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Objective: To determine if the National Center for Health Statistics (NCHS) growth curves (including 867 white infants, born between 1929 and 1975, in the Yellow Springs, Ohio, area) reflect contemporary infant growth in pediatric practices., Design: Observational cohort study of healthy term infants. Office personnel obtained standardized measurements at health maintenance visits., Setting: Ten pediatric community practices that were members of the Chicago, III, area Pediatric Practice Research Group (PPRG)., Methods: Measurements of 1574 PPRG infants, seen on at least 5 occasions between 2 and 54 weeks of age, generated sex-specific growth curves using a 3-parameter mathematical model fitted to the serial data for each infant. Values from the computed curves were compared with NCHS growth references at 1, 3, 6, 9, and 12 months. The birth weights of PPRG and NCHS cohorts were compared., Results: Mean birth weight of PPRG infants was significantly greater than a similar NCHS measure. Compared with the NCHS reference curve, PPRG infants were heavier at 1, 3, and 6 months, longer on all comparisons, and had greater head circumferences, particularly in the early months of age., Conclusions: The NCHS growth curves do not accurately reflect infant growth in this cohort. Nationally representative data are needed to revise the NCHS growth curves.

Objective: To determine the prevalence and correlates of psychiatric disorders among preschool children in a primary care pediatric sample., Method: In a two-stage design, 3,860 preschool children were screened; 510 received fuller evaluations., Results: For quantitative assessment of disorder (> or = 90th percentile), prevalence of behavior problems was 8.3%. "Probable" occurrence of an Axis I DSM-III-R disorder was 21.4% (9.1%, severe). Logistic regression analyses indicated significant demographic correlates for quantitative outcomes (older age, minority status, male sex, low socio-economic status, father absence, small family size) but not for DSM-III-R diagnoses. Maternal and family characteristics were generally not significant. Child correlates included activity level, timidity, persistence, and IQ., Conclusions: Overall prevalence of disorder was consistent with rates for older children; correlates varied by approach used for classification.

Little attention has been paid to evaluating the use of DSM-III-R with preschool children. Children (N = 510) ages 2 to 5 years who were screened at the time of a pediatric visit were selected to participate in an evaluation which included questionnaires, a semistructured interview, developmental testing, and a play observation. Following the evaluation, two clinical child psychologists independently assigned DSM-III-R diagnoses. For each diagnostic category, kappa and Y coefficients were calculated; Y coefficients are less sensitive to base rates of disorders. For overall agreement, the weighted mean kappa (.61), and mean Y (.66) were moderately high. Overall agreement that the child had at least one of the disruptive disorders was substantial (kappa = .64; Y = .65); agreement that there was at least one of the emotional disorders was moderate for kappa (.54), but substantial for Y (.70). Kappa coefficients were higher for major categories of disorder than for specific disorders; however, Y coefficients did not show a decline for specific disorders. Interrater reliability of DSM-III-R appears to be similar for preschoolers and older children.

This paper explores various approaches to achieving representative and generalizable practice-based data. The data used were derived from original research conducted by the Pediatric Practice Research Group (PPRG), a research consortium including full-time staff at Children's Memorial Hospital and 132 practitioners in 35 Chicago-area practices in a variety of settings ranging from Chicago's inner city to rural northwest Indiana. Sampling issues addressed include sampling frame, source (population or practice), geographical representation, seasonal representation, survey instrument design, socioeconomic diversity, and contact and response rates.

