ABSTRACTS

OCTUBRE 2007

PEDIATRICS Vol. 120 No. 4 October 2007, pp. e788-e794 (doi:10.1542/peds.2006-3765)

Postdischarge Infant Mortality Among Very Low Birth Weight Infants: A Population-Based Study

Amir Kugelman, MD^a, Brian Reichman, MBChB^b,c, Irena Chistyakov, MD^a, Valentina Boyko, MSc^b, Orna Levitski, BA^b, Liat Lerner-Geva, MD, PhD^b,c, Arieh Riskin, MD^a, David Bader, MD, MHA^a in collaboration with the Israel Neonatal Network

OBJECTIVE. The objective of this study was to identify factors that were associated with death after discharge from the NICU of very low birth weight infants in a population-based study.

METHODS. From a national cohort of 13430 very low birth weight infants who were born in Israel from 1995 to 2003, 10602 infants were discharged from the hospital and composed the study population. Demographic and clinical data regarding the pregnancy, delivery, and neonatal course were obtained from the Israel national very low birth weight infant database. Data on each case of death during the postdischarge period until 1 year of age were provided by the Ministry of Health from national linked birth and death certificates. Univariate analyses and a multivariable logistic regression analyses were performed to examine the perinatal and neonatal risk factors for postdischarge death.

RESULTS. The postdischarge mortality rate was 7.5 per 1000 (80 of 10602 infants discharged from the hospital). The death rate was significantly higher in non-Jewish infants, infants who were born to young mothers, and infants who were born to low-educated mothers. After adjustment for demographic characteristics and perinatal and neonatal variables, postdischarge mortality was independently associated with congenital malformations, neonatal seizures, necrotizing enterocolitis, and bronchopulmonary dysplasia.

CONCLUSION. Although the postdischarge death rate was relatively low in our cohort of very low birth weight infants, attention should be focused on the subgroups of infants who are at higher risk to decrease their mortality further.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. e815-e825 (doi:10.1542/peds.2006-3122)

Characteristics of Neonatal Units That Care for Very Preterm Infants in Europe: Results From the MOSAIC Study

Patrick Van Reempts, MD, PhD^a, Ludwig Gortner, MD, PhD^b, David Milligan, MD^c, Marina Cuttini, MD, PhD^d, Stavros Petrou, PhD^e, Rocco Agostino, MD^f, David Field, MD^g, Lya den Ouden, MD, PhD^h, Klaus Børch, MDⁱ, Jan Mazela, MD^j, Manuel Carrapato, MD^k, Jennifer Zeitlin, DSc^l for the MOSAIC Research Group

OBJECTIVES. We sought to compare guidelines for level III units in 10 European regions and analyze the characteristics of neonatal units that care for very preterm infants.

METHODS. The MOSAIC (Models of Organising Access to Intensive Care for Very Preterm Births) project combined a prospective cohort study on all births between 22 and 31 completed weeks of gestation in 10 European regions and a survey of neonatal unit characteristics. Units that admitted 5 infants at <32 weeks of gestation were included in the analysis (N = 111). Place of hospitalization of infants who were admitted to neonatal care was analyzed by using the cohort data (N = 4947). National or regional guidelines for level III units were reviewed.

RESULTS. Six of 9 guidelines for level III units included minimum size criteria, based on number of intensive care beds (6 guidelines), neonatal admissions (2), ventilated patients (1), obstetric intensive care beds (1), and deliveries (2). The characteristics of level III units varied, and many were small or unspecialized by recommended criteria: 36% had fewer than 50 very preterm annual admissions, 22% ventilated fewer than 50 infants annually, and 28% had fewer than 6 intensive care beds. Level II units were less specialized, but some provided mechanical ventilation (57%) or high-frequency ventilation (20%) or had neonatal surgery facilities (17%). Sixty-nine percent of level III and 36% of level I or II units had continuous medical coverage by a qualified pediatrician. Twenty-two percent of infants who were <28 weeks of gestation were treated in units that admitted fewer than 50 very preterm infants annually (range: 2%–54% across the study regions).

