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This study was aimed at examining the associations between health disparities and physical activity, and their contributions to health and academic problems in schoolchildren.Pertinent data from a community-wide survey were analyzed, which included 2930 households with schoolchildren aged 7–14 years. Associations between the parents' self-reported race/ethnicity, parental education, household income, children's health status, physical activity, and academic problems were determined by Chi-square and logistic regression analyses. Contributory factors for children's health status, physical activity, and academic problems were predicted by logistic regression fitting.Within white/Caucasian children, 86.0% had very good/excellent health and 77.9% were physically active, values higher than those in Latino/Hispanic (77.8%, p

OBJECTIVE: In response to limitations in access to subspecialty care, I present personal observations and suggestions related to education of future pediatricians regarding development of critical thinking skills, care of complex and chronically ill patients, development of empathy, and restoration of responsibility that may help ameliorate this serious problem. Toward this end, I also offer 1 approach, a 24/7 telephone consultation network, for enriching interaction of primary care providers (PCPs) and subspecialists who can potentially provide rapid access to needed advice, reduce demand for subspecialty appointments, bolster decision-making and expertise, and realign resources with need. METHODS: Data were obtained from 579 requests by PCPs for telephone consultation by subspecialists in 8 areas (including child psychiatry). RESULTS: Of calls, 27% took CONCLUSIONS: Development of rapid telephone consultation networks could provide increased access to care for those children in greatest need, use limited resources more efficiently, foster collegial and productive relationships between medical providers, and increase expertise of PCPs and subspecialists.

* Abbreviation: EPA — : entrustable professional activity Within this compendium of perspectives and expert consensus about the education of subspecialty fellows, we are told that “ Recent advances in medical education allow the question of required duration of training to be examined using the metric of the pediatrics milestones.…” The consensus also reinforces that “Training should remain at three years for now, but over time the Board could allow a shorter or longer period to demonstrate expertise in a particular subspecialty. ” 1 Here we have the setting for 2 fundamental, but potentially conflicting, metrics, time versus maturation, that can collide and put substantial strain on resources intended to educate and certify fellows. If time is used as the gating mechanism for the advancement of fellows, it stands to reason that there will be heterogeneity of skills, knowledge, and maturity upon completion of the requisite time. Alternatively, if maturation is used as the gating mechanism, then there will likely be heterogeneity in the time to completion. It is worth exploring some of the consequences of these options. To the extent that the milestones (such as the Denver Developmental Screening Test) and entrustable professional activities (EPAs; such as the driver’s road test) will provide a blueprint for assessing the maturation of a fellow, the potential benefit is a rigorous, reproducible, and logical method to recognize what competencies have been achieved throughout the course of education and clinical practice. In addition, this method should provide a means to track a fellow’s progress in real time, which would permit formative feedback and potential for midcourse adjustments and, even more importantly, for self-directed learning and development. This approach requires validation of the evaluation, establishment of confidence intervals, measurement of interrater agreement, certainty that the maturational schema is properly ordered, and assessment of ease of application. It is essential to recognize that … Address correspondence to George Lister, MD, Department of Pediatrics, Yale School of Medicine, PO Box 208064, New Haven, CT 06520-8064. E-mail: george.lister{at}yale.edu

Participants of the first colloquium of the Residency Review and Redesign in Pediatrics (R3P) Project considered possible scenarios affecting pediatric practice over the next 15 to 20 years and speculated about the knowledge and skills that pediatricians would need to care for children, adolescents, and young adults in the future. They concluded that the imponderables and complexity of that undertaking fell into the category of a “wicked problem” with no unique solutions. The specifics of the future cannot be predicted, but the themes important to thinking about the future are clear and must be incorporated into thinking about pediatric residency education.

