ABSTRACT
The objective of this project was to develop plots of daily insulin dosages by percentile in diabetic children and to analyze various factors, such as metabolic control, age, and duration of diabetes that might influence the insulin prescription. Patients in extremely poor metabolic control (HbA1C > 9.8%) and patients with less than 1 year of diabetes were excluded from analysis. Patients were aged 2-21 years and the mean age at diagnosis was 8 years. Thirty-two percent of the patients were younger than 5 years and 15% were older than 15 years at diagnosis. Ninety-nine percent of patients used both regular and intermediate-acting (NPH or Lente) insulin 10-30 min before breakfast and again in the evening. Ten percent of the patients used only regular insulin at supper but used intermediate-acting insulin at bedtime. Insulin doses varied between 0.3 and 1.2 U/kg/day in prepubertal children (mean, 0.8 U/kg/day) and 0.5 and 1.8 U/kg body weight/day in pubertal children (mean, 1.25 U/kg/day). Average insulin doses in boys and girls were similar, except at ages 10-13, when the dose was significantly higher in girls. The insulin dose declined after age 17 in both genders to a value at age 21 that was 20-30% lower than the highest dose during pubertal years. Insulin dose did not correlate with duration of disease after 2 years, the ratio of morning to evening insulin, the ratio of regular to intermediate-acting insulin, or body mass. There was a slight association between higher insulin doses and higher glycosylated hemoglobin values. The results indicate that insulin requirements vary over a wide range in a group of children with metabolic control ranging from 'excellent' to 'fair' and correlate primarily with age and pubertal development. About 25% of prepubertal children and 50% of pubertal and post-pubertal children use more than 1 U insulin/kg/day--a dose commonly believed to be an 'upper limit' by many health professionals. The data should provide guidelines for the range of insulin dosing required to achieve fairly good to excellent control in diabetic children of various ages.
Subject(s)
Diabetes Mellitus, Type 1/drug therapy , Insulin/administration & dosage , Adolescent , Adult , Aging/metabolism , Blood Glucose/metabolism , Body Weight , Child , Child, Preschool , Circadian Rhythm , Dose-Response Relationship, Drug , Female , Glycated Hemoglobin/metabolism , Humans , Insulin/therapeutic use , Male , Puberty , Time FactorsABSTRACT
OBJECTIVE: To evaluate the effectiveness of an experiential alcohol and other drug curriculum on pediatric residents' knowledge, attitudes, and skills in alcohol and other drug (AOD) issues. DESIGN: Nonrandomized control trial. SETTING: Two university pediatric residency programs. PARTICIPANTS: Pediatric residents (n = 44). INTERVENTION: Intervention residents received an experiential AOD curriculum consisting of participation in an adolescent assessment program, interactive didactic sessions, role-playing practice, and interviewing skills sessions. The control group received no formal training. MAIN OUTCOME MEASURES: Pretesting and posttesting each group using written and Objective Structured Clinical Examination evaluations using standardized patients. Evaluations were videotaped and scored by an expert panel using a standardized scoring process. RESULTS: Pretest comparisons of written knowledge and clinical skills as assessed by the Objective Structured Clinical Evaluation showed no significant differences between the intervention and the control groups. Analysis of written test scores revealed that residents' general knowledge as well as knowledge of screening techniques and management resources related to AOD issues increased significantly more for the intervention group than for the control group from pretest to posttest (P < .001). Evaluation of the videotapes showed significant improvement for the intervention group compared with controls in overall score and in the use of specific screening techniques and interviewing skills (P < .05). Self-assessment of residents' interest, confidence, and competence in AOD issues improved significantly for intervention residents vs controls (P < .05). CONCLUSIONS: Pediatric residents receiving an experiential AOD curriculum increased their knowledge and clinical skills in AOD issues significantly more than residents receiving no formal training. Similar curricula and evaluation could be used by other primary care residency programs and could be implemented in other areas of adolescent health risk behaviors.