CONCLUSIONS. No consensus exists in Europe about size or other criteria for NICUs. A better understanding of the characteristics associated with high-quality neonatal care is needed, given the high proportion of very preterm infants who are cared for in units that are considered small or less specialized by many recommendations.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. e992-e1001 (doi:10.1542/peds.2006-2775)

Modeling the Impact of Formal and Informal Supports for Young Children With Disabilities and Their Families

Donald B. Bailey, Jr, PhD^a, Lauren Nelson, PhD^b, Kathy Hebbeler, PhD^c and Donna Spiker, PhD^c

OBJECTIVE. The purpose of this work was to examine factors related to perceived impact of early intervention on children with disabilities and their families.

METHODS. A nationally representative sample of 2100 parents completed a 40-minute telephone interview near their child's third birthday. Structural equation modeling examined the relationships between 3 support variables (quality of child services, quality of family services, and family/community support) and 2 outcomes at 36 months (impact on child and impact on family) and determined whether these relationships were mediated by 2 perceptual variables (optimism and confidence in parenting) or moderated by 5 demographic variables (poverty, maternal education, ethnicity, age of initial Individual Family Service Plan, and health at 36 months).

RESULTS. Perceived impact of early intervention on both child and family were significantly related to each other. The quality of child services was related to impact on the child but not on the family. The quality of family services was related to both child and family impact. Informal support was not related to perceived impact on children or families but was strongly related to confidence in parenting and optimism. Neither optimism nor confidence in parenting mediated the relationships between services or supports and perceived impact. Minority families and families of children with poor health reported lower quality of services, but these characteristics did not moderate the relationships between services and perceived impact on the child. However, both poverty status and minority status were associated with perceptions of impact on the family.

CONCLUSIONS. Findings reinforce the role of high-quality services in maximizing perceived impact. They also highlight the important role of informal support in promoting optimism and confidence in parenting. Poverty status, minority status, and poor health of the child are salient factors in predicting lower perceived quality of and benefit from services.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. e1017-e1027 (doi:10.1542/peds.2006-3482)

Effects of Prenatal Cocaine Exposure on Growth: A Longitudinal Analysis

Gale A. Richardson, PhD^a, Lidush Goldschmidt, PhD^b and Cynthia Larkby, PhD^a

OBJECTIVE. There has been a limited amount of research on the long-term effects of prenatal cocaine exposure on growth of the infant, and there has been no use of longitudinal growth models. We investigated the effects of prenatal cocaine exposure on offspring growth from 1 through 10 years of age by using a repeated-measures growth-curve model.

METHODS. Women were enrolled from a prenatal clinic and interviewed at the end of each trimester of pregnancy about their cocaine, crack, alcohol, marijuana, tobacco, and other drug use. Fifty percent of the women were white, and 50% were black. Follow-up assessments occurred at 1, 3, 7, and 10 years of age.

RESULTS. Cross-sectional analyses showed that children exposed to cocaine during the first trimester (n = 99) were smaller on all growth parameters at 7 and 10 years, but not at 1 or 3 years, than the children who were not exposed to cocaine during the first trimester (n = 125). The longitudinal analyses indicated that the growth curves for the 2 groups diverged over time: children who were prenatally exposed to cocaine grew at a slower rate than children who were not exposed. These analyses controlled for other factors associated with child growth.