Objective: This study was designed to determine: (1) the prevalence of elevated blood lead (BPb) levels (BPb > or = 10 micrograms/dL) in Chicago suburban children attending Pediatric Practice Research Group practices at 12 and 24 months of age, and (2) the efficacy of the Centers for Disease Control and Prevention (CDC) and Illinois lead exposure risk assessment questions., Methods: Parents bringing their 1- and 2-year-old children for health supervision visits at pediatric practices completed questionnaires. BPb levels were drawn on children. Both questionnaire and an analyzable BPb level were obtained on 1393 subjects (79.2%)., Results: Only 2.1% of our sample had a venous BPb level > or = 10 micrograms/dL (0.48 mumol/L); no subjects had a level > or = 30 micrograms/dL (1.45 mumol/L). The CDC risk assessment questions had a sensitivity of .69 and specificity of .70. Due to the low prevalence of elevated BPb levels in this sample, CDC and Illinois screening strategies had high negative predictive values (.99) and low positive predictive values (.05 and .04, respectively). However, some of the subjects with BPb levels > or = 10 micrograms/dL were not at high risk by CDC and Illinois screening questions; 9 of 29 subjects with elevated lead levels (31%) did not respond affirmatively to any CDC risk assessment questions. The question best predicting an elevated BPb was the determination that the house the child lives in was built before 1960 (sensitivity = .83, specificity = .67). This question is not currently included in CDC or Illinois screening strategies. Screening based on the single question "Was your house built before 1960?" would have missed only five (17%) of the children with BPb levels > or = 10 micrograms/dL. Three of these five children were among the 17.1% of 1-year-olds and 26.3% of 2-year-olds in our sample who had moved., Conclusions: In this sample, children living in houses built before 1960 should be considered at high risk for high-dose lead exposure. Due to the high mobility of our sample, phrasing the question to include lifetime exposure (ie, Has your child ever lived in a house built before 1960?) should also be considered. Selective BPb testing of high-risk children in low-prevalence suburban areas using this question would miss few children with elevated BPb. Useful risk assessment questions in other areas and other populations may differ.

Anticipatory guidance on injury prevention should reflect the risks children face, yet hazard exposure information is generally unavailable. The objectives of this study were (1) to obtain information on age-specific exposure of Chicago-area children to amusement park rides, sleds, snow discs, bunkbeds, skateboards, fireworks, toboggans, and air guns and (2) to assess methodological issues in gathering exposure information by parental survey in pediatric practices. Questionnaires were received from 679 families, including 1469 children. The proportion of families with at least one exposed child varied: amusement park rides (94%), sleds (67%), snow discs (25%), bunkbeds (24%), skateboards (22%), fireworks (17%), toboggans (15%), and air guns and rifles (6%). Use of skateboards, air guns and rifles, and bunkbeds was highest in males. Use of skateboards, air guns and rifles, and snow discs peaked among young adolescents (ages 10 to 14), whereas use of sleds, toboggans and amusement park rides peaked among young children (ages 5 to 9) and young adolescents. Use of bunkbeds peaked among young children. Log linear analyses found: the likelihood of exposure to sleds and snow discs was highest in rural communities and for families owning their own home; toboggan exposure was highest among home owners; air gun and rifle exposure was highest in rural areas; fireworks exposure decreased with increased paternal education; exposure to skateboards was highest in single family dwellings and suburban home owners. This study generates the only available current estimates for use of these products, and demonstrates that in-office parental surveys concerning exposure are feasible. The findings can help guide future hazard exposure research and may affect anticipatory guidance in some settings.(ABSTRACT TRUNCATED AT 250 WORDS)

This study examined how well private-practice pediatricians can identify emotional/behavioral problems among preschool children. Children aged 2 through 5 (N = 3876) were screened during a visit to 1 of 68 pediatricians who rendered an opinion about the presence of emotional/behavioral problems. Subsequently, children who scored above the 90th percentile for behavioral problems on the Child Behavior Checklist, along with children matched on age, sex, and race who had screened low, were invited for an intensive second-stage evaluation. There were 495 mothers and children who participated in that evaluation, which included a behavioral questionnaire, maternal interview, play observation, and developmental testing. Two PhD-level clinical child psychologists rendered independent opinions about the presence of an emotional/behavioral disorder. The psychologists identified significantly higher rates of problems overall--13.0% when the criterion was independent agreement that the child had an emotional/behavioral problem and a regular psychiatric diagnosis was assigned, vs 8.7% based on pediatricians' ratings. Prevalence rates based on psychologists' independent ratings were significantly higher than pediatricians' for both sexes, 4- through 5-year-olds, and whites, but not for 2- through 3-year-olds, African-Americans, and all minorities. Prevalence rates based on psychologists' ratings were significantly higher than the pediatricians' for all subgroups when V-code diagnoses were included in the psychologists' ratings. Overall, pediatricians' sensitivity was 20.5%, and specificity was 92.7%. At least 51.7% of the children who had an emotional/behavioral problem based on the psychologist's independent agreement had not received counseling, medication, or a mental health referral from the pediatrician.(ABSTRACT TRUNCATED AT 250 WORDS)