Subject(s)
Alcohol Drinking , Curriculum , Health Knowledge, Attitudes, Practice , Internship and Residency/methods , Pediatrics/education , Pharmaceutical Preparations , Adolescent , Adult , Female , Humans , MaleABSTRACT
PURPOSE: To determine the prevalence of cigarette, alcohol and other drug use and associated factors of use among predominantly Caucasian small-city pregnant adolescents, a little-studied population. METHODS: At the initial prenatal visit 117 enrollees completed a self-administered questionnaire. Patients provided urine samples for drug metabolites. Chart review determined medical provider documentation of substance use. RESULTS: Thirty-five percent of patients were positive for alcohol or other drug use by questionnaire self-report, provider report or initial urine drug screening test. Thirteen percent of patients were positive for at least one drug metabolite in the urine. Multiple logistic regression analysis indicated a model with four significant risk factors associated with pregnant adolescent alcohol and other drug use: lack of closeness with the father of the baby, neither parent in the home, patient experiencing consequences of alcohol and other drug use, and father of the baby experiencing consequences of alcohol and other drug use. CONCLUSIONS: The high prevalence of cigarette, alcohol and other drug use in this predominantly Caucasian sample was comparable to previous inner city data. Awareness of risk factors may improve identification and management of substance use among pregnant adolescents.
PIP: During May 1990-July 1991, health workers recruited 117 pregnant adolescents at two hospital-based perinatal clinics and two family practice residency clinics in Madison, Wisconsin, into a study designed to determine the prevalence of cigarette, alcohol, and other drug use among pregnant teenagers in a small US city. 68.4% of the teenagers were Caucasian. They underwent a urine drug screening for amphetamines, benzodiazepines, cannabinoids, cocaine, opiates, LSD, and phencyclidine at the initial and third-trimester visits. The provider reviewed the medical record from the initial prenatal visit detailing the history of substance abuse. Based on the self-reports, 48.3% smoked cigarettes, 8.6% drank alcohol, and 7.7% used other drugs. 12.8% of the patients tested positive for at least one drug metabolite. These prevalences were similar to those of other inner city data. The medical provider report showed that 56.3% had used tobacco, 22.7% had used alcohol, and 11.4% had used other drugs. Medical providers detected 98.2% of the cigarette smokers, 60% of the alcohol users, and only 25% of the users of other drugs. During the third-trimester visit, 8 of 81 patients (9.9%) tested positive for marijuana (6) and cocaine (2). Of these 81 teenagers, 16 were positive for other drug use either at the first- or third-trimester visits. Three tested positive for other drug use during both visits. No significant difference in the percentage of cigarette smokers between positive and negative substance users existed. Risk factors for alcohol and other drug use included: neither parent at home (odds ratio [OR] = 3.47); father of the baby not close to the pregnant teenager (OR = 10.26); father of the baby had at least one consequence related to alcohol and other drug use (OR = 3.45); and pregnant teenager had at least one consequence related to alcohol and other drug use (OR = 8.19). These findings suggest that if clinicians are aware of these risk factors, identification and management of substance use among pregnant teenagers will improve.
Subject(s)
Alcohol Drinking/epidemiology , Pregnancy in Adolescence , Smoking/epidemiology , Substance Abuse Detection , Substance-Related Disorders/epidemiology , Adolescent , Alcohol Drinking/psychology , Female , Humans , Logistic Models , Pregnancy , Pregnancy in Adolescence/psychology , Prevalence , Risk Factors , Smoking/psychology , Substance-Related Disorders/psychology , Surveys and Questionnaires , Wisconsin/epidemiologyABSTRACT
Fetal embryo, head, and brain tissue from different gestational ages were analyzed for retinol content, nuclear retinoic acid receptor and cytosolic retinoic acid binding protein levels after maternal ethanol ingestion and compared with fetal levels in control diet pregnancies. Retinol levels in fetal embryo and brain of ethanol-ingesting pregnancies were 2- to 3-fold higher than fetal embryo and brain retinol of control pregnancies. Nuclear retinoic acid receptor was lower in 10-day embryo of ethanol pregnancies and apparently unaffected in fetal head and brain by maternal ethanol consumption at other days of gestation. In fetal head there was a significant overall ethanol effect on cytosolic retinoic acid binding protein, with increased levels in fetal tissue from ethanol-consuming pregnancies. These observations of altered embryo, fetal head, and fetal brain retinol and receptor protein levels support the hypothesis of a possible role of vitamin A in fetal alcohol syndrome.