CONCLUSIONS. To our knowledge, this is the first study of the long-term effects of prenatal cocaine exposure to conduct longitudinal growth-curve analyses using 4 time points in childhood. Children who were exposed to cocaine during the first trimester grew at a slower rate than those who were not exposed. These findings indicate that prenatal cocaine exposure has a lasting effect on child development.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. e1028-e1034 (doi:10.1542/peds.2006-3433)

Influence of Gender and Age on Upper-Airway Length During Development

Ohad Ronen, MD^a, Atul Malhotra, MD^b and Giora Pillar, MD, PhD^c

OBJECTIVE. Obstructive sleep apnea has a strong male predominance in adults but not in children. The collapsible portion of the upper airway is longer in adult men than in women (a property that may increase vulnerability to collapse during sleep). We sought to test the hypothesis that in prepubertal children, pharyngeal airway length is equal between genders, but after puberty boys have a longer upper airway than girls, thus potentially contributing to this change in apnea propensity.

METHODS. Sixty-nine healthy boys and girls who had undergone computed tomography scans of their neck for other reasons were selected from the computed tomography archives of Rambam and Carmel hospitals. The airway length was measured in the midsagittal plane and defined as the length between the lower part of the posterior hard palate and the upper limit of the hyoid bone. Airway length and normalized airway length/body height were compared between the genders in prepubertal (4- to 10-year-old) and postpubertal (14- to 19-year-old) children.

RESULTS. In prepubertal children, airway length was similar between boys and girls (43.2 ± 5.9 vs 46.8 ± 7.7 mm, respectively). When normalized to body height, airway length/body height was significantly shorter in prepubertal boys than in girls (0.35 ± 0.03 vs 0.38 ± 0.04 mm/cm). In contrast, postpubertal boys had longer upper airways (66.5 ± 9.2 vs 52.2 ± 7.0 mm) and normalized airway length/body height (0.38 ± 0.05 vs 0.33 ± 0.05 mm/cm) than girls.

CONCLUSIONS. Although boys have equal or shorter airway length compared with girls among prepubertal children, after puberty, airway length and airway length normalized for body height are significantly greater in boys than in girls. These data suggest that important anatomic changes at puberty occur in a gender-specific manner, which may be important in explaining the male predisposition to pharyngeal collapse in adults.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. e1035-e1042 (doi:10.1542/peds.2006-3567)

Infants With Bronchopulmonary Dysplasia Suckle With Weak Pressures to Maintain Breathing During Feeding

Katsumi Mizuno, MD, PhD, Yoshiko Nishida, MD, Motohiro Taki, MD, Satoshi Hibino, MD, Masahiko Murase, MD, Motoichirou Sakurai, MD, PhD and Kazuo Itabashi, MD, PhD

OBJECTIVE. Preterm infants with bronchopulmonary dysplasia often demonstrate sucking difficulties. The aim of this study was to determine whether the severity of bronchopulmonary dysplasia affects not only coordination among suck–swallow–respiration but also sucking endurance and performance itself.

PATIENTS AND METHODS. Twenty very low birth weight infants were studied. Infants with anomalies or intraventricular hemorrhage were excluded from the evaluation. Subjects were divided into 3 groups: no bronchopulmonary dysplasia (7 infants), bronchopulmonary dysplasia without home oxygen therapy (7 infants), and bronchopulmonary dysplasia with home oxygen therapy (6 infants). In addition to sucking efficiency, pressure, frequency, duration, and duration of sucking burst, length of deglutition apnea, number of swallows per burst, and respiratory rate were also measured during bottle-feeding at 40 weeks' postmenstrual age. In addition, PCO₂ and oxygen saturation were measured at rest and during bottle-feeding.

RESULTS. Infants with severe bronchopulmonary dysplasia demonstrated not only the lowest sucking pressure and sucking frequency, shortest sucking burst duration, and lowest feeding efficiency but also the lowest frequency of swallows during the run and the longest deglutition apnea. The respiratory rate was highest, and the decrease in oxygen saturation was largest, in infants with severe bronchopulmonary dysplasia.