Background.—African American infants have a higher incidence of SIDS and increased risk of being placed in the prone position for sleep. Objective.—To determine new barriers and more information about previously identified barriers that interfere with adherence to the Back-to-Sleep recommendations among inner-city, primarily African Americans. Design/Methods.—We conducted 9 focus groups with caregivers of infants and young children from women, infants, and children centers and clinics in New Haven and Boston. Themes were identified using standard qualitative techniques. Results.—Forty-nine caregivers participated, of whom 86% were African American, 6% were Hispanic, 4% were white, and 4% were other. Four themes were identified: 1) Safety: Participants chose the position for their infants based on which position they believed to be the safest. Some participants did not choose to put their infants in the supine position for sleep because they feared their infants would choke; 2) Advice: Participants relied on the advice of more experienced female family members. Health care providers were not uniformly a trusted source of advice; 3) Comfort: Participants made choices about their infants sleeping positions based on their perceptions of whether the infants appeared comfortable. Participants thought that their infants appeared more comfortable in the prone position; 4) Knowledge: Some participants had either limited or erroneous knowledge about the Back-to-Sleep recommendations. Conclusions.—We identified multiple barriers to adherence to recommendations regarding infant sleep position. Data obtained from these focus groups could be used to design educational interventions aimed at improving communication about and adherence to the Back-to-Sleep recommendations.

In 1981, the Report of the Medical Consultants on the Diagnosis of Death established guidelines for the diagnosis of brain death and, in 1995, the American Academy of Neurology published practice parameters to standardize determination of brain death. In 1987, the American Academy of Pediatrics established guidelines for determining brain death in children. Despite the establishment of these guidelines, the declaration of "death" based on the cessation of brain function remains complex and controversial. In this review are discussed the current guiding principles and the controversies in the diagnosis of brain death in children.

Intrinsic properties of lung and chest wall tissues can lead to breathing rate (frequency [f]) and amplitude (tidal volume [VT]) dependence of respiratory system resistance (R) and elastance (E). To explore these dependencies on R and E within physiological limits of tidal volume and breathing frequencies during early childhood. we measured airway opening pressure (Pao) and flow (V'ao) in 15 anesthetized, paralyzed, intubated, and mechanically ventilated healthy children (age 1 day to 72 months; weight 2.5-21 kg) at multiple combinations of VT (6, 10, and 14 mL/kg) and frequency (10, 20, and 30 breaths/min). In each instance, R and E were estimated by multiple linear regression applied to the tracheal pressure, flow, and volume (V), assuming a simple series R-E model. R decreased substantially with increasing frequency and weight (Wt), but was unaffected by changes in VT (R = 764Wt(-0.91) x f(-0.57)). E decreased sharply with increasing Wt, was lower at higher VT, and was slightly, yet significantly, increased at higher frequency (E = 2,905Wt(-1.38) x VT(-0.18) x f(0.11)). Such frequency dependence of R and E is consistent with stress adaptive, or viscoelastic, properties of respiratory tissues. The small V dependence of E is similar to that observed in other species under healthy conditions and presumably reflects the combined nonlinear pressure-volume relationships of the healthy parenchymal and chest wall tissues. Lack of VT dependence of R at high inspiratory flow rates suggests that turbulent flows are either not an important form of energy dissipation in the lower airways of children or they are counterbalanced by a decrease in tissue damping at high VT. The above regression models represent the first attempt to quantify simultaneously the separate effects of lung growth as well as rate and amplitude of breathing on R and E. Similar equations based on a larger sample of healthy subjects can provide normative R and E values for comparison with mechanically ventilated children with lung disease.

