Comparison of computerized digital and film-screen radiography: response to variation in imaging kVp. A controlled prospective study, in an animal model chosen to simulate portable neonatal radiography, was performed to compare the response of the Philips Computed Radiography (CR) system and conventional 200 speed film-screen (FS) to variation in imaging kVp. Acceptable images were obtained on the CR system over a very wide kVp range. In contrast the FS system produced acceptable images over a narrow kVp range. This ability suggests that the CR system should eliminate the need for repeat examinations in cases where a suboptimal kVp setting would have resulted in an unacceptable FS image. CR technology should therefore be ideally suited to portable radiography especially in situations where selection of correct exposure factors is difficult as in the neonatal nursery.


Dynamic ultrafast high resolution CT findings in a case of Swyer-James syndrome. In a patient with Swyer-James syndrome, the dynamic, ultrafast HRCT (DUHRCT) findings show multifocal bilateral air-trapping that was not seen on chest radiography or conventional CT scan. This technique accentuates the air trapping associated with post-infectious obliterative bronchiolitis, which is underappreciated by plain chest radiography and conventional CT.


Abdominal (liver, spleen) and bone manifestations of cat scratch disease. Cat scratch disease is usually a self-limiting illness. Patients may develop systemic complications including hepatic granulomas, splenic abscesses, mesenteric adenitis, osteolytic lesions, as well as dermatologic and CNS complications. In this paper the literature is reviewed and two cases are discussed which present the imaging findings in patients with hepatic, splenic, mesenteric, and bony manifestations of cat scratch disease.


Ultrasonography of congenital muscular torticollis. The sonographic appearance of the sternocleidomastoid muscles of 36 children with congenital muscular torticollis was studied. Sternocleidomastoid tumour was detected in all of them and the images were more complex than described in the literature. A patchy echo-texture was as frequent as a homogeneous echo-texture, and was more common in the younger child. The echo-genicity of the mass could be hyperechoic, isoechoic or hypoechoic relative to normal muscle. A hypoechoic rim surrounding the mass was frequently present. Change of the proportion of the mass relative to the entire muscle-mass complex in different ages matching clinical observations was also noted. These sonographic findings would be important in establishing a sonographic diagnosis. The higher sensitivity of ultrasound in detection of sternocleidomastoid tumour over clinical methods, and the importance of the sonographic findings in the management of congenital muscular torticollis were also discussed.


Perinatal hip assessment in very low birth weight infants. Fifty healthy low birth weight infants (less than 1500 g) without risk factors for congenital hip dysplasia (CHD) were examined by ultrasonography (100 hips) at 40 weeks corrected age and controlled at 3 months postnatal age. Sonographic assessment was performed using the classification of Graf. A physiological delay of hip maturation was observed in 10% of the patients (type IIa). At follow-up all of them had normal hip morphology without any pathological finding. Our results suggest that prematurity alone should not be considered a risk factor for CHD.


Occipital horn syndrome. Additional radiographic findings in two new cases. Occipital horn syndrome, a rare genetic disorder of copper metabolism, was recognized in 2 unrelated patients. Radiographs of these patients at various ages allowed confirmation of previously described radiographic findings. In addition, new radiographic manifestations were encountered. These pathognomonic radiographic findings are presented and the clinical and biochemical features of occipital horn syndrome are reviewed.


Dysplastic gangliocytoma (Lhermitte-Duclos disease): CT and MR imaging. Dysplastic gangliocytoma (Lhermitte-Duclos disease) is a rare entity. Usually presenting as a posterior fossa mass, dysplastic gangliocytoma is not a true neoplasm but a hard-to-characterize lesion that may represent an abnormality of cell migration or a phacomatosis. Previous reports of CT findings are rare in the radiologic literature, and high-field (1.5 Tesla) MR images have never been described in the pediatric age group. We present a case of dysplastic gangliocytoma in a one-year-old boy with CT and MR findings.


Color flow imaging in children with clinically suspected testicular torsion. 32 boys with symptoms of an acute scrotum had testicular sonography with color flow imaging (CFI). Patients ranged in age from 4-15 years (avg = 11 yrs). Symptoms were present from 12 h to 5 days (avg = 42 hrs). CFI correctly predicted presence or absence of testicular perfusion in 11 boys who had surgical exploration of the scrotum. 8 of these 11 patients had hemorrhagic infarction of the testicle, 1 had torsion of the appendix epididymis, 1 had epididymitis, and 1 had bilateral incomplete torsions with normal testicular perfusion. The remaining 21 patients did not have an operation. At least a 1 year follow-up of all patients has shown no clinical evidence of testicular atrophy to suggest a missed diagnosis of torsion. Absence or markedly decreased testicular flow was easily identified and indicates testicular ischemia/infarction. Conversely, hyperemia of the testis and/or epididymis is usually associated with trauma or infection. However, incomplete torsion or spontaneous detorsion may demonstrate normal testicular flow on CFI. Only close correlation of clinical symptomatology and gray scale findings with CFI can identify these patients, who remain at high risk for subsequent complete torsion and infarction.


Juvenile xanthogranuloma: non-X histiocytosis with systemic involvement. Two patients with different patterns of soft tissue and bone involvement demonstrate the variability of extracutaneous manifestations of juvenile xanthogranuloma, a non-X histiocytosis, better known to dermatologists than to radiologists.


Juvenile xanthogranuloma with extracutaneous lesions. The purpose of this article is to present a case of juvenile xanthogranuloma with pulmonary, retroperitoneal and splenic involvement. The similar echographic pattern of the cutaneous and visceral lesions was very helpful in order to suggest the correct diagnosis.


Neonatal phrenic nerve paralysis resulting from intercostal drainage of pneumothorax. Four cases of phrenic nerve paralysis complicating chest tube placement in the newborn for pneumothorax are presented. This complication is related to abnormal location of the medial end of the chest tube. It is suggested that on the frontal chest radiograph, the medial end of the chest tube should be no less than 1 cm from the spine.


MRI of sequela of transverse myelitis.

MRI of sequela of transverse myelitis. A 4-year-old boy developed acute paraplegia, associated with sensory impairement and bowel and urinary dysfunction after an URI. MRI showed diffuse hyperintensity in T2WI in the spinal cord below the T6 level. Acute transverse myelitis was diagnosed based on the clinical presentations and MRI findings. The patient had poor recovery and two months later, a follow-up MRI disclosed a severe diffuse atrophic change of the spinal cord in the affected segment.


An unusual presentation of urogenital rhabdomyosarcoma (sarcoma botryoides) in a Nigerian child. A 5-year-old child who presented with what was diagnosed clinically as posterior urethral valve and radiologically as multiple urethral and vesical polyps is described. This lesion was found on histological investigation to be a rhabdomyosarcoma (sarcoma botryoides).


Obstruction of cerebral arteries in childhood stroke. Middle cerebral artery obstruction in children is reviewed by our two cases. Ischemic childhood stroke was caused by moyamoya disease in the first, and by fibromuscular dysplasia in the second patient. In both cases transcranial Doppler sonography and cranial CT were performed, but the final diagnosis was made by angiography. The importance of angiography in childhood stroke is emphasized.


Solitary ivory vertebra due to primary Ewing's sarcoma. Dense sclerosis of most of the vertebral body has been termed as "ivory vertebra". While this condition occurs rather frequently in adults it is not found very often in children.


Juvenile gout with typical radiographic findings. Gout, a common disorder in adults is exceedingly rare in the first decade of life and uncommon in teenagers. A recent book on bone diseases in childhood does not even mention gout [7]. Childhood podagra with a radiographic findings is a very unusual finding indeed.


Amyloid goiter in a child--US, CT and MR evaluation. There are few radiological descriptions of amyloid goiter, basically in adult patients of oriental origin. We present a ten-year-old boy with Still's disease and secondary thyroid amyloidosis, describing the US, CT and MR findings.


A role for tumor necrosis factor-alpha and interferon-gamma in the regulation of interleukin-4-induced human thymocyte proliferation in vitro. Heightened sensitivity in the Down syndrome (trisomy 21) thymus. The influence of recombinant interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF) on IL-4-induced proliferation of postnatal human thymocytes from eight children with Down syndrome (DS, trisomy 21) and 18 control children was evaluated. DS thymuses were studied because they are characterized by cortical depletion and abnormal thymocyte differentiation. IL-4, without mitogen, induced a dose-dependent proliferation of both DS and control thymocytes. The proliferation was comparable to that induced by IL-2 and far greater than the proliferation mediated by IL-1 beta in the absence of mitogen. The level of IL-4 responsiveness correlated with the proportion of cells expressing the gamma, delta chains of the T cell receptor. Furthermore, thymocyte preparations greatly enriched for T cell receptor gamma, delta-bearing cells were found to vigorously proliferate when treated with IL-4. Both IFN-gamma and TNF inhibited IL-4-driven proliferation in a dose-dependent manner, but DS thymocytes were found to be significantly more sensitive to inhibition by both cytokines. Our studies suggest an important role for IL-4 in the proliferation of T cell receptor gamma, delta+ thymocytes and demonstrate regulatory functions for IFN-gamma and TNF in human thymocyte proliferation. The increased sensitivity of DS thymocytes to IFN-gamma and TNF may explain anatomical abnormalities in DS thymuses and suggests the involvement of genes encoded on human chromosome 21 in the responses to both IFN-gamma and TNF.