Subject(s)
Alcohol Drinking/physiopathology , Brain/embryology , Fetal Alcohol Spectrum Disorders/embryology , Vitamin A/metabolism , Animals , Embryonic and Fetal Development/physiology , Female , Gestational Age , Humans , Infant, Newborn , Liver/embryology , Maternal-Fetal Exchange/physiology , Pregnancy , Rats , Rats, Sprague-Dawley , Tretinoin/metabolismABSTRACT
Preterm infants often receive immunizations late or in reduced dosage. The purpose of this study was to describe the knowledge of parents of preterm infants about immunizations. We sent a questionnaire to the parents of preterm infants who attended our Neonatal Follow-up Clinic. Of the 112 families who returned the survey, only 45% correctly answered that preterm infants should be immunized at the same age as full-term infants. Nearly 40% of parents stated that "how premature the baby was" influenced time of immunization. Over 25% reported that the infant had to reach a minimum weight to be immunized. Parents who received information from neonatal intensive care or Neonatal Follow-up Clinic staff or a public health nurse were not more correctly informed about immunizations. Parents of prematures often are not correctly informed about immunizations. Information about immunizations for preterm infants should be incorporated into NICU discharge planning.
Subject(s)
Diphtheria-Tetanus-Pertussis Vaccine , Immunization , Infant, Premature , Parents/psychology , Adult , Female , Health Knowledge, Attitudes, Practice , Humans , Infant, Newborn , Male , Surveys and QuestionnairesABSTRACT
A new clinical scoring system for patients with cystic fibrosis is needed because of recent advances in diagnosis and treatment which have changed the course of this disease. Chest radiograph scoring is the best objective measure of pulmonary disease for longitudinal studies beginning with infants; however, based on pilot studies, previous scoring systems are not sensitive enough in discriminating between degrees of mild lung disease. Therefore, a new radiographic scoring system was developed with the goal of achieving both sensitivity and reproducibility. This objective was pursued by applying multiattribute utility theory, using a panel of interpreters with expertise in cystic fibrosis radiology, and employing mathematical modeling techniques to weight the various components. The system was developed and validated in three phases including comparison to the Brasfield method of quantitative radiology. The data demonstrate that the new system can be applied reliably and conveniently to generate reproducible scores of pulmonary disease severity. Evaluation of the scores by four independent raters using chest radiographs from 61 patients at an average age of 8.37 years revealed good agreement with a .714 Kendall coefficient of concordance. Assessment of serial changes over time was performed using a group of 176 chest radiographs from 25 patients ranging from 4 weeks to 6 years old; this showed that the Wisconsin system generates score differences that are greater in magnitude with disease progression compared with the Brasfield method. Therefore, the new method is more sensitive to progression of mild disease and should be superior to prior radiographic scoring systems for evaluating therapies designed to modify the early course of disease. The Wisconsin system is designed to be useful in longitudinal clinical studies involving young children with cystic fibrosis and is capable to detecting progression from normality to mild lung disease.
Subject(s)
Cystic Fibrosis/diagnostic imaging , Neonatal Screening/methods , Severity of Illness Index , Adolescent , Adult , Child , Child, Preschool , Cystic Fibrosis/classification , Cystic Fibrosis/epidemiology , Data Collection/methods , Evaluation Studies as Topic , Hospitals, Pediatric , Hospitals, University , Humans , Infant , Infant, Newborn , Medical Records/standards , Models, Statistical , Neonatal Screening/instrumentation , Neonatal Screening/standards , Radiography , Reproducibility of Results , Respiratory Function Tests/standards , Sensitivity and Specificity , Wisconsin/epidemiologyABSTRACT
Stretched diameter of the atrial septal defect (ASD), determined by balloon sizing at cardiac catheterization, is commonly used to select the sizes of the devices used for transcatheter closure of the secundum ASD. We have previously evaluated the utility of pulmonary/systemic flow ratio and angiographic and echocardiographic (echo) sizes of the ASD in estimating stretched ASD diameter in a group of 16 patients and determined that echo diameter had the best correlation with stretched diameter (r = 0.82; p less than 0.001). The stretched diameter can be estimated: 1.05 x echo diameter in millimeters + 5.49. In this study we have prospectively evaluated this formula in estimating the stretched ASD diameter by two-dimensional echo measurements obtained in two (long and short-axis) subcostal views in another group of 21 patients aged 2.5 to 29 years (median 4.5 years). The echo size of the ASD was 9.7 +/- 3.0 mm, whereas the measured stretched diameter was 15.3 +/- 4.0 mm. The predicted stretched ASD diameter was calculated according to the above formula and was 15.7 +/- 3.1 mm, not significantly different (p greater than 0.1) from the measured stretched diameter. The correlation between predicted and measured stretched ASD sizes was excellent (r = 0.9; p less than 0.001). The mean squared error was 2.4. The differences between measured and predicted values were within 2 mm in all but three patients. It is concluded that stretched ASD diameter can be estimated accurately by two-dimensional subcostal echo measurements, which in turn could be used for selection of device size for occlusion of the ASD.
