Infant

Background: The WHO recommends exclusive breastfeeding (EBF) for 6 mo after birth. However, the time at which breast milk ceases to provide adequate energy and nutrition, requiring the introduction of complementary foods, remains unclear. Most studies that investigated this issue were observational and potentially confounded by variability in social circumstances or infant growth. Objective: We hypothesized that EBF infants would consume more breast milk at age 6 mo than infants receiving breast milk and complementary foods. Design: We measured anthropometric outcomes, body composition, and breast-milk intake at age 6 mo in infants who were randomly assigned at age 4 mo either to 6-mo EBF or to the introduction of complementary foods with continued breastfeeding. We recruited 119 infants from health centers in Reykjavik and neighboring municipalities in Iceland. In 100 infants who completed the protocol (50/group), breast-milk intake was measured by using stable isotopes, and complementary food intakes were weighed over 3 d in the complementary feeding (CF) group. Results: Breast-milk intake was 83 g/d (95% CI: 19, 148 g/d) greater in EBF (mean 6 SD: 901 6 158 g/d) than in CF (818 6 166 g/d) infants and was equivalent to 56 kcal/d; CF infants obtained 63 6 52 kcal/d from complementary foods. Estimated total energy intakes were similar (EBF: 560 6 98 kcal/d; CF: 571 6 97 kcal/d). Secondary outcomes (anthropometric outcomes, body composition) did not differ significantly between groups.

Objective: To examine the significance of neonatal risk factors from the individual, family, social, and parenting behavior domains of the ecological model of child maltreatment in predicting maltreatment reports in the first 4 years of life, and to examine the extent to which the interactions of life event stress and social support modify those risk factors. Method: Mothers of 708 predominantly at-risk infants were interviewed in their homes soon after their infants' discharge from the hospital. State child abuse and neglect central registry data were tracked every 6 months until the infants reached their fourth birthdays. Results: The incidence of maltreatment reports was higher in households where the mothers were depressed, complained of psychosomatic symptoms, had not graduated from high school, consumed alcohol, participated in public income support programs, cared for more than one dependent child, or were separated from their own mothers at age 14 years (p Ͻ .1). In interaction models including these seven predisposing variables, there were significant interactions (p Ͻ .01) between social support, as measured by the social well-being index after the birth of the index child, and depression, and between social well-being and stress, as measured by an increase in total life events. Conclusion: Some predisposing risk factors measured soon after birth continue to be significant predictors of child maltreatment reports through the fourth year of life. In general, families with low levels of social support had a higher risk of a maltreatment report. For families with lower levels of maternal depression and/or life event stress, low social support significantly increased the risk of a maltreatment report by as much as a factor of four.

Mitochondrial DNA depletion syndromes (MDSs) form a group of autosomal recessive disorders characterized by profoundly decreased mitochondrial DNA copy numbers in affected tissues. Three main clinical presentations are known: myopathic, encephalomyopathic and hepatocerebral. The first is associated with mutations in thymidine kinase 2 (TK2) and p53-induced ribonucleotide reductase B subunit (RRM2B); the second with mutations in succinate synthase A (SUCLA2) and B (SUCLG1); the third with mutations in Twinkle (PEO1), pol-γA (POLG1), deoxyguanosine kinase (DGUOK) and MPV17 (MPV17). In this work, we review the MDS-associated phenotypes and present our own experience of 32 MDS patients, with the aim of defining the mutation frequency of the known genes, the clinical spectrum of the diseases, and the genotype–phenotype correlations. Five of our patients carried previously unreported mutations in one of the eight MDS genes.

interaction infant − Oxytocin shapes parental motion during father Supplementary data ml An infant-oriented parental repertoire contributes to an infant's development and well-being. The role of oxytocin (OT) in promoting affiliative bonds and parenting has been established in numerous animal and human studies. Recently, acute administration of OT to a parent was found to enhance the carer's, but at the same time also the infant's, physiological and behavioural readiness for dyadic social engagement. Yet, the exact cues that are involved in this affiliative transmission process remain unclear. The existing literature suggests that motion and vocalization are key social signals for the offspring that facilitates social participation, and that distance and motion perception are modulated by OT in humans. Here, we employed a computational method on video vignettes of human parent-infant interaction including 32 fathers that were administered OT or a placebo in a crossover experimental design. Results indicate that OT modulates parental proximity to the infant, as well as the father's head speed and head acceleration but not the father's vocalization during dyadic interaction. Similarly, the infant's OT reactivity is positively correlated with father's head acceleration. The current findings are the first to report a relationship between the OT system and parental motion characteristics, further suggesting that the cross-generation transmission of parenting in humans might be underlaid by nuanced, infant-oriented, gestures relating to the carer's proximity, speed and acceleration within the dyadic context.