Importance A strong association between infant bed sharing and sudden infant death syndrome or unintentional sleep-related death in infants has been established. Occurrences of unintentional sleep-related deaths among infants appear to be increasing. Objectives To determine the trends and factors associated with infant bed sharing from 1993 through 2010, including the association of physician advice on bed sharing. Design National Infant Sleep Position study conducted with annual telephone surveys. Setting The 48 contiguous states. Participants Nighttime caregivers of infants born within 7 months of each survey administration. Approximately 1000 interviews were completed annually. Main Outcomes and Measures Infant bed sharing as a usual practice. Results Of 18 986 participants, 11.2% reported an infant sharing a bed as a usual practice. Bed sharing increased from 1993 (6.5%) to 2010 (13.5%). Although bed sharing increased significantly among white respondents from 1993 to 2000 ( P P = .48). Black and Hispanic respondents reported an increase in bed sharing throughout the study period, with no difference between the earlier and later periods ( P = .63 and P = .77, respectively). After accounting for the study year, factors associated with increase in infant bed sharing as a usual practice included maternal educational level of less than high school compared with college or greater (adjusted odds ratio, 1.42 [95% CI, 1.12-1.79]); black (3.47 [2.97-4.05]), Hispanic (1.33 [1.10-1.61]), and other (2.46 [2.03-2.97]) maternal race or ethnicity compared with white race; household income of less than $20 000 (1.69 [1.44-1.99]) and $20 000 to $50 000 (1.29 [1.14-1.45]) compared with greater than $50 000; living in the West (1.61 [1.38-1.88]) or the South (1.47 [1.30-1.66]) compared with the Midwest; infants younger than 8 weeks (1.45 [1.21-1.73]) or ages 8 to 15 weeks (1.31 [1.17-1.45]) compared with 16 weeks or older; and being born prematurely compared with full-term (1.41 [1.22-1.62]). Almost 46% of the participants reported talking to a physician about bed sharing. Compared with those who did not receive advice from a physician, those who reported their physicians had a negative attitude were less likely to have the infant share a bed (adjusted odds ratio, 0.66 [95% CI, 0.53-0.82]), whereas a neutral attitude was associated with increased bed sharing (1.38 [1.05-1.80]). Conclusions and Relevance Our finding of a continual increase in bed sharing throughout the study period among black and Hispanic infants suggests that the current American Academy of Pediatrics recommendation about bed sharing is not universally followed. The factors associated with infant bed sharing may be useful in evaluating the impact of a broad intervention to change behavior.

Extracorporeal membrane oxygenation (ECMO) is a means of diverting a fraction or all of the circulation through a device that permits gas exchange across a permeable membrane. The site of removal and the site of return of blood are dictated primarily by practical considerations based on the volume of flow of blood to be diverted and whether a particular organ is to be bypassed. The prototype of extracorporeal oxygenation is heart-lung bypass, used for various types of cardiac surgery, in which the entire venous return is diverted through an oxygenator (bubble or membrane type) and returned to the aorta. Since the earliest reports of the use of ECMO in neonates, venoarterial bypass has been the preferred route, with blood drained from the right atrium and returned either to the carotid artery or to the femoral artery, although the former seems to have been used most often (2;4;11;12;14;18). In some reports, veno-venous bypass has also been accomplished with removal of blood from the right atrium and return into the umbilical or femoral vein (13;19). Gas exchange across the lung may also continue, although the ventilator rate, tidal volume, or peak inspiratory pressure are usually reduced markedly during the period of extracorporeal oxygenation. Anticoagulation is accomplished with few problems by infusion of heparin sulfate throughout the duration of the procedure. There now have been enough reports in the literature (individual cases or series of patients) to demonstrate that the procedure can be carried out with a minimum of technical difficulties in newborn infants (2;3;4;11;12;18), although the selection of “appropriate” patients reduces the morbidity and technical challenges of the procedure.

Persistent pulmonary hypertension of the newborn or persistent fetal circulation is a clinical syndrome that is usually apparent within the first 2 days after birth because of the presence of hypoxemia (2;12;19). The syndrome was first described in an abstract by Gersony, Due, and Sinclair (6) in 1969. Two infants were reported who had “RV decompensation, cyanosis and clear lung fields… in the absence of recognizable cardiac, pulmonary, hematologic or CNS disease.” The syndrome has been associated with aspiration of meconium, diaphragmatic hernia, asphyxia, hemorrhage, shock, and maternal infection (4;18). In other cases, there is no clear antecedent event. Despite considerable interest in the problem and a wealth of research related to pulmonary vasoregulation and vascular development in the fetus and newborn, the etiology of the syndrome remains obscure 20 years since its recognition.