Current recommendations for the management of pediatric foreign body ingestions are based on studies of patients cared for at tertiary care hospitals; they call for aggressive evaluation because of a high incidence of complications. Two hundred forty-four children with suspected foreign body ingestions were prospectively followed to analyze adverse outcomes, ie, procedures, complications, and hospitalizations. Patient enrollment into the study was from three sources: (1) patients who referred themselves to a tertiary pediatric emergency department, (2) patients referred to the same tertiary pediatric emergency department after an initial evaluation by another hospital or physician, and (3) patients who reported their foreign body ingestions to a private pediatric practitioner participating in the study. Most children were well toddlers in normal circumstances, under parent supervision at the time of ingestion. Coins were the most common item ingested (46%). Procedures were done in 53 (24%) of 221 patients and complications occurred in 48 (22%) of 221. Complications were higher in patients referred to the emergency department (63%) than in emergency department self-referred patients (13%) or private practice patients (7%) (chi 2, P < .01). These findings demonstrate the risk of drawing conclusions regarding a universal standard of care from studies involving only hospital-based patients.

Congenital dysplasia of the hip (CDH) continues to be missed by routine physical screening examinations in the early months when treatment is most effective. Real-time ultrasonography (US) is valuable in the detection of CDH in the young infant. We performed a prospective study to evaluate one US screening strategy that targets a select "high-risk newborn" population at risk for CDH aiming to increase the early diagnosis of this condition. From 1772 consecutive births at one hospital, we identified 97 (5.5%) newborns with risk factors for CDH: breech delivery, 73 babies; family history, 26 babies; postural abnormalities, five babies; and oligohydramnios, four babies. Eleven newborns had two risk factors. We studied 69 of these newborns with US. There were four cases of CDH in this group. Three of these babies had completely normal pediatric physical examination results at the time of the US study (at 14, 75, and 100 days, respectively) despite dysplasia diagnosed by US. All were successfully treated with a harness as outpatients. We conclude that a screening program entailing identification and subsequent US of the hip of newborns with specific physical and historical risk factors for CDH increases early diagnosis. Further analysis suggests this approach is cost-effective.

Renewed interest in practice-based research reflects growing realization of the limitations of research from a hospital perspective. Practice-based pediatric research promises to broaden the range and severity of conditions commonly studied, to enhance the study of the natural history of disease and of normal development, to provide normal controls and standards, and to facilitate recruitment of adequate sample sizes. Cohort, incidence, and health services research will be promoted by the development of patients registries. The Chicago area Pediatric Practice Research Group is a research consortium of 81 practitioners in 27 office practices. Formed in 1984, it receives logistic and financial support from Children's Memorial Hospital, with which it is affiliated. The Pediatric Practice Research Group has undertaken six studies, most with outside funding. During these studies, some unifying characteristics of practice-based research have emerged. These include the need to tailor study protocols to individual practice characteristics and routines and the critical role of office staff in the conduct of research. Features can be identified that make specific studies more or less intrusive into office functioning. It has proved feasible to obtain data of high quality and reproducibility despite geographically scattered data collection sites. This review of Pediatric Practice Research Group activities and experience is intended to open an exchange of ideas with others interested in practice-based research.

Confirmation of deficient beta-hexosaminidase activity in suspected cases of GM2 gangliosidosis may be difficult with available assay systems if the residual activity is high (as in many juvenile cases and genetic compounds). Hexosaminidase activity is normal in the AB-variant (activator protein deficiency), although GM2-ganglioside (GM2) catabolism is severely impaired. We therefore examined ganglioside degradation in intact fibroblasts in culture. Intracellular ganglioside levels were determined in cultured human skin fibroblasts grown in standard tissue culture medium or medium supplemented with mixed bovine brain gangliosides. Cellular uptake and catabolism of the added gangliosides were manifested by modest increases in the intracellular concentrations of gangliosides GT + GD and GM1 in all cells tested, and marked accumulation of GM2 in fibroblasts from patients with GM2 gangliosidoses. Intracellular GM2 increased five- to fifteen-fold in all of the GM2 gangliosidosis cell lines tested, including those from patients with infantile Tay-Sachs disease (TSD), Sandhoff disease, late infantile and juvenile variants of TSD with high residual enzyme activity, adult onset GM2 gangliosidosis, and the AB-variant. Significant GM2 accumulation did not occur in fibroblasts from patients with GM2 gangliosidosis grown in standard medium, or in normal fibroblasts grown in ganglioside enriched medium. Our method of ganglioside feeding employs commercially available materials and no special equipment. It should be useful for the confirmation of impaired GM2 catabolism in a variety of settings.