There are frequent applications for endoscopy in neurosurgery. However, endoscopic surgery in children has peculiar characteristics and is associated with different rates of success. In this study, the authors report on their experience with 134 consecutive endoscopy procedures performed in 126 patients<18 years of age. Between April 1993 and October 2007, 134 endoscopic procedures were performed in 126 children. Indications for surgery included brain tumors in 48 children, cystic lesions in 24, aqueductal stenosis in 23, various malformations in 20, hemorrhage and infarction in 6, and isolated ventricles in 5 children. In this long-term followup study, data were analyzed with respect to clinical and radiological success rates, as well as shunt dependence both in relation to lesion origin, and to the type of endoscopic procedure performed (endoscopic third ventriculostomy [ETV], septostomy, aqueductoplasty, or cystocisternostomy). Finally, the influence of patient age on the succ...

The development of imitation during the second year of life plays an important role in domains of socio-cognitive development such as language and social learning. Deficits in imitation ability in persons with autism spectrum disorder (ASD) have also been repeatedly documented from toddlerhood into adulthood, raising the possibility that early disruptions in imitation contribute to the onset of ASD and the deficits in language and social interaction that define the disorder. This study prospectively examined the development of imitation between 12 and 24 months of age in 154 infants at familial risk for ASD and 78 typically developing infants who were all later assessed at 36 months for ASD or other developmental delays. The study established a developmental measure of imitation ability, and examined group differences over time, using an analytic Rasch measurement model. Results revealed a unidimensional latent construct of imitation and verified a reliable sequence of imitation skills that was invariant over time for all outcome groups. Results also showed that all groups displayed similar significant linear increases in imitation ability between 12 and 24 months and that these increases were related to individual growth in both expressive language and ratings of social engagement, but not fine motor development. The group of children who developed ASD by age 3 years exhibited delayed imitation development compared to the low-risk typical outcome group across all time-points, but were indistinguishable from other high-risk infants who showed other cognitive delays not related to ASD.

Objectives: Recent studies have suggested that survival following the Norwood procedure is influenced by anatomy and is worse for patients with hypoplastic left heart syndrome (HLHS), particularly aortic atresia (AA), as compared to other forms of functional single ventricle and systemic outflow tract obstruction. The current study was undertaken to evaluate our recent experience with the Norwood procedure and to evaluate potential predictors of operative and 1-year mortality. Methods: A retrospective study of risk factors for operative and 1-year mortality in 158 patients undergoing the Norwood procedure between January 1, 1998 and June 30, 2001. Results: HLHS was present in 102 patients (70 with AA) and other forms of functional single ventricle with systemic outflow tract obstruction in the remaining 56. Operative survival was 77% (122/158), 78% for patients with HLHS and 75% for patients with other diagnoses. Multivariable analysis identified birth weight (odds ratio (OR) 0.18/kg, 95% confidence limit (CL) 0.08-0.42, P , 0:001), associated cardiac anomalies (OR 4.45, 95% CL 1.50-13.2, P ¼ 0:001), total support time (OR 1.02/min, 95% CL 1.01-1.03, P ¼ 0:004), and extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) support (OR 17.8, 95% CL 4.40-71.0, P , 0:001) as predictors of operative mortality. The anatomic diagnosis (HLHS versus non-HLHS) was not a predictor of mortality, P ¼ 0:6). The Kaplan-Meier survival estimate at 1 year was 66% (95% CL 58-73%) and was not different for patients with HLHS compared to non-HLHS, P ¼ 0:5. For patients who have survived the Norwood procedure, survival to 1 year was 86% (95% CL 78-91%). Presence of an extra-cardiac anomaly or genetic syndrome (OR 2.70, 95% CL 0.98-7.41%, P ¼ 0:05) and presence of an additional cardiac defect (OR 3.99, 95% CL 1.67-9.57, P ¼ 0:002) were predictors of worse survival in the first year of life. Conclusions: The Norwood procedure is currently being applied to a heterogeneous group of patients. Operative and 1-year survival are equivalent for patients with HLHS and those with other cardiac defects. The presence of additional cardiac or extra-cardiac anomalies are predictors of poor outcome. q

Background-Transcranial Doppler ultrasonography (TCD) is used to predict stroke risk in children with sickle cell anemia (SCA), but has not been adequately studied in children under age 2 years. Procedure-TCD was performed on infants with SCA enrolled in the BABY HUG trial. Subjects were 7-17 months of age (mean 12.6 months). TCD examinations were successfully performed in 94% of subjects (n=192). Results-No patient had an abnormal TCD as defined in the older child (time averaged maximum mean velocity ≥ 200cm/sec) and only 4 subjects (2%) had velocities in the conditional range (170-199cm/sec). TCD velocities were inversely related to hemoglobin concentration and directly related to increasing age. Conclusion-Determination of whether the TCD values in this very young cohort of infants with SCA can be used to predict stroke risk later in childhood will require analysis of exit TCD's and long-term follow-up, which is ongoing. (ClinicalTrials.gov number, NCT00006400

