the mean PaO2 was
107.3 ± 59.3 mmHg and the median 91 mmHg. At this pulse oxygen
saturation level, 39.5% of the samples had PaO2
values of 40 to 80 mmHg and 59.5% had values of >80 mmHg.
CONCLUSIONS. High PaO2 occurs very rarely in neonates breathing supplemental
oxygen when their pulse oxygen saturation values are 85% to 93%. This
pulse oxygen saturation range also is infrequently associated with
low PaO2 values. Pulse oxygen saturation values of >93% are
frequently associated with PaO2 values of >80 mmHg, which may be
of risk for some newborns receiving supplemental oxygen.
Key
Words:
oxygen therapy • pulse oxygen saturation • normoxemia • hypoxemia • hyperoxemia
• oxygen arterial tension • newborns • oxyhemoglobin dissociation curve
Abbreviations: SpO2—pulse
oxygen saturation • P50—partial pressure of a gas required to
achieve 50% saturation • FIO2—fraction of inspired oxygen
Accepted Sep 17,
2007.
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Patterns of Brain Injury in Neonates Exposed to
Perinatal Sentinel Events
a Departments of Paediatrics
and Neonatal Medicine
b Imaging Sciences, Medical Research Council, Clinical Sciences
Centre, Imperial College, Hammersmith Campus, London, United Kingdom
OBJECTIVES. We studied (1) the pattern of brain
injury in term neonates with encephalopathy with evidence of a
preceding hypoxic sentinel event, (2) prenatal and perinatal risk
factors, and (3) the correlation between neuroimaging findings and
developmental outcomes.
METHODS. We identified, among 500 term neonates with
encephalopathy who were studied with MRI between 1992 and 2005, 48
infants with evidence of a preceding acute hypoxic event, and we
reviewed their MRI scans retrospectively. Prenatal and perinatal
data were compared with those for term normal low-risk infants. Neurodevelopmental
outcomes were assessed at a minimum of 12 months.
RESULTS. Five patterns of brain injury were
identified, as follows: pattern I, basal ganglia and thalami lesions
associated with severe white matter damage (n = 6; 14%); pattern II,
basal ganglia and thalami lesions with mild or moderate white matter
changes (n = 24; 56%); pattern III, isolated thalamic injury
(n = 2; 5%); pattern IV, moderate white matter damage only (n
= 1; 2%); pattern V, mild white matter changes or normal findings (n
= 10; 23%). No scan showed evidence of long-standing injury. The
internal capsule was abnormal in 93% of infants with patterns I
and II, and 86% of those infants died or developed cerebral palsy. Infants
with patterns III and IV had developmental delay and diplegic
cerebral palsy, respectively. Pattern V was associated with normal
outcomes. Case infants were significantly more often of African
descent, born to pluriparous or hypertensive mothers. Uterine
rupture followed previous cesarean section in 8 of 11 cases. Cord
prolapse accompanied undiagnosed breech presentation in 4 of 9
cases.
CONCLUSIONS. Basal ganglia and thalami lesions are the
imaging signature in term neonates exposed to hypoxic-ischemic
sentinel events. Patterns of central gray matter and secondary white
matter injury were associated with higher risks of severe morbidity and
death. Affected infants did not seem intrinsically different from
our low-risk population. These data support the need for anticipating
sentinel events and expediting delivery.
Key Words:
hypoxic ischemia • encephalopathy • sentinel event • magnetic resonance imaging
• basal ganglia
Abbreviations:
BGT—basal ganglia and thalami • WM—white matter • HIE—hypoxic-ischemic
encephalopathy • TOBY—total-body hypothermia • CP—cerebral palsy •
GA—gestational age • BW—birth weight • HC—head circumference • CS—cesarean
section • PLIC—posterior limb of the internal capsule • DQ—developmental
quotient
Accepted Sep 6, 2007.
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Ibuprofen-Induced Patent Ductus Arteriosus
Closure: Physiologic, Histologic, and Biochemical Effects on the Premature Lung
a Department of Pediatrics,
University of Texas Health Science Center, San Antonio, Texas
b Department of Medicine, National Jewish Medical and Research
Center, Denver, Colorado
c Pharmaceutical Discovery Division, SRI International, Menlo Park,
California
d Pulmonary Biology, Cincinnati Children's Hospital, University of
Cincinnati, Cincinnati, Ohio
e Department of Pediatrics, University of Utah, Salt Lake City, Utah
f Department of Virology and Immunology, Southwest Foundation for
Biomedical Research, San Antonio, Texas
g Cardiovascular Research Institute
h Department of Pediatrics, University of California, San Francisco,
California
OBJECTIVE. The goal was to study the pulmonary,
biochemical, and morphologic effects of a persistent patent ductus
arteriosus in a preterm baboon model of bronchopulmonary dysplasia.