My challenge here is to convey the lessons I have learned in serving as a mentor to budding physicianscientists; yet, this is not as easy as it seems at first blush for at least two reasons. First, so many outstanding scientists, including Nobel laureates, have extolled the virtues of their own mentors who were central to their success. Thus, it feels pretentious to explain how to be a mentor, as if I have now reached some Olympian stature. Furthermore, I realize that those who might at first glance at this article have already thought about the topic throughout their career and acknowledged its importance. I certainly do not wish to provide obvious and unneeded advice.

* Abbreviations: SIDS = : sudden infant death syndrome • ECG = : electrocardiogram • LQTS = : long QT syndrome We read with interest the article on the proposed association of prolonged QT interval and the sudden infant death syndrome (SIDS) by Schwartz et al.1 Recognizing the previous failures to determine cause(s) for SIDS and the risks of changing practice in response to one study, we wish to take this opportunity to place the findings of the study in perspective and reflect on directions that might be pursued. Although the mechanism for SIDS (the most common cause of death from 1 month to 1 year of age) remains unknown, certain factors, such as smoking during pregnancy and sleep position of the infant lter the risk of SIDS.2–7 The hypothesis that there is a relationship between SIDS and prolonged QT has been previously raised by Schwartz8 and other authors,9–12 and disputed by some,13–15 but the recent data by Schwartz et al1 are the most compelling to date. Schwartz et al obtained electrocardiogram (ECG) recordings 3 to 4 days after birth in 34 443 newborn infants, 24 of whom died within the first year after birth with a diagnosis of SIDS. The authors found that these 24 infants had an average QT interval (corrected for heart rate) that was longer than in 9725 randomly selected living infants and longer than in 10 infants who died of other causes. Accordingly, this report raises several important questions. What is the cause of the long QT interval in the infants? Schwartz et al1 suggest that the prolonged QT might be caused by: a) different rates of development of the right and left sympathetic nerves rendering the infant susceptible to an arrhythmia during sudden increases in sympathetic activity8 ,16 ,17; or b) mutation in one of the genes encoding sodium or potassium channels, as has been identified … Address correspondence to George Lister, MD, Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064.

To report longitudinal home recordings of hemoglobin O(2) saturation by pulse oximetry (Spo(2)) during unperturbed sleep in preterm and term infants.We recorded continuous pulse oximetry during the first 3 minutes of each hour of monitor use (nonevent epochs) for 103 preterm infants born at1750 g and ≤ 34 weeks postmenstrual age (PMA), and 99 healthy term infants.Median baseline Spo(2) was approximately 98% for both the preterm and term groups. Episodes of intermittent hypoxemia occurred in 74% of preterm and 62% of term infants. Among infants with intermittent hypoxemia, the number of seconds/hour of monitoring90% Spo(2) was initially significantly greater in the preterm than the term group and declined with age at a similar rate in both groups. The 75(th) to 95(th) percentiles for seconds/hour of Spo(2)90% in preterm infants were highest at 36 weeks PMA and progressively decreased until 44 weeks PMA, after which time they did not differ from term infants.Clinically inapparent intermittent hypoxemia occurs in epochs unperturbed by and temporally unrelated to apnea or bradycardia events, especially in preterm infants at 36 to 44 weeks PMA.

A wide variety of artifacts may be found when monitoring the ECG in a neonatal intensive care unit. Many of the artifacts resemble arrhythmias, and unless they are recognized as artifacts they may lead to serious errors of diagnosis and therapy. Many of the artifacts are caused by patient movement such as seizures, tremulousness, or hiccups. Others may be introduced by the monitor itself or be caused by electrical equipment in the vicinity. A group of ECC tracings is presented to illustrate the various artifacts encountered. Features that distinguish the artifacts from the arrhythmias they mimic are described, as are suggestions for elimination of the artifacts.