Enhanced response of human circulating erythroid progenitor cells to hGH and to IGF-I in children with insufficient growth hormone secretion. The response of hematopoietic progenitors to the growth promoting effects of hGH and IGF-I has been documented. In this study, the effects of recombinant hGH and IGF-I on the growth of circulating erythroid burst forming cells (BFU-E) from growth-IGF-I retarded children with insufficient growth hormone secretion (IGHS) were evaluated and compared with values obtained from either children with short stature and normal growth hormone levels (SNGH) or normal donors. Both recombinant hGH and IGF-I had significantly greater stimulatory effects on the growth of BFU-E from the IGHS compared with the SNGH and with the normally growing children. At its optimal concentration of 200 micrograms/L, recombinant hGH had a stimulatory effect on the growth of BFU-E from 11 IGHS children yielding a mean +/- SD value of 2.0 +/- 0.3-fold above the unstimulated controls compared with 1.45 +/- 0.16-fold and 1.36 +/- 0.04-fold stimulation of BFU-E from six SNGH and five normal donors, respectively. Similarly, IGF-I, at its optimal concentration of 0.065 nmol/L (0.5 ng/mL), stimulated IGHS-derived BFU-E growth 1.67 +/- 0.25-fold above unstimulated controls, compared with 1.28 +/- 0.17-fold and 1.3 +/- 0.1-fold stimulation of BFU-E from SNGH and from normal donors, respectively. The hGH- and IGF-I-induced stimulatory effects could be neutralized by their respective specific MAb.(ABSTRACT TRUNCATED AT 250 WORDS)


Elevated growth hormone secretory rate in premature infants: deconvolution analysis of pulsatile growth hormone secretion in the neonate. Premature infants have higher circulating concentrations of growth hormone (GH) than term infants. Previous investigations of these differences have used sampling frequencies of every 30 min with subsequent application of pulse detection algorithms, such as the CLUSTER program, to assess serum GH pulse parameters. To determine differences in GH secretory rates or GH t1/2 values between premature and term infants, we have sampled 11 neonates at 15-min intervals. We performed deconvolution analysis of the resultant plasma GH values to estimate GH secretory and clearance parameters. Five premature infants (gestational age range 24-34 wk) and six term infants (gestational age range 38-42 wk) were sampled every 15 min for 6 h. All subjects had indwelling arterial catheters. GH was measured (in duplicate) by RIA using 10 microL of plasma. Premature infants had higher secretory burst amplitudes (2.2 +/- 0.13 micrograms/L/min versus 1.4 +/- 0.27 micrograms/L/min, p = 0.02), higher production rates (product of the total number of bursts and the mean mass of GH secreted per burst, 811 +/- 173 micrograms/L/6 h versus 283 +/- 77 micrograms/L/6 h, p = 0.03), and a higher mass of GH per secretory burst (106 +/- 25 micrograms/L versus 38 +/- 11 micrograms/L, p = 0.049) than term infants. The integrated plasma GH concentration exhibited a strong trend toward a higher value in the premature infants (18,100 +/- 800 micrograms/L versus 10,200 +/- 2,700 micrograms/L, p = 0.067).(ABSTRACT TRUNCATED AT 250 WORDS)


Changes in IGF-I and -II, IGF binding protein, and IGF receptor transcript abundance after uterine artery ligation. Altered IGF activity may be one mechanism involved in the pathogenesis of intrauterine growth retardation (IUGR). We assessed the expression of IGF, IGF binding protein (IGFBP), and IGF receptor transcripts in liver, carcass, and placenta of fetal rats with IUGR resulting from unilateral uterine artery ligation. We found that uterine artery ligation on d 17 of gestation resulted in reduced body weight, liver weight, and placental weight on d 20 in the fetuses from the ligated uterine horn (UA-lig) compared with those from the opposite, nonligated uterine horn (UA-nonlig) and those from dams with no surgery or anesthesia. As assessed by solution hybridization, UA-lig fetuses exhibited significantly higher hepatic IGFBP-1, IGFBP-2, and IGF-II transcript abundance than UA-nonlig controls (increased 110, 50, and 31%, respectively). The only major difference among groups in carcass and placenta mRNA abundance was a 44% decrease in placental IGF-II expression in UA-lig pups compared with pups from dams that had had no surgery or anesthesia. Serum IGFBP, analyzed by ligand blot, showed a 2.4-fold increase in the doublet IGFBP-1/-2 band in UA-lig fetuses. Serum immunoreactive IGFBP-2 was unchanged among the groups, indicating that IGFBP-1 accounted for the increase in doublet intensity. Our results suggest that increased serum IGFBP-1 concentrations may decrease IGF activity in serum and thus inhibit IGF-stimulated cell proliferation or, by crossing the endothelial border, inhibit the activity of locally produced IGF. Decreased IGF-II expression in placenta also may contribute to decreased placental growth and, in turn, to IUGR.(ABSTRACT TRUNCATED AT 250 WORDS)


Destripeptide insulin-like growth factor-I in milk from bovine somatotropin-treated cows. Total somatomedins from milk of bovine somatotropin-treated cows were isolated and characterized to determine the relative amount of the three amino acid N-terminally truncated form of IGF-I (destripeptide IGF-I). The somatomedin fraction was isolated using organic solvent and solid-phase extractions followed by preparative reverse phase HPLC and affinity chromatography. The overall yield of IGF-I was 28%, and destripeptide IGF-I was recovered with similar efficiency. The isolated somatomedins were resolved by capillary zonal electrophoresis and identified using recombinant somatomedin standards. The concentration of destripeptide IGF-I relative to full length IGF-I was determined by amino terminal sequencing and by bioassay. Results from these experiments indicated that the level of destripeptide IGF-I in milk from somatotropin-treated cows was less than 3% of the IGF-I concentration. Destripeptide IGF-I is therefore a minor component of the somatomedins present in milk from treated cows and does not contribute significantly to the proliferative activity of this milk.


Early dietary antigens delay the development of gut mucosal barrier in preweaning rats. To determine the effects of early antigen exposure on the maturation of the gastrointestinal mucosal barrier, rat pups were divided into three groups at the age of 14 d. In addition to normal maternal milk, group CM (n = 24) received daily a gavage feed of cow's milk and group PH (n = 20) a whey protein hydrolysate during the experimental feeding period (14-20 d). Controls (n = 15) remained on maternal milk only. At 21 d, when "gut closure" normally occurs, intestinal absorption of horseradish peroxidase (HRP), was examined in vitro in Ussing chambers. The absorption of intact HRP [geometric mean (95% confidence interval)] was significantly higher in group CM [35.3 (16.7, 74.7) ng.h-1.cm-2] than in group PH [5.2 (1.4, 19.5) ng.h-1.cm-2] and in controls [3.4 (0.8, 15.1) ng.h-1.cm-2; F = 5.54, p = 0.006]. The absorption of degraded HRP was comparable in all groups. There were no modifications in electrical parameters in association with increased mucosal permeability to HRP. Furthermore, in group CM electron-microscopic studies disclosed accumulation of HRP in the cytoplasm of the epithelial cells and in the intercellular spaces where cell junctions remained unaltered. These results indicate that early administration of antigens delays the process of gut closure. They further suggest that continuously enhanced endocytosis of macro-molecules is induced by an insult to the mucosa as part of the host response to these antigens, irrespective of the protection afforded by maternal milk.


Synergistic effects of thyroxine and dexamethasone on enzyme ontogeny in rat small intestine. The synergistic effects of dexamethasone (DEX) and thyroxine (T4) on the postnatal maturation of the 13-d-old rodent small intestine has been studied. Previous studies have shown that hydrocortisone and T4 produced a synergistic response in enzyme maturation. However, T4 elevates corticosteroid-binding globulin, which reduces the clearance of hydrocortisone. Thus, the apparent synergy between T4 and hydrocortisone may have been due to increased glucocorticoid availability. DEX, which does not bind to corticosteroid-binding globulin, was given (d8-12) at 25 pmol (i.e. 0.01 micrograms)/g body wt/d as established by a dose-response study in which this dose of DEX induced one third the maximum response in sucrase activity. In this way, synergy with T4 (130 pmol/g body wt/d, i.e. 0.1 micrograms/g body wt/d, d 5-12) could still be observed. Glucoamylase, lactase, acid beta-galactosidase, alkaline phosphatase, and sucrase activities were determined in two regions of the small intestine. Overall, the results for the two hormones administered alone showed intestinal maturation to be not significantly affected in the T4 group and partially stimulated in the DEX group. When combined, DEX + T4 synergistically increased jejunal sucrase, ileal glucoamylase, and duodenal alkaline phosphatase, and lowered ileal acid beta-galactosidase. The striking exceptions to the general pattern were two brush border enzymes that normally decline during intestinal maturation, namely ileal alkaline phosphatase and jejunal and ileal lactase. For these enzymes, DEX alone did not elicit precocious maturation, and there was no evidence for a synergistic interaction of these two hormones. Serum corticosterone concentrations also were measured. When corticosterone concentrations were compared with enzyme activity, no correlation was found.(ABSTRACT TRUNCATED AT 250 WORDS)


Enterohepatic distribution of carnitine in developing piglets: relation to glucagon and insulin. L-Carnitine plays a crucial role in the perinatal transition from carbohydrate to lipid-derived energy. To examine the potential contribution of assimilated dietary carnitine to the elevated hepatic concentrations in newborns, we measured carnitine concentrations in sow milk, jejunum, and liver, and in vitro jejunal carnitine transport in piglets aged 1-36 d. Hepatic and sow milk total carnitine concentrations peaked soon after birth and declined with age (p = 0.035 and 0.026, respectively). Although jejunal total carnitine concentrations remained stable, jejunal carnitine flux was higher at 2 d of age than in older piglets. To examine the possible signals that regulate hepatic carnitine, portal enteroinsular hormones were measured by RIA. Portal glucagon (p = 0.0006), insulin (p = 0.0001), and glucagon:insulin ratio (p = 0.037) were related to age. Portal glucagon was highest in newborns and during weaning, whereas insulin increased progressively with age; the portal glucagon:insulin ratio, like hepatic carnitine, peaked soon after birth and fell with age. A multiple regression analysis indicated a positive association between glucagon and hepatic carnitine and a negative one between insulin and hepatic carnitine (R = 0.802, p = 0.001). An overall pattern of elevated dietary carnitine levels and increased small intestinal absorption and hepatic accumulation of carnitine is noted in early development. The finding of a similar pattern in glucagon-to-insulin ratio suggests that both hormones may participate in the regulation of enterohepatic carnitine distribution in newborns.


