PEDIATRICS electronic pages

PEDIATRICS electronic pages

e14 ABSTRACT. Hepatitis B Vaccination of Premature Infants: A Reassessment of Current Recommendations for Delayed Immunization. Genevieve A. Losonsky, MD; Steven S. Wasserman, PhD; Ina Stephens, MD; Frank Mahoney, MD; Patricia Armstrong, RN; Karl Gumpper, RPH; Susan Dulkerian, MD; David J. West, PhD, MPH; and Ira H. Gewolb, MD. Objective. Current American Academy of Pediatrics and United States Public Health Service Immunization Practices Advisory Committee recommendations for hepatitis B immunization in premature infants weighing [is less than] 2 kg at birth born to hepatitis B surface antigen ([HB.sub.S] Ag)-negative mothers are to delay the initiation of vaccination until such infants reach 2 kg or until 2 months of age. This proposal to delay vaccination at birth in these low-risk infants was based on limited studies not conducted in the United States. We sought to reassess current recommendations to delay administration of hepatitis B vaccine in low-risk premature infants by determining the immunogenicity of early hepatitis B vaccination in a US population and identifying variables associated with poor immunogenicity.

Methods. A total of 148 infants [is less than] 37 weeks’ gestation born to mothers negative for [HB.sub.S]Ag were recruited at birth and stratified to three birth weight groups: [is less than] 1000 g, 1000 to 1500 g, and [is greater than] 1500 g. Recombinant hepatitis B vaccine was administered within the first week of life, at 1 to 2 months of age, and at 6 to 7 months of age. Serum obtained at birth and after the second and third doses of vaccine was tested for antibody to [HB.sub.S]Ag. Variables associated with poor response were sought prospectively by collecting demographic and clinical data.

Results. A total of 118 subjects (83%) completed the study. Postsecond dose sera were available for 117 infants and postthird dose sera were available for 112 infants. The seroprotection rate (attaining [is greater than or equal to] 10 mIU/mL [HB.sub.S] antibody) after two doses was low (25%) regardless of birth weight; infants weighing [is less than] 1000 g at birth had the poorest response (11%). The seroprotection response rate after three doses of vaccine increased with birth weight; infants weighing [is less than or equal to] 1500 g at birth (groups 1 and 2) had lower rates of response (52% and 68%, respectively) than did infants weighing [is greater than] 1500 g at birth (group 3; 84% response rate). The seroprotection response rate of group 3 infants after three doses of vaccine, although low, could not be differentiated from the response rates reported for full-term infants using 95% confidence intervals. Of all infants who did not achieve protective levels of antibody after three doses of vaccine, 96% (26/27) weighed [is less than] 1700 g at birth. The geometric mean [HB.sub.S] antibody levels in responders were 88 and 386 mIU/mL after two and three doses, respectively. Of 36 children with a birth weight [is greater than] 1500 g, 33 (91%) achieved levels of [HB.sub.S] antibody [is greater than] 100 mIU/mL after three doses of vaccine, compared with 25/35 (71%) of infants with birth weight [is less than] 1500 g.

Using logistic regression analysis, nonresponders were more likely than were responders to have been treated with steroids (26% vs 9%) and to have had a low birth weight (1037 g vs 1455 g). In addition, the seroresponse rate of black infants was more likely than that of white infants to be associated with poor weight gain (falling off 2 percentile ranks in weight) in the first 6 months of life: 22% of black and 60% of white children who failed to gain weight adequately responded to vaccination, compared with 92% of black and 70% of white children who were growing adequately. Of interest, the only infant with a birth weight of [is greater than] 1700 g who did not make protective levels of specific antibody after three doses of vaccine was 2300 g at birth, but had inadequate weight gain in the first 6 months of life.