Safety, reactogenicity and immunogenicity of GSK Biologicals' hexavalent DTPa-HBV-IPV/Hib vaccine (Infanrix)hexa) was assessed when used for primary vaccination at 3, 4 and 5 months of age (N = 2163), compared to the separate administration of DTPa-IPV/Hib and HBV vaccines (N = 720). A similar safety and reactogenicity profile was demonstrated for both vaccine regimens, as well as a good immune response for all antigen components. By offering protection against six diseases in a series of single injections, the hexavalent DTPa-HBV-IPV/Hib vaccine was shown to be a safe, well tolerated and immunogenic alternative to primary immunization with licensed separately administered vaccines.

This paper describes the outcomes in six children with hypoplastic cochlear nerves, demonstrated on magnetic resonance imaging who were selected for implantation because they had clear responses to sound, with hearing aids. In four of the six children the internal auditory canals were abnormally narrow; however in the remaining two the internal auditory canals were of normal width. After activation of their devices, all six children had auditory thresholds within the normal range for implanted congenitally deaf children. However the progress of all these children after 2 to 6 years of implant use turned out to be disappointing. Five of the children developed only the ability to detect the presence of sound, and were unable to discriminate accurately between speech sounds. They remain at Category of Auditory Performance (CAP) level 2: sign is their primary mode of communication. All fi ve children also remain at Speech Intelligibility Rating (SIR) level 2, with unintelligible connected speech. The sixth child was able to develop some understanding of common phrases through listening alone, however he remains at CAP level 4 and his SIR level also remains at 2. The benefi t of cochlear implantation in this group of children is likely to be considerably restricted. In specifi c cases it may be appropriate to offer a cochlear implant to a child with hypoplastic auditory nerves but careful counselling of the family about likely outcomes is essential.

Background. Perioperative myocardial injury is a major determinant of postoperative cardiac dysfunction for congenital heart disease, but its assessment during this period is difficult. The objective of this study was to determine the suitability of using postoperative serum concentrations of cardiac troponin I (cTnI) for this purpose.

In this paper, we revisit the revolutionary principles-equity, social justice, and health for all; community participation; health promotion; appropriate use of resources; and intersectoral action-raised by the 1978 Alma-Ata Declaration, a historic event for health and primary health care. Old health challenges remain and new priorities have emerged (eg, HIV/AIDS, chronic diseases, and mental health), ensuring that the tenets of Alma-Ata remain relevant. We examine 30 years of changes in global policy to identify the lessons learned that are of relevance today, particularly for accelerated scale-up of primary health-care services necessary to achieve the Millennium Development Goals, the modern iteration of the "health for all" goals. Health has moved from under-investment, to single disease focus, and now to increased funding and multiple new initiatives. For primary health care, the debate of the past two decades focused on selective (or vertical) versus comprehensive (horizontal) delivery, but is now shifting towards combining the strengths of both approaches in health systems. Debates of community versus facility-based health care are starting to shift towards building integrated health systems. Achievement of high and equitable coverage of integrated primary health-care services requires consistent political and fi nancial commitment, incremental implementation based on local epidemiology, use of data to direct priorities and assess progress, especially at district level, and eff ective linkages with communities and non-health sectors. Community participation and intersectoral engagement seem to be the weakest strands in primary health care. Burgeoning task lists for primary health-care workers require long-term human resource planning and better training and supportive supervision. Essential drugs policies have made an important contribution to primary health care, but other appropriate technology lags behind. Revitalisng Alma-Ata and learning from three decades of experience is crucial to reach the ambitious goal of health for all in all countries, both rich and poor.

Background. Estimates of US childhood asthma prevalence were affected by the 1997 National Health Interview Survey (NHIS) redesign. In 1997, only 5.5% of children were estimated to have asthma compared with 7.5% in 1995. The contribution of the survey redesign to this reported decline is unknown. Objective. To examine the impact of the NHIS 1997 redesign on childhood asthma prevalence estimates. Methods. In 1988, 50% of children from the core NHIS participated in a Child Health Supplement (CHS). The CHS questions differ from those in the core NHIS and are similar to the new asthma questions used in the 1997 NHIS. First, childhood asthma prevalence estimates from the 1988 core NHIS and the CHS were directly compared. A second comparison was limited to the sample participating in both the core NHIS and the CHS. For this sample, the percent difference between core NHIS and CHS estimates was calculated for 6 race/age strata (black and white, ages 0-4, 5-10, and 11-17 years). The 1997 estimates for each stratum were adjusted by these differences, and a new adjusted 1997 estimate was produced using the 1997 population distribution for each stratum. Results. The first method resulted in an 18.6% difference between asthma prevalence estimates from the 1988 core NHIS and CHS (5.1% vs. 4.3%). Simply inflating the 1997 asthma prevalence estimate of 5.5% by 18.6% yielded an adjusted estimate of 6.5%. The second stratification method produced an adjusted 1997 asthma prevalence estimate of 7.3%. Conclusion. The redesigned NHIS likely produces lower asthma prevalence estimates than the previous NHIS. Adjusting the 1997 estimate to compensate for the redesign suggests that childhood asthma prevalence has plateaued since 1995, not declined.

