Damian McNamara

FORT LAUDERDALE, FLA. – Some children with sleep-disordered breathing experience significant cognitive deficits, but not all do, and identification of those at risk remains a clinical challenge, according to a sleep medicine expert.

The range of individual susceptibility is wide, Dr. David Gozal said. “A child can have a mild [sleep] disturbance and be affected or have severe sleep apnea and be unaffected cognitively.” Together with apnea severity and environmental factors, individual differences in susceptibility complete the triple-risk model of obstructive sleep apnea morbidity, said Dr. Gozal, professor and vice chair of research, department of pediatrics, University of Louisville (Ky.).

In general, increased apnea severity is associated with greater impairments in cognition. For example, the Louisville study investigators, including Dr. Gozal, found significant neurocognitive deficits with higher apnea/hypopnea index (AHI) scores among snoring children (J. Sleep Res. 2004;13:165–72).

With increases in AHI severity, a child's IQ can decrease, Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. For children with an AHI of 5 or more, for example, there is average loss of 6–8 IQ points. “If you are born with an IQ of 100, that can be the difference between going to college or not.”

At any AHI level in the study, however, there were children without any cognitive deficit, again pointing to the individual variability, said Dr. Gozal, who is also a respiratory/sleep physiologist in the division of sleep medicine at Kosair Children's Hospital Research Institute, also in Louisville.

Specifically, significantly higher impairments in phonological processing, visual and auditory attention, and social problems were found among children with an AHI greater than 5, compared with those scoring 5 or less. High scorers also had significantly worse thought problems, delinquent or oppositional behavior, aggressiveness, externalizing of problems, and deficits in verbal comprehension ability.

In another study of 297 poorly performing first graders, there was a 6- to 9-fold increase in sleep apnea, compared with the general population (Pediatrics 1998;102:616–20).

In terms of potential misdiagnosis, there is some overlap between children with attention-deficit/hyperactivity disorder (ADHD) symptoms and those with obstructive sleep apnea (OSA) who demonstrate intrinsic daytime sleepiness. These patients can benefit from stimulant treatment, Dr. Gozal said.

The diagnosis of sleep apnea may be completely overlooked, since these patients improve with stimulants, similarly to children with ADHD who also are intrinsically sleepy. However, children with a formal diagnosis of ADHD-inattentive type who are not sleepy will be more likely to improve with addition of a norepinephrine reuptake inhibitor to treat their prefrontal cortex executive dysfunction, he said.

The way a child lives affects the way the sleep-disordered breathing affects them, Dr. Gozal said. “Physical activity is actually protective of our children when they have sleep apnea.”

Given such individual variability in risk of adverse cognitive outcomes in these children, Dr. Gozal and his associates are searching for a prognostic marker. They found that elevated plasma C-reactive protein levels, an indicator of increased systemic inflammation, might indicate children with OSA are at greater neurocognitive risk (Am. J. Respir. Crit. Care Med. 2007;176:188–93).

They assessed 278 children and found high-sensitivity C-reactive protein (hsCRP) levels almost triple among children with cognitive deficits, compared with those without. Participants were 5- to 7-year-old children recruited from the community.

The mean hsCRP was 0.48 plus or minus 0.12 mg/dL in children with OSA and cognitive deficits, compared with 0.21 plus or minus 0.08 mg/dL in children with the condition and normal cognitive scores. This difference was statistically significant.

Dr. Gozal and his associates wrote, “We show in a community-based study of snoring and nonsnoring school-aged children, that children with OSA have increased levels of hsCRP and also exhibit decreased cognitive performances compared with control children.”

FORT LAUDERDALE, FLA. – Some children with sleep-disordered breathing experience significant cognitive deficits, but not all do, and identification of those at risk remains a clinical challenge, according to a sleep medicine expert.

The range of individual susceptibility is wide, Dr. David Gozal said. “A child can have a mild [sleep] disturbance and be affected or have severe sleep apnea and be unaffected cognitively.” Together with apnea severity and environmental factors, individual differences in susceptibility complete the triple-risk model of obstructive sleep apnea morbidity, said Dr. Gozal, professor and vice chair of research, department of pediatrics, University of Louisville (Ky.).

In general, increased apnea severity is associated with greater impairments in cognition. For example, the Louisville study investigators, including Dr. Gozal, found significant neurocognitive deficits with higher apnea/hypopnea index (AHI) scores among snoring children (J. Sleep Res. 2004;13:165–72).

With increases in AHI severity, a child's IQ can decrease, Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. For children with an AHI of 5 or more, for example, there is average loss of 6–8 IQ points. “If you are born with an IQ of 100, that can be the difference between going to college or not.”

At any AHI level in the study, however, there were children without any cognitive deficit, again pointing to the individual variability, said Dr. Gozal, who is also a respiratory/sleep physiologist in the division of sleep medicine at Kosair Children's Hospital Research Institute, also in Louisville.

Specifically, significantly higher impairments in phonological processing, visual and auditory attention, and social problems were found among children with an AHI greater than 5, compared with those scoring 5 or less. High scorers also had significantly worse thought problems, delinquent or oppositional behavior, aggressiveness, externalizing of problems, and deficits in verbal comprehension ability.

In another study of 297 poorly performing first graders, there was a 6- to 9-fold increase in sleep apnea, compared with the general population (Pediatrics 1998;102:616–20).

In terms of potential misdiagnosis, there is some overlap between children with attention-deficit/hyperactivity disorder (ADHD) symptoms and those with obstructive sleep apnea (OSA) who demonstrate intrinsic daytime sleepiness. These patients can benefit from stimulant treatment, Dr. Gozal said.