METHODS. Preterm baboons (treated prenatally with
glucocorticoids) were delivered at 125 days of gestation (term: 185
days), given surfactant, and ventilated for 14 days. Twenty-four
hours after birth, newborns were randomly assigned to receive either
ibuprofen (to close the patent ductus arteriosus; n = 8) or
no drug (control; n = 13).
RESULTS. After treatment was started, the ibuprofen
group had significantly lower pulmonary/systemic flow ratio, higher
systemic blood pressure, and lower left ventricular end diastolic
diameter, compared with the control group. There were no differences
in cardiac performance indices between the groups. Ventilation index
and dynamic compliance were significantly improved with ibuprofen. The
improved pulmonary mechanics in ibuprofen-treated newborns were not
attributable to changes in levels of surfactant protein B, C, or D,
saturated phoshatidylcholine, or surfactant inhibitory proteins. There
were no differences in tracheal concentrations of cytokines commonly
associated with the development of bronchopulmonary dysplasia. The
groups had similar messenger RNA expression of genes that regulate
inflammation and remodeling in the lung. Lungs from
ibuprofen-treated newborns were significantly drier (lower wet/dry
ratio) and expressed 2.5 times more epithelial sodium channel
protein than did control lungs. By 14 days after delivery, control
newborns had morphologic features of arrested alveolar development
(decreased alveolar surface area and complexity), compared with
age-matched fetuses. In contrast, there was no evidence of alveolar
arrest in the ibuprofen-treated newborns.
CONCLUSIONS. Ibuprofen-induced patent ductus
arteriosus closure improved pulmonary mechanics, decreased total
lung water, increased epithelial sodium channel expression, and
decreased the detrimental effects of preterm birth on
alveolarization.
Key
Words:
patent ductus arteriosus • cytokines • lung remodeling • bronchopulmonary
dysplasia • pulmonary edema • wet/dry ratio • compliance • indomethacin •
surfactant • epithelial sodium channel
Abbreviations: BPD—bronchopulmonary
dysplasia • PDA—patent ductus arteriosus • ENaC—epithelial sodium channel •
BALF—bronchoalveolar lavage fluid • MCP—monocyte chemoattractant protein •
MIP—macrophage inflammatory protein • IL—interleukin • TNF—tumor necrosis
factor • IFN—interferon
Accepted Sep 17,
2007.
[Full Text of McCurnin et al.] [Reprint
(PDF) Version of McCurnin et al.]
The Best-Interest Standard Is Not Applied for
Neonatal Resuscitation Decisions
Departments of a Pediatrics
b Family Medicine, McGill University, Montreal, Quebec, Canada
OBJECTIVE. Legal and ethical standards require
resuscitation when it is considered to be in the patient's best
interest. We hypothesized that newborn infants might be dealt with
according to different standards, compared with older patients.
METHODS. An anonymous questionnaire describing 8
currently incompetent patients with potential neurologic sequelae who
required resuscitation was administered to groups of physicians and
students. Survival and morbidity rates were explicitly described; a
very preterm infant, a full term infant and a 2-month-old infant had
identical outcomes. Two patients, a 7-month-old infant and an
80-year-old patient, were previously significantly impaired. Respondents
were asked whether resuscitation was in the patient's best interest and
whether they would comply with the families' wishes if resuscitation was
refused.
RESULTS. There was an 85% response rate (n =
524). The largest proportions of respondents stated that it was in
the best interests of the 2-month-old infant and the 7-year-old
child to be resuscitated (97% and 94%, respectively), followed by
the 50-year-old patient and the term infant (87%), the 2 patients
with 5% chance of survival (76% and 80%), the premature infant
(69%), and finally the 80-year-old patient (32%). Approximately one
fifth of the respondents who thought that it was in a patient's best
interests to be resuscitated would nevertheless accept the family's
refusal of resuscitation for all scenarios except the 80-year-old
patient (72% acceptance) and the preterm infant (54% acceptance).
CONCLUSIONS. Whether resuscitation is considered in a
patient's best interests is not closely related to survival rates or
disability. Newborn infants and particularly preterm infants are
systematically devalued, in comparison with older patients whose
outcomes are the same or worse. Accepting a family's refusal of
resuscitation, even among respondents who thought that resuscitation
was in the patient's best interest, was much more common for the
newborns.
Key Words:
ethics • resuscitation • best-interest standard
Accepted Sep 20,
2007.