The longitudinal growth in stature for 509 males and 311 females was characterized from early childhood to adulthood. A triphasic generalized logistic (BTT) model (Bock et al. [1994] Chicago: SSI) was used through the AUXAL software program. Growth parameters were derived from the estimated distance and velocity curves for each individual. A set of estimated growth parameters, including adult stature, was selected to develop equations, through the forward stepwise regression method, for the prediction of adult stature for Japanese boys and girls. Am.

Dyssomnias Sleep duration Early childhood Risk factors Consequences Model s u m m a r y Dyssomnias are largely under-diagnosed in infants and toddlers. This literature review proposes an integrative model based on empirical data on determinants and consequences of sleep disturbances occurring in early life. This model proposes that parental behaviors that impede the child's autonomy toward sleep periods are primary grounds for the development of dyssomnias, e.g., parental presence until the child falls asleep, and putting an already sleeping child to bed. The model also indicates the serious potential consequences of a modest but chronic loss of sleep in childhood. At least three developmental domains could be directly affected: behavioral/social competence, cognitive performance, and physical condition. Thus, children with short nocturnal sleep duration before age 3.5 years show increased risk of high hyperactivity-impulsivity scores and low cognitive performance at 6 years compared to children who sleep 11 h per night, after controlling for potentially confounding variables. Moreover, persistent short sleep duration in early infancy increased the risk of suffering of obesity at 6 years of age, after controlling for potentially confounding variables. Finally, the importance of allowing the child to sleep at least 10 h per night in early childhood is stressed, as the National Sleep Foundation Poll suggests, for optimal child development.

Background Rickets affects young infants and toddlers. However, there is a paucity of literature regarding the types of fractures that occur in rachitic patients. Objective To evaluate the age of patients at which radiographically evident rickets occurs, and to characterize the age incidence and fractures that are observed in infants and toddlers with radiographically evident rickets. Materials and methods A retrospective study of children younger than 24 months was performed. Clinical data and radiographs were reviewed. Radiographs obtained within 1 month of the diagnosis were evaluated for the presence or absence of osteopenia, presence or absence of fraying–cupping, and presence and characterization of fractures. Results After exclusion criteria were applied, 45 children were included in the study. Children with rickets evident by radiograph were in the age range of 2–24 months. Fractures were present in 17.5% of the study group, exclusively in mobile infants and toddlers. Fracture types included transverse long bone fractures, anterior and anterior-lateral rib fractures, and metaphyseal fractures. All fractures occurred exclusively in patients with severe, overtly evident rickets. Conclusion Fractures occur in older infants and toddlers with overt rickets and can be seen by radiograph. Fractures do not resemble high-risk non-accidental trauma fractures.

This research aimed to develop a Fetal Alcohol Behavior Scale (FABS) that describes the behavioral essence of fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE), regardless of age, race, sex, and 10. Using a reference sample of 472 diagnosed patients with FAS or FAE, ages 2 to 51, five studies are described. The FABS demonstrates high item-to-scale reliability (Cronbach's (Y = 0.91) and good test-retest reliability (r = 0.69) over an average interval of 5 years. It identifies many of the subjects with known or presumed prenatal alcohol exposure in detection studies using both prison and general samples. FABS scores also predict dependent living among adult patients with FASIFAE. The FABS is uncorrelated with 10, sex, age, race, and diagnosis (FAS versus FAE). We outline areas of further work to define the specificity and utility of this FABS.