Carrier-mediated beta-D-hydroxybutyrate transport in brush-border membrane vesicles from rat placenta. Carrier-mediated beta-D-hydroxybutyrate transport in brush-border membrane (maternal-sided) vesicles prepared from trophoblast rat placenta was studied. The existence of a carrier-mediated transport system for beta-D-hydroxybutyrate in brush-border membrane vesicles was substantiated by the strong inhibitory effect of the protein modifier p-chloromercuriphenyl sulfonic acid and by the saturability of beta-D-hydroxybutyrate uptake as a function of beta-D-hydroxybutyrate concentration. beta-D-hydroxybutyrate uptake was stimulated by the presence of an inward-directed proton gradient but not by an inward-directed Na+ gradient. The mechanism for transport of beta-D-hydroxybutyrate seems to be a beta-D-hydroxybutyrate/H+ symport and not a beta-D-hydroxybutyrate/OH- antiport because beta-D-hydroxybutyrate transport was not sensitive to 4,4-diisothiocyano-2,2'-stilbenedisulfonic acid or furosemide. The Km, Vmax, and kd calculated by applying the iteration procedure to the data were 16 mM, 58 nmol.mg-1.10 s-1, and 0 nL.mg-1.s-1, respectively. The beta-D-hydroxybutyrate transport system might be shared by other monocarboxylic acids, and the carrier shows reversibility and exchange properties. There were no significant changes in the kinetic parameters of the beta-D-hydroxybutyrate transport system during the last 3 d of gestation. Nevertheless, there was a significant increase in the capacity of the beta-D-hydroxybutyrate transport system in brush-border membrane vesicles prepared from fasted pregnant rats, suggesting that the rise in maternal ketone body levels occurring as a consequence of maternal starvation is concurrent with the stimulation of the activity of the beta-D-hydroxybutyrate placental carrier to supply the fetus with ketone bodies.(ABSTRACT TRUNCATED AT 250 WORDS)


Tin-protoporphyrin-mediated disruption in vivo of heme oxygenase-2 protein integrity and activity in rat brain. The ability of synthetic metalloporphyrins to suppress heme oxygenase activity and bilirubin formation has recently become of considerable clinical and experimental interest for suppression of jaundice in humans, including neonatal hyperbilirubinemia. The present investigation compares the biochemical effects of Sn- and Zn-protoporphyrins on the predominant heme oxygenase isozyme present in the brain (HO-2) at activity, protein, and transcript levels and describes the ability of Sn-protoporphyrin to adversely affect this isozyme. Specifically, 6 h after a modest dose (50 mumol/kg, i.v.) of Sn-protoporphyrin, heme oxygenase activity in rat brain was nearly undetectable. In addition, as revealed by Western blot analysis, HO-2 protein level was decreased by 20% and the electrophoretic behavior of the protein in the microsomal membranes was altered. Moreover, the activity of NADPH-cytochrome P-450 reductase, which is required for the oxidation of heme molecule, was markedly decreased (60% of control). Western immunoblot analysis revealed also a pronounced decrease in the reductase protein level. The inducible form of heme oxygenase, HO-1, was not detectable by immunoblotting in brain microsomes of either control or Sn-protoporphyrin-treated animals. Northern blot analyses did not reveal decreases in the levels of the single HO-1 mRNA (1.8 kb) or the two HO-2 transcripts (1.3 and 1.9 kb), suggesting that Sn-protoporphyrin mediates its effects on heme oxygenase isozymes at the protein level. Zn-protoporphyrin, on the other hand, had no deleterious effect on brain parameters presently investigated.(ABSTRACT TRUNCATED AT 250 WORDS)


Caffeine decreases zinc and metallothionein levels in heart of newborn and adult rats. The purpose of the present study is to show that dietary caffeine, heart tissue Zn levels, and metallothionein (MT) concentration are all interrelated in newborn rats. Dams with eight pups in the control group were fed a 20% protein diet upon delivery, whereas dams in the experimental group were fed a 20% protein diet supplemented with caffeine (2 mg/100 g body weight). Offspring were killed at d 22 postbirth and the hearts and livers were removed to determine the Zn and MT concentrations. Hearts of the newborn rats in the caffeine group showed decreased Zn levels as well as decreased MT concentration. To explain the observed effects in newborn rats, the relationship between Zn and MT levels was studied in adult female rats. They were injected intraperitoneally with either ZnCl2 (20 mg/kg body weight) dissolved in saline solution or ZnCl2 and caffeine (4 mg/kg body weight) over a period of 2 d. Injection of ZnCl2 into adult female rats resulted in an increase in heart MT levels, whereas injection of caffeine caused decreased Zn levels and MT concentration. Current findings indicate that dietary caffeine intake during the lactational period by newborn pups causes a decrease of the heart Zn and MT levels.


Analysis of dynamic atrial dimension and function during early cardiac development in the chick embryo. Although atrial morphologic changes are well documented, the description of early atrial function is limited. We used videomicroscopic methods to define the function of the contracting atrium in stage 16 to 24 white Leghorn chick embryos. We exposed the embryo in ovo (right side up) and imaged the ventricle, then repositioned the embryo (left side up) and imaged the atrium (n greater than or equal to 8 per stage). We traced the atrial endocardial border and then measured atrial perimeter (mm) and cross-sectional area (mm2). A 20-MHz pulsed Doppler velocity meter was used to measure atrioventricular blood velocity during atrial imaging in an additional six stage 21 embryos. Data were tested by analysis of variance and regression analysis. Mean heart rate change after repositioning was -4 +/- 1%. Atrial maximum and minimum area increased linearly versus embryo stage (y = 0.10x - 1.41, r = 0.89, p less than 0.05 and y = 0.05x - 0.67, r = 0.82, p less than 0.05, respectively). Shortening fraction (percentage of reduction) of atrial perimeter and area decreased from 32.3 +/- 2.0% to 27.5 +/- 1.8% (p less than 0.05) and 56.2 +/- 3.0% to 47.7 +/- 2.0% (p less than 0.05), respectively, from stage 16 to 24. During atrial contraction, the velocity of circumferential wall shortening increased linearly with stage (y = 0.22x - 2.08, r = 0.81, p less than 0.01); however, the velocity of lengthening was similar between stages (p = 0.45). Simultaneous atrial imaging and pulsed Doppler velocity measurement showed that passive atrioventricular flow occurred late in atrial lengthening and active atrioventricular flow occurred during atrial contraction.(ABSTRACT TRUNCATED AT 250 WORDS)


Recognition of a fetal subdiaphragmatic venous vestibulum essential for fetal venous Doppler assessment. Ultrasonic visualization of the human fetal subdiaphragmatic area demonstrated anatomical relationships, different from descriptions in the literature. Four human fetal postmortem specimens at 18, 26, 28, and 34 wk of gestation were examined to ascertain morphologic details of intra- and perihepatic vasculature. Drawings of these dissected preparations were compared with ultrasonic images from the same region. With both methods the presence of a venous vestibulum immediately proximate to the diaphragm could be demonstrated. The abdominal inferior vena cava ends in a funnel-like structure, which also contains the orifices of the hepatic veins, the ductus venosus, and a phrenic vein. A considerable variability in Doppler flow recordings could result from blood propelling out of these various vessels into the vestibulum. It is, therefore, suggested that information on blood-flow velocities in venous hepatic vessels should be obtained more distally in the separate vessels and not at the entrance into the right atrium.


Arterial oxygen tension threshold range for the onset of arousal and breathing in fetal sheep. Mechanisms for the control of episodic fetal breathing movements or the onset of continuous breathing at birth remain unknown. Lung distension with 100% O2 at a continuous positive airway pressure of 30 cm H2O may induce arousal and continuous breathing. To investigate 1) the threshold range of arterial oxygen tension (PaO2) for the onset of arousal and breathing and 2) the graded response of breathing to various levels of PaO2, we studied 10 fetal sheep between 135 and 142 d of gestation (term = 147 +/- 2 d). Each fetus was instrumented to record sleep states, diaphragmatic electromyogram, arterial pH, and blood gas tensions. PaO2 threshold was determined through an indwelling O2 sensor catheter. Fetal lungs were distended at a continuous positive airway pressure of 40 cm H2O with 100% N2 or with O2 ranging from 40 to 100% via an in situ endotracheal tube. At the onset of arousal (n = 10), PaO2, arterial carbon dioxide tension, and Hb O2 saturation increased from control values of 21.7 +/- 0.75 torr (2.9 +/- 0.09 kPa), 41.8 +/- 1.1 torr (5.47 +/- 0.15 kPa), and 52.9 +/- 2.6% to 65.6 +/- 9.6 torr (8.74 +/- 1.28 kPa), 46.9 +/- 1.3 torr (6.25 +/- 0.17 kPa), and 92.9 +/- 2.06%, respectively, whereas the pH decreased from 7.31 +/- 0.006 to 7.27 +/- 0.009 (mean +/- SEM; p = 0.001, 0.04, 0.002, and 0.001, respectively). Seven of 10 fetuses breathed continuously. In these fetuses, PaO2 and arterial carbon dioxide tension further increased and pH decreased; however, no further significant increase in Hb O2 saturation was observed.(ABSTRACT TRUNCATED AT 250 WORDS)


Increased respiratory drive and limited adaptation to loaded breathing in bronchopulmonary dysplasia. Ventilatory parameters and respiratory drive with and without an added acute resistive load were assessed in 11 healthy preterm infants and 11 infants with bronchopulmonary dysplasia (BPD). Lung mechanics (breathing frequency, tidal volume, minute ventilation, compliance, and resistance) were determined with esophageal manometry and pneumotachography. Respiratory drive was assessed by determining the airway pressure measured 100 ms after the onset of an inspiratory effort against an occlusion. Infants were studied at baseline and with an external inspiratory resistive load of 213.7 cm H2O/L/s. Infants with BPD had similar breathing frequency, tidal volume, and minute ventilation, lower compliance, and greater resistance and airway pressure at 100 ms than healthy preterm infants at rest. With loading, healthy preterm infants demonstrated increased airway pressure at 100 ms, whereas infants with BPD showed no change. Although the healthy preterm infants had decreased minute ventilation and tidal volume with loading, decreases in ventilation were greater in the infants with BPD. These data demonstrate that infants with BPD have responded to a chronic intrinsic load with increased drive. However, this may result in decreased ventilatory reserve and hence, a limited ability to adapt to acute pulmonary loads.


Antioxidant defense mechanisms of endothelial cells and renal tubular epithelial cells in vitro: role of the glutathione redox cycle and catalase. We recently demonstrated that endothelial cells are more susceptible than renal tubular epithelial cells to oxidant injury and that renal tubular epithelial cells with proximal tubular characteristics including porcine proximal tubular epithelial cells, opossum kidney proximal tubular epithelial cells, and normal human kidney cortical epithelial cells are more susceptible to oxidant injury than the distal nephron-derived Madin Darby canine kidney cell line. To determine the basis of this differential response, we evaluated several antioxidant defenses in the five cell lines. Glutathione levels were not significantly different among the five cell lines, but catalase and glutathione reductase levels were significantly (p less than 0.01) lower in endothelial cells compared to all renal tubular epithelial cells. Among renal tubular epithelial cells, Madin Darby canine kidney cells had significantly (p less than 0.05) higher glutathione peroxidase activity. To further evaluate the role of antioxidant defenses in limiting oxidant injury, we determined two responses to oxidant injury (ATP depletion and 51Cr release) when glutathione was depleted with buthionine sulfoxamine and when catalase was inhibited with aminotriazole. Oxidant-induced ATP depletion was accentuated when catalase was inhibited as well as when glutathione was depleted with buthionine sulfoxamine. In contrast, inhibition of catalase had little or no effect on 51Cr release, whereas glutathione depletion resulted in accentuated 51Cr release. We conclude that the increased susceptibility of endothelial cells to oxidant injury as compared with epithelial cells is associated with lower antioxidant defenses. Disruption of the glutathione redox cycle results in accentuated ATP depletion and lytic injury, whereas inhibition of catalase results in accentuated ATP depletion with little effect on lytic injury.(ABSTRACT TRUNCATED AT 250 WORDS)