Conclusions. This study supports current recommendations of the American Academy of Pediatrics and the Centers for Disease Control and Prevention for delaying the initiation of hepatitis B immunization beyond the first week of life for premature infants at low risk for hepatitis B infection, particularly in newborns weighing [is less than] 1700 g at birth. In addition, we have identified variables other than birth weight that were associated with an inadequate immune response to early hepatitis B vaccination in premature infants, such as poor weight gain in the first 6 months of life and steroid use in the first few months of life. Pediatrics 1999;103(2). URL: http:// www.pediatrics.org/cgi/content/full/103/2/e14; premature, hepatitis B, early vaccination.

e15 ABSTRACT. Chest Roentgenogram in the Evaluation of Heart Defects in Asymptomatic Infants and Children With a Cardiac Murmur: Reproducibility and Accuracy. Niels H. Birkebaek, MD; Lars K. Hansen, MD; Bo Elle, MD; Poul E. Andersen, MD, PhD; Merete Friis, MD; Mogens Egeblad, MD; Karen Damgaard-Pedersen, MD, DMSc; Nina T. Nielsen, MD; and Henrik Oxhoj, DMSc. Objectives. To evaluate the reproducibility and the accuracy of pediatric radiologists’ assessments of chest radiographs with respect to the presence or absence of heart defects in children with an asymptomatic heart murmur.

Design. Ninety-eight children, ages 1 month to 15 years (median, 30.1 months), referred for evaluation of a heart murmur were consecutively included. They all had a standard chest radiograph and a color Doppler echocardiograph (CDE) performed. Six specialists in pediatric radiology evaluated the chest radiographs independently on two occasions 6 months apart. The radiologists were asked to classify each set of films into one of two categories: heart disease or no heart disease. The outcome of the CDE was considered the definite diagnosis. [Kappa] statistics were used to analyze the reproducibility of the radiologic assessments. Sensitivity, specificity, and the predictive value of a positive and a negative test were used for evaluation of the accuracy of the radiologic assessments.

Results. Mean intra- and interobserver [Kappa] values were all [is less than] 0.6, and the majority were [is less than] 0.4. Mean sensitivity was 0.3 (range: 0.17-0.52), mean predictive value of a positive test was 0.4, implying that 60% of the positive assessments were falsely positive. Mean specificity was 0.86 (range: 0.75-0.93) and the mean predictive value of a negative test was 0.80 implying that 20% of the negative assessments were falsely negative.

Conclusion We found a low reproducibility, as well as a low accuracy, of the radiologic assessments of the chest radiographs of children with an asymptomatic heart murmur with respect to the presence or absence of heart disease. A false-positive radiologic assessment of the chest radiograph with respect to heart defects causes unnecessary anxiety and further examinations, whereas a false-negative assessment might result in omission of relevant investigations and proper identification of the heart defect. We cannot recommend the use of chest radiographs in the initial evaluation of the asymptomatic child with a heart murmur. If a heart defect cannot be excluded by clinical examination a CDE must be performed. Pediatrics 1999;103(2). URL: http://www. pediatrics.org/cgi/content/full/103/2/e15; child, cardiac murmur, chest radiograph, reproducibility, accuracy.

e16 ABSTRACT. Recombinant Human Erythropoietin Treatment for Chemotherapy-related Anemia in Children. Ali Varan, MD; Munevver Buyukpamukcu, MD; Tezer Kutluk, MD, PhD; and Canan Akyuz, MD. Objective. The efficacy and safety of recombinant human erythropoietin (rHuEPO) treatment in chemotherapy-induced anemia in children were investigated, rHuEPO is used to treat chemotherapy-induced anemia. Several studies recommend 150 to 300 IU/kg rHuEPO for 2 to 8 months. There are only a few controlled trials in children and no precise data about the optimal dose and duration of rHuEPO treatment is available.

Patients and Methods. Thirty-four patients receiving chemotherapy for treatment of their solid tumors between October 1996 and June 1997 were included in this study. Patients were randomly selected for each group. The male/ female ratio was 20/14, and the median age was 5 years (range, 1-16 years). They had normal hemoglobin levels at the time of diagnosis. When hemoglobin levels decreased to levels lower than 10 g/dL, rHuEPO (150 IU/kg/d, 3 times a week, subcutaneously) was given to 17 patients for 2 months. Their renal, liver, and pulmonary functions were normal. None of the patients had hematologic disease. We did not use any other drugs such as iron or granulocyte colony-stimulating factor. There were 17 patients in the control group. Fifteen patients got chemotherapy regimens including cisplatin (CDDP), but 19 were treated with regimens without CDDP. At the end of rHuEPO treatment, all patients were examined in terms of transfusion requirements and rate of change in hemoglobin levels.