CONCLUSIONS. Feeding problems depend on the severity of bronchopulmonary dysplasia. Infants with bronchopulmonary dysplasia demonstrated not only poor feeding coordination but also poor feeding endurance and performance.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. 723-733 (doi:10.1542/peds.2006-1939)

Adverse Birth Outcome Among Mothers With Low Serum Cholesterol

Robin J. Edison, MD, MPH^a, Kate Berg, PhD^a, Alan Remaley, MD^b, Richard Kelley, MD, PhD^c, Charles Rotimi, PhD^d, Roger E. Stevenson, MD^e and Maximilian Muenke, MD^a

OBJECTIVE. The objective of this study was to assess whether low maternal serum cholesterol during pregnancy is associated with preterm delivery, impaired fetal growth, or congenital anomalies in women without identified major risk factors for adverse pregnancy outcome.

METHODS. Mother-infant pairs were retrospectively ascertained from among a cohort of 9938 women who were referred to South Carolina prenatal clinics for routine second-trimester serum screening. Banked sera were assayed for total cholesterol; <10th percentile of assayed values (159 mg/dL at mean gestational age of 17.6 weeks) defined a "low total cholesterol" prenatal risk category. Eligible women were aged 21 to 34 years and nonsmoking and did not have diabetes; neonates were liveborn after singleton gestations. Total cholesterol values of eligible mothers were adjusted for gestational age at screening before risk group assignment. The study population included 118 women with low total cholesterol and 940 women with higher total cholesterol. Primary analyses used multivariate regression models to compare rates of preterm delivery, fetal growth parameters, and congenital anomalies between women with low total cholesterol and control subjects with mid–total cholesterol values >10th percentile but <90th percentile.

RESULTS. Prevalence of preterm delivery among mothers with low total cholesterol was 12.7%, compared with 5.0% among control subjects with mid–total cholesterol. The association of low maternal serum cholesterol with preterm birth was observed only among white mothers. Term infants of mothers with low total cholesterol weighed on average 150 g less than those who were born to control mothers. A trend of increased microcephaly risk among neonates of mothers with low total cholesterol was found. Low maternal serum cholesterol was unassociated with risk for congenital anomalies.

CONCLUSIONS. Total serum cholesterol <10th population percentile was strongly associated with preterm delivery among otherwise low-risk white mothers in this pilot study population. Term infants of mothers with low total cholesterol weighed less than control infants among both racial groups.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. 770-777 (doi:10.1542/peds.2007-0514)

Sensitivity of Amplitude-Integrated Electroencephalography for Neonatal Seizure Detection

Renée A. Shellhaas, MD^a,b, Adina I. Soaita, MD, DPH^c and Robert R. Clancy, MD^a,b

BACKGROUND. Conventional electroencephalography remains the gold standard for the diagnosis and quantification of neonatal seizures. However, amplitude-integrated electroencephalography (aEEG) is being introduced to neonatal intensive care as an adjunct for neonatal seizure detection.

OBJECTIVES. This study's purpose was to determine the sensitivity of neonatal seizure detection in a single electroencephalogram channel (C₃C₄), used to simulate the raw signal from which aEEG is derived. We also aimed to determine the sensitivity of seizure detection by neonatologists by using aEEG and to establish those neonatal seizure characteristics that are associated with their correct detection by aEEG.

METHODS. Conventional electroencephalograms with neonatal seizures were reviewed for electroencephalogram background and neonatal seizure characteristics (site of onset, duration, and peak-to-peak amplitude). The presence, duration, and peak-to-peak amplitude of each seizure were simultaneously noted in a single electroencephalogram channel (C₃C₄). aEEGs generated from this channel were reviewed for background and seizures by 6 neonatologists with varying aEEG interpretation expertise.

