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ObjectiveThe goal of this study was to generate and report standardized growth curves for weight, height, head circumference, and BMI for non-growth hormone-treated white male and female US subjects with Prader-Willi syndrome (PWS) between 3 and 18 years of age and develop standardized growth charts.MethodsAnthropometric measures (N = 133) were obtained according to standard methods from 120 non-growth hormone-treated white subjects (63 males and 57 females) with PWS between 3 and 18 years of age. Standardized growth curves were developed for the third, 10th, 25th, 50th, 75th, 90th, and 97th percentiles by using the LMS method for weight, height, head circumference, and BMI for PWS subjects along with the normative third, 50th, and 97th percentiles from national and international growth data. The LMS smoothing procedure summarized the distribution of the anthropometric variables at each age using three parameters: power of the Box-Cox transformation λ (L), median μ (M) and coefficient of variation δ (S).ResultsWeight, height, head circumference, and BMI standardized growth charts representing 7 percentile ranges were developed from 120 non-growth hormone-treated white male and female US subjects with PWS (age range: 3-18 years) and normative third, 50th, and 97th percentiles from national and international data.ConclusionsWe encourage the use of syndrome-specific growth standards to examine and evaluate subjects with PWS when monitoring growth patterns and determining nutritional and obesity status. These variables can be influenced by culture, individual medical care, diet intervention, and physical activity plans.

ObjectiveTo generate and report standardized growth curves for weight, length, head circumference, weight/length, and BMI for non-growth hormone-treated white infants (boys and girls) with Prader-Willi syndrome (PWS) between 0 and 36 months of age. The goal was to monitor growth and compare data with other infants with PWS.MethodsAnthropometric measures (N = 758) were obtained according to standard methods and analyzed from 186 non-growth hormone-treated white infants (108 boys and 78 girls) with PWS between 0 and 36 months of age. Standardized growth curves were developed and the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles were calculated by using the LMS (refers to λ, μ, and σ) smoothing procedure method for weight, length, head circumference, weight/length, and BMI along with the normative 50th percentile using Centers for Disease Control and Prevention national growth data from 2003. The data were plotted for comparison purposes.ResultsFive separate standardized growth curves (weight, length, head circumference, weight/length, and BMI) representing 7 percentile ranges were developed from 186 non-growth hormone-treated white male and female infants with PWS aged 0 to 36 months, and the normative 50th percentile was plotted on each standardized infant growth curve.ConclusionsWe encourage the use of these growth standards when examining infants with PWS and evaluating growth for comparison purposes, monitoring for growth patterns, nutritional assessment, and recording responses to growth hormone therapy, commonly used in infants and children with PWS.

OBJECTIVE. The aim of this study was to determine the site, extent, and resolution of tissue involvement when extensive limb swelling occurred in the injected limb for children who received diphtheria-tetanus-acellular pertussis or reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine at 4 to 6 years of age. METHODS. Children who had experienced an injection site reaction at 18 months of age were assigned randomly to receive an intramuscular injection of either reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine or diphtheria-tetanus-acellular pertussis vaccine between 4 and 6 years of age. Children who developed extensive limb swelling were recruited for assessment by clinical examination; ultrasound studies of the affected and opposite (control) arms were performed 24 to 48 hours after immunization and 48 to 96 hours later. RESULTS. Twelve children with extensive limb swelling were enrolled in the study. Ultrasound examinations demonstrated swelling of both the subcutaneous and muscle layers of the vaccinated arm. Ultrasound assessment showed that the swelling exceeded the clinical measurements of skin redness and swelling. Subcutaneous and muscle tissues expanded to 281% and 111% of the tissue thicknesses of the control arm, respectively. Repeat ultrasound examinations after 48 to 96 hours showed considerable resolution of muscle swelling, compared with subcutaneous tissue swelling. There was no significant difference in the extent of swelling detected between children who received diphtheria-tetanus-acellular pertussis vaccine and those who received reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine. CONCLUSION. Extensive limb swelling reactions after diphtheria-tetanus-acellular pertussis or reduced-antigen content booster immunizations involved swelling of subcutaneous and muscle tissues with swelling and duration more marked in subcutaneous tissue. Key Words local reaction, adverse events, diphtheria, pertussis, tetanus, ultrasound Abbreviations DTaP--diphtheria-tetanus-acellular pertussis Tdap--reduced-antigen content diphtheria-tetanus-acellular pertussis DTwP-- diphtheria-tetanus-whole-cell Pertussis ELS--extensive limb swelling ISR--injection site reaction CI--confidence interval, IMMUNIZATION IS A key primary prevention activity that has assisted significantly in the reduction of rates of childhood morbidity and premature death. Important components of a responsible immunization program are [...]