Results. One patient in the study group needed a blood transfusion, whereas 8 patients needed a transfusion in the control group. Patients in the study group had less transfusion requirements compared with the control group. The mean hemoglobin levels before and after the study were 8.48 [+ or -] 0.98 g/dL and 8.41 [+ or -] 1.65 g/dL in the control group and 8.50 [+ or -] 0.85 g/dL and 10.21 [+ or -] 2.14 g/dL in the rHuEPO group, respectively. Optimal hemoglobin increments began in 4 weeks and continued during treatment. CDDP-receiving and CDDP-nonreceiving groups did not have any difference in pretreatment serum erythropoietin levels, rHuEPO treatment was more effective in patients treated with non-CDDP regimens. Mean hemoglobin level increased from 8.68 [+ or -] 0.73 g/dL to 10.26 [+ or -] 1.84 g/dL in 9 patients treated with non-CDDP chemotherapy regimens in the erythropoietin group, although it increased from 8.28 [+ or -] 0.97 g/dL to 10.15 [+ or -] 2.5 g/dL in 8 patients treated with CDDP-containing regimens in the erythropoietin group, rHuEPO caused high blood pressure in only 1 patient that resolved spontaneously after cessation of erythropoietin treatment for a week.

Conclusion. rHuEPO treatment (150 IU/kg/d 3 times a week) is effective and safe in children with chemotherapy-induced anemia. It decreases blood transfusion requirements in solid tumor patients. Our results show that the response to rHuEPO in CDDP-induced anemia is less than the response in non-CDDP receiving patients. Higher doses may be necessary in patients using CDDP. Pediatrics 1999;103(2). URL: http://www.pediatrics.org/ cgi/content/full/103/2/el6; erythropoietin, solid tumors, chemotherapy, anemia, children.

e17 ABSTRACT. Assessment of Infant Cardiopulmonary Resuscitation Rescue Breathing Technique: Relationship of Infant and Caregiver Facial Measurements. Cynthia A. Dembofsky, MD; Eric Gibson, MD; Vinay Nadkarni, MD; Sara Rubin; and Jay S. Greenspan, MD. Objective. Although a few infants ever require resuscitation, pediatric cardiopulmonary resuscitation (CPR) is performed most commonly under 1 year of age. American Heart Association guidelines for pediatric basic life support recommend that the caregiver place his/her mouth over the infant’s mouth and nose to create a seal. The way CPR is currently taught encourages parents to attempt to seal the nose and open the mouth of the infant for rescue breathing. Recent studies suggest some parents may have trouble sealing an infant’s nose and open mouth, but their study participant numbers were small. The aim of this report is to estimate, among a large cohort, the ability of caregivers to create a seal to their infants for the provision of rescue breathing according to current guidelines.

Methods. Infants up to 1 year of age (n = 281) and their caregivers were enrolled from Philadelphia pediatric offices. Facial measurements of the infants were obtained to estimate the length needed to seal the nose and open mouth, and the nose and closed mouth. Mouth widths of the caregivers were compared with their infant’s nose and mouth lengths. One-way analysis of variance with Tukey’s postmortem analysis and ordinary least squares means regression were used for univariate analysis with analysis of covariance used to control for the effects of multiple variables when necessary. Infant measurements were stratified into 3-month age quadrants to compare against matched adult caregiver measurements.

Results. Most caregivers (n = 270) were female. Females had smaller mouth widths than males (4.9 [+ or -] 0.5 cm vs 5.2 [+ or -] 0.5 cm). Infant nose and mouth length increased during the first year of life, with the largest increase between 0 to 3 months and 3 to 6 months (4.2 [+ or -] 0.4 cm to 4.7 [+ or -] 0.4 cm). As infant age and face length increased, a progressively higher rate of adult females were estimated not to be able to cover their infant’s nose and open mouth, with the greatest increase again between 0 to 3 months (9%) and 3 to 6 months (40%). All female caregivers except 1 were predicted to be able to seal their infant’s nose and closed mouth by our measurements.