RESULTS. A total of 851 neonatal seizures from 125 conventional electroencephalograms were analyzed. The patients' conceptional ages were 34 to 50 weeks. Because 94% of the conventional electroencephalograms had 1 neonatal seizure visible in C₃C₄, and 78% of all neonatal seizures appeared in the C₃C₄ channel, the theoretical sensitivity of seizure detection in a single electroencephalogram channel was high. However, seizures were briefer and lower in amplitude in C₃C₄ compared with conventional electroencephalography. Neonatologists identified seizures in 22% to 57% of the 125 records of neonatal seizure. They detected 12% to 38% of the 851 individual seizures. Multivariate analysis revealed that the appearance of seizures in C₃C₄, neonatal seizure duration, seizure amplitude, seizure count per hour, and neonatologists' experience with aEEG interpretation all correlated with neonatal seizure detection.

CONCLUSIONS. Even among physicians who have extensive experience, many neonatal seizures are difficult to detect on an aEEG, especially when they are infrequent, brief, or of low amplitude.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. 778-784 (doi:10.1542/peds.2007-0540)

Very Low Birth Weight Increases Risk for Sleep-Disordered Breathing in Young Adulthood: The Helsinki Study of Very Low Birth Weight Adults

E. Juulia Paavonen, MD, PhD, BSocSc^a, Sonja Strang-Karlsson, MD^b,c, Katri Räikkönen, PhD^a, Kati Heinonen, PhD^a, Anu-Katriina Pesonen, PhD^a, Petteri Hovi, MD^b,c, Sture Andersson, MD, PhD^c, Anna-Liisa Järvenpää, MD, PhD^c, Johan G. Eriksson, MD, PhD^b,d and Eero Kajantie, MD, PhD^b,c

OBJECTIVE. We investigated whether very low birth weight (<1500 g) is associated with the risk of sleep-disordered breathing in young adulthood.

METHODS. The study was a retrospective longitudinal study of 158 young adults born with very low birth weight and 169 term-born control subjects (aged 18.5–27.1 years). The principal outcome variable was sleep-disordered breathing defined as chronic snoring.

RESULTS. The crude prevalence of chronic snoring was similar in both groups: 15.8% for the very low birth weight group versus 13.6% for the control group. However, after controlling for the confounding variables in multivariate logistic regression models (age, gender, current smoking, parental education, height, BMI, and depression), chronic snoring was 2.2 times more likely in the very low birth weight group compared with the control group. In addition, maternal smoking during pregnancy was significantly and independently of very low birth weight related to risk of sleep-disordered breathing. Maternal preeclampsia, standardized birth weight, and, for very low birth weight infants, small-for-gestational-age status were not related to sleep-disordered breathing.

CONCLUSIONS. Premature infants with very low birth weight have a twofold risk of sleep-disordered breathing as young adults. In addition, maternal smoking during pregnancy increases the risk of sleep-disordered breathing by more than twofold.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. 785-792 (doi:10.1542/peds.2007-0211)

Neurodevelopmental Outcome in Survivors of Periventricular Hemorrhagic Infarction

Haim Bassan, MD^a, Catherine Limperopoulos, PhD^a, Karen Visconti, PhD^b, D. Luisa Mayer, PhD^c, Henry A. Feldman, PhD^d, Lauren Avery, PhD^e, Carol B. Benson, MD^f, Jane Stewart, MD^e, Steven A. Ringer, MD, PhD^g, Janet S. Soul, MD, CM^a, Joseph J. Volpe, MD^a and Adré J. du Plessis, MBChB, MPH^a

OBJECTIVES. Periventricular hemorrhagic infarction is a serious complication of germinal matrix-intraventricular hemorrhage in premature infants. Our objective was to determine the neurodevelopmental and adaptive outcomes of periventricular hemorrhagic infarction survivors and identify early cranial ultrasound predictors of adverse outcome.

METHODS. We retrospectively evaluated all cranial ultrasounds of 30 premature infants with periventricular hemorrhagic infarction and assigned a cranial ultrasound–based periventricular hemorrhagic infarction severity score (range: 0–3) on the basis of whether periventricular hemorrhagic infarction (1) involved 2 territories, (2) was bilateral, or (3) caused midline shift. We then performed neuromotor, visual function, and developmental evaluations (Mullen Scales of Early Learning, Vineland Adaptive Behavior Scale). Developmental scores below 2 SD from the mean were defined as abnormal.