Objective. Exposure to endotoxin in early life has been proposed as a factor that may protect against the development of allergic diseases such as eczema. The objective of this study was to examine the relation between endotoxin exposure in early life and eczema in the first year of life in children with parental history of asthma or allergies. Methods. This study used a prospective birth cohort study of 498 children who had a history of allergy or asthma in at least 1 parent and lived in metropolitan Boston. A subset of 401 living rooms had house dust samples adequate for analysis of endotoxin. Results. In multivariate analyses adjusting for gender, income, and season of birth, endotoxin levels in the living room at 2 to 3 months of age was inversely associated with physician- or nurse-diagnosed eczema in the first year of life (odds ratio [OR] for each quartile increment: 0.76; 95% confidence interval [CI]: 0.61-0.96). Exposure to a dog in the home at age 2 to 3 months was also inversely associated with eczema in the first year of life, but the CI widened when endotoxin was included in the multivariate model (OR: 0.54; 95% CI: 0.27-1.09). Other variables associated with eczema in the first year of life included paternal history of eczema (OR: 1.91; 95% CI: 1.03-3.55) and maternal specific immunoglobulin E positivity to [greater than or equal to] 1 allergen (OR: 1.61; 95% CI: 1.01-2.56). Conclusions. Among children with parental history of asthma or allergies, exposure to high levels of endotoxin in early life may be protective against eczema in the first year of life. In these children, paternal history of eczema and maternal sensitization to at least 1 allergen are associated with an increased risk of eczema in the first year of life. ABBREVIATIONS. Ig, immunoglobulin; OR, odds ratio; CI, confidence interval; [T.sub.h]2, T-helper cell type 2., Eczema is the most common atopic disease in infancy, and 60% of affected individuals manifest characteristic lesions during the first year of life. (1) The prevalence of eczema has increased [...]

Objective. Previous studies of predictors of atopic dermatitis have had limited sample size, small numbers of variables, or retrospective data collection. The purpose of this prospective study was to investigate several perinatal predictors of atopic dermatitis occurring in the first 6 months of life. Design. We report findings from 1005 mothers and their infants participating in Project Viva, a US cohort study of pregnant women and their offspring. The main outcome measure was maternal report of a provider's diagnosis of eczema or atopic dermatitis in the first 6 months of life. We used multiple logistic regression models to assess the associations between several simultaneous predictors and incidence of atopic dermatitis. Results. Cumulative incidence of atopic dermatitis in the first 6 months of life was 17.1%. Compared with infants born to white mothers, the adjusted odds ratio (OR) for risk of atopic dermatitis among infants born to black mothers was 2.41 (95% confidence interval [CI]: 1.47, 3.94) and was 2.58 among infants born to Asian mothers (95% CI: 1.27, 5.24). Male infants had an OR of 1.76 (95% CI: 1.24, 2.51). Increased gestational age at birth was a predictor (OR: 1.14; 95% CI: 1.02, 1.27, for each 1-week increment), but birth weight for gestational age was not. Infants born to mothers with a history of eczema had an OR of 2.67 (95% CI: 1.74, 4.10); paternal history of eczema also was predictive, although maternal atopic history was more predictive than paternal history. Several other perinatal, social, feeding, and environmental variables were not related to risk of atopic dermatitis. Conclusions. Black and Asian race/ethnicity, male gender, higher gestational age at birth, and family history of atopy, particularly maternal history of eczema, were associated with increased risk of atopic dermatitis in the first 6 months of life. These findings suggest that genetic and pre- and perinatal influences are important in the early presentation of this condition. Pediatrics 2004;113:468-474; atopic dermatitis, eczema, perinatal, infancy, gestational age, race/ethnicity, gender. ABBREVIATIONS. BMI, body mass index; OR, odds ratio; CI, confidence interval; IgE, immunoglobulin E., Atopic dermatitis is a chronic inflammatory skin disease that occurs with a peak onset in infancy and a large majority of cases presenting in the first few years of life. [...]