Background: The incidence of residual ventricular septal defects (VSDs) after surgery is 5-25%. Redo surgery is associated with higher risks. Methods: Between January 2000 to December 2008, 170 patients underwent percutaneous VSD closure in our centre: 22(16M) of these had 23 closures for residual VSDs. Median age was 32.5 yrs (1.4-79). All patients had echocardiographic signs of left ventricle volume overload (Q p /Q s ! 1.5). Nine patients had previous VSD closure, 6 tetralogy of Fallot repair, and 7, other procedures. There were 15 muscular, 6 perimembranous and 2 apical VSDs. Results: Amplatzer VSD devices were used in all. Median VSD size was 8 mm (4.3-16). Median fluoroscopy time was 33 minutes (15-130). There were three adverse events: 1 ventricular fibrillation requiring DC cardioversion; 1 transient complete atrio-ventricular block reverting to sinus rhythm at 24-hours; one patient had transient atrial flutter during the procedure. All procedures were successful; no additional procedures were required. Trivial residual shunts were seen in 3 patients at follow-up. There were no late events. One patient experienced arrhythmic death 5-yrs after procedure. One patient was reoperated due to dehiscence of VSD patch 2-yrs after the second successful percutaneous closure. Conclusions: Transcatheter closure of postsurgical residual VSD is safe and efficacious management option and obviates the need for further surgery and by-pass. V C 2009 Wiley-Liss, Inc.

Dear Editor, Cochlear implantation in congenital and acquired deafness is an approved auditory rehabilitation treatment. Malformations are of special interest nowadays, as the indication for cochlear implant surgery is expanding. Inner-ear malformations constitute about 20% of congenital sensorineural hearing loss. 1 In a retrospective evaluation, we found 12% malformations in children and 3% malformations in adults. 2 In 1987, Jackler 1 presented a classification of inner-ear malformations, based on the embryological genesis. Sennaroglu and Saatci 3 suggested an extension, based on the initial classification. The basic classification distinguishes malformations of the cochlea and vestibular labyrinth, and additionally abnormalities of the internal auditory canal (IAC). This classification provides an excellent basis for detecting malformations of the inner ear. Nevertheless, it must be expanded to include malformations due to syndromes, which, in their complexity, are not simple to classify, for example innerear malformations in Mondini dysplasia, CHARGE-syndrome and X-linked deafness syndrome. We used these classifications in 29 patients as a basis for a newly developed flow chart which enabled us to preoperatively calculate adaptation of the surgical procedure according to the extent of the malformations. The description of our flow chart is based on two patients with complex malformations of the labyrinth.

10. DC cultures were generated as described (5, 22). Immature I-A kϩ DCs grown from C3H/HeN, C3H/HeJ, and CBA/J (Jackson Labs, Bar Harbor, ME) marrow suspensions were pulsed with HEL (1 to 3 mg/ml) with or without LPS (1 to 10 ng/ml, E. coli 0111.B4) for 1 to 3 hours, washed, and chased in HEL-and LPS-free media. Similar results were obtained with DCs from each strain. DC cultures contained supernatant from mGM-CSFexpressing J558L cells (from A. Lanzavecchia, Basel Institute, Basel, Switzerland). LPS was removed from HEL (Sigma) with Kuttsuclean adsorbent (Maruha Corporation, Ibaraki, Japan). Maturation stimuli included LPS, CD40L, tumor necrosis factor-␣, or replating (22). 11. DCs were fixed with 4% (wt/vol) paraformaldehyde and washed in phosphate-buffered saline. Cells were incubated with monoclonal antibodies (mAbs) on ice as described (23). The rat mAb C4H3 was provided by R. Germain (NIH, Bethesda, MD). C4H3 was purified on protein A-Sepharose and biotinylated. Cells were labeled with biotin-conjugated mAbs (Pharmingen) to I-E k (14-4-4S) or I-A k (10-2.16) and fluorescein

Survival rate of extremely low gestational age (ELGA) newborns has increased over 80% in the last 15 years, but its consequences on the short-and longer-term developmental competencies may be severe. The aim of this study was to describe growth trajectories of linguistic, motor and cognitive skills among ELGA children, compared to full-term (FT) peers, from the first to the third year of life, a crucial period for development. Growth curve analysis was used to examine individual and group differences in terms of initial status at 12 months and rate of growth through the second and the third year of life with five points of assessment. Twenty-eight monolingual Italian children, of whom 17 were ELGA (mean GA 25.7 weeks) and 11 were FT children, were assessed through the BSID-III at 12, 18, 24, 30 and 36 months for language skills and at 12, 24 and 30 months for motor and cognitive skills. ELGA children presented significantly lower scores than FT peers in language, motor and cognitive skills and they did not overcome their disadvantage by 3 years, even if their corrected age was taken into account. Concerning growth curves, in motor development a significant increasing divergence was found showing a Matthew effect with the preterm sample falling further behind the FT sample. In linguistic and cognitive development, instead, a stable gap between the two samples was found. In addition, great interindividual differences in rate of change were observed for language development in both samples. Our findings highlight the theoretical and clinical relevance of analyzing, through growth curve analyses, the developmental trajectories of ELGA children in language skills taking into account their inter-individual variability also across motor and cognitive domains.