The diagnosis of sleep apnea may be completely overlooked, since these patients improve with stimulants, similarly to children with ADHD who also are intrinsically sleepy. However, children with a formal diagnosis of ADHD-inattentive type who are not sleepy will be more likely to improve with addition of a norepinephrine reuptake inhibitor to treat their prefrontal cortex executive dysfunction, he said.

The way a child lives affects the way the sleep-disordered breathing affects them, Dr. Gozal said. “Physical activity is actually protective of our children when they have sleep apnea.”

Given such individual variability in risk of adverse cognitive outcomes in these children, Dr. Gozal and his associates are searching for a prognostic marker. They found that elevated plasma C-reactive protein levels, an indicator of increased systemic inflammation, might indicate children with OSA are at greater neurocognitive risk (Am. J. Respir. Crit. Care Med. 2007;176:188–93).

They assessed 278 children and found high-sensitivity C-reactive protein (hsCRP) levels almost triple among children with cognitive deficits, compared with those without. Participants were 5- to 7-year-old children recruited from the community.

The mean hsCRP was 0.48 plus or minus 0.12 mg/dL in children with OSA and cognitive deficits, compared with 0.21 plus or minus 0.08 mg/dL in children with the condition and normal cognitive scores. This difference was statistically significant.

Dr. Gozal and his associates wrote, “We show in a community-based study of snoring and nonsnoring school-aged children, that children with OSA have increased levels of hsCRP and also exhibit decreased cognitive performances compared with control children.”

FORT LAUDERDALE, FLA. – Some children with sleep-disordered breathing experience significant cognitive deficits, but not all do, and identification of those at risk remains a clinical challenge, according to a sleep medicine expert.

The range of individual susceptibility is wide, Dr. David Gozal said. “A child can have a mild [sleep] disturbance and be affected or have severe sleep apnea and be unaffected cognitively.” Together with apnea severity and environmental factors, individual differences in susceptibility complete the triple-risk model of obstructive sleep apnea morbidity, said Dr. Gozal, professor and vice chair of research, department of pediatrics, University of Louisville (Ky.).

In general, increased apnea severity is associated with greater impairments in cognition. For example, the Louisville study investigators, including Dr. Gozal, found significant neurocognitive deficits with higher apnea/hypopnea index (AHI) scores among snoring children (J. Sleep Res. 2004;13:165–72).

With increases in AHI severity, a child's IQ can decrease, Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. For children with an AHI of 5 or more, for example, there is average loss of 6–8 IQ points. “If you are born with an IQ of 100, that can be the difference between going to college or not.”

At any AHI level in the study, however, there were children without any cognitive deficit, again pointing to the individual variability, said Dr. Gozal, who is also a respiratory/sleep physiologist in the division of sleep medicine at Kosair Children's Hospital Research Institute, also in Louisville.

Specifically, significantly higher impairments in phonological processing, visual and auditory attention, and social problems were found among children with an AHI greater than 5, compared with those scoring 5 or less. High scorers also had significantly worse thought problems, delinquent or oppositional behavior, aggressiveness, externalizing of problems, and deficits in verbal comprehension ability.

In another study of 297 poorly performing first graders, there was a 6- to 9-fold increase in sleep apnea, compared with the general population (Pediatrics 1998;102:616–20).

In terms of potential misdiagnosis, there is some overlap between children with attention-deficit/hyperactivity disorder (ADHD) symptoms and those with obstructive sleep apnea (OSA) who demonstrate intrinsic daytime sleepiness. These patients can benefit from stimulant treatment, Dr. Gozal said.

The diagnosis of sleep apnea may be completely overlooked, since these patients improve with stimulants, similarly to children with ADHD who also are intrinsically sleepy. However, children with a formal diagnosis of ADHD-inattentive type who are not sleepy will be more likely to improve with addition of a norepinephrine reuptake inhibitor to treat their prefrontal cortex executive dysfunction, he said.

The way a child lives affects the way the sleep-disordered breathing affects them, Dr. Gozal said. “Physical activity is actually protective of our children when they have sleep apnea.”

Given such individual variability in risk of adverse cognitive outcomes in these children, Dr. Gozal and his associates are searching for a prognostic marker. They found that elevated plasma C-reactive protein levels, an indicator of increased systemic inflammation, might indicate children with OSA are at greater neurocognitive risk (Am. J. Respir. Crit. Care Med. 2007;176:188–93).

They assessed 278 children and found high-sensitivity C-reactive protein (hsCRP) levels almost triple among children with cognitive deficits, compared with those without. Participants were 5- to 7-year-old children recruited from the community.

The mean hsCRP was 0.48 plus or minus 0.12 mg/dL in children with OSA and cognitive deficits, compared with 0.21 plus or minus 0.08 mg/dL in children with the condition and normal cognitive scores. This difference was statistically significant.

Dr. Gozal and his associates wrote, “We show in a community-based study of snoring and nonsnoring school-aged children, that children with OSA have increased levels of hsCRP and also exhibit decreased cognitive performances compared with control children.”

The American Academy of Pediatrics and the American Heart Association have issued a joint statement clarifying recent recommendations made by the AHA on evaluating and treating children and adolescents with attention-deficit/hyperactivity disorder.

The original AHA recommendations suggested that a child's risk for adverse cardiac outcomes be evaluated before initiating pharmacologic treatment of ADHD (“Screen ADHD Patients First, Heart Group Says,” CLINICAL PSYCHIATRY NEWS, May 2008, p. 17).