RESULTS. Median adjusted age at evaluation was 30 months (range: 12–66 months). Eighteen subjects (60%) had abnormal muscle tone, and 7 (26%) had visual field defects. Developmental delays involved gross motor (22 [73%]), fine motor (17 [59%]), visual receptive (13 [46%]), expressive language (11 [38%]), and cognitive (14 [50%]) domains. Impairment in daily living and socialization was documented in 10 (33%) and 6 (20%) infants, respectively. Higher cranial ultrasound–based periventricular hemorrhagic infarction severity scores predicted microcephaly and abnormalities in gross motor, visual receptive, and cognitive function.

CONCLUSIONS. In the current era, two thirds of periventricular hemorrhagic infarction survivors develop significant cognitive and/or motor abnormalities, whereas adaptive skills are relatively spared. Higher cranial ultrasound–based periventricular hemorrhagic infarction severity scores predict worse outcome in several modalities and may prove to be a valuable tool for prognostication.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. 793-804 (doi:10.1542/peds.2007-0440)

Motor and Executive Function at 6 Years of Age After Extremely Preterm Birth

Neil Marlow, DM^a, Enid M. Hennessy, MSc^b, Melanie A. Bracewell, MBBS^a, Dieter Wolke, PhD^c for the EPICure Study Group

BACKGROUND. Studies of very preterm infants have demonstrated impairments in multiple neurocognitive domains. We hypothesized that neuromotor and executive-function deficits may independently contribute to school failure.

METHODS. We studied children who were born at 25 completed weeks' gestation in the United Kingdom and Ireland in 1995 at early school age. Children underwent standardized cognitive and neuromotor assessments, including the Kaufman Assessment Battery for Children and NEPSY, and a teacher-based assessment of academic achievement.

RESULTS. Of 308 surviving children, 241 (78%) were assessed at a median age of 6 years 4 months. Compared with 160 term classmates, 180 extremely preterm children without cerebral palsy and attending mainstream school performed less well on 3 simple motor tasks: posting coins, heel walking, and 1-leg standing. They more frequently had non–right-hand preferences (28% vs 10%) and more associated/overflow movements during motor tasks. Standardized scores for visuospatial and sensorimotor function performance differed from classmates by 1.6 and 1.1 SDs of the classmates' scores, respectively. These differences attenuated but remained significant after controlling for overall cognitive scores. Cognitive, visuospatial scores, and motor scores explained 54% of the variance in teachers' ratings of performance in the whole set; in the extremely preterm group, additional variance was explained by attention-executive tasks and gender.

CONCLUSIONS. Impairment of motor, visuospatial, and sensorimotor function, including planning, self-regulation, inhibition, and motor persistence, contributes excess morbidity over cognitive impairment in extremely preterm children and contributes independently to poor classroom performance at 6 years of age.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. e1097-e1106 (doi:10.1542/peds.2006-2083)

Swaddling: A Systematic Review

Bregje E. van Sleuwen, MSc^a, Adèle C. Engelberts, MD, PhD^b, Magda M. Boere-Boonekamp, MD, PhD^c, Wietse Kuis, MD^d, Tom W.J. Schulpen, MD^e and Monique P. L'Hoir, MSc, PhD^a