Background  Extremely low and very low gestational age (ELGA and VLGA) constitutes a risk factor for development even in absence of cerebral damage, as an immature central nervous system is exposed to invasive and inadequate stimulation. We tested the hypothesis that GA impacts developmental outcomes and trajectories of preterms without major cerebral damage in the first 2 years of life, expecting poorer developmental outcomes and higher rate of impairment with the decreasing of GA. We also evaluated whether GA, together with developmental outcomes in the first year of life, was related to developmental outcomes at 24 months.Methods  Eighty-eight infants, divided into three GA groups (ELGA: ≤28 weeks; VLGA: 29–32 weeks; full term: >37 weeks) were assessed longitudinally at 6, 12, 18 and 24 months using the Griffiths Mental Development Scales.Results  Use of a repeated measure multivariate analysis of variance resulted in several significant findings. GA was associated with the developmental quotient (DQ) scores (P= 0.006); and locomotor (P < 0.001), eye and hand co-ordination (P= 0.016) and performance (P= 0.040) sub-scale quotient (SQ) scores; age of evaluation was also associated with DQ scores (P= 0.002), and locomotor (P < 0.001) and performance (P < 0.001) SQ scores. In particular, ELGAs exhibited lower DQ and SQ scores compared with the VLGA and full-term groups; some ELGAs showed mild, moderate or severe cognitive impairments, while few VLGAs mild impairments. Linear regression analysis showed that GA (P= 0.034) and 12-month developmental outcome (P < 0.001) were related to 24-month developmental outcome.Conclusions  Different developmental trajectories emerged in relation to GA, with poorer developmental outcomes and higher rates of impairment in ELGAs and few mild impairments in VLGAs. The relevance of taking into account both GA and repeated assessments in the first 2 years of life was shown.

The anatomy and physiology of nerve tissue and the peripheral nerve are reviewed. The importance of the anatomical and physiological understanding of nerve tissue in the surgical repair of nerve injuries is discussed. This includes an outline of the light and electron microscopic histology of nerve and a short review of axoplasmic flow. In addition, the nerve coverings, endoneurium, perineurium, and epineurium, are described. The relationship of these coverings to the surgical therapy of nerve injuries is outlined. By maintaining, where possible, nerve fascicle continuity and by restoring, where practical, the normal physiology of distorted but not disrupted fascicles, with the use of careful internal neurolysis, optimal clinical return of function should be achieved.

This article reports an evidence-based practice project using the Iowa Model of Evidence-Based Practice to Promote Quality Care for a common nursing procedure, nasogastric tube placement verification in children. Little research exists regarding the care of nasogastric tubes in children, and traditional verification methods prevail. Auscultation of air insufflation over the abdomen is still used to check placement in many settings, despite research dating back to the 1980s questioning this approach. X-ray remains the only certain way to verify placement, but getting an X-ray before each feeding would be costly and impractical. Additional bedside methods are needed. Project results demonstrate a decrease (93.3% to 46.2%) in the use of auscultation and improved use of other, more reliable methods to determine nasogastric tube placement. Changing practice can be challenging. However, with persistence and re-infusion, this project provides an important example of how the evidence-based ...

Introduction: With recent advances in brain imaging and neurosurgical techniques, there has been a renewed interest in the surgical separation of craniopagus twins. Successful separation in recent cases, along with widespread publicity, has attracted craniopagus twins from all over the world to be referred to pediatric neurosurgical centers for evaluation and consideration for surgical separation. Separation of blood supply: It has become apparent, however, that the most critical decisions in surgical planning are related to separation of the blood supply to the conjoined brains. In fact, in craniopagus twins that survive pregnan-cy or the first few days of life, there is usually little shared brain tissue. The shared blood supply is far and away the more critical issue. It is very difficult to successfully separate craniopagus twins in one surgical procedure. Staged separation, with gradual re-routing of the shared blood supply, has been a successful alternative. Case studies and discussion: We discuss here our experience with three sets of craniopagus twins and our approach to staged separation.

Objectives: To compare the absolute latencies of peaks I, III and V and interpeak intervals of premature and full-term children. Methods: Prospective, comparative cohort study. Study subjects were premature and full-term children with auditory brainstem response (ABR) measured at ages 4, 12 and 20 months. The children had previously undergone otorhinolaryngolic and audiologic evaluations to exclude those with altered hearing. Results: One hundred and twenty-four children were included in the study (73 premature). No differences were found between children of different sexes nor between the right and left ears of the individual children, so the statistical unit sed for the study was the ear. Using the t-test for independent samples, the absolute latencies of peaks I, III and IV and the interpeak intervals I-III, I-IV and III-V presented statistically significant differences between the groups at ages 4 and 12 months. At 20 months, only peak I failed to show a difference in absolute latency. Strong inverse correlation was found (Pearson's coefficient) between gestational age and absolute peak latency, as well as for interpeak intervals. Conclusions: Maturation of the auditory system, as measured by ABR, occurs differently between premature and full-term children, suggesting that gestational age be taken into consideration when using ABR in premature children younger than 20 months old.