However, the joint statement, issued May 16, clarifies that treatment of a pediatric patient with ADHD should not be withheld because an electrocardiogram has not been done. The statement also says that certain heart conditions in children may be difficult, or in some cases impossible, to detect. So “the AAP and AHA feel that it is prudent to carefully assess children for heart conditions who need to receive treatment with drugs for ADHD,” according to the statement.

In a separate policy statement, the AAP said on May 28 that it does not recommend screening ECGs “unless the patient's history, family history, or the physical examination raises concerns.”

Both statements came in the wake of huge public reaction to the AHA's original recommendations.

The AHA statement, “made it seem to the public as if the policy had changed, when in fact it had not,” Dr. Richard Friedman, coauthor of the 11-page AAP policy statement, said in an interview. “It was so highly publicized–that was the problem. It was on “The Today Show” and in the Wall Street Journal and the New York Times. People the next day were calling for appointments and saying 'My kid is on this medication and never had an ECG.'”

Dr. Friedman said the AAP thought it needed to respond quickly, given the huge response.

“The AHA statement created a tremendous amount of anxiety for parents and for physicians considering or ordering ADHD medications,” said Dr. Friedman, professor of pediatrics, Texas Children's Hospital, Houston.

Dr. Timothy K. Knilans, also a coauthor of the AAP statement, said the AHA's recommendations were surprising “given the absence of any new scientific information.”

ADHD, which is common in the congenital heart disease population, “is severely undertreated, as cardiologists aren't fully aware of the problem and pediatricians are afraid to use the drugs in this population. This is the problem that the AHA group should have focused on–not screening for all kids,” said Dr. Knilans, director, clinical cardiac electrophysiology and pacing, Cincinnati Children's Hospital Medical Center.

On the same day the joint statement was released, the AHA released an erratum to its scientific statement, Dr. Rose Marie Robertson, chief science officer of the AHA, Dallas, said in an interview.

The erratum lists 19 corrections. For example, the original news release stated that children diagnosed with ADHD “should” have an ECG before beginning treatment with stimulant drugs.

“The recommendation in the scientific statement was intended to indicate that it is reasonable for a physician to consider ordering an ECG in children with ADHD if they feel it is warranted,” Dr. Robertson said.

The American Academy of Child and Adolescent Psychiatry; the American College of Cardiology; Children and Adults with Attention-Deficit/Hyperactivity Disorder; the National Initiative for Children's Healthcare Quality; and the Society for Developmental and Behavioral Pediatrics also endorsed the clarification.

“In practical terms, there is no change in policy for getting ECGs for patients,” Dr. Friedman said.

The documents cited in this article are available online at www.aap.org/new/ecg-adhd.htm

The American Academy of Pediatrics and the American Heart Association have issued a joint statement clarifying recent recommendations made by the AHA on evaluating and treating children and adolescents with attention-deficit/hyperactivity disorder.

The original AHA recommendations suggested that a child's risk for adverse cardiac outcomes be evaluated before initiating pharmacologic treatment of ADHD (“Screen ADHD Patients First, Heart Group Says,” CLINICAL PSYCHIATRY NEWS, May 2008, p. 17).

However, the joint statement, issued May 16, clarifies that treatment of a pediatric patient with ADHD should not be withheld because an electrocardiogram has not been done. The statement also says that certain heart conditions in children may be difficult, or in some cases impossible, to detect. So “the AAP and AHA feel that it is prudent to carefully assess children for heart conditions who need to receive treatment with drugs for ADHD,” according to the statement.

In a separate policy statement, the AAP said on May 28 that it does not recommend screening ECGs “unless the patient's history, family history, or the physical examination raises concerns.”

Both statements came in the wake of huge public reaction to the AHA's original recommendations.

The AHA statement, “made it seem to the public as if the policy had changed, when in fact it had not,” Dr. Richard Friedman, coauthor of the 11-page AAP policy statement, said in an interview. “It was so highly publicized–that was the problem. It was on “The Today Show” and in the Wall Street Journal and the New York Times. People the next day were calling for appointments and saying 'My kid is on this medication and never had an ECG.'”

Dr. Friedman said the AAP thought it needed to respond quickly, given the huge response.

“The AHA statement created a tremendous amount of anxiety for parents and for physicians considering or ordering ADHD medications,” said Dr. Friedman, professor of pediatrics, Texas Children's Hospital, Houston.

Dr. Timothy K. Knilans, also a coauthor of the AAP statement, said the AHA's recommendations were surprising “given the absence of any new scientific information.”

ADHD, which is common in the congenital heart disease population, “is severely undertreated, as cardiologists aren't fully aware of the problem and pediatricians are afraid to use the drugs in this population. This is the problem that the AHA group should have focused on–not screening for all kids,” said Dr. Knilans, director, clinical cardiac electrophysiology and pacing, Cincinnati Children's Hospital Medical Center.

On the same day the joint statement was released, the AHA released an erratum to its scientific statement, Dr. Rose Marie Robertson, chief science officer of the AHA, Dallas, said in an interview.

The erratum lists 19 corrections. For example, the original news release stated that children diagnosed with ADHD “should” have an ECG before beginning treatment with stimulant drugs.

“The recommendation in the scientific statement was intended to indicate that it is reasonable for a physician to consider ordering an ECG in children with ADHD if they feel it is warranted,” Dr. Robertson said.