[Full Text of Janvier et al.] [Reprint
(PDF) Version of Janvier et al.]
Newborn Hearing Screening and Detection of
Congenital Cytomegalovirus Infection
Departments of a Pediatrics
b Otolaryngology
c Internal Medicine, University of Texas Southwestern Medical
Center, Dallas, Texas
OBJECTIVES. The objectives were to determine
the frequency of congenital cytomegalovirus infection among newborns
who did not pass hearing screening tests or had confirmed hearing
loss and to determine how often abnormal hearing screening results
were the only manifestation of congenital cytomegalovirus infection.
METHODS. Retrospective chart review was performed for
newborns who had abnormal hearing screening results and positive
urine cytomegalovirus culture results at Parkland Memorial Hospital
between September 1, 1999, and August 31, 2004.
RESULTS. During the 5-year study period, 572 of 79047
newborns (7 of 1000 live births) did not pass hearing screening
tests. Cytomegalovirus infection was identified in 24 (5%) of 483
tested infants and 16 (6%) of the 256 infants with subsequently
confirmed hearing impairment. Of those 16 infants, 12 (75%) were
identified as having congenital cytomegalovirus infection only
because of failure to pass newborn hearing screening tests.
CONCLUSIONS. Congenital cytomegalovirus infection was
present for 6% of newborns with confirmed hearing impairment, and
the majority of those infants were identified on the basis of
abnormal newborn hearing screening results.
Key Words:
congenital cytomegalovirus infection • newborn hearing screening
Abbreviations:
CMV—cytomegalovirus • PMH—Parkland Memorial Hospital • AABR—automated auditory
brainstem response
Accepted Sep 19,
2007.
[Full Text of Stehel et al.] [Reprint
(PDF) Version of Stehel et al.]
Unbound Bilirubin Concentration is Associated
With Abnormal Automated Auditory Brainstem Response for Jaundiced Newborns
Department of Pediatrics, Division of Neonatology,
California Pacific Medical Center, San Francisco, California
OBJECTIVE. This study was conducted to
determine whether incidental jaundice affects automated auditory
brainstem response results.
METHODS. We reviewed the medical charts of jaundiced
newborns of 34
weeks of gestation who underwent automated auditory brainstem response
testing within 4 hours of plasma total bilirubin concentration and
unbound bilirubin concentration measurements. We tested the
hypothesis that the likelihood of abnormal automated auditory brainstem
response results would increase as total bilirubin and unbound
bilirubin concentrations increased.
RESULTS. Forty-four infants with proximate total
bilirubin concentration, unbound bilirubin concentration, and
automated auditory brainstem response measurements were identified,
and 4 (9%) had bilateral refer automated auditory brainstem response
results. The mean total bilirubin concentration of 21.4 mg/dL (SD:
4.0 mg/dL; range: 14.4–29.5 mg/dL) for the 40 infants with bilateral
pass automated auditory brainstem response results was not significantly
different from that of 23.0 mg/dL (range: 14.9–33.1 mg/dL) for
the 4 infants with bilateral refer automated auditory brainstem response
results. However, the mean unbound bilirubin concentration of 1.32
µg/dL (range: 0.22–2.99 µg/dL) for the 40 infants with bilateral
pass results was significantly lower than the mean of 2.62 µg/dL
(range: 0.88–4.41 µg/dL) for the 4 infants with bilateral refer
results. Logistic regression showed that increasing unbound
bilirubin concentrations but not increasing total bilirubin
concentrations were associated with of bilateral refer automated
auditory brainstem response results.
CONCLUSIONS. The probability of bilateral refer
automated auditory brainstem response results increases
significantly with increasing unbound bilirubin concentrations but
not with increasing total bilirubin concentrations. Because unbound
bilirubin concentrations are also more closely correlated with
bilirubin neurotoxicity than are total bilirubin concentrations,
bilateral refer automated auditory brainstem response results for
jaundiced newborns may indicate increased risk of bilirubin
neurotoxicity, in addition to the possibility of congenital
deafness.
Key Words:
newborn jaundice • hyperbilirubinemia • unbound bilirubin • peroxidase test •
free bilirubin • automated auditory brainstem response • hearing screening
Abbreviations:
AABR—automated auditory brainstem response • TBC—total bilirubin concentration
Accepted Sep 17,
2007.