The effect of monosaturated and polyunsaturated fatty acids on oxygen toxicity in cultured cells. The influence of oleic, linoleic (LIN), and eicosapentaenoic (EPA) acids incorporated into cellular lipids on susceptibility to O2-induced toxicity was evaluated in Chinese hamster fibroblasts (HA1) using a clonogenic cell survival assay. Fatty acid incorporation was achieved by incubating HA1 cells in 21% O2 for 72 h in the presence or absence of media supplemented with 25 microM oleic acid, 25 microM LIN, or 2, 4, and 25 microM EPA. This fatty acid incorporation period increased the percentage of composition in phospholipids 2-fold for oleic acid, 6-fold for LIN, and 6- to 20-fold for EPA. Vitamin E, total glutathione, superoxide dismutase activity, glutathione transferase activity, and catalase activity were unchanged, relative to control, in the 25-microM EPA-treated group, and only total glutathione was elevated in the LIN-treated group. After the incorporation period, the cells were placed in non-fatty acid supplemented media and exposed to 95% O2, and clonogenic survival responses were evaluated at time intervals up to 100 h. Sensitization to O2 toxicity in EPA-treated cells was apparent after 24 h of O2 exposure, whereas LIN-treated cells were significantly (p less than 0.05) sensitized to hyperoxia after 54 h of exposure, indicating that EPA was a more potent sensitizer for O2 injury. Furthermore, cells supplemented with 4 and 25 microM EPA were more sensitive to O2 toxicity than cells supplemented with 2 microM EPA. In contrast, cells treated with 25 microM oleic acid were significantly more resistant to O2 toxicity at 51, 72, and 98 h of O2 exposure.(ABSTRACT TRUNCATED AT 250 WORDS)


Long term efficacy of hepatitis B vaccine in infants born to hepatitis B e antigen-positive mothers. The long term protective efficacy of recombinant hepatitis B vaccine, administered alone or concomitantly with hepatitis B immunoglobulin, was assessed in 263 healthy neonates of hepatitis B e antigen-positive mothers. Infants received the first dose of vaccine at birth; additional doses were given at either Months 1, 2 and 12 or Months 1 and 6. During the follow-up period, which ranged from 2 to 4 years, protective titers (> or = 10 mIU/ml) of anti-hepatitis B surface antibodies were found in virtually all infants who had responded to the primary course of vaccination. "Natural boosts," without persistent infection, were observed in only a small number of children. All children who were shown to have become chronic carriers were infected within the first year of life. No statistical difference in long term protective efficacy could be shown between the two vaccination schedules used or between the use of vaccine alone or vaccine plus hepatitis B immunoglobulin for either schedule.


Comparison of high titer Edmonston-Zagreb, Biken-CAM and Schwarz measles vaccines in Peruvian infants. In an effort to identify the optimal dose and strain of measles vaccination for early immunization, Peruvian infants were randomly assigned to receive one of three measles vaccines in varying doses at 5 to 6 or 8 to 9 months of age. Edmonston-Zagreb vaccines were significantly (P < 0.001) more immunogenic than equivalent or higher titers of Schwarz or Biken-CAM vaccines as determined by neutralization antibody response 3 months after vaccination. Eighty-two percent of infants who received high titer Edmonston-Zagreb vaccine at 5 to 6 months of age developed protective concentrations of measles antibody, a response rate similar to that observed after standard titer Schwarz (81%) or high titer Biken-CAM vaccine (81%) at 8 to 9 months of age. No significant differences in the rates of fever, rash or other adverse events were noted by vaccine group 10 to 14 days after vaccination. Although the high titer vaccines are more immunogenic in young infants than standard vaccines, long term safety must be assured before these vaccines can be put into widespread use.


Serum adenosine deaminase in the early diagnosis of typhoid fever. To study the usefulness of the enzyme adenosine deaminase for the early diagnosis of typhoid fever, its activity in serum was assayed in 277 children admitted to the Hospital Guillermo Grant Benavente at Concepción, Chile, from March, 1988, to December, 1990. The children were distributed into seven groups: control, N = 82; bacteremia, N = 8; acute viral respiratory infection, N = 43; febrile children with miscellaneous etiologies, N = 49; pulmonary tuberculosis, N = 3; hepatitis A virus infection, N = 30; and typhoid fever, N = 62. The medium serum adenosine deaminase values were significantly higher in children with typhoid fever (P < 0.0001) in relation to the values in the control group (122.2 +/- 40.7 vs 28.1 +/- 8.4 units/liter at 37 degrees C). This test had a sensitivity of 91.9% and a specificity of 92.5% in identifying the patient with typhoid fever when using 80 units/liter as the cutoff values. The positive predictive value of the test was 83.8% and the negative predictive value was 96%. Determination of adenosine deaminase values in serum could be helpful in the early diagnosis of typhoid fever.


Intermediate resistance of Streptococcus pneumoniae to penicillin in children in day-care centers. This study was performed to determine the prevalence, serotypes and antibiotic susceptibility patterns of penicillin-resistant Streptococcus pneumoniae in children younger than 3 years of age in day-care centers in Houston, TX. Nasopharyngeal cultures were obtained on two occasions, in March and May, 1989, from 140 children in 4 day-care centers. All penicillin-resistant S. pneumoniae organisms isolated in this study had minimum inhibitory concentrations to penicillin of between 0.1 and 0.5 microgram/ml and were thus intermediately resistant. No highly resistant S. pneumoniae (minimum inhibitory concentration > or = 1.0 microgram/ml) was isolated in this study. Nasal carriage of S. pneumoniae occurred in 39% of children; carriage of intermediately resistant S. pneumoniae occurred in 4% of children. Of the 39% of children who carried S. pneumoniae, 11% carried intermediately resistant strains. In one day-care center with a prior history of intermediately resistant S. pneumoniae (Center 1), the prevalence of intermediate penicillin resistance was significantly (P = 0.047) higher than in the other three centers. Among children surveyed twice 15% of Center 1 children carried an intermediately penicillin-resistant strain at least once, whereas in the other centers 3% of children carried an intermediately resistant strain at least once. Sixty-two percent of intermediately penicillin-resistant strains were resistant to multiple antibiotics and all were serotype 14. Intermediately penicillin-resistant S. pneumoniae isolates were prevalent among young children in day-care centers in Houston and may persist in some day-care centers and become endemic.


Risk factors associated with severe measles in Puerto Rico. From January to April, 1990, 695 measles cases were reported to the Puerto Rico Health Department; there were 12 measles-associated deaths (case fatality ratio, 17/1000), more than in any year since 1967. We conducted a case-control study of risk factors for severe measles. We identified 16 children (ages 5 to 34 months) with severe measles and selected children with nonsevere measles as controls (39 hospitalized and 38 nonhospitalized). Controls were frequency matched to severe measles cases by region of residence. One case and two controls had been vaccinated. An underlying illness was present in 50% of cases and 16% of nonhospitalized controls (Mantel-Haenszel weighted odds ratio 5.3; 95% confidence interval 1.4, 20.2). In a multivariate analysis cases were significantly more likely than hospitalized controls to be from families with an annual income of < $5000 (odds ratio (OR), 26.9), to have a mother without a high school degree (OR 11.1), to be anemic (hemoglobin < 10 g/dl) (OR 15.9) and have an underlying illness (OR 18.3). During measles outbreaks preventing severe illness requires aggressive control measures and strategies to increase vaccine coverage of children with underlying illnesses and of low socioeconomic status.


Epidemiology of measles in the United States in 1989 and 1990. During 1989 and 1990 measles incidence increased sharply in the United States. We compared cases reported during these years with those reported between 1981 and 1988. Incidence increased 462% in 1989, and incidence in 1990 (11.2/100,000) was the highest in more than a decade. Although all ages were affected the greatest increases were in children < 5 years and in adults. Incidence was 7- to 10-fold higher among racial/ethnic minority preschoolers than whites, and 80% of vaccine-eligible preschool age cases were unvaccinated. Complications occurred in 9418 (20.5%) cases, most frequently in young children and adults. Large urban outbreaks affecting predominantly unvaccinated preschoolers were common; 47% of all cases reported in 1990 were associated with 5 outbreaks. Reasons for the increased incidence are not clear. Current information suggests no change in vaccination coverage among preschool age children or in vaccine efficacy. Continued surveillance and evaluation of epidemiologic and laboratory data are necessary. The most pressing need is to improve age-appropriate vaccination among preschool age children.


Respiratory tract colonization with Ureaplasma urealyticum and bronchopulmonary dysplasia in neonates in southern Israel. Ureaplasma urealyticum has been recognized as an important potential pathogen in premature neonates. Reported rates of colonization of the respiratory tract vary. Data on neonatal ureaplasma colonization outside the United States and Western Europe are rare. Therefore we prospectively studied nasopharyngeal and endotracheal colonization in a cohort of 114 preterm and 100 full term infants within 48 hours of birth. The colonization rate was 24% in the premature infants and zero in the full term infants. Bronchopulmonary dysplasia developed in 19% of infants with nasopharyngeal Ureaplasma colonization and in 4.6% of noncolonized infants (P < 0.03). Bronchopulmonary dysplasia developed in 40% of intubated infants with positive endotracheal Ureaplasma cultures and only in 9.8% of infants with negative endotracheal cultures (P < 0.04). Thus Ureaplasma colonization of either the nasopharynx or the trachea was associated with an increased risk for the development of bronchopulmonary dysplasia (relative risk, 4.0 and 4.1, respectively).