Subject(s)
Echocardiography , Heart Septal Defects, Atrial/diagnostic imaging , Heart Septal Defects, Atrial/therapy , Prostheses and Implants , Catheterization , Child, Preschool , Heart Septal Defects, Atrial/epidemiology , Humans , Predictive Value of TestsABSTRACT
Recombinant hGH (rhGH) augments short-term linear growth in experimental animals and children with chronic renal failure. Significant augmentation of final height, however, requires prolonged growth hormone therapy during years of growth. The effects of prolonged rhGH treatment on linear growth, progression of renal dysfunction, and longevity in the setting of renal insufficiency are unknown. We examined at 9, 15, and 25 wk growth in length and weight, glomerular filtration rate measured by inulin and creatinine clearance, food efficiency (g ingested/weight gained), and survival in treated (U-GH) and untreated (U) 75% nephrectomized uremic rats and in treated (S-GH) and untreated (S) sham-operated rats. We also measured kidney weight to body weight ratios at the time the rats were killed. Treatment was rhGH 1.0 mg s.c. three times a week during wks 4-12 of life. Length of U-GH rats was greater than that of U rats (p less than 0.05) at 15 and 25 wk (but not at 9 wk) and equal to that of S rats throughout the study. Length of S-GH rats exceeded that of S rats. At 9 wk, weight was diminished in both U and U-GH rats (p less than 0.05) versus S and S-GH rats; by 15 wk, U-GH rat weight was equal to S rat weight. Glomerular filtration rate measured by creatinine was markedly reduced in U and U-GH rats and did not increase in response to prolonged rhGH in either U-GH or S-GH rats. Diminished food efficiency of U rats versus S rats (p less than 0.05) was not improved significantly by rhGH.(ABSTRACT TRUNCATED AT 250 WORDS)
Subject(s)
Growth Hormone/administration & dosage , Kidney Failure, Chronic/drug therapy , Animals , Glomerular Filtration Rate/drug effects , Growth/drug effects , Growth Disorders/drug therapy , Growth Disorders/etiology , Kidney/drug effects , Kidney/pathology , Kidney/physiopathology , Kidney Failure, Chronic/complications , Kidney Failure, Chronic/pathology , Male , Rats , Rats, Inbred Strains , Time FactorsABSTRACT
Preterm infants often receive their diphtheria-tetanus-pertussis (DTP) immunizations on a delayed schedule or in reduced dosage. Since primary care physicians (PCPs) immunize many preterm infants, the purpose of this study was to describe PCPs' knowledge about the use of DTP immunizations in preterm infants. Among the 479 PCPs who completed the questionnaire, 84% of pediatricians and 60% of family physicians correctly identified chronologic age as a criterion for initiating DTP immunizations in preterm infants. However, nearly 45% of PCPs linked this with other criteria such as a minimum weight requirement. Family physicians' answers differed from the recommendations more often than pediatricians' answers. The answers of pediatricians and family physicians who completed residency greater than 20 years ago differed from the recommendations more often than those who completed training less than or equal to 20 years ago. The answers of PCPs with fewer than five preterm infants in their practices differed from the recommendations more frequently than the answers of those with five or more preterm infants in their practices. Educational interventions are needed to bring PCPs' knowledge and practices into compliance with the American Academy of Pediatrics recommendations concerning DTP immunizations for preterm infants.