The effect of physical training on the exercise performance of 26 patients following surgical repair of tetralogy of Fallot (16 patients) and ventricular septal defect (ten patients) was evaluated. Base line exercise testing was performed on a bicycle ergometer using the technique of Godfrey. Patients were placed on a six-week alternate day submaximal interval home exercise program of varying duration and intensity. Work loads at 50%, 60%, and 70% maximum oxygen consumption were selected to maintain heart rates between 130 and 160 beats per minute. Subjects completed an average of 18 of the possible 21 training sessions (range 11 to 21). A 25% improvement (P < .001) was noted in maximum work capacity (747 to 935 km). Sixty-five percent of the patients performed at less than expected maximum work capacity prior to training, but only 31% performed at less than expected maximum work capacity after training. Repeat testing at work loads of one-third, one-half, and two-thirds the original maximum work capacity revealed improved aerobic efficiency as manifested by significantly decreased oxygen consumption and heart rate at each level of work. No significant difference was noted in maximum oxygen consumption. It is concluded that physical training can improve the exercise performance of patients after surgical repair, permitting the individuals to function at levels of activity at, or closely approaching, normal.

We previously found limited tolerance to acute reduction in cardiac output in lambs at the nadir of their physiological anemia [Am. J. Physiol. 253 (Heart Cir. Physiol. 12): H100-H106, 1987]. To determine the effect of hemoglobin concentration [Hb] on critical cardiac output, critical systemic O2 transport, and peripheral O2 extraction, we performed 31 experiments in 12 one-mo-old lambs at four [Hb] (means +/- SD in g/dl): 7.4 +/- 0.6, 10.5 +/- 0.5, 14.5 +/- 0.5, and 16.5 +/- 0.6. Desired [Hb] was obtained by exchange transfusion with packed red cells or plasma. Cardiac output was reduced by inflation of a balloon-tipped catheter in the right atrium, and critical levels were defined at the point where O2 consumption decreased and/or arterial blood lactate concentration increased in response. With lower [Hb], cardiac output was unchanged, systemic O2 transport was reduced, and fractional O2 extraction was increased, keeping O2 consumption constant at base line. As [Hb] was reduced, critical cardiac output was significantly higher, whereas critical systemic O2 transport was independent of [Hb], as were fractional O2 extraction and mixed venous PO2 at the critical point. Thus peripheral O2 extraction was not affected by changes in [Hb] during progressive decreases in cardiac output. We conclude that 4-wk-old lambs have decreased tolerance to reductions in cardiac output and systemic O2 transport because their relative anemia provides them with a base-line cardiac output and systemic O2 transport close to the critical level.

Angiotensin-converting enzyme (ACE) activity of the cerebral microcirculation of anesthetized dogs was measured from cerebral venous outflow curves after bolus injection of a synthetic ACE substrate, [3H]benzoyl-phenylalanyl-alanylproline ([3H]BPAP), into a common carotid artery. Cerebral BPAP metabolism was quantified by measuring the concentration of [3H]benzoyl-phenylalanine (the product of BPAP hydrolysis by ACE) in blood samples from the sagittal sinus after occlusion of the lateral sinuses with bone wax. Instantaneous BPAP metabolism in each sample increased as a function of time after injection, suggestive of perfusion heterogeneity, and averaged 59 +/- 4% (n = 8) over a single pass during normoxia and normocapnia. The ratio of Vmax (the maximal rate of cerebral BPAP metabolism) to Km (the concentration at Vmax/2), was calculated from instantaneous outflow curves using a model based on first-order kinetics. Increases in cerebral blood flow during either hypoxia or hypercapnia significantly reduced BPAP metabolism to 33 +/- 3 (n = 7) and 24 +/- 3% (n = 5), respectively; however, Vmax/Km of ACE activity (0.19 +/- 0.03 ml/s) was not affected by either condition. The lack of change in apparent kinetics of ACE activity (i.e., in Vmax/Km) during hypoxia or hypercapnia suggests that recruitment of cerebral capillaries was not a quantitatively significant factor in controlling BPAP metabolism with this degree of either hypoxia or hypercapnia.