Conclusions. Infant face length grows rapidly during the first year of life with the most rapid growth occurring during the first 6 months. As early as 3 to 6 months of infant age, many adult caregivers’ facial measurements, especially female, predict that they may not be able to form a seal for mouth-to-nose and open-mouth infant rescue breathing. By related measurements, nearly 100% of caregivers should be able to seal their infant’s nose and closed mouth. If facial measurement predictions correlate with functional inability to seal an infant’s nose and open mouth, infant CPR rescue breathing instruction will need to emphasize head position and creation of a seal over the mouth and nose without teaching that the mouth be open. Pediatrics 1999;103(2). URL: http://www. pediatrics.org/cgi/content/full/103/2/e17; pediatric basic life support, infant CPR, rescue breathing, sudden infant death syndrome, acute life-threatening episode.

e18 ABSTRACT. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Wasif A. Khan, MB, BS; Ujjwal Dhar, MB, BS; Mohammed A. Salam, MB, BS; Jeffrey K. Griffiths, MD, MPH&TM; William Rand, PhD; and Michael L. Bennish, MD. Background and Objective. Alterations in consciousness, including seizures, delirium, and coma, are known to occur during Shigella infection. Previous reports have suggested that febrile convulsions and altered consciousness are more common during shigellosis than with other childhood infections. Those reports, however, have been from locations where S dysenteriae type 1 was not common, thus making it difficult to assess the specific contribution that S dysenteriae type 1 infection, and Shiga toxin, might make to the pathogenesis of altered consciousness in children with shigellosis. In this study we seek to determine the prevalence, risk factors, and outcome of altered consciousness in children with shigellosis in Bangladesh, a country where infection with all four species of Shigella is common. We particularly focus on the importance of metabolic abnormalities, which we have previously shown to be a common feature of shigellosis in this population.

Methods. This study was conducted at the Diarrhea Treatment Centre of the International Centre for Diarrhoeal Disease Research, Bangladesh in Dhaka, Bangladesh, which provides care free of charge to persons with diarrhea. During 1 year, a study physician identified all inpatients infected with Shigella by checking the logs of the Clinical Microbiology Laboratory daily. Study physicians obtained demographic and historical information by reviewing the patient charts and by interviewing patients, or their parents or guardians, to confirm or complete the history of illness obtained on admission. Patients were categorized as being conscious or unconscious based on a clinical scale; having a seizure documented in the hospital; or having a seizure by history during the current illness that was not witnessed by medical personnel. Patient outcome was classified as discharged improved, discharged against medical advice, transferred to another health facility, or died in the Treatment Centre. Laboratory examinations were ordered at the discretion of the attending physician; all such information was recorded on the study form. Clinical management was by the attending physician. Factors independently predictive of a documented seizure, or of unconsciousness, were determined using a multiple logistic regression analysis. For this analysis variables associated with unconsciousness or a documented seizure in the analysis of variance or [chi square] analyses were entered into the regression equation and eliminated in a backward stepwise fashion if the probability associated with the likelihood ratio statistic exceeded .10.

Results. During this 1-year study, 83 402 persons with diarrhea came to the Treatment Centre for care, and 6290 patients were admitted to the inpatient unit. Shigella was isolated from a stool or rectal swab sample of 863 (13.7%) of the inpatients.

Seventy-one (8%) of the inpatients with shigellosis were [is greater than or equal to] 15 years old; 61 (86%) were conscious; 10 (14%) were unconscious; none had either a documented seizure or a seizure by history during this illness. Seven hundred ninety-two patients were [is less than] 15 years old (92%); 654 (83%) were conscious; 73 (9%) were unconscious; 41 (5%) had a documented seizure (compared with [is greater than or equal to] 15-year age group); 24 (3%) had a seizure by history during this illness. Of the 41 patients with documented seizures, 19 (46.3%) had a seizure at the time of admission, and 22 (53.7%) had a seizure after admission. Twenty-five (61.0%) of the 41 patients with documented seizures were reported to have a seizure during this illness before coming to the Treatment Centre.