Swaddling was an almost universal child-care practice before the 18th century. It is still tradition in certain parts of the Middle East and is gaining popularity in the United Kingdom, the United States, and the Netherlands to curb excessive crying. We have systematically reviewed all articles on swaddling to evaluate its possible benefits and disadvantages. In general, swaddled infants arouse less and sleep longer. Preterm infants have shown improved neuromuscular development, less physiologic distress, better motor organization, and more self-regulatory ability when they are swaddled. When compared with massage, excessively crying infants cried less when swaddled, and swaddling can soothe pain in infants. It is supportive in cases of neonatal abstinence syndrome and infants with neonatal cerebral lesions. It can be helpful in regulating temperature but can also cause hyperthermia when misapplied. Another possible adverse effect is an increased risk of the development of hip dysplasia, which is related to swaddling with the legs in extension and adduction. Although swaddling promotes the favorable supine position, the combination of swaddling with prone position increases the risk of sudden infant death syndrome, which makes it necessary to warn parents to stop swaddling if infants attempt to turn. There is some evidence that there is a higher risk of respiratory infections related to the tightness of swaddling. Furthermore, swaddling does not influence rickets onset or bone properties. Swaddling immediately after birth can cause delayed postnatal weight gain under certain conditions, but does not seem to influence breastfeeding parameters.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. 855-864 (doi:10.1542/peds.2007-0078)

Pseudo-asthma: When Cough, Wheezing, and Dyspnea Are Not Asthma

Miles Weinberger, MD and Mutasim Abu-Hasan

Although asthma is the most common cause of cough, wheeze, and dyspnea in children and adults, asthma is often attributed inappropriately to symptoms from other causes. Cough that is misdiagnosed as asthma can occur with pertussis, cystic fibrosis, primary ciliary dyskinesia, airway abnormalities such as tracheomalacia and bronchomalacia, chronic purulent or suppurative bronchitis in young children, and habit-cough syndrome. The respiratory sounds that occur with the upper airway obstruction caused by the various manifestations of the vocal cord dysfunction syndrome or the less common exercise-induced laryngomalacia are often mischaracterized as wheezing and attributed to asthma. The perception of dyspnea is a prominent symptom of hyperventilation attacks. This can occur in those with or without asthma, and patients with asthma may not readily distinguish the perceived dyspnea of a hyperventilation attack from the acute airway obstruction of asthma. Dyspnea on exertion, in the absence of other symptoms of asthma or an unequivocal response to albuterol, is most likely a result of other causes. Most common is the dyspnea associated with normal exercise limitation, but causes of dyspnea on exertion can include other physiologic abnormalities including exercise-induced vocal cord dysfunction, exercise-induced laryngomalacia, exercise-induced hyperventilation, and exercise-induced supraventricular tachycardia. A careful history, attention to the nature of the respiratory sounds that are present, spirometry, exercise testing, and blood-gas measurement provide useful data to sort out the various causes and avoid inappropriate treatment of these pseudo-asthma clinical manifestations.

PEDIATRICS Vol. 120 No. 4 October 2007, pp. 898-921 (doi:10.1542/peds.2007-2333)

Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs

Joint Committee on Infant Hearing

Key Words: hearing screening

THE POSITION STATEMENT

The Joint Committee on Infant Hearing (JCIH) endorses early detection of and intervention for infants with hearing loss. The goal of early hearing detection and intervention (EHDI) is to maximize linguistic competence and literacy development for children who are deaf or hard of hearing. Without appropriate opportunities to learn language, these children will fall behind their hearing peers in communication, cognition, reading, and social-emotional development. Such delays may result in lower educational and employment levels in adulthood.¹ To maximize the outcome for infants who are deaf or hard of hearing, the hearing of all infants should be screened at no later than 1 month of age. Those who do not pass screening should have a comprehensive audiological evaluation at no later than 3 months of age. Infants with confirmed hearing loss should receive appropriate intervention at no later than 6 months of age from health care and education professionals with expertise in hearing loss and deafness in infants and young children. Regardless of previous hearing-screening outcomes, all infants with or without risk factors should receive ongoing surveillance of communicative development beginning at 2 months of age during well-child visits in the medical home.² EHDI systems should guarantee seamless transitions for infants and their families through this process.

2007 JCIH POSITION STATEMENT UPDATES