Lack of predictive value of maternal human immunodeficiency virus p24 antigen for transmission of infection to their children. The association of maternal-to-infant transmission of human immunodeficiency virus type 1 (HIV-1) with maternal p24 antigenemia was assessed in 86 HIV-1-infected mothers. We retrospectively examined serum or plasma samples collected in the peripartum period (delivery +/- 11 days; sd 16.89 days; range, delivery +/- 2 months). Immune complexes of p24 antigen and anti-p24 antibody were dissociated using acid hydrolysis (Method A, glycine-HCl buffer; Method B, HCl) in an attempt to increase the sensitivity of the test. The detection of HIV-1 p24 antigenemia in serum was increased from 23 of 86 (26.7%) to 37 of 82 (45.1%) following acid hydrolysis with Method A (chi square = 5.4, P = 0.02) and to 36 of 78 (46.1%) with Method B (chi square = 5.874, P = 0.015). Mothers of HIV-1-infected children were no more likely to have p24 antigenemia than mothers of seroreverted infants when untreated samples were assayed (7 of 23 vs. 10 of 48; chi square = 0.348, P = 0.55). Although acid hydrolysis increased the ability to detect p24 antigen, it did not enhance any association between p24 antigenemia and maternal-to-infant transmission of HIV infection: Method A, 9 of 23 in mothers of infected children vs. 21 of 45 in mothers of seroreverted children (chi square = 0.112, P = 0.738); and Method B, 9 of 22 in mothers of infected children vs. 18 of 42 in mothers of seroreverted children (chi square = 0.014; P = 0.907), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)


IgG1, IgG2 and IgM responses to two Haemophilus influenzae type b conjugate vaccines in young infants. PRP-meningococcal outer membrane protein complex (PRP-OMPC) and oligosaccharide linked to variant diphtheria toxin (HbOC) Haemophilus influenzae type b (HIB) conjugate vaccines have both been licensed for United States infants at 2 months of age. Differences in serologic responses for these vaccines have been noted with PRP-OMPC producing an early response at 2 months of age and HbOC producing a higher response after a third dose at 6 months of age. To further characterize the nature of these distinct responses, we measured the IgG1, IgG2 and IgM anti-HIB concentrations by enzyme-linked immunosorbent assay after administration of both vaccines. PRP-OMPC produced an IgM and IgG1 anti-HIB response following the initial dose at 2 months of age. After two doses of HbOC an increase in IgG1 and IgM were noted and after a third dose at 6 months of age an IgG2 anti-HIB response occurred. In addition 33 study subjects were boosted with PRP-OMPC at age 18 months and compared with 34 subjects who received only a primary dose. The anti-HIB IgG1 and IgG2 concentrations following the booster dose were both significantly higher for the primed group (P = 0.0001 and P = 0.001, respectively). Both HIB conjugate vaccines produce predominantly IgG1 anti-HIB antibody responses. The early response to PRP-OMPC vaccine at 2 months of age may result from adjuvant characteristics of the OMPC.


Outbreaks of summer rotavirus linked to laboratory practices. The National Rotavirus Surveillance System. In temperate regions rotavirus diarrhea is a disease of the cooler months of the year, but little is known about its patterns in the summer. We report on the first year of national surveillance of rotavirus, during which we actively investigated patterns of summer activity. We obtained data on rotavirus testing from 85 laboratories in 48 states, conducted a survey of their testing practices and retested for confirmation positive specimens from laboratories reporting high rates of positivity during the summer. During 1989 participating laboratories reported 4011 specimens tested for rotavirus during July and August, of which 436 (11%) were said to be positive. Most laboratories reported low rates of positivity during these months (median percent positive, 3), but five had very high rates of summer positivity (> 30%). These five laboratories were geographically separated, and neighboring laboratories showed little rotavirus activity. Positive specimens submitted by four of these centers with high rates of summer rotavirus could not be confirmed. A survey of laboratory methods found one commercial assay (TestPack) and two laboratory practices (failure to use controls and involvement of more than six technicians in the testing process) to be associated with high rates of summer positivity. Moderate rates of positivity (11 to 30%) were fond frequently in the southwest during July and August; reference testing of specimens from these laboratories confirmed positivity.(ABSTRACT TRUNCATED AT 250 WORDS)


Mechanical ventilation in preterm infants: neurosonographic and developmental studies. Surviving preterm infants of less than 34 weeks' gestation who were selected on the basis of serial cranial ultrasonographic findings during their nursery course had repeated neurologic and developmental examinations during late infancy and early childhood that established the presence (n = 46) or absence (n = 205) of spastic forms of cerebral palsy. Of the 205 infants without cerebral palsy, 22 scored abnormally low on standardized developmental testing during early childhood. The need for mechanical ventilation beginning on the first day of life (n = 92) was significantly related to gestational age, birth weight, Apgar scores, patent ductus arteriosus, grade III/IV intracranial hemorrhage, large periventricular cysts, and the development of cerebral palsy. In the 192 mechanically ventilated infants, vaginal bleeding during the third trimester, low Apgar scores, and maximally low PCO2 values during the first 3 days of life were significantly related to large periventricular cysts (n = 41) and cerebral palsy (n = 43), but not to developmental delay in the absence of cerebral palsy (n = 18). The severity of intracranial hemorrhage in mechanically ventilated infants was significantly associated with gestational age and maximally low measurements of PCO2 and pH, but not with Apgar scores or maximally low measurements of PO2. Logistic regression analyses controlling for possible confounding variables disclosed that PCO2 values of less than 17 mm Hg during the first 3 days of life in mechanically ventilated infants were associated with a significantly increased risk of moderate to severe periventricular echodensity, large periventricular cysts, grade III/IV intracranial hemorrhage, and cerebral palsy. Neurosonographic abnormalities were highly predictive of cerebral palsy independent of PCO2 measurements.(ABSTRACT TRUNCATED AT 250 WORDS)


Lyme arthritis as the incorrect diagnosis in pediatric and adolescent fibromyalgia. In areas endemic for Lyme disease there is increasing concern and anxiety about possible chronic and untreatable manifestations of the disease. The authors have diagnosed fibromyalgia in many patients with chronic musculoskeletal complaints in whom chronic Lyme arthritis had previously been diagnosed as the cause of their joint pains. Fibromyalgia is a common disorder, causing arthralgia (not true arthritis), fatigue, and debility. The repeated and/or long-term antibiotic therapy prescribed for "chronic Lyme disease" is not successful in curing the symptoms of fibromyalgia. Especially in areas where anxiety about Lyme disease is great, it is important to be careful in diagnosing chronic Lyme disease. Fibromyalgia is a potentially treatable and curable cause of chronic complaints and should be considered in the differential diagnosis of "refractory Lyme arthritis."


Prolonged dexamethasone therapy reduces the incidence of cryotherapy for retinopathy of prematurity in infants of less than 1 kilogram birth weight with bronchopulmonary dysplasia. To determine whether prolonged dexamethasone therapy, used in the treatment of bronchopulmonary dysplasia (BPD), affects the incidence of cryotherapy for retinopathy of prematurity, the authors conducted a retrospective review of all infants admitted to a neonatal intensive care unit between October 1988 and October 1990 (n = 957) whose birth weights were less than 1 kg (n = 90). All admissions were reviewed to determine birth weight, gestational age, survival, incidence of BPD and cryotherapy, use and duration of dexamethasone therapy, length of mechanical ventilation, continuous positive airway pressure, and additional supplemental oxygen. Of all neonatal intensive care unit admissions, 9.4% weighed less than 1 kg, and 64% survived for greater than 28 days (n = 58). Of the survivors, 82% had BPD. Cryotherapy for retinopathy of prematurity was used only in those with birth weights of less than 1 kg and with BPD. All those treated with dexamethasone (n = 23) had BPD and significantly lower gestational ages (25.6 vs 26.4 weeks) (P = .05) and birth weights (759 vs 824 g) (P < .05) than those not treated (n = 25). Dexamethasone was used in 23 of 48 infants (9 for < or = 24 days, 14 for > 24 days). Eleven required cryotherapy: 5 of 25 with no dexamethasone, 5 of 9 treated for 24 days or less, and 1 of 14 treated for longer than 24 days (P < .04). In those treated with prolonged (> 24 days) dexamethasone, cryotherapy was significantly reduced compared with those treated for shorter periods. Although the probability was significant, the 95% confidence intervals were wide.(ABSTRACT TRUNCATED AT 250 WORDS)


Severe retinopathy of prematurity and steroid exposure. During a 3-year period (1988 through 1990) an increase was observed in the number of infants born at 23- to 26-weeks' gestation who required cryotherapy for severe retinopathy of prematurity (0/20, 1988; 3/14, 1989; 6/18, 1990; P = .015). Inasmuch as this was not related to improved survival, a retrospective case-control study was conducted to try to explain this observation. Of 52 surviving infants who had been born at 23 to 26 weeks' gestation, 9 required cryotherapy and the other 43 served as control subjects. There were no differences between groups in birthweight, gestational age, or the number of infants with hyaline membrane disease, intraventricular hemorrhage, or hydrocephalus. Factors related to the need for cryotherapy included patent ductus arteriosus (P = .046), mechanical ventilation for more than 21 days (P = .045), and the use of steroids for lung disease (P < .001). In this neonatal intensive care unit, steroids are administered according to the attending neonatologist's preference. Inasmuch as steroids are considered only for infants still ventilator dependent at 21 days, this group was analyzed separately (n = 36). Of the 21 factors examined, only the use of steroids for lung disease was associated with the need for cryotherapy (P < .001).


Oral ketamine premedication to alleviate the distress of invasive procedures in pediatric oncology patients. This study prospectively evaluated the efficacy of oral ketamine in alleviating procedure-related distress in pediatric oncology patients. Ketamine (10 mg/kg) was administered orally to 35 children and adolescents, ranging in age from 14 months to 17 years (mean = 6.5 years). Procedure-related distress was evaluated by using parent/clinician ratings and the Observational Scale of Behavioral Distress (OSBD-R). Eighty-seven percent of children were sedated within 45 minutes. Clinician and parent ratings were similar, with 77% rating procedural distress as low (0 to 3). The OSBD-R scores were low throughout all phases of the study. Although this study was neither randomized nor placebo-controlled, statistical comparison of the OSBD-R scores of the patients who received oral ketamine with those of historical controls (from a study previously performed at the same institution but using intravenous midazolam) showed significantly less distress (P < .001) during the procedure in children who received oral ketamine. Additionally, OSBD-R scores of the patients who received oral ketamine were significantly lower (P < .001) during all phases than those of the saline placebo group in the other study. No cardiorespiratory side effects related to ketamine were noted. The majority of patients showed recovery from sedation within 2 hours following the procedure. In conclusion, oral ketamine effectively alleviated procedure-related distress in pediatric oncology patients.


Variability and self-regulation of energy intake in young children in their everyday environment. Recent data from small numbers of children studied under controlled protocols indicate that intraindividual variation in energy consumption over 24 hours is smaller than variation from eating occasion to eating occasion, implying that children self-regulate their energy consumption. This hypothesis was tested in children living in their everyday environment. Between 1986 and 1989, 24-hour recalls were administered on seven occasions (four times in 1986 through 1987 and three times in 1988 through 1989) to the mothers of 181 preschool children in New York City. Each 24-hour period was divided into six meals or snacks. The coefficient of variation (standard deviation divided by the mean) was calculated for each child for energy consumption at each eating occasion and for the day as a whole. Coefficients of variation for energy consumption at the six eating occasions ranged from 46.5% to 165.8%, compared with 30.3% for the whole day. This coefficient of variation for the observed whole-day energy consumption was significantly less (P < .001) than would be expected if no autoregulation of energy intake (no meal-to-meal correlation) occurred. These findings in children living in their everyday environment are consistent with observations under more controlled study conditions. These data suggest that children who eat less at one meal compensate at another, although the data do not address the issues of longer term energy self-regulation, overall energy balance, or diet quality.