Clinical features that are known to cause altered consciousness–fever, severe dehydration, hypoglycemia, hyponatremia, or meningitis–were present in 38 (92.7%) of the 41 patients in whom a seizure was witnessed and in 67 (91.8%) of the 73 patients who were unconscious. Nineteen (46.3%) of the patients who had a seizure documented had two of these five features, 4 (9.8%) had three, and 1 (2.4%) had four of these features; among unconscious patients two of the features were present in 25 (34.2%) and three in 2 (2.7%). In a multiple regression analysis factors independently associated with a documented seizure in patients [is less than] 15 years old were a shorter duration of diarrhea, higher body temperature, higher median weight-for-age, increased proportion of immature leukocytes, higher serum potassium, and lower serum sodium. Factors associated with unconsciousness were older age, a shorter duration of diarrhea, higher admission temperature, severe dehydration, and higher serum potassium. In the multiple logistic regression analysis we found no association between the infecting species of Shigella and either the occurrence of seizures or altered consciousness.

Patients who were unconscious (death rate 48%) or had a documented seizure (death rate (29%) were at significantly increased risk of death compared with conscious patients (death rate 6%) or patients who had a seizure by history (no deaths). There were no deaths among patients 15 years or older.

Conclusions. This study had a substantially larger number of patients than any of the previously published clinical studies on seizures or altered consciousness during shigellosis. The results of this study suggest that seizures in shigellosis in the population studied occur in an age group–children 5 years of age or less–known to be at increased risk of seizures from fever or metabolic alterations. This study also suggests that, at least in the majority of these inpatients, altered consciousness is not related to Shiga toxin, which is produced in appreciable amounts only by the S dysenteriae type 1 serotype. Direct infection of the central nervous system also was not a major cause of altered consciousness in these patients. Both diminished consciousness and documented seizures are associated with a poor outcome in Banhgladeshi childre with shigellosis. Prompt attention to fever reduction and metabolic alterations may help reduce these potentially lethal complications, but often this is not easy to accomplish in the poor countries where shigellosis is endemic. Pediatrics 1999;103(2). URL: http:// www.pediatrics.org/cgi/content/full/103/2/e18; Shigella, Shigella dysenteriae, dysentery, bacillary; central nervous system, risk factors, convulsions, unconsciousness, diarrhea, infantile; Bangladesh, developing countries.

e19 ABSTRACT. Lipoid Pneumonia: A Silent Complication of Mineral Oil Aspiration. Hari P. R. Bandla, MD; Scott H. Davis, MD; and Nancy Eddy Hopkins, PhD. Introduction. Chronic constipation is a common symptom in pediatrics, and physicians often use mineral oil to treat chronic constipation in children. Mineral oil, a hydrocarbon, may not elicit a normal protective cough reflex and may impair mucociliary transport. These effects can increase the likelihood of its aspiration and subsequent impaired clearance from the respiratory tract. We report a case of a child with neurodevelopmental delay with chronic constipation and a history of chronic mineral oil ingestion presenting as asymptomatic exogenous lipoid pneumonia (ELP).

Case History. A 6-year-old white boy with a history of developmental delay was found to have an infiltrate in his right upper lobe on a chest radiograph obtained during evaluation for thoracic scoliosis. The patient had a long history of constipation with daily use of mineral oil. He was fed by mouth and had occasional episodes of coughing and choking during feeding. He was asymptomatic at presentation and physical examination was unremarkable. The patient was advised to stop administration of the mineral oil and was treated empirically with antibiotics during a 3-month period. At follow-up examination the patient continued to be asymptomatic, with the radiologic persistence of the infiltrate. Diagnosis of lipoid pneumonia was made by diagnostic bronchoscopy with bronchoalveolar lavage (BAL). The exogenous origin of the lipid in the BAL fluid was confirmed by gas chromatography/mass spectrometry.

Discussion. The clinical presentation of ELP is nonspecific and ranges from the totally asymptomatic patient with incidental radiologic finding, like our patient, to the patient with acute or chronic symptoms attributable to pneumonia, pulmonary fibrosis, or cor pulmonale. Bronchoscopy with BAL can be successful in establishing the diagnosis of ELP by demonstration of a high lipid-laden macrophage index. Treatment of ELP in children is generally supportive, with the symptoms and roentgenographic abnormalities resolving within months after stopping the use of mineral oil.