Many doctors and nurses believe infants feel pain similarly to adults and think that pain relieving measures are not adequately provided during painful nursery procedures. A total of 374 doctors and nurses were surveyed to determine how painful 12 common procedures were perceived to be, and how often pain relieving medicines or comfort measures were employed. Nine of the twelve procedures were considered to be at least moderately painful, and both doctors and nurses agreed that drugs and comfort measures were not used as often as they should be., Background. Despite an increased awareness among clinicians regarding pain and pain management for infants undergoing surgery, pain associated with procedures performed outside the operating room may not be adequately managed. Purpose. To examine the beliefs and self-described behavior of physicians and nurses regarding the management of procedural pain in newborn infants. Methods. A survey was distributed to 467 clinicians (nurses and physicians) working in 11 level II and 4 level III nurseries in a large metropolitan area. Respondents were asked to rate the painfulness of 12 common bedside nursery procedures and how often pharmacologic and nonpharmacologic (comfort) measures are currently used and should be used for those procedures. Demographic data were also collected. Results. Surveys were completed by 374 clinicians (80% response rate). Physicians and nurses believe infants feel as much pain as adults and that 9 of the 12 listed procedures are moderately to very painful. Neither pharmacologic nor comfort measures are believed to be used frequently, even for the most painful procedures. Physicians and nurses believe both pharmacologic and comfort measures should be used more frequently, but nurses believe comfort measures should be used more frequently than do physicians. Beliefs about infant pain and procedural pain were related to pain management preferences. Physicians' but not nurses' ratings were associated with significant personal pain. Conclusions. Despite their beliefs that infants experience significant procedure-related pain, clinicians believe pain management for infants remains below optimal levels. Barriers to more consistent and effective pain management need to be identified and surmounted. Pediatrics 1997;100:626-632; pain, infant, bedside procedures, anesthesia, comfort., Pain has a long history of being undermanaged across the lifespan.[1-4] However, it has been recognized as being particularly inferior for infants. Various reasons for poor pain management in infants [...]