Dietary intake of healthy children with cystic fibrosis compared with normal control children. Because a low calorie intake may result in growth failure and malnutrition in patients with cystic fibrosis (CF), the dietary and energy intakes of 22 children with CF who had mild lung disease and excellent Shwachman scores were examined and compared with those of 23 normal control subjects similar in age (5 to 10 years), gender, and weight. The children with CF consumed significantly more calories than the control subjects. Calorie intake was 111 +/- 19.9% (mean +/- SD) of estimated requirements (World Health Organization recommendations) for the CF group and 97 +/- 18.7% for the control group (P = .014). Calories consumed per kilogram of body weight were 117% of World Health Organization (CF) vs 97% (control) (P = .009). Calorie intake compared to the 1989 Recommended Dietary Allowance was 106 +/- 20.6% for the CF group vs 93 +/- 19.1% for the control group. Fat consumed as a percent of total calories was similar: 33.5% (CF) vs 32.2% (control). All children with CF had pancreatic insufficiency and, on average, consumed a large number of pancreatic enzyme supplements, resulting in dietary fat absorption of 86 +/- 12%. It is concluded that these children with CF were able to maintain normal growth and energy stores on a diet that was relatively high in calories compared to control subjects and moderate in percent fat, along with an aggressive pancreatic enzyme supplement regimen.


Sleeping through the night: a developmental perspective. This study examines falling asleep and night waking in human infants during the first 8 months of life. All-night time-lapse video recordings were obtained at 3 weeks and 3 months of age; a Sleep Habits Interview was completed at these ages and repeated at 8 months of age by telephone interview. At the 3-week and 3-month ages, self-report measures of maternal psychologic distress, depression, and self-esteem were also obtained. The data are examined from both cross-sectional (age group) and longitudinal (individual) perspectives. Parent-infant interactions at bedtime and during the middle of the night changed significantly with increasing age. At 3 weeks of age, most infants were put into their cribs for the night already asleep. When they awakened in the middle of the night, they were removed from their cribs. By the time they returned to their cribs, they were again asleep. By 3 months of age, infants who were put into the crib awake at bedtime and allowed to fall asleep on their own were more likely to return to sleep on their own after awakenings later in the night. In contrast, infants who were put into the crib already asleep at the beginning of the night were significantly more likely to be removed from the crib following a subsequent nighttime awakening. Thus, the pattern of bedtime sleep onset was related to sleep onset following an awakening in the middle of the night. This association was present at 8 months as well.(ABSTRACT TRUNCATED AT 250 WORDS)


Neonatal therapeutic intervention scoring system: a therapy-based severity-of-illness index. Severity-of-illness scales have proven valuable in assessing clinical outcomes and resource consumption in adult and pediatric intensive care, but they have been less extensively developed for neonatal care. The National Therapeutic Intervention Scoring System (NTISS) was created by modifying the Therapeutic Intervention Scoring System (TISS). From the 76 original TISS items, 42 were deleted and 28 added to form the NTISS. Like TISS, NTISS assigns score points from 1 to 4 for various intensive care therapies. Admission-day NTISS scores were calculated for 1643 newborns admitted to three neonatal intensive care units (NICUs) between November 1, 1989, and September 30, 1990. NTISS scores ranged from 0 to 47 with a mean of 12.3 +/- 8.7 (SD). There was little correlation with birth weight (r = -.11) or gestational age (r = -.17), but NTISS scores were highly correlated with expected markers of illness severity, including mortality risk estimates by neonatal attending physicians (r = .70, P < .0001), in-hospital mortality rates (P < .05), and a measure of nursing acuity (Medicus) (r = .69, P < .0001). In addition, admission-day NTISS scores were found to be predictive of both NICU length of stay (r = .37, P < .0001) and total hospital charges for survivors (r = .65, P < .0001). It is concluded that NTISS is a valid measure of therapeutic intensity that is independent of birth weight and can be used as an indicator of neonatal illness severity and resource utilization. Further validation in other NICUs is required.


Evaluation of the reconstructed carotid artery following extracorporeal membrane oxygenation. Over a 12-month period, 28 neonatal patients in respiratory failure were supported with extracorporeal membrane oxygenation (ECMO), and 11 of these underwent successful repair of the right carotid artery post-ECMO. Nine of 11 were studied with duplex color-flow Doppler imaging between 14 and 109 days of age and again at 1 year of age. A velocity ratio (A/B) of the peak systolic velocity above the level of the anastomosis to the peak systolic velocity below the anastomosis was measured to assess the degree of stenosis, if any, at the repair site. Antegrade flow through the carotid was detected post-ECMO in 8 of 9 infants, and antegrade and retrograde flow was documented in 1 infant. A/B ratios ranged from 1.00 to 8.60 (A/B ratio of 1 is normal; 2.0 indicates at least a 50% obstruction to flow). Four of 9 patients had ratios greater than 2.0, and 8 of 9 exhibited some evidence of obstruction. Follow-up scans were performed on 8 of 9 infants between 12 and 18 months of age. All infants examined showed marked improvement in A/B ratio and patency of the vessel, documenting that initial narrowing of the vessel is reversible. No infant had evidence of embolic phenomena to the right side of the brain by magnetic resonance imaging. Repair of the common carotid artery post-ECMO is technically feasible without increasing the risk of brain injury.


Subspecialization within pediatric practice: a broader spectrum. This study was undertaken to describe subspecialty characteristics and practices of the population of pediatricians given the ongoing controversy regarding a projected manpower oversupply of general pediatricians. A questionnaire was mailed to a national random sample of 1620 United States physicians listed in the American Medical Association's Physician Masterfile as being in office-based pediatric practice. The final response rate was 63%. Seventy percent of respondents designated their practices as "general pediatrics" versus 17% as "general pediatrics with a specific subspecialty interest" and 13% as "subspecialty practice." The general pediatricians with a specific subspecialty interest were intermediate in the proportion that had some training in a pediatric fellowship program (general pediatricians with a specific subspecialty interest, 63% versus general pediatricians, 14%, P < .0001, and pediatricians with a subspecialty practice, 92%, P < .0001) and that were certified in a pediatric subspecialty by the American Board of Pediatrics (general pediatricians with a specific subspecialty interest 16% versus general pediatricians, 2%, P < .0001, and pediatricians with a subspecialty practice, 62%, P < .0001). They were also intermediate in the proportion involved in various academic pursuits. Their practices, however, more closely resembled general pediatricians than pediatricians with a subspecialty practice in their location, setting, associates, and commitment to primary care. They were more likely than general pediatricians to utilize or provide specialized tests or procedures. A large percentage of pediatricians incorporate subspecialty elements into their general pediatric practices. Models of current and projected pediatric manpower supply need to be reassessed in light of this form of practice.


Day care center attendance and diarrheal morbidity in Colombia. This study was designed to determine whether day care center attendance was associated with increased risk of diarrheal disease among poor children in an urban, developing country setting. From July 17 to December 18, 1988, mothers of 493 Colombian children less than 5 years old (241 attendees and 252 nonattendees) were interviewed weekly about diarrheal events during the previous week. The incidence of diarrhea was greater for day care center attendees than for nonattendees (3.2 vs 2.0 episodes per child-year, P < .0005). For children less than 2 years of age, attendees experienced 7.2 episodes/child-year vs 3.5 episodes per child-year for nonattendees (P < .0005). Analyses controlling for water source and availability, excreta disposal, socioeconomic status, and duration of follow-up showed that the increased diarrheal risk was limited to children younger than 3 years of age spending more than 30 hours per week in the centers. In addition, although the risk among attendees of suffering diarrheal episodes of longer duration was fairly constant across levels of socioeconomic status, this risk was inversely proportional to socioeconomic status for nonattendees. In summary, the increase in risk of diarrhea among young, full-time day care attendees was modest, yet important, because diarrhea continues to be a major cause of morbidity and mortality in Colombian children.


Health insurance coverage of adolescents: a current profile and assessment of trends. Data from the National Health Interview Survey reveal that 4.7 million or 15% of US adolescents aged 10 through 18 were uninsured in 1989. Among adolescents, 73% were privately insured, 10% were publicly insured, and 2% were both privately and publicly insured. Poor, near-poor, and minority adolescents were at the greatest risk for lack of health insurance coverage. Among adolescents without insurance, cost continued to be cited as the leading barrier to obtaining coverage. A comparison of 1989 National Health Interview Survey data with a previous analysis, in which 1984 data were used, revealed a 10% increase in the proportion of adolescents without insurance coverage. The increase in the proportion of uninsured adolescents was entirely attributable to an erosion of private health insurance coverage. No significant change occurred in the proportion of adolescents with coverage under public programs. Planned expansions of the federally and state-financed Medicaid programs will help to stem further increases in the size of the uninsured adolescent population. However, unless marked improvements occur in the private health insurance sector, progress will be limited.


The cost of assistive devices for children with mobility limitation. This study evaluated the costs of assistive devices for children with motor limitations at home, in day care, and in school, and the effect of diagnosis and severity of disabilities on costs. 201 children (mean age 7.4 years) who used 1274 various assistive devices (85.7% at home, 6.1% in day care, and 8.2% in school) were studied. The cost per device varied from $8.14 to $8138 with an average value of $539 per device. The distribution of costs per capita was unequal: 52.2% of children used 15.6% of total costs and 4.5% of children used 20.8% of total costs. The severity of motor impairment and the age of the child were the most important indicators associated with the need and cost of assistive devices. Assistive devices for basic needs, such as sitting, mobility, and personal hygiene, had a relatively low effect on costs in comparison with the high-technology devices, like powered wheelchairs and computers. Better cooperation with day care and school professionals, better assessment of needs, follow-up and recirculation of assistive devices are ways to promote rehabilitation services and partly solve the discrepancies between the costs of available technology and the resources to pay for it.


Biologic, foster, and adoptive parents: care givers of children exposed perinatally to human immunodeficiency virus in the United States. The Pediatric Spectrum of Disease Clinical Consortium. Children born to human immunodeficiency virus (HIV)-infected mothers often do not live with a biologic parent because of drug use, illness, or death of the mother. Public health officials need to know the number and proportion of children who will require care by someone other than a biologic parent (alternative care giver). The Pediatric Spectrum of Disease project, conducted in six different geographic regions in the United States, assesses issues specific to HIV in children. Among the information being collected in this study are data regarding the primary care giver. Of 1683 children born to HIV-infected mothers and enrolled through 1990, 55% (937) were living with a biologic parent, 10% (169) with another relative, 28% (455) were in foster care, 3% (55) had been adopted, and 4% (67) lived in group settings or with other care givers. In all locations and for all racial/ethnic groups, children of mothers who used intravenous drugs were more likely to be living with an alternative care giver than were children of mothers who had not used intravenous drugs (odds ratio 4.15). However, there were striking variations by study location (odds ratio range 1.4 to 7.2). The data suggest that maternal drug use may be the most important factor determining whether a child lives with a biologic parent and that there are also regional differences in alternative care placement.