The American Academy of Child and Adolescent Psychiatry; the American College of Cardiology; Children and Adults with Attention-Deficit/Hyperactivity Disorder; the National Initiative for Children's Healthcare Quality; and the Society for Developmental and Behavioral Pediatrics also endorsed the clarification.

“In practical terms, there is no change in policy for getting ECGs for patients,” Dr. Friedman said.

The documents cited in this article are available online at www.aap.org/new/ecg-adhd.htm

The American Academy of Pediatrics and the American Heart Association have issued a joint statement clarifying recent recommendations made by the AHA on evaluating and treating children and adolescents with attention-deficit/hyperactivity disorder.

The original AHA recommendations suggested that a child's risk for adverse cardiac outcomes be evaluated before initiating pharmacologic treatment of ADHD (“Screen ADHD Patients First, Heart Group Says,” CLINICAL PSYCHIATRY NEWS, May 2008, p. 17).

However, the joint statement, issued May 16, clarifies that treatment of a pediatric patient with ADHD should not be withheld because an electrocardiogram has not been done. The statement also says that certain heart conditions in children may be difficult, or in some cases impossible, to detect. So “the AAP and AHA feel that it is prudent to carefully assess children for heart conditions who need to receive treatment with drugs for ADHD,” according to the statement.

In a separate policy statement, the AAP said on May 28 that it does not recommend screening ECGs “unless the patient's history, family history, or the physical examination raises concerns.”

Both statements came in the wake of huge public reaction to the AHA's original recommendations.

The AHA statement, “made it seem to the public as if the policy had changed, when in fact it had not,” Dr. Richard Friedman, coauthor of the 11-page AAP policy statement, said in an interview. “It was so highly publicized–that was the problem. It was on “The Today Show” and in the Wall Street Journal and the New York Times. People the next day were calling for appointments and saying 'My kid is on this medication and never had an ECG.'”

Dr. Friedman said the AAP thought it needed to respond quickly, given the huge response.

“The AHA statement created a tremendous amount of anxiety for parents and for physicians considering or ordering ADHD medications,” said Dr. Friedman, professor of pediatrics, Texas Children's Hospital, Houston.

Dr. Timothy K. Knilans, also a coauthor of the AAP statement, said the AHA's recommendations were surprising “given the absence of any new scientific information.”

ADHD, which is common in the congenital heart disease population, “is severely undertreated, as cardiologists aren't fully aware of the problem and pediatricians are afraid to use the drugs in this population. This is the problem that the AHA group should have focused on–not screening for all kids,” said Dr. Knilans, director, clinical cardiac electrophysiology and pacing, Cincinnati Children's Hospital Medical Center.

On the same day the joint statement was released, the AHA released an erratum to its scientific statement, Dr. Rose Marie Robertson, chief science officer of the AHA, Dallas, said in an interview.

The erratum lists 19 corrections. For example, the original news release stated that children diagnosed with ADHD “should” have an ECG before beginning treatment with stimulant drugs.

“The recommendation in the scientific statement was intended to indicate that it is reasonable for a physician to consider ordering an ECG in children with ADHD if they feel it is warranted,” Dr. Robertson said.

The American Academy of Child and Adolescent Psychiatry; the American College of Cardiology; Children and Adults with Attention-Deficit/Hyperactivity Disorder; the National Initiative for Children's Healthcare Quality; and the Society for Developmental and Behavioral Pediatrics also endorsed the clarification.

“In practical terms, there is no change in policy for getting ECGs for patients,” Dr. Friedman said.

The documents cited in this article are available online at www.aap.org/new/ecg-adhd.htm

Compliance with immunization recommendations goes beyond missed doses—administration of vaccines before the recommended age and/or too close together may add to suboptimal coverage, according to Elizabeth T. Luman, Ph.D., and her associates.

Researchers conducted a nationally representative study of compliance with Advisory Committee on Immunization Practices (ACIP) vaccine recommendations (Am. J. Prev. Med. 2008;34:463-70).

"We knew that about one in five toddlers [was] missing a vaccination, but we were surprised that mistimed doses reduced coverage by another 10%," Dr. Luman said in an interview. "In total, about one in four children aged 19-35 months [is] not current" on vaccinations.

Dr. Luman and her associates at the Centers for Disease Control and Prevention assessed 17,563 children aged 19-35 months. They used 2005 vaccination histories from the National Immunization Survey (NIS).

The estimated coverage with the 4:3:1:3:3 vaccination series incorporating all ACIP recommendations was 72%. This is 9 percentage points lower than calculations based only on counting doses. Compliance was lowest with the DTaP and greatest with the poliovirus vaccine.

"It's important that children get all the recommended doses, but timing is important as well, so vaccines will be most effective," said Dr. Luman, a researcher at the CDC's National Center for Immunization and Respiratory Diseases in Atlanta. She and her associates disclosed they had no relevant financial disclosures.

"The implication of this particular article is that if you did not vaccinate at the appropriate time, you're vulnerable to a particular disease," Dr. John Bradley said in an interview. "We want people to get the vaccine in the recommended time slot if possible, but that is not to say that if you have to reschedule the appointment … that you are completely susceptible to that disease."

Dr. Bradley is a member of the American Academy of Pediatrics Committee on Infectious Diseases. The ACIP recommendations are developed in collaboration with the AAP and the American Academy of Family Physicians.

The researchers recognized that sometimes a vaccine cannot be given at the recommended time. "Administering a vaccination a few days early is preferred to missing the opportunity to vaccinate a child who is unlikely to return at the appropriate time," the authors wrote. "However, the observance of both age-appropriate vaccination and sufficient time between doses in a series maximizes the immune response and the vaccine's efficacy."