Survanta appears to be safe in the prevention and treatment of respiratory distress syndrome (RDS) among premature infants. Survanta is a synthetic lung surfactant that reduces surface tension and improves the elasticity of the lungs. Of 8,168 premature infants, 2,670 were given Survanta for the prevention of RDS, and 5,498 were given Survanta for the treatment of RDS. Overall, 56.8% of the infants required more than one dose, and 23% received the maximum four doses. There were problems with the administration of Survanta at least once in 30.4% of the infants. Adverse events occurred in 0.5% of the infants, but only one event was attributed to Survanta treatment. The overall survival rate was 84.4%., From September 1989 through July 1991, before commercial availability, Survanta (beractant intratracheal suspension), a modified bovine-derived surfactant used for prevention and treatment of neonatal respiratory distress syndrome, was made available to 231 neonatal intensive care units in the United States and Canada under a Treatment Investigational New Drug protocol. Results of this open clinical experience are reported. Investigators could give one dose of Survanta soon after birth to neonates weighing 600 to 1250g (prevention strategy). Neonates weighing 600 to 1750g who were not treated at birth could begin Survanta therapy if respiratory distress syndrome developed within 8 hours of birth (rescue strategy). All neonates could receive up to three more doses over the first 48 hours of life at minimum intervals of 6 hours if they met retreatment criteria. Qualifications for enrollment closely matched those used in previous randomized controlled clinical trials. This report includes results from 8168 neonates who completed the study. Treatment Investigational New Drug rates for intracranial hemorrhage, patent ductus arteriosus, pulmonary hemorrhage, pulmonary air leaks, bronchopulmonary dysplasia, death or bronchopulmonary dysplasia, pulmonary interstitial emphysema, pretreatment sepsis, and posttreatment sepsis were less than for treated neonates in the controlled trials and survival was equivalent across studies. Problems with treatment administration were reported with 30.4% of doses, while adverse events were reported in 0.5% of neonates. The results of the Treatment Investigational New Drug protocol revealed no new safety concerns associated with the widespread use of Survanta and confirmed the safety profile established in earlier controlled trials. Pediatrics 1993; 91:546-551; Treatment Investigational New Drug, pulmonary surfactant, bovine surfactant, respiratory distress syndrome, hyaline membrane disease, prematurity, neonatal mortality.

Chronic fatigue may be a symptom of an immune disorder, infection, or allergy, and has been associated with various clinical syndromes. Studies have been conducted to assess the relation between chronic fatigue and certain viruses, including the Epstein-Barr virus and enteroviruses, such as Coxsackie. Recent results do not support a viral cause of chronic fatigue, however, and interest has focused more on psychological factors. The infectious and psychological aspects of chronic fatigue in adolescents were assessed. The study involved nine female and six male adolescents with chronic fatigue, whose average age was 14.5 years. Chronic fatigue was associated with an acute illness in 11 subjects. Results from the medical history, physical examination, laboratory tests, and blood tests for viruses were not very informative. Major depression was identified in five subjects, whereas the remaining 10 patients had symptoms of depression resulting from another condition. The subjects were assessed 13 to 32 months after the start of the study, and complete recovery was noted in four patients and marked improvement in another four subjects. However, seven patients had no change or worsening of chronic fatigue. The relation between chronic fatigue in adolescents and depression requires further study. (Consumer Summary produced by Reliance Medical Information, Inc.)

Infants born prematurely have an increased risk of respiratory distress syndrome, a lung disorder, because the lungs are still immature and do not produce adequate quantities of a substance called surfactant. This condition can be fatal. Studies have shown that a natural surfactant derived from other species given once at birth to these infants can reduce the severity of respiratory distress syndrome, but survival rates have not been shown to increase. This study examined whether giving multiple doses of a natural surfactant derived from cows (bovine surfactant) to these infants could increase their chances of surviving respiratory distress syndrome. Infants born at 23 to 29 weeks gestation weighing between 600 and 1,250 grams (1.3 to 2.8 pounds) were included in the study. A total of 430 infants participated, with 210 assigned to the treatment group and 220 to the control group. The treatment group received the surfactant at birth and again when needed (delivered into the trachea, or windpipe), while the control group received a dose of air, which functioned as a placebo. Results showed that in the first 28 days after birth, 1.9 percent of the treated and 15.6 percent of the untreated infants died from respiratory problems, a significant difference. Respiratory distress syndrome developed in 28 percent of the treated and in 56.9 percent of the control infants. The treated infants also had lower rates of developing pulmonary interstitial emphysema, at 23.3 percent versus 36.9 percent for the control group. These results indicate that multiple treatments with a natural surfactant at birth and again when needed can reduce the rates of illness and death from respiratory problems in infants born prematurely. (Consumer Summary produced by Reliance Medical Information, Inc.)