Conclusion. Lipoid pneumonia as a result of mineral oil aspiration still occurs in the pediatric population. It can mimic other diseases because of its nonspecific clinical presentation and radiographic signs. In patients with swallowing dysfunction and pneumonia, a history of mineral oil use should be obtained and a diagnosis of ELP should be considered in the differential diagnoses if mineral oil use has occurred. Our case points to the need for increased awareness by the general pediatricians of the potential hazards of mineral oil use for chronic constipation. Pediatrics 1999;103(2). URL: http://www. pediatrics.org/cgi/content/full/103/2/e19; bronchoalveolar lavage, constipation, exogenous lipoid pneumonia, lipid-laden macrophages, mineral oil.

e20 ABSTRACT. Clinical and Hematologic Features Do Not Reliably Identify Children With Unsuspected Meningococcal Disease. Nathan Kuppermann, MD, MPH; Richard Malley, MD; Stanley H. Inkelis, MD; and Gary R. Fleisher, MD. Objective. To determine the frequency of unsuspected meningococcal disease (UMD) in young febrile children with meningococcal infections and evaluate whether clinical and laboratory parameters commonly used in the evaluation of fever can help identify children with UMD.

Methods. We reviewed the records of children with meningococcal disease from 1985 to 1996 at four referral centers. Children who were evaluated as outpatients and then discharged to home, from whom Neisseria meningitidis was isolated from blood or cerebrospinal fluid cultures obtained during these outpatient visits, were considered to have UMD. We compared clinical and laboratory parameters between these children and 6414 febrile outpatients 3 to 36 months old with negative blood cultures enrolled in a separate study of occult bacteremia.

Results. We identified 381 children with meningococcal disease, of whom 45 (12%) had UMD. Of the 45 with UMD, 37 (82%) were 3 to 36 months old. Compared with the 6414 culture-negative patients, these 37 patients with UMD were significantly younger (8.9 [+ or -] 5.4 vs 14.2 [+ or -] 8.1 months) and had significantly higher band counts (14.3 [+ or -] 11.1 vs 7.3 [+ or -] 7.5%). There were no significant differences, however, in temperature, white blood cell counts, and absolute neutrophil counts. Multivariate analysis identified young age and the band count as independent predictors of UMD.

Conclusions. Children ultimately diagnosed with meningococcal disease have commonly been evaluated as outpatients and discharged to home before diagnosis. Of the hematologic parameters frequently used in the evaluation of fever, only the band count differs significantly between young febrile children with UMD and those with negative cultures. Because UMD is uncommon in young febrile pediatric outpatients, however, the predictive value of the band count is low. Thus, the complete blood count is not routinely helpful for the diagnosis of UMD. Pediatrics 1999;103(2). URL: http://www. pediatrics.org/cgi/content/full/103/2/e20; Neisseria meningitidis, meningococcal infections, bacteremia, complete blood count, neutrophil.

e21 ABSTRACT. Human Immunodeficiency Virus Status and Delayed-Type Hypersensitivity Skin Testing in Ugandan Children. Anna Maria Mandalakas, MD; Laura Guay, MD; Philippa Musoke, MD; Cindie Carroll-Pankhurst, PhD; and Karen N. Olness, MD. Background. In previous studies, delayed-type hypersensitivity (DTH) skin testing has been shown to be affected by several factors including nutritional status, intercurrent infection, host immune status, and previous exposure to the antigen being used.

Objective. To determine the effect of human immunodeficiency virus type 1 (HIV-1) status on DTH skin testing in a cohort of HIV-1-infected and noninfected Ugandan children followed prospectively from birth.

Design. Nested case-control study.

Setting. Primary care clinic serving study participants at Mulago Hospital Makerere University, Kampala, Uganda.

Participants. Thirty HIV-1-infected children and 30 age-matched, HIV-1-noninfected children.

Methods. After completion of history and physical, each child underwent Mantoux skin testing with both Candida and purified protein derivative (PPD). Results of skin testing were read in 48 to 72 hours. Complete chart reviews were performed on all children. CD4 lymphocyte counts were obtained on all HIV-1-infected children at the time the skin testing was read.

Results. The average age of participants was 67 months (range, 51-92 months). HIV-1-infected children (mean CD4 lymphocyte count, 1069 m[L.sup.-1]; range, 86-3378 m[L.sup.-1]), compared with noninfected, age-matched peers, developed significantly smaller PPD reaction size (mean, 1.18 mm [+ or -] 4.3 vs 3.6 mm [+ or -] 7.6, respectively). Candida responses were not different between the two groups of children. Among HIV-1-infected children, there was a larger Candida reaction size in children who had recently received chloroquine treatment. There was no significant correlation between Candida reactivity and PPD reactivity, progressive HIV-1 disease, or CD4 lymphocyte count. The six children diagnosed clinically with active tuberculosis had lower absolute CD4 lymphocyte counts than children without tuberculosis. Lack of reaction to PPD was associated with lower CD4 lymphocyte counts and progressive HIV-1 disease.