"Medical science doesn't know how much wiggle room we have. To give a week early or late—those studies have not been done," said Dr. Bradley, who is also director of the division of infectious diseases at Children's Hospital and Health Center, San Diego. "The timing of vaccines and boosters is based on a best guess of optimal timing" based on large-scale trials reviewed by the Food and Drug Administration. Dr. Bradley said he has no financial disclosures related to vaccines.

About 6% of children received at least one age-invalid vaccination in the 4:3:1:3:3 series. Another 3% received at least one interval-invalid vaccination; this figure included 0.3% who received MMR immunization too soon following a varicella vaccination. In addition, approximately 14% of children had a third dose of hepatitis B vaccine prior to the age of 6 months, the minimum valid age.

Limitations of the study include vaccination histories reported by vaccine providers identified through parents, as well as a lack of information regarding vaccine contraindications, including allergic reactions.

"Health care providers, along with parents and vaccination programs, have done an outstanding job of increasing vaccination levels in the U.S.," Dr. Luman said. "But continued vigilance and improvements are needed to make sure that every child and every community [is] protected from these deadly diseases. Good communication between providers and parents can help increase parental awareness of the benefits of vaccination, and ensure that children are brought in for all their vaccinations at the right time." n

Compliance with immunization recommendations goes beyond missed doses—administration of vaccines before the recommended age and/or too close together may add to suboptimal coverage, according to Elizabeth T. Luman, Ph.D., and her associates.

Researchers conducted a nationally representative study of compliance with Advisory Committee on Immunization Practices (ACIP) vaccine recommendations (Am. J. Prev. Med. 2008;34:463-70).

"We knew that about one in five toddlers [was] missing a vaccination, but we were surprised that mistimed doses reduced coverage by another 10%," Dr. Luman said in an interview. "In total, about one in four children aged 19-35 months [is] not current" on vaccinations.

Dr. Luman and her associates at the Centers for Disease Control and Prevention assessed 17,563 children aged 19-35 months. They used 2005 vaccination histories from the National Immunization Survey (NIS).

The estimated coverage with the 4:3:1:3:3 vaccination series incorporating all ACIP recommendations was 72%. This is 9 percentage points lower than calculations based only on counting doses. Compliance was lowest with the DTaP and greatest with the poliovirus vaccine.

"It's important that children get all the recommended doses, but timing is important as well, so vaccines will be most effective," said Dr. Luman, a researcher at the CDC's National Center for Immunization and Respiratory Diseases in Atlanta. She and her associates disclosed they had no relevant financial disclosures.

"The implication of this particular article is that if you did not vaccinate at the appropriate time, you're vulnerable to a particular disease," Dr. John Bradley said in an interview. "We want people to get the vaccine in the recommended time slot if possible, but that is not to say that if you have to reschedule the appointment … that you are completely susceptible to that disease."

Dr. Bradley is a member of the American Academy of Pediatrics Committee on Infectious Diseases. The ACIP recommendations are developed in collaboration with the AAP and the American Academy of Family Physicians.

The researchers recognized that sometimes a vaccine cannot be given at the recommended time. "Administering a vaccination a few days early is preferred to missing the opportunity to vaccinate a child who is unlikely to return at the appropriate time," the authors wrote. "However, the observance of both age-appropriate vaccination and sufficient time between doses in a series maximizes the immune response and the vaccine's efficacy."

"Medical science doesn't know how much wiggle room we have. To give a week early or late—those studies have not been done," said Dr. Bradley, who is also director of the division of infectious diseases at Children's Hospital and Health Center, San Diego. "The timing of vaccines and boosters is based on a best guess of optimal timing" based on large-scale trials reviewed by the Food and Drug Administration. Dr. Bradley said he has no financial disclosures related to vaccines.

About 6% of children received at least one age-invalid vaccination in the 4:3:1:3:3 series. Another 3% received at least one interval-invalid vaccination; this figure included 0.3% who received MMR immunization too soon following a varicella vaccination. In addition, approximately 14% of children had a third dose of hepatitis B vaccine prior to the age of 6 months, the minimum valid age.

Limitations of the study include vaccination histories reported by vaccine providers identified through parents, as well as a lack of information regarding vaccine contraindications, including allergic reactions.

"Health care providers, along with parents and vaccination programs, have done an outstanding job of increasing vaccination levels in the U.S.," Dr. Luman said. "But continued vigilance and improvements are needed to make sure that every child and every community [is] protected from these deadly diseases. Good communication between providers and parents can help increase parental awareness of the benefits of vaccination, and ensure that children are brought in for all their vaccinations at the right time." n

Compliance with immunization recommendations goes beyond missed doses—administration of vaccines before the recommended age and/or too close together may add to suboptimal coverage, according to Elizabeth T. Luman, Ph.D., and her associates.

Researchers conducted a nationally representative study of compliance with Advisory Committee on Immunization Practices (ACIP) vaccine recommendations (Am. J. Prev. Med. 2008;34:463-70).

"We knew that about one in five toddlers [was] missing a vaccination, but we were surprised that mistimed doses reduced coverage by another 10%," Dr. Luman said in an interview. "In total, about one in four children aged 19-35 months [is] not current" on vaccinations.

Dr. Luman and her associates at the Centers for Disease Control and Prevention assessed 17,563 children aged 19-35 months. They used 2005 vaccination histories from the National Immunization Survey (NIS).