This study addresses the extent to which insecure and disorganized attachments increase risk for externalizing problems using meta-analysis. From 69 samples (N = 5,947), the association between insecurity and externalizing problems was significant, d = 0.31 (95% CI: 0.23, 0.40). Larger effects were found for boys (d = 0.35), clinical samples (d = 0.49), and from observation-based outcome assessments (d = 0.58). Larger effects were found for attachment assessments other than the Strange Situation. Overall, disorganized children appeared at elevated risk (d = 0.34, 95% CI: 0.18, 0.50), with weaker effects for avoidance (d = 0.12, 95% CI: 0.03, 0.21) and resistance (d = 0.11, 95% CI: )0.04, 0.26). The results are discussed in terms of the potential significance of attachment for mental health. Support from the Netherlands Organization for Scientific Research to Marinus van IJzendoorn (NWO SPINOZA award) and to Marian Bakermans-Kranenburg (NWO VIDI grant) is gratefully acknowledged.

The current study, utilizing data from the National Early Head Start Research and Evaluation Project explored the relationship between biological father presence and emotion regulation over toddlerhood among children from low-income families. Conceptualizing biological father presence as a proxy for family role development, results are interpreted from a role development theoretical perspective. The latent growth curve model was compared based on child ethnoracial status (African American, Caucasian, Hispanic) and child gender. Consistent biological father presence was associated with toddlers' regulatory development across toddlerhood, and this relationship was most robust among Caucasian toddlers as compared to African American toddlers. Findings for Hispanic toddlers were not significantly different from those of Caucasian or African American families. Results bolster the literature on father presence and child outcomes. Analyses address consistency in father presence as a proxy for coherent role development and define a link between consistent father presence and children's regulatory development, demonstrating ethnoracial differences which are likely attributed to the social construction of family roles.

Pathologic conditions involving the temporal bone in infants and children are now commonly diagnosed by computed tomography (CT). The importance of utilizing high resolution computed tomography (HRCT) with magnified, thin (1.5 mm) scans in both the axial and coronal planes is stressed in order to obtain the maximal anatomic information that is critical for proper diagnosis. A retrospective analysis of 388 cases reveals a positive diagnostic yield ranging from 65% in temporal bone trauma to 20% in clinically suspected neoplasm. Selected case reports of congenital abnormalities, inflammatory processes, traumatic lesions, and tumors will be presented. We conclude that HRCT is an excellent diagnostic modality and should be used liberally to evaluate the temporal bone in children.

Gut microbial communities represent one source of human genetic and metabolic diversity. To examine how gut microbiomes differ among human populations, here we characterize bacterial species in fecal samples from 531 individuals, plus the gene content of 110 of them. The cohort encompassed healthy children and adults from the Amazonas of Venezuela, rural Malawi and US metropolitan areas and included mono-and dizygotic twins. Shared features of the functional maturation of the gut microbiome were identified during the first three years of life in all three populations, including age-associated changes in the genes involved in vitamin biosynthesis and metabolism. Pronounced differences in bacterial assemblages and functional gene repertoires were noted between US residents and those in the other two countries. These distinctive features are evident in early infancy as well as adulthood. Our findings underscore the need to consider the microbiome when evaluating human development, nutritional needs, physiological variations and the impact of westernization.

Background: Though noted in the clinical literature for more than 50 years, attachment disorders have been studied systematically only recently. In part because of the ubiquity of attachments in humans, determining when aberrant behavior is best explained as an attachment disorder as opposed to insecure attachment has led to some confusion. In this selective review, we consider the literature on reactive attachment disorder and disinhibited social engagement disorder and describe an emerging consensus about a number of issues, while also noting some areas of controversy and others where we lack clear answers. We include a brief history of the classification of the disorders, as well as measurement issues. We describe their clinical presentation, causes and vulnerability factors, and clinical correlates, including the relation of disorders to secure and insecure attachment classifications. We also review what little is known and what more we need to learn about interventions. Methods: We conducted a literature search using PubMed, PsycINFO, and Cochrane Library databases, using search terms 'reactive attachment disorder,' 'attachment disorder,' 'indiscriminate behavior,' 'indiscriminate friendliness,' 'indiscriminate socially disinhibited reactive attachment disorder,' 'disinhibited social engagement disorder,' and 'disinhibited social behavior.' We also contacted investigators who have published on these topics. Findings: A growing literature has assessed behaviors in children who have experienced various types of adverse caregiving environments reflecting signs of putative attachment disorders, though fewer studies have investigated categorically defined attachment disorders. The evidence for two separate disorders is considerable, with reactive attachment disorder indicating children who lack attachments despite the developmental capacity to form them, and disinhibited social engagement disorder indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries. Conclusions: Although many questions remain to be answered, especially regarding appropriate interventions, we know considerably more about attachment disorders than we did only a decade ago.