[Full Text of Ahlfors and Parker] [Reprint (PDF) Version of Ahlfors
and Parker]
Association of Functional Limitation With
Health Care Needs and Experiences of Children With Special Health Care Needs
a Department of Pediatrics,
Wake Forest University School of Medicine, Winston-Salem, North Carolina
b Department of Pediatrics, Albert Einstein College of
Medicine/Children's Hospital at Montefiore, Bronx, New York
OBJECTIVE. The goal was to evaluate whether
having a functional limitation was associated with health care needs
and experiences of children with special health care needs.
METHODS. We used caregivers' responses in the National
Survey of Children with Special Health Care Needs (2001). Functional
limitation was categorized as severe, some, or no limitation. We
performed analyses of the relationships of functional limitation to
measures of health care needs and experiences.
RESULTS. Children with special health care needs with
severe functional limitation were more likely to have received
specialized educational services, to have had physician visits, and
to have needed health services, compared with those with no
limitation. They had significantly greater odds of delayed care,
unmet health care and care-coordination needs, referral problems,
dissatisfaction, and difficulty using health services, compared with
those without limitation. Caregivers of children with special health
care needs with severe limitation were twice as likely as those with
no limitation to report that providers did not spend enough time,
listen carefully, provide needed information, and make family
members partners in the child's care. Compared with children with
special health care needs without limitation, those with severe
limitation had worse health insurance experiences, in terms of
insurance coverage, copayments, being able to see needed providers,
and problems with health insurance. The impact on families (financial
problems, need to provide home care, or need to stop or to cut work)
of children with special health care needs with severe functional
limitation was much greater than the impact on families of children
with special health care needs without limitation. For most measures
examined, results for some limitation were between those for severe
limitation and no limitation.
CONCLUSIONS. Functional limitation is significantly
associated with the health care needs and experiences of children
with special health care needs.
Key Words:
children • special needs • functional limitation • health care
Abbreviations:
CSHCN—children with special health care needs • NSCSHCN—National Survey of
Children with Special Health Care Needs • FPL—federal poverty level
Accepted Sep 17,
2007.
[Full Text of Nageswaran et al.] [Reprint
(PDF) Version of Nageswaran et al.]
Use of Soy Protein-Based Formulas in Infant
Feeding
Soy protein-based formulas have been available
for almost 100 years. Since the first use of soy formula as a milk
substitute for an infant unable to tolerate a cow milk protein-based
formula, the formulation has changed to the current soy protein
isolate. Despite very limited indications for its use, soy
protein-based formulas in the United States may account for nearly
25% of the formula market. This report reviews the limited
indications and contraindications of soy formulas. It will also
review the potential harmful effects of soy protein-based formulas
and the phytoestrogens contained in these formulas.
Key Words: soy
protein • infant formula • infant feeding • cow milk protein allergy •
nutrition • galactosemia • vegetarian
Abbreviations:
AAP—American Academy of Pediatrics • IgE—immunoglobulin E
[Full Text of Bhatia et al.] [Reprint
(PDF) Version of Bhatia et al.]
Prolonged Neonatal Jaundice and the Diagnosis
of Biliary Atresia: A Single-Center Analysis of Trends in Age at Diagnosis and
Outcomes
Division of Gastroenterology, St Louis Children's
Hospital, Departments of Pediatrics and Surgery, Washington University School
of Medicine, St Louis, Missouri
ABSTRACT
Age at diagnosis is a modifiable risk factor in
outcomes after hepatoportoenterostomy in biliary atresia; however,
distinguishing biliary atresia from other more common causes of
prolonged neonatal jaundice can be difficult. To focus attention on
diagnosis of biliary atresia, we analyzed secular trends in the age
at diagnosis, and other factors that might influence outcome. We
performed a retrospective analysis of 55 consecutive infants with
biliary atresia presenting to a single academic pediatric center
over 15-year period from 1990 to 2004. The median age at diagnosis
was 60 days (range: 21–152). In recent era (2000–2004), the
median age was 69.0 days, compared with 48.5 days (1990–1994) and
59.5 days (1995–1999), respectively. Consistent with previous studies,
the median age at diagnosis of those with poor outcomes (death or
liver transplant) exceeded those with good outcomes after the
hepatoportoenterostomy (72 vs 52 days, P < .001). The lack
of improvement, or a concerning trends toward an increase in the age
at diagnosis of biliary atresia, is perhaps attributable to neonatal
follow-up practices. Efforts to make an earlier diagnose of this
important condition deserve wider application and study.
Key Words:
neonatal jaundice • biliary atresia • conjugated bilirubinemia
Abbreviations: BA, biliary atresia • KP,
Kasai portoenterostomy • BARC, Biliary Atresia Research Consortium
Accepted Nov 2, 2007.
[Full Text of Wadhwani et al.] [Reprint
(PDF) Version of Wadhwani et al.]
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