The estimated coverage with the 4:3:1:3:3 vaccination series incorporating all ACIP recommendations was 72%. This is 9 percentage points lower than calculations based only on counting doses. Compliance was lowest with the DTaP and greatest with the poliovirus vaccine.

"It's important that children get all the recommended doses, but timing is important as well, so vaccines will be most effective," said Dr. Luman, a researcher at the CDC's National Center for Immunization and Respiratory Diseases in Atlanta. She and her associates disclosed they had no relevant financial disclosures.

"The implication of this particular article is that if you did not vaccinate at the appropriate time, you're vulnerable to a particular disease," Dr. John Bradley said in an interview. "We want people to get the vaccine in the recommended time slot if possible, but that is not to say that if you have to reschedule the appointment … that you are completely susceptible to that disease."

Dr. Bradley is a member of the American Academy of Pediatrics Committee on Infectious Diseases. The ACIP recommendations are developed in collaboration with the AAP and the American Academy of Family Physicians.

The researchers recognized that sometimes a vaccine cannot be given at the recommended time. "Administering a vaccination a few days early is preferred to missing the opportunity to vaccinate a child who is unlikely to return at the appropriate time," the authors wrote. "However, the observance of both age-appropriate vaccination and sufficient time between doses in a series maximizes the immune response and the vaccine's efficacy."

"Medical science doesn't know how much wiggle room we have. To give a week early or late—those studies have not been done," said Dr. Bradley, who is also director of the division of infectious diseases at Children's Hospital and Health Center, San Diego. "The timing of vaccines and boosters is based on a best guess of optimal timing" based on large-scale trials reviewed by the Food and Drug Administration. Dr. Bradley said he has no financial disclosures related to vaccines.

About 6% of children received at least one age-invalid vaccination in the 4:3:1:3:3 series. Another 3% received at least one interval-invalid vaccination; this figure included 0.3% who received MMR immunization too soon following a varicella vaccination. In addition, approximately 14% of children had a third dose of hepatitis B vaccine prior to the age of 6 months, the minimum valid age.

Limitations of the study include vaccination histories reported by vaccine providers identified through parents, as well as a lack of information regarding vaccine contraindications, including allergic reactions.

"Health care providers, along with parents and vaccination programs, have done an outstanding job of increasing vaccination levels in the U.S.," Dr. Luman said. "But continued vigilance and improvements are needed to make sure that every child and every community [is] protected from these deadly diseases. Good communication between providers and parents can help increase parental awareness of the benefits of vaccination, and ensure that children are brought in for all their vaccinations at the right time." n

FORT LAUDERDALE, FLA. — Transcatheter insertion of a stented aortic valve through the left ventricular apex is possible for patients with critical valvular aortic stenosis, according to a multicenter study.

Feasibility is based on a total of 36 procedures at three institutions. Valve recipients were high risk because they were aged older than 70 years, had significant comorbidities, and/or had a Society of Thoracic Surgeons Predicted Risk of Mortality score of 15% or more.” Dr. Lars G. Svensson said at the annual meeting of the Society of Thoracic Surgeons.

Dr. Svensson and his associates conducted the FDA-approved study to assess feasibility of less invasive transcatheter delivery for such high-risk patients. Without surgery, 1-year survival is an estimated 30%. Also, 30%-60% of people with critical valvular aortic stenosis do not receive treatment, according to registry data.

The study is a new arm of PARTNER, an ongoing, randomized assessment of retrograde transfemoral arterial delivery of the same device, the Sapien THV Valve (Edwards Lifesciences). The investigational device is a balloon-expandable stainless steel stent with an internally mounted equine pericardial valve.

“This is pioneering work in a high-risk group of patients with a very challenging procedure,” said Dr. Thomas A. Vassiliades, study discussant and surgeon in the division of cardiac surgery, Emory University, Atlanta.

Surgeons begin with a check for calcium that might obstruct device insertion. Then the valve is crimped down and placed inside a loader before transcatheter insertion. The most common entry point in the study was via the sixth intercostal space. After placement, there is rapid pacing for balloon inflation.

“Team cooperation is essential to success. A lot of cardiologists are also involved, and the procedure would not be as successful without them,” said Dr. Svensson, a thoracic surgeon at the Cleveland Clinic. Dr. Svensson serves on the executive committee board of Edwards Lifesciences but does not receive any financial compensation.

There was considerable hemodynamic and functional improvement, Dr. Svensson said. For example, a mean 1.6-cm

Comorbidities were a “big factor” in patient outcomes, Dr. Svensson said. For example, 50% had prior coronary bypass surgery and approximately one-third had porcelain aortas. There were four failed implants, for an overall implant success rate of 89%. Physicians converted these four failures to open procedures.

There were six deaths within 30 days for a 16.7% mortality rate. One patient died from multiple organ failure and the other cause of death was stroke 5 days postoperatively. There were four procedure-related deaths. “We realize these are [very ill patients] and it is a complicated procedure, but we need to know how many benefit by 6 months by having the device,” Dr. Vassiliades said. He had no financial disclosures, but his institution is participating in the transfemoral arm of the PARTNER study. At 6 months, survival was 59%, Dr. Svensson replied.

Dr. Vassiliades questioned a counterintuitive finding that outcomes were better in the first 20 patients. Dr. Svensson replied that some aspects of the procedure had to be relearned after a 6-month downtime.

After transapical insertion, a stent valve is positioned across the native aortic valve. Cleveland Clinic/Lars G. Svensson

FORT LAUDERDALE, FLA. — Transcatheter insertion of a stented aortic valve through the left ventricular apex is possible for patients with critical valvular aortic stenosis, according to a multicenter study.