Asphyxial deaths utilising plastic bags or wrappings occurring over a 20-year period from March 1984 to February 2004 were reviewed at Forensic Science SA, Australia. A total of 45 cases were identified, with three occurring in infants and children (one accidental asphyxia; two homicides). Of the remaining 42 adults the male to female ratio was approximately 1:1 (23 and 19 cases, respectively), with all deaths attributed to suicide. The 42 adult cases represented 1.2% of the 3569 suicides autopsied at the centre over the time period of the study. The age ranges of the adult victims were 19-88 years (mean = 47.1 years) for the males, and 32-89 years (mean = 60.5 years) for the females. The adult female victims were significantly older than the males (p < 0.001). A number of victims had histories of depression and had taken prescription medications. A significant difference was found in the temporal occurrence of the adult deaths, with six cases occurring between 1984 and 1989, nine between 1989 and 1994, 11 between 1994 and 1999, and 16 between 1999 and 2004 (p < 0.001). Plastic bag asphyxial deaths were rare and in adults were due to suicide involving either older females or younger males. A significant increase in cases in South Australia in recent years was demonstrated, possibly related to publicity surrounding assisted suicides, and the ready availability of suicide manuals and information on suicide techniques from the internet.

Autism Diagnostic Observation Schedule (ADOS) Modules 1-3 item and domain total distributions were reviewed for 1,630 assessments of children aged 14 months to 16 years with an autism spectrum disorder (ASD) or with heterogeneous nonspectrum disorders. Children were divided by language level and age to yield more homogeneous cells. Items were chosen that best differentiated between diagnoses and were arranged into domains on the basis of multifactor item-response analysis. Reflecting recent research, the revised algorithm now consists of two new domains, Social Affect and Restricted, Repetitive Behaviors (RRB), combined to one score to which thresholds are applied, resulting in generally improved predictive value.

The globally escalating thyroid nodule incidence rates may be only partially ascribed to better diagnostics, allowing for the assessment of environmental risk factors on thyroid disease. Endocrine disruptors or thyroid-disrupting chemicals (TDC) like bisphenol A, phthalates, and polybrominated diphenyl ethers are widely used as plastic additives in consumer products. This comprehensive review studied the magnitude and uncertainty of TDC exposures and their effects on thyroid hormones for sensitive subpopulation groups like pregnant women, infants, and children. Our findings qualitatively suggest the mixed, significant (α = 0.05) TDC associations with natural thyroid hormones (positive or negative sign). Future studies should undertake systematic meta-analyses to elucidate pooled TDC effect estimates on thyroid health indicators and outcomes.

Operations on intersexuals indicate that the sex of a person is based on more than biology. Expectations about proper gender activities furnish the frameworks through which certain features and combinations of features are understood to be fundamental to bodies and to comprise their sex. Yet, we can ask whether this interpretation is either coherent or consistent with our fuller conceptions of ourselves. Is there a point to interpreting a person as a sex? The concept of race does not hold up as a scientifically viable way of grouping human beings. It does not identify a cluster of genes at the biological level that could serve to sever human beings into neatly separable groups. It does not help identify discrete packages of color and morphology that could separate groups. It is muddled and asymmetrical in its groupings of individuals by ancestry. Finally, while genetic predispositions to certain diseases might provide a more useful way of grouping individuals, at least for medical purposes, such groupings deviate from ordinary uses of the term "race." Yet, if race is not scientifically viable, sex would seem to be fundamental. Surely, it succeeds in separating individuals along all of the lines at which the concept of race fails: the concept of sex identifies chromosomal differences between males and females; it points to transparent packages of features such as bone structure, genitalia, and the like; and it refers usefully to predispositions to different diseases such as ovarian and prostate cancer. Finally, it lacks any asymmetry in its application. One is male if one has an X and a Y chromosome; one is female if one has twoX chromosomes. These chromosomal facts, together with appropriate hormones, cause primary and secondary physical traits that Hypatia vol. 16, no. 3 (Summer 2001) 0 by Georgia Warnke

This study examined whether language deficits persist even in children with optimal outcomes. We examined a group of children with prior diagnoses on the autism spectrum who had IQs in the normal range, were in age-appropriate mainstream classes, and had improved to such an extent that they were considered to be functioning at the level of their typically developing peers. Fourteen such children between the ages of five and nine were matched on age and sex with typically developing children, and were given a battery of 10 language tests to investigate their language abilities. Results indicated that while these children's grammatical capabilities are mostly indistinguishable from their peers, they are still experiencing difficulties in pragmatic and semantic language.