Infants born prematurely often suffer from lung problems such as respiratory distress syndrome that increase their risk of illness and death above that of full-term infants. Premature infants lack a substance called surfactant in the lungs which is essential for respiratory function. In the past decade, it was found that a surfactant derived from cows (bovine surfactant) could be given to these infants, and that this decreased the need for oxygen and ventilation (use of a breathing machine). Further studies found that a single dose given at birth reduced the severity of the symptoms of respiratory distress syndrome, but did not necessarily increase survival rates. This study examined if giving more than a single dose of the surfactant when disease persisted would increase survival rates in these infants. The study involved 798 infants born prematurely weighing between 600 and 1,750 grams (1.3 and 3.9 pounds) that developed respiratory distress syndrome within six hours after birth. The infants were randomly assigned to one of two groups; one was the control group (396 infants) and the other received an initial dose of the surfactant with repeated doses if needed (402 infants). Results showed that in the first 28 days after birth, 36 treated infants (9 percent) and 80 untreated infants (20 percent) died from respiratory distress syndrome. Deaths from all causes during this period were 74 (18 percent) in the treated group and 108 (27 percent) in the untreated group. Mean airway pressure and oxygenation values, measures of respiratory function, during the first 72 hours of life were significantly better in the treated than in the untreated infants. The treated infants also developed significantly fewer cases of pulmonary interstitial emphysema and of pulmonary air leaks than the untreated infants. These results indicate that multiple doses of bovine surfactant given to premature infants with respiratory distress syndrome can reduce the incidence of illness and death. (Consumer Summary produced by Reliance Medical Information, Inc.)

Respiratory distress syndrome (RDS) is a common breathing complication in premature and low-birth-weight infants. It is caused by a deficiency in surfactant, a protein which makes the lungs pliable. When the lungs are inflexible and cannot expand properly, this results in labored breathing and decreased oxygen intake. In an effort to prevent RDS, a natural surfactant can be given to infants at birth. The results of a multicenter trial of single-dose modified bovine surfactant Survanta, a surfactant derived from cows, are reported. Of the 160 low-birth-weight infants (1.7 to 2.8 pounds, or 750 to 1,250 grams) born between 24 and 30 weeks of pregnancy, 79 were treated with Survanta (100 milligrams per kilogram), while 81 were given air without surfactant. All the infants were treated within 37 minutes of birth. The study evaluations, which included chest X-rays, blood gases, inspired oxygen and airway pressure, were assessed over the next 72 hours. The infants receiving Survanta had less severe RDS assessed by chest X-ray findings and improved inspired oxygen than infants receiving no therapy. There was no major difference in the incidence of the most common complications of prematurity, namely necrotizing enterocolitis (tissue death in the intestinal tract), bronchopulmonary dysplasia (development of abnormal lung tissue), pneumothorax (leakage of air from the lungs into the thoracic cavity), intraventricular hemorrhage (bleeding in the spaces of the brain), sepsis (infection) and a patent ductus arteriosus (the maintenance of a connection between the aorta and the pulmonary artery that normally closes after birth). Treated infants had a lower incidence of pneumothorax and an increased incidence of necrotizing enterocolitis. The incidence of all other complications of prematurity were same in the treated and nontreated groups. Survanta therapy improved the inspired oxygen fraction and increased the number of survivors without bronchopulmonary dysplasia in a small subgroup of infants who weighed less than 2.2 pounds (1 kilogram). Although Survanta did not reduce the incidence of RDS complications, it was useful in decreasing the severity of chest X-ray findings and improved oxygenation in the first 72 hours of life. Infants of very low birth weights may benefit the most from Survanta therapy. (Consumer Summary produced by Reliance Medical Information, Inc.)

To the Editor.-- The American Academy of Pediatrics Committee on Adolescence policy statement on emergency contraception (1) reports the effectiveness of the Yuzpe regimen (ethinyl estradiol and levonorgestrel) in terms […]