Conclusions. In HIV-1-infected Ugandan children, DTH skin testing was influenced by the choice of antigen selected, HIV-1 infection, and recent treatment with chloroquine. Based on these findings, we believe that further prospective, longitudinal investigation into the role of chloroquine in HIV-1-infected children is needed. We emphasize the limitations of DTH skin testing in HIV-infected children as an adjunct in the diagnosis of active tuberculosis. Pediatrics 1999;103(2). URL: http:// www.pediatrics.org/cgi/content/full/103/2/e21; pediatric, human immunodeficiency virus, tuberculosis, purified protein derivative, Candida, chloroquine.

e22 ABSTRACT. Renal Medullary Carcinoma in an Adolescent With Sickle Cell Trait. Katherine E. Warren, MD; Vinod Gidvani-Diaz, MD; and Bertrand Duval-Amould, MD. We describe the complex presentation of a patient with renal medullary carcinoma, a newly described entity primarily affecting young patients with sickle cell trait. Renal medullary carcinoma is an aggressive, rapidly destructive tumor associated with a delayed diagnosis and a poor outcome. The most common presenting signs and symptoms include hematuria, abdominal or flank pain, and weight loss. Sickle cell trait as the sole cause of hematuria in young black patients is a diagnosis of exclusion. Hemoglobin electrophoresis, intravenous pyelography, and computed tomography scans should be the minimal studies performed in young black patients with hematuria. Pediatrics 1999;103(2). URL: http://www.pediatrics.org/cgi/ content/full/103/2/e22; sickle cell trait, hematuria, renal medullary carcinoma, renal tumors.

e23 ABSTRACT. A Comparison of the Mogen and Gomco Clamps in Combination With Dorsal Penile Nerve Block in Minimizing the Pain of Neonatal Circumcision. Peter S. Kurtis, MD; Hema N. DeSilva, MBBS; Bruce A. Bernstein, PhD; Lillian Malakh, BA; and Neil L. Schechter, MD. Objectives. 1) To compare the Mogen and Gomco clamps with regard to pain experienced during neonatal circumcision, and 2) to assess neonatal circumcision pain with and without dorsal penile nerve block (DPNB).

Design/Methods. A randomized, controlled, nonblinded clinical trial; 48 healthy, full-term infants were randomized into one of the following four groups: Gomco vs Mogen with (+) or without (-) DPNB. DPNB+ infants were injected with 0.8 mL of 1% lidocaine before circumcision. DPNB- infants received no placebo injection. Heart rate, respiratory rate, and oxygen saturation (Sa[O.sub.2]) during the procedure were monitored and data transferred to computer files by using the Datalab software system. Crying was recorded on videotape. Pre- and postcircumcision saliva samples for cortisol analysis were collected. Heart rate, respiratory rate, Sa[O.sub.2] cortisol changes, and duration of crying were evaluated statistically with two-way analyses of variance and t tests.

Results. The type of clamp but not the use of anesthesia was significantly associated with the length of the procedure (mean Mogen time, 81 seconds; mean Gomco time, 209 seconds) and percentage of respiratory rate change. The use of anesthesia but not the type of clamp was significantly associated with percentage of crying time and percentage of Sa[O.sub.2] change during the procedure. Heart rate changes and total crying time were significantly associated with both the type of clamp and the use of anesthesia. Neither clamp type nor anesthesia status was significantly associated with salivary cortisol changes, although the mean increase for the DPNB- group was approximately twice that for the DPNB+ group. Fifty-six percent of infants circumcised with the Mogen clamp and DPNB did not cry at all during the procedure.