Contribution of the 13C-urea breath test to the detection of Helicobacter pylori gastritis in children. Serology, 13C-urea breath test, histology, Campylobacter-like organism testing, and culture were performed in 95 consecutive children to evaluate the contribution of these tests to the detection of Helicobacter pylori infection. In analyses considering any combination of three positive tests as "gold standard" for diagnosing H pylori infection, 26 children were Helicobacter positive (27%), which is only one patient more than the number of children with only a positive culture. The accuracy of culture was excellent when "any combination of three positive tests" was used as the gold standard (sensitivity 96%, specificity 100%, positive predictive value 100% [false positivity 0%], negative predictive value 99% [false-negative results 1%]). The results of invasive and noninvasive tests were comparable. When culture was considered as "gold standard," the sensitivity of serology and 13C-urea breath test was 96%; the specificity was 96% and 93%, respectively; the positive predictive value was 89% and 83% (false-positive results in 11% and 17%); and the negative predictive value for both was 99% (false-negative results in 1%). It is concluded that culture can be used as gold standard, but that non-invasive tests such as serology and/or 13C-urea breath test can be used to diagnose H pylori infection in children, since each has at least 95% sensitivity and 92% specificity.


The sit-up test: an alternate clinical test for evaluating pediatric torticollis. The sit-up test, a new evaluation method for differentiating between ocular and orthopaedic torticollis, was evaluated against the monocular occlusion test, using results of three-step testing for standardization. The study group consisted of 31 patients with torticollis between the ages of 4 and 12.5 years. Subjects were selected based only on their ability to cooperate with three-step testing. Three-step testing identified 27 of the 31 patients as having ocular torticollis, with the remaining 4 having an orthopaedic etiology. Sit-up testing correctly identified all 27 ocular torticollis patients, with no false positives or false negatives. Monocular occlusion testing detected at best 22 (81.4%) of the ocular torticollis patients, with no false positives.


Risk factors for the central nervous system manifestations of gastroenteritis-associated hemolytic-uremic syndrome. Hemolytic-uremic syndrome is usually a consequence of enteric verotoxigenic Escherichia coli infection, and a prevailing hypothesis contends that systemically absorbed verotoxins are responsible for the multiple organ involvement. In an attempt to determine whether the central nervous system (CNS) manifestations could occur owing to factors that reflect a toxin insult, the authors studied the association of clinical and laboratory variables with the development of neurological disease. Ninety-one patients with hemolytic-uremic syndrome from 1982 through 1990 were included. Twenty-seven (18 female, 9 male) had a CNS disorder; 17 of these had seizures and there were two deaths. Multivariate analyses led to the following observations: female gender (odds ratio [OR] 8.50; 95% confidence interval [CI] 2.08 to 50.0), prolonged use of an antimotility pharmacological agent (OR 8.50; 95% CI 1.69 to 42.81), and an increased hemoglobin level (OR 1.11; 95% CI 1.05 to 1.17) were associated with an increased risk for developing a neurological manifestation. Prior administration of a blood product was associated with a decreased risk (OR 0.12; 95% CI 0.02 to 0.52). The findings suggest that other mechanisms for CNS disease may exist in addition to direct toxin insult.


Impact of childhood asthma on health.

Impact of childhood asthma on health. In 1988, the National Health Interview Survey contained a supplemental questionnaire on childhood conditions that included asthma. The authors used these data from 17,110 households to determine the disease burden resulting from asthma and to determine the functional status of children with and without asthma by linking information from the core and supplemental questionnaires. The prevalence of asthma in children younger than 18 years of age in the United States as reported by an adult in the household was 4.3% in 1988 and was 3.2% in 1981, the last time a comparable questionnaire was used in the National Health Interview Survey. The difference between the prevalences of asthma was statistically significant (95% confidence interval for the difference was 0.7% to 1.5%). An estimated 2.7 million children younger than 18 years were reported by an adult in the household to have had asthma in the past year. The added burden of illness experienced by children with asthma compared with children without asthma was an additional 10.1 million days missed from school, 12.9 million contacts with medical doctors, and 200,000 hospitalizations. Almost 30% of children with asthma had some limitation in activity, compared with only 5% of children without asthma. A greater proportion of black children experienced more severe functional disability and had more frequent hospitalizations than white children with asthma. Ten percent of children with asthma had severe disease as measured by frequency of bother and limitations in function; these children accounted for 35% of hospitalizations for asthma and 77% of the days in the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)


Improved survival accounts for most, but not all, of the increase in bronchopulmonary dysplasia. The incidence of bronchopulmonary dysplasia (BPD) increased from 10.6% in 1976 through 1980, to 21.7% (1981 through 1985), and to 32.9% (1986 through 1990) in very low birth weight neonates (1500 g or less) admitted to the Vanderbilt Neonatal Intensive Care Unit, while there was a concurrent decline in incidence of neonatal death (NEOD) during the same periods (26.4%, 18.3%, and 15.9%, respectively). Population changes in risk factors (birth weight, sex, race, location of birth, gestational age, diagnosis of hyaline membrane disease, and 5-minute Apgar score) over time do not account for this increase. To estimate the proportion of the increase in BPD attributable to the concurrent decline in NEOD during these periods, separate logistic regression models for NEOD and BPD were calculated from patients born during 1976 through 1985. These results were used to predict the expected number of cases of NEOD and BPD during 1986 through 1990, assuming that the adjusted incidence of NEOD and BPD remained constant from 1976 through 1985, to 1986 through 1990. The increase in the combined outcome, NEOD/BPD, over the three time periods (34.2%, 36.1%, and 43.5%) remained statistically significant after adjustment for the risk factors listed above. During 1986 through 1990, the predicted number of NEOD was 83 more than the number observed, while the predicted number with BPD was 115 less than the number observed. If all 83 averted cases of NEOD during 1986 through 1990 had developed BPD, then 83 (72%) of the 115 excess cases of BPD could be attributed to averted NEOD. The approximate 95% confidence interval for this estimate was 58% to 87%.(ABSTRACT TRUNCATED AT 250 WORDS)


Birth asphyxia alters neonatal intestinal motility in term neonates. As an extension of an earlier study showing that manometry can identify preterm newborns at risk for feeding intolerance, the authors investigated whether abnormalities of intestinal motor activity underlie the feeding intolerance seen in asphyxiated newborns. Low-compliance perfusion manometry was recorded within the first postnatal week in 25 term neonates admitted consecutively for respiratory diseases. Eleven of these neonates were identified to have experienced birth asphyxia because three concurrent features were present: 1-minute Apgar score of less than 2; 5-minute Apgar score of less than 4; and recurrent seizures within the first 48 postnatal hours. The remaining 14 neonates, who did not have any of these three characteristics, were considered to be nonasphyxiated control neonates. Motor activity differed in nonasphyxiated and asphyxiated neonates during fasting and feeding. During fasting, asphyxiated neonates had less migrating activity than nonasphyxiated neonates. In addition, episodes of motor quiescence and clustered phasic activity were less well organized in asphyxiated neonates. Both groups of neonates displayed a change in motor activity in response to a feeding infusion; however, the response was initiated significantly sooner in asphyxiated than in control neonates. All of the 11 asphyxiated neonates were intolerant of enteral feedings during the first poststudy week, but no control neonate was feeding intolerant. Six of the asphyxiated neonates were reevaluated 1 to 2 weeks later. During this latter study, motor activity in these asphyxiated neonates was similar to that of nonasphyxiated neonates; 5 of 6 of these neonates subsequently tolerated enteral feedings. It is speculated that changes in motor activity underlie the feeding intolerance that asphyxiated neonates typically exhibit.(ABSTRACT TRUNCATED AT 250 WORDS)


Double versus single phototherapy in low birth weight newborns. Conventional phototherapy systems that simultaneously irradiate the front and the back of the baby lower the serum bilirubin level more rapidly than one-sided systems, but they are impractical. Fiberoptic phototherapy makes it easy to administer conventional phototherapy from above while the infant lies on a fiberoptic phototherapy blanket. Newborns with birth weights less than 2500 g were randomly assigned to receive either single (n = 37) or double (n = 33) phototherapy. The groups were similar in clinical and laboratory characteristics. After 18 hours of therapy the serum bilirubin concentration declined by 31 +/- 11% in the double and 16 +/- 15% in the single phototherapy group (2.9 +/- 1.1 vs 1.6 +/- 1.4 mg/dL), and the difference in the total serum bilirubin levels after 18 hours of therapy was significant (double phototherapy group 7.1 +/- 2.7 mg/dL vs single phototherapy group 8.2 +/- 2.6 mg/dL). After 18 hours of treatment the serum bilirubin level was less than the phototherapy threshold level in 26 of 37 single phototherapy patients vs 32 of 33 double phototherapy patients. Double phototherapy was well tolerated. It is concluded that this type of double phototherapy is more effective than single phototherapy in low birth weight newborns. Double phototherapy may be useful when it is necessary to reduce an elevated serum bilirubin level as rapidly as possible or when the bilirubin level is rising with single phototherapy.


Recombinant erythropoietin as treatment for the late hyporegenerative anemia of Rh hemolytic disease. Infants with Rh hemolytic disease can develop a "late" anemia characterized by low serum concentrations of erythropoietin but erythroid progenitors that remain highly erythropoietin-responsive. Erythropoietin administration was evaluated in two patients as an alternative to transfusion. Reticulocyte counts increased after 5 days of treatment, and hematocrits increased after 10 days. Neither patient received erythrocyte transfusions following erythropoietin therapy.