Feasibility is based on a total of 36 procedures at three institutions. Valve recipients were high risk because they were aged older than 70 years, had significant comorbidities, and/or had a Society of Thoracic Surgeons Predicted Risk of Mortality score of 15% or more.” Dr. Lars G. Svensson said at the annual meeting of the Society of Thoracic Surgeons.

Dr. Svensson and his associates conducted the FDA-approved study to assess feasibility of less invasive transcatheter delivery for such high-risk patients. Without surgery, 1-year survival is an estimated 30%. Also, 30%-60% of people with critical valvular aortic stenosis do not receive treatment, according to registry data.

The study is a new arm of PARTNER, an ongoing, randomized assessment of retrograde transfemoral arterial delivery of the same device, the Sapien THV Valve (Edwards Lifesciences). The investigational device is a balloon-expandable stainless steel stent with an internally mounted equine pericardial valve.

“This is pioneering work in a high-risk group of patients with a very challenging procedure,” said Dr. Thomas A. Vassiliades, study discussant and surgeon in the division of cardiac surgery, Emory University, Atlanta.

Surgeons begin with a check for calcium that might obstruct device insertion. Then the valve is crimped down and placed inside a loader before transcatheter insertion. The most common entry point in the study was via the sixth intercostal space. After placement, there is rapid pacing for balloon inflation.

“Team cooperation is essential to success. A lot of cardiologists are also involved, and the procedure would not be as successful without them,” said Dr. Svensson, a thoracic surgeon at the Cleveland Clinic. Dr. Svensson serves on the executive committee board of Edwards Lifesciences but does not receive any financial compensation.

There was considerable hemodynamic and functional improvement, Dr. Svensson said. For example, a mean 1.6-cm

Comorbidities were a “big factor” in patient outcomes, Dr. Svensson said. For example, 50% had prior coronary bypass surgery and approximately one-third had porcelain aortas. There were four failed implants, for an overall implant success rate of 89%. Physicians converted these four failures to open procedures.

There were six deaths within 30 days for a 16.7% mortality rate. One patient died from multiple organ failure and the other cause of death was stroke 5 days postoperatively. There were four procedure-related deaths. “We realize these are [very ill patients] and it is a complicated procedure, but we need to know how many benefit by 6 months by having the device,” Dr. Vassiliades said. He had no financial disclosures, but his institution is participating in the transfemoral arm of the PARTNER study. At 6 months, survival was 59%, Dr. Svensson replied.

Dr. Vassiliades questioned a counterintuitive finding that outcomes were better in the first 20 patients. Dr. Svensson replied that some aspects of the procedure had to be relearned after a 6-month downtime.

After transapical insertion, a stent valve is positioned across the native aortic valve. Cleveland Clinic/Lars G. Svensson

FORT LAUDERDALE, FLA. — Transcatheter insertion of a stented aortic valve through the left ventricular apex is possible for patients with critical valvular aortic stenosis, according to a multicenter study.

Feasibility is based on a total of 36 procedures at three institutions. Valve recipients were high risk because they were aged older than 70 years, had significant comorbidities, and/or had a Society of Thoracic Surgeons Predicted Risk of Mortality score of 15% or more.” Dr. Lars G. Svensson said at the annual meeting of the Society of Thoracic Surgeons.

Dr. Svensson and his associates conducted the FDA-approved study to assess feasibility of less invasive transcatheter delivery for such high-risk patients. Without surgery, 1-year survival is an estimated 30%. Also, 30%-60% of people with critical valvular aortic stenosis do not receive treatment, according to registry data.

The study is a new arm of PARTNER, an ongoing, randomized assessment of retrograde transfemoral arterial delivery of the same device, the Sapien THV Valve (Edwards Lifesciences). The investigational device is a balloon-expandable stainless steel stent with an internally mounted equine pericardial valve.

“This is pioneering work in a high-risk group of patients with a very challenging procedure,” said Dr. Thomas A. Vassiliades, study discussant and surgeon in the division of cardiac surgery, Emory University, Atlanta.

Surgeons begin with a check for calcium that might obstruct device insertion. Then the valve is crimped down and placed inside a loader before transcatheter insertion. The most common entry point in the study was via the sixth intercostal space. After placement, there is rapid pacing for balloon inflation.

“Team cooperation is essential to success. A lot of cardiologists are also involved, and the procedure would not be as successful without them,” said Dr. Svensson, a thoracic surgeon at the Cleveland Clinic. Dr. Svensson serves on the executive committee board of Edwards Lifesciences but does not receive any financial compensation.

There was considerable hemodynamic and functional improvement, Dr. Svensson said. For example, a mean 1.6-cm

Comorbidities were a “big factor” in patient outcomes, Dr. Svensson said. For example, 50% had prior coronary bypass surgery and approximately one-third had porcelain aortas. There were four failed implants, for an overall implant success rate of 89%. Physicians converted these four failures to open procedures.

There were six deaths within 30 days for a 16.7% mortality rate. One patient died from multiple organ failure and the other cause of death was stroke 5 days postoperatively. There were four procedure-related deaths. “We realize these are [very ill patients] and it is a complicated procedure, but we need to know how many benefit by 6 months by having the device,” Dr. Vassiliades said. He had no financial disclosures, but his institution is participating in the transfemoral arm of the PARTNER study. At 6 months, survival was 59%, Dr. Svensson replied.