Twenty-six patients with hand infections caused by drug injection were seen at Detroit General Hospital between 1974 and 1976 and were followed up. The duration of drug abuse was 2 to 25 years. The time before the patient sought medical help ranged from three days to 20 weeks. Among the 26 patients were three webspace infections, three finger abscesses, four gangrene of distal phalanx, nine cellulitis and abscess, one ulceration of the thenar eminence, and two ulcerations of the volar aspect. Follow-up was difficult due to unreliability of drug addicts.

A study was conducted to evaluate the efficacy of family history factors as screening criteria for childhood hypercholesterolemia. When they were seen for routine care at one of eight office practices, 1005 prepubertal children underwent random serum cholesterol determinations. Parental and grandparental histories of cardiovascular risk factors and atherosclerotic complications prior to 55 years of age were also obtained. Of the initial group, 274 children had total cholesterol levels greater than or equal to 175 mg/dL, and 175 of these children returned for retesting after an overnight fast. A total of 88 children were found to have low-density lipoprotein-cholesterol (LDL-C) values greater than or equal to 90th percentile for age and sex. Maternal and paternal histories of hypercholesterolemia were significantly associated with elevated LDL-C (odds ratio = 7.3 and 2.9, respectively), but had extremely low sensitivities (0.09, 0.15) despite modest positive predictive values (0.42, 0.22). Grandparental histories of sudden death, peripheral vascular disease, and gout were associated with elevated LDL-C, but sensitivities and positive predictive values for all of these factors were less than 0.22. Family history factors most commonly recommended as criteria for cholesterol screening in children did not identify half of all the children with elevated LDL-C and did not selectively identify the most severely affected children. Adding information concerning the presence of childhood obesity did not result in appreciable improvement in LDL-C detection beyond that achieved by family history factors alone. It was concluded that if thorough identification of young children with elevated LDL-C is desired, inclusive population screening rather than a family history-based strategy would be the most effective approach.

In the past four years, four cases of gasoline contact burns have been treated at the Detroit General Hospital Emergency Department. Signs are erythema and blister formation within 24 hours. Treatment is removal of contaminated clothing and washing the surface with soap and water plus open exposure of the wounds. Renal failure is not caused by skin absorption but may develop following inhalation.

To define a subset of injured children for whom emergency cervical spine radiography may be unnecessary, we performed a retrospective chart and radiologic review. Two entry methods were used: All injured children, from birth through 16 years, who had received cervical spine radiographs at The Children's Memorial Hospital from September 1983, to September 1984, were included. All patients from birth to 16 years with proven or suspected cases of cervical spine injury who had received cervical spine radiographs and who had been treated at either the Children's Memorial Hospital or the Northwestern University Spine Trauma Unit during period 1974 to 1984 also were included. Each child's chart was reviewed, and 84 clinical variables were recorded. All radiographs were reviewed by a pediatric neuroradiologist. Of 206 children studied, 59 had cervical spine injuries. A clinical algorithm was derived using the following eight variables: neck pain; neck tenderness; limitation of neck mobility; history of trauma to the neck; and abnormalities of reflexes, strength, sensation, or mental status. The following decision rule was selected: Positive findings in any of these eight variables mandates cervical spine radiography. This algorithm correctly identified 58 of 59 children with cervical spine injury, yielding a sensitivity of 98% and specificity of 54%. Cervical spine radiographs could have been avoided in 79 children (38% of the entire sample). This algorithm performed better than did models derived from logistic regression analysis of the same data. Validation trials are required prior to the implementation of this or other clinical decision algorithms in practice.