Stereologic methods were used to study lung development in sheep from 2 to 171 days of age. Most growth occurs within the first 2 months when there is a threefold increase in lung volume, but allometric relationships show that this increase does not keep pace with body weight. Alveolar and capillary surface areas increase as lung volume to a power only slightly larger than 1, suggesting a modest increase in complexity; this is confirmed by only a two- to threefold increase in total alveolar number. Allometric power functions are essentially unchanged even during the first 30 days so that throughout development, the surface for gas exchange is added at a fairly constant rate. A slight increase in septal volume during the first 30 days is probably due to relative increase in capillary luminal volume through a progressive distension of capillaries. The results suggest that the active newborn lamb requires an alveolar lung, but in the postnatal period functional needs increase only moderately. In contrast, other mammals, such as the rat, are helpless as newborns and have a primitive saccular lung that must undergo considerable morphogenesis to meet the demands of the active adult.

The examination of multiple bones from a child who died of complications of septicemia and osteomyelitis elucidated the pathologic processes of infantile osteomyelitis. From a metaphyseal focus, there is spread in several directions. Most important, the infection can spread across the growth plate, along transphyseal vessels, to penetrate the epiphysis. Areas of direct destruction of growth plate were frequent findings, and allowed another route into the epiphysis.

Although a considerable amount of information is available regarding the remodeling and growth of the pulmonary arterial circulation, relatively little is known regarding postnatal development of the pulmonary microcirculation. We hypothesized that the maximal velocity (Vmax) of pulmonary angiotensin-converting enzyme (ACE) activity, measured from indicator-dilution outflow curves using a synthetic substrate, 3H-labeled benzoyl-phenylalanyl-alanyl-proline (BPAP), is directly related to the capillary endothelial cell surface area in the lungs of developing lambs. Accordingly we measured apparent kinetics of pulmonary ACE activity in 22 anesthetized ventilated lambs (2–171 days old) and compared our functional assessment to simultaneous in vivo determinations of CO diffusing capacity (DLCO) and postmortem structural assessment of alveolar septal dimensions using stereology and electron microscopy. There was a progressive increase in Vmax of ACE in this age group, with little change in apparent affinity for BPAP. Similar functional manifestation of growth was noted by an age-dependent increase in DLCO. Neither Vmax nor DLCO was significantly affected by an increase in left atrial pressure to 19 Torr (via inflation of a balloon in the left atrium), suggesting little recruitment of vessels under conditions of the present protocol. A close correlation was observed when either Vmax for ACE activity or DLCO was plotted vs. capillary endothelial cell surface area. Double logarithmic transformation of capillary endothelial cell surface area, Vmax-ACE and DLCO vs. lung volume revealed power functions with slopes all greater than that predicted from isotropic growth, suggesting selective differential postnatal development of the endothelium of the alveolar septum in lambs from 2–171 days of age.

This study was designed to determine whether alterations in systemic oxygen transport induced by the use of vasodilators for pulmonary hypertension would simultaneously affect oxygen uptake in patients with chronic obstructive pulmonary disease (COPD). Six stable patients with moderate to severe COPD were studied during resting conditons, nitroprusside infusion, a second control period, and after administration of hydralazine. Systemic oxygen transport fell with nitroprusside infusion (523 ± 94 to 418 ± 78 ml/min/m2, p < 0.05). With this there was a fall in oxygen uptake (135 ± 11 to 119 ± 12 ml/min/m2, p < 0.05), but only a minimal increase in oxygen extraction. In contrast, systemic oxygen transport was augmented in all patients when hydralazine was administered (444 ± 121 to 840 ± 157 ml/min/m2, p < 0.05). There was also a net increase in oxygen uptake in these patients (122 ± 19 to 148 ± 21 ml/min/m2, p < 0.05). We postulate that these clinically stable patients have a resting oxygen uptake that may b...