Subject(s)
Diphtheria-Tetanus-Pertussis Vaccine/administration & dosage , Health Knowledge, Attitudes, Practice , Infant, Premature , Physicians, Family , Practice Patterns, Physicians' , Age Factors , Body Weight , Humans , Immunization Schedule , Infant, Newborn , Infant, Premature, Diseases , Odds Ratio , Pediatrics , Regression AnalysisABSTRACT
The purpose of this study was to characterize the nutritional status of infants diagnosed with cystic fibrosis (CF) through neonatal screening and to determine if they would achieve normal nutrition when managed with early intervention. In addition, nutrient intake was assessed to determine energy and macronutrient-consumption patterns. Evaluation of growth revealed that normal patterns could be achieved with mean energy intake values at ages 6 and 12 mo of 481 and 426 kJ/kg body wt (115 and 102 kcal/kg body wt), respectively. Biochemical assessment demonstrated low alpha-tocopherol and linoleic acid values at diagnosis in the majority of infants whereas one-third had abnormal indices of protein nutriture. Essential fatty acid deficiency was also demonstrated at diagnosis by abnormal triene-tetraene ratio values in 27% of screened infants. With predigested formula and dietary supplementation, there was improvement in all indices of nutritional status and only a low percentage of patients showed mild biochemical abnormalities at age 12 mo.
Subject(s)
Cystic Fibrosis/physiopathology , Nutritional Status , Anthropometry , Birth Weight , Cystic Fibrosis/diagnosis , Cystic Fibrosis/therapy , Diet , Humans , Infant , Severity of Illness Index , Time FactorsABSTRACT
Stretched diameter of the atrial septal defect (ASD), measured by balloon sizing, is generally used as a guide to the selection of the size of the device utilized for transcatheter closure of the ASD. Balloon sizing is a cumbersome procedure and sometimes requires the use of very large size balloon catheters. Several methods of assessment of ASD size, namely, echographic, pulmonary-to-systemic flow ratio (Qp:Qs), and angiographic measures, were undertaken in a group of 16 patients, aged 7 months to 45 years (median, 4.5 years), who were being evaluated for transcatheter closure of ASD; the results were compared with the stretched diameter. Although the echographic size of the ASD (9.9 +/- 4.1 mm, mean +/- SD) is similar (p greater than 0.1) to the angiographic size (7.9 +/- 2.5 mm), it is much smaller (p less than 0.01) than the stretched diameter (16.1 +/- 5.3 mm). When the relationship between various measures of ASD was examined, although the Qp:Qs ratio and angiographic size have a significant (p less than 0.05) correlation with the stretched diameter (r = 0.55 and 0.54, respectively), the echo diameter has the best correlation coefficient, r = 0.82, p less than 0.001. The stretched diameter can be estimated by the equation: 1.05 x echo + 5.49 mm. It is concluded that the echographic diameter is a useful adjunct in the estimation of the stretch ASD diameter, which in turn can be used in the selection of the size of the device for transcatheter occlusion of the ASD.
Subject(s)
Catheterization/methods , Cineangiography , Echocardiography , Heart Septal Defects, Atrial/diagnosis , Prostheses and Implants , Cardiac Catheterization , Child, Preschool , Heart Septal Defects, Atrial/pathology , Heart Septal Defects, Atrial/therapy , HumansABSTRACT
Presymptomatic infants diagnosed through neonatal screening for cystic fibrosis can have biochemical evidence of malnutrition. With aggressive dietary management and treatment with pancreatic enzymes, normal biochemical indices of nutrition can be achieved at 12 months of life in most cases. Males with cystic fibrosis appear to be more at risk than females for abnormal growth and biochemical indices of nutrition in the first year of life. This may be related to the observed decrease in fat intake when compared to females. Males, especially, should be carefully observed for development of nutritional abnormalities based on this data. Careful attention should be paid to vitamin E and essential fatty acid status in all CF infants. The numbers in this study are small and the long-term consequences of early nutritional intervention await the conclusion of the randomized, controlled study on-going in Wisconsin.