Impact of a matched term control group on interpretation of developmental performance in preterm infants. One hundred twenty-four children who were born at 24 to 31 weeks' gestation and 124 term children matched in social background underwent serial developmental evaluations. The Bayley Mental Developmental Index at 6, 15, and 24 months and the McCarthy General Cognitive Index at 4 years were used to classify cognitive outcome for preterm children as normal (indices higher than 1 SD below the mean), mild-moderately delayed (indices between 1 and 2 SD below the mean), or severely delayed (indices > or = 2 SD below the mean). Classifications based on norms derived from the performance of the term control group were compared with those based on published standardized test scores. The control group had substantially higher mean (+/- SD) Bayley Mental Developmental Indices at 6 (111 +/- 11), 15 (114 +/- 13), and 24 months (115 +/- 21) than the published test mean (100 +/- 16). Consequently, significantly more preterm children were classified as normal when the Bayley test mean was used than when the performance of the control group was used to define the normal range (84% vs 52% at 6 months, 82% vs 49% at 15 months, and 70% vs 47% at 24 months). Severe cognitive delays were infrequent when defined by test mean (6% to 11%) but two to three times greater when the control group scores were used. In contrast, the control group had a mean McCarthy General Cognitive Index at 4 years (102 +/- 14) that was similar to the published test mean (100 +/- 16).(ABSTRACT TRUNCATED AT 250 WORDS)


Delayed recognition of human immunodeficiency virus infection in preadolescent children. Thirty-two (18%) of 181 children cared for at our institution who were infected with the human immunodeficiency virus type 1 (HIV-1) were first seen, and HIV was diagnosed, when they were 4 years of age and older. Initial complaints or diagnoses for these children included the following: hematologic disorders (5) (3 idiopathic thrombocytopenic purpura, 1 neutropenia, 1 anemia); recurrent bacterial infections (10); Pneumocystis carinii pneumonia (3); developmental delay (1); skin disorders (2) (1 genital wart, 1 chronic zoster); weight loss (3); malignancy (1); and nephropathy (1). Eight children were referred for evaluation because of maternal HIV-1 infection. The risk factors for HIV-1 infection included maternal/perinatal exposure (22), perinatal blood transfusion (6), blood transfusion during infancy (2), and sexual abuse (2). Ten (31%) of the 32 children have subsequently died. The longest survival from perinatal infection was 12 years. HIV-1 infection in children can result in a prolonged clinical latency and can masquerade as other pathologic conditions. The absence of clinical symptoms in older children at risk for HIV-1 infection should not deter HIV testing.


Mental disorders in chronically ill children: parent-child discrepancy and physician identification. Mental disorders affect 18% to 20% of children and adolescents. The rate in children with chronic illness is probably higher. This study of chronically ill children addresses the discrepancy between parent and child reports of child psychiatric disorders and the extent to which pediatricians agree with reports by children and parents regarding such problems. Eighty-three subjects, aged 9 to 18 (mean = 12.6), were recruited; they had the following diagnoses: cystic fibrosis, diabetes, inflammatory bowel disease, and cancer. Subjects and one parent were interviewed separately, using the Diagnostic Interview Schedule for Children (DISC-2.1). The subject's physician completed a questionnaire asking about the presence of a range of mental disorders. Forty-one (49%) subjects reached threshold criteria for a psychiatric diagnosis, using both parent and child as informants. Psychiatric disorders were identified in only 22 subjects (54%) by the child and in 28 (68%) by parent alone. Thus, reliance on one informant resulted in failure to identify one third to one half of psychiatric disorders. Physicians' ratings agreed significantly with children's reports but not with parental reports, suggesting that physicians are sensitive to children's concerns but may underestimate the value and importance of parents' reports. Clinical and research evaluations of chronically ill children, as well as clinician identification of mental health problems, will be influenced by the choice of informant.


Hyperactivity in school-age boys and subsequent risk of injury. Hyperactive boys between 6 and 8 years of age, identified through systematic population-based screening of a community in London, were compared prospectively with a nonhyperactive control group to determine whether they were at greater risk of sustaining injuries. The study sample was drawn from 1296 completed parent and teacher questionnaires. Hyperactive groups were designated in three ways (parental report, teacher report, and combined parent and teacher report). Injuries were assessed by reviewing the medical records of the five emergency departments serving the community. Although boys with conduct problems did sustain more injuries than control subjects, no relationship between hyperactivity and injury was found. Similarly, when milder injuries were excluded from the analysis, the association remained negative. The absence of an association could not be accounted for by differential parental protectiveness of boys designated hyperactive. This study, which has a power of .80 to determine an increase in the relative risk of injury of 1.5, found no effect for hyperactive behavior in boys. Hyperactive behavior is probably not a risk factor for injury; if it is, it exerts a modest effect, less than 1.5, therefore accounting for less than 4% of injuries to school-aged boys.


Wheezing in infants with cystic fibrosis: clinical course, pulmonary function, and survival analysis. Wheezing is a common finding in infants with cystic fibrosis (CF). This study was undertaken to determine the prevalence of wheezing in infants with CF and to compare the clinical outcome of those who wheezed in infancy with that of those who did not. The study cohort included 229 CF patients born between 1965 and 1979 with CF diagnosed before 2 years of age. Fifty-seven (25%) had physician-documented wheezing during the first 2 years of life. Wheezing had resolved by the age of 2 years in 50% of the patients and by the age of 4 years in 75%. Although wheezing seemed to be linked to a family history of allergy and asthma, the frequency of the delta F508 mutation was similar to that of the non-wheezers. There was no significant difference in survival at the age of 13 years between the two groups. At the age of 7 years, patients who had wheezed had significantly lower forced expiratory flow rate at mid-expiratory phase (85 +/- 34% predicted) compared with those with no wheezing history (101 +/- 34% predicted). At the age of 13 years, forced expiratory volume in 1 second values was lower in the wheezing group (69 +/- 24% predicted vs 78 +/- 21% predicted), as was forced expiratory flow rate at mid-expiratory phase (56 +/- 33% predicted vs 69 +/- 30% predicted). In conclusion, although wheezing in infants with CF seems to have diminished with age, pulmonary function abnormalities were more evident at 7 and 13 years of age in the group that wheezed than in the group that did not.


Kernicterus in preterm newborns: past, present, and future. This historical overview of kernicterus in prematurity, from the 1950s to the present, provides a unique perspective on this clinical conundrum. Three separate periods of pediatric history are detailed in relationship to our understanding of kernicterus in the preterm newborn: (1) the pre-intensive care era (1950 to 1965); (2) the low bilirubin kernicterus era (1965 to 1982); and (3) the 1980s. Each period demonstrates selected insights regarding kernicterus in prematurity, and together with recent reports suggest that premature newborns are now at extremely low risk of developing kernicterus when managed using current standards of care. However, the current conservative empiric guidelines for preventing kernicterus are questioned, and it is suggested that additional study is needed to clarify this issue in the 1990s.


Short-term effects of feed composition on sleeping and crying in newborns. To determine whether the composition of feedings would affect newborn behavior independently of the act of feeding itself, 53 two- to three-day-old normal newborns were randomly assigned to receive an extra feeding of water, carbohydrate (lactose), or balanced formula 3 hours after their usual early morning feeding. Previous studies in adult humans and animals, and a single study in human newborns, have indicated that more sleep might be expected following the carbohydrate feed compared with the water and balanced-formula feeds because of recruitment of centrally mediated serotonergic systems. Behavioral effects were assessed for 40 minutes postfeeding by direct observation of the newborn's states (quiet, active, and indeterminate sleep; drowsiness; non-cry wakefulness; and fret/cry). Feed composition did affect behavior, and the effects were fairly specific to particular newborn states. Non-cry wakefulness and drowsiness were unrelated to the presence or type of nutrients, but they tended to occur soon after the meal in all groups. Crying was increased in water-fed newborns relative to both carbohydrate- and formula-fed newborns. Sleeping showed specific patterns of change in all three groups. Sleep duration was increased in the balanced-formula group compared with the water group throughout the observation period. Contrary to the prediction, sleeping duration in carbohydrate-fed newborns never exceeded that of formula-fed newborns; rather, it resembled that of water-fed newborns early in the postprandial period, but formula-fed newborns later. These effects could not easily be explained by potential confounding factors such as handling, volume ingested, caloric intake, or plasma glucose concentration.(ABSTRACT TRUNCATED AT 250 WORDS)


Risk of sepsis in newborns with severe hyperbilirubinemia. Because bacterial infection is a potential cause of hyperbilirubinemia, some authors suggest that newborns with significant unexplained indirect hyperbilirubinemia should be evaluated for sepsis. We reviewed the charts of 306 newborns admitted to a pediatric ward within 21 days of birth with a diagnosis of indirect hyperbilirubinemia (peak serum bilirubin level 316 +/- 48, range 217 to 498 mumol/L) (18.5 +/- 2.8, 12.7 to 29.1 mg/dL). Ninety percent were fully or partially breast-fed. Sepsis was identified in 0 of 306 newborns (upper 95% confidence limit for the risk of sepsis = 1%). The overwhelming majority of newborns who require readmission to hospital for indirect hyperbilirubinemia are healthy, breast-fed newborns and do not need to be investigated for sepsis. If indirect hyperbilirubinemia is ever the only manifestation of bacteremia or incipient sepsis, it must be a rare event.


Audiologic assessment of extremely low birth weight infants: a preliminary report. The aim of this study was to assess all relevant aspects of auditory function, including acuity and perception, of a cohort of extremely low birth weight (< 1000 g) children who survived to 8 years of age; 42 of the 59 consecutive survivors born over a 4-year period from January 1, 1977, had a full auditory assessment. Of the 42 children, 4 (9.5%) had a sensorineural hearing impairment, 5 (11.9%) had a conductive hearing impairment, 24 (57.1%) had figure/ground differentiation problems, and 20 (47.6%) had a short-term auditory memory problem. The 4 children with sensorineural hearing impairments had had significantly higher maximum concentrations of bilirubin in the newborn period (median 167 mumol/L vs 138 mumol/L and had required more intensive care; at 8 years of age they were significantly disadvantaged in verbal ability. The 5 children with conductive hearing impairments were not significantly different on any perinatal or other 8-year outcome variables. The proportion with figure/ground differentiation problems (57.1%) was significantly higher than in a normative population (11.7%, chi 2 = 24.2). Extremely low birth weight children with figure/ground differentiation problems were more likely to be restless in the classroom (45.0% [9/20]) than those without these problems (16.7% [2/12]), but the difference was not statistically significant (chi 2 = 2.7). Children with short-term auditory memory problems had significantly higher maximum bilirubin concentrations in the newborn period (median 152 mumol/L vs 137.5 mumol/L). At 8 years of age they had significantly reduced intelligence and reading ability.(ABSTRACT TRUNCATED AT 250 WORDS)


Single daily bottle use in the early weeks postpartum and breast-feeding outcomes. A prospective study of breast-feeding mothers was undertaken to determine the effects of limited bottle use and infant temperament on breast-feeding outcomes. White, married, primigravida women who were committed prenatally to breast-feeding for at least 6 weeks (n = 121) were randomly assigned to one of two groups: a planned bottle group that would offer one bottle daily between the second and sixth weeks postpartum and a total breast-feeding group that would avoid bottles during the same period. Group assignment had no effect on the occurrence of breast-feeding problems, on mothers' achievement of 90% of their prenatal breast-feeding duration goals, or on weeks to weaning across the study period. At 6 months postpartum, 59% of the planned bottle group and 69% of the total breast-feeding group were still breast-feeding. No main or interactive effects of infant temperament on breast-feeding outcomes were found.