Conclusions. DPNB is effective in reducing neonatal circumcision pain with either the Mogen or the Gomco clamp. For a given anesthesia condition, the Mogen clamp is associated with a less painful procedure than the Gomco. The Mogen clamp with DPNB causes the least discomfort during neonatal circumcision. Pediatrics 1999;103(2). URL: http://www.pediatrics.org/cgi/content/full/103/21e23; circumcision, anesthesia for neonatal circumcision, dorsal penile nerve block, neonatal pain, newborn.

e24 ABSTRACT. Nasal Continuous Positive Airway Pressure and Early Surfactant Therapy for Respiratory Distress Syndrome in Newborns of Less Than 30 Weeks’ Gestation. Henrik Verder, MD; Per Albertsen, MD; Finn Ebbesen, MD; Gorm Greisen, MD; Bengt Robertson, MD; Aksel Bertelsen, PhD; Lone Agertoft, MD; Birgitte Djernes, MD; Erling Nathan, MD; and Jes Reinholdt, MD. Objective. To determine whether early versus late treatment with porcine surfactant (Curosurf) reduces the requirement of mechanical ventilation in very preterm infants primarily supported by nasal continuous positive airway pressure (nasal CPAP).

Design. Multicenter randomized, controlled trial.

Patients. The study population comprised 60 infants [is less than] 30 weeks’ gestation with respiratory distress syndrome (RDS) who had an arterial to alveolar oxygen tension ratio (a/AP[O.sub.2]) of 0.35 to 0.22.

The cohort from which the study population was generated comprised 397 infants.

Results. The need for mechanical ventilation or death within 7 days of age was reduced from 63% in the late-treated infants to 21% in early-treated infants. Increasing numbers of antenatal steroid doses also improved the outcome, especially in the early-treated infants. Six hours after randomization mean a/AP[O.sub.2] rose to 0.48 in the early-treated infants compared with 0.36 in the late-treated. The need of mechanical ventilation before discharge was reduced from 68% in the late-treated to 25% in the early-treated infants.

Conclusions. Nasal CPAP in combination with early treatment with Curosurf significantly improves oxygenation and reduces the subsequent need for mechanical ventilation in infants [is less than] 30 weeks’ gestational age with RDS. Pediatrics 1999;103(2). URL: http://www.pediatrics. org/cgi/content/full/103/2/e24; respiratory distress syndrome, pulmonary surfactant, Curosurf, nasal continuous positive airway pressure.

e25 ABSTRACT. Indications for Surfactant Therapy–The a[APO.sub.2] Coming of Age. Robert T. Hall, MD. Indications for administration of surfactant to infants with established respiratory distress syndrome (RDS; rescue therapy) remains an area of continued investigation. Current recommendations vary from use in infants who are intubated and have an a[APO.sub.2] [is less than] 0.22 to use in infants receiving–[is greater than]40% oxygen administered in a hood when the Pa[O.sub.2] is [is less than] 80 TORR (a[APO.sub.2] approximately [is less than]0.36).

This commentary is written in response to the article by Verder et al, in this issue of Pediatrics, who evaluated early versus late treatment of RDS in 60 preterm infants [is less than]30 weeks’ gestation receiving nasal continuous positive airway pressure (CPAP). Early-treated infants (a[APO.sub.2], 0.22 to 0.35; mean, 0.26) had a lower incidence of mechanical ventilation or death (21%) than did late-treated infants (63%), who did not receive surfactant treatment until the a[APO.sub.2] was [is less than] 0.22 (0.15 to 0.21; mean, 0.16). The authors conclude that although approximately half of infants [is less than] 30 weeks’ gestation with RDS can be treated with nasal CPAP alone, early treatment with surfactant when the a[APO.sub.2] is 0.22 to 0.36 reduced significantly the need for mechanical ventilation.

Limitations of applicability of the study to widespread use include determination of [PO.sub.2] values from transcutaneous measurements, which may vary from those obtained from arterial samples and affect significantly a[APO.sub.2] ratios. Likewise, use of nasal CPAP significantly affects oxygenation, and interpretation of results cannot be extrapolated to intubated infants or those receiving oxygen delivered under a hood. Nonetheless, the use of the a[APO.sub.2] ratio and early administration of surfactant are supported by this study. Pediatrics 1999;103(2). URL: http://www.pediatrics.org/cgi/content/full/103/2/e25; arterial to alveolar oxygen tension ratio, nasal continuous positive airway pressure, respiratory distress syndrome, surfactant, transcutaneous [O.sub.2] determinations, very low birth weight.

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