Dr. Vassiliades questioned a counterintuitive finding that outcomes were better in the first 20 patients. Dr. Svensson replied that some aspects of the procedure had to be relearned after a 6-month downtime.

After transapical insertion, a stent valve is positioned across the native aortic valve. Cleveland Clinic/Lars G. Svensson

MIAMI — Minimizing exposure to employee lawsuits—including sexual harassment and discrimination claims—begins with hiring the right employee for your office, a labor and employment attorney told a gathering of pediatricians.

Also, fairness and consistency are important. Always provide one office assistant the same raises, benefits, and time off as another. “Doctors' offices are small, and there are no secrets,” said Chad K. Lang, who practices labor law in Miami.

“I am here to help you deal with a commodity you deal with every day—your employees,” Mr. Lang said at a pediatric update conference sponsored by Miami Children's Hospital.

“They can be your greatest asset or your greatest nightmare.”

Laws concerning labor and employment are about much more than worker's compensation. The only law that may not apply to a small practitioner is the Family and Medical Leave Act, which only applies to staff with a minimum of 50 employees. Although federal law generally applies to firms or practices with 15 or more employees, discrimination law applies to those with only 5 employees.

Prevention is the best strategy. Mr. Lang recommends that you look under a microscope at every employment decision you make. He estimated that about 90% of all employee disputes are caused by 10% of employees.

Avoid general employment application forms; customize one with questions relevant to work in a medical practice, he said. Also, train interviewers to spot facial expressions that indicate lying or shading of the truth. “What if you find out 6 months later someone you hired was jailed for embezzlement? You need to know enough about employment law so you can recognize a red flag and know [when] to call someone to help.”

Fairness, documentation, and consistency—“those three words can win a lawsuit,” Mr. Lang continued.

There cannot be discrimination if a physician treats all employees the same. “But if you give one person a $10,000 raise and the other a $5,000 raise … everyone will know about it. When that person leaves, whether [they leave] voluntarily or not, they sue,” Mr. Lang said.

“And most attorneys work on a contingency fee, so there is no cost to the employee.”

Wage-hour audits are another fairness issue. “You need to have someone figure out if you are treating your employees correctly. Are they truly exempt from overtime?” Mr. Lang said. “Let's say you pay someone $60,000 per year. Are they entitled to overtime? It depends on their job description.”

Wage-hour audits are the No. 1 legal issue that companies face in the United States, Mr. Lang said. Beginning in 2001, the number of wage-hour class action lawsuits surpassed the number of class actions for race, sex, national origin, color, religion, and age in federal courts—combined.

Mr. Lang also addressed the perils of dating in the workplace. “I have three sexual harassment cases now based solely on a supervisor dating a subordinate,” he said. “What do you think a subordinate employee will do if they are fired? They will sue, and most likely they will win.”

Some employers have policies that address dating in the workplace. “What has recently become a trend that I cannot believe is a 'love contract,'” Mr. Lang said. Some companies allow workers to date but they have to inform the employer when a relationship develops. Also, they are required to sign a contract stating that they are not being coerced, he noted.

Once a year, hire an expert to train your office managers about harassment and discrimination, Mr. Lang suggested. “Why? It's an insurance policy,” he said.

An employee handbook with a specific process for making sexual harassment complaints is recommended. Complaints should be made to at least two people—one of each gender—listed in the handbook by job title instead of name. This will ensure that an employee has someone to talk with besides the person doing the alleged harassment.

A meeting attendee asked Mr. Lang about his fees. “I charge about $2,000–$2,500 to develop a new handbook or revise one. A 3-hour training once a year costs about $1,000,” Mr. Lang said. His rates as a law firm partner range from $250/hour to $350/hour. He also has trained associates who charge less per hour for consultation.

Another element of legal protection is, not surprisingly, “documentation, documentation, documentation,” Mr. Lang said. “But do not write down anything you do not want someone to read. This sounds like something your grandmother would tell you.”

Never assume your e-mail, text message, or instant message (IM) is not going to be exhibit No. 1 in a lawsuit, Mr. Lang said. “Good employment lawyers have great experts that will get e-mails and IMs. Do not assume they are gone after you delete them.”

Mr. Lang's last piece of advice was “know a good employment lawyer.”

MIAMI — Minimizing exposure to employee lawsuits—including sexual harassment and discrimination claims—begins with hiring the right employee for your office, a labor and employment attorney told a gathering of pediatricians.

Also, fairness and consistency are important. Always provide one office assistant the same raises, benefits, and time off as another. “Doctors' offices are small, and there are no secrets,” said Chad K. Lang, who practices labor law in Miami.

“I am here to help you deal with a commodity you deal with every day—your employees,” Mr. Lang said at a pediatric update conference sponsored by Miami Children's Hospital.

“They can be your greatest asset or your greatest nightmare.”

Laws concerning labor and employment are about much more than worker's compensation. The only law that may not apply to a small practitioner is the Family and Medical Leave Act, which only applies to staff with a minimum of 50 employees. Although federal law generally applies to firms or practices with 15 or more employees, discrimination law applies to those with only 5 employees.

Prevention is the best strategy. Mr. Lang recommends that you look under a microscope at every employment decision you make. He estimated that about 90% of all employee disputes are caused by 10% of employees.

Avoid general employment application forms; customize one with questions relevant to work in a medical practice, he said. Also, train interviewers to spot facial expressions that indicate lying or shading of the truth. “What if you find out 6 months later someone you hired was jailed for embezzlement? You need to know enough about employment law so you can recognize a red flag and know [when] to call someone to help.”

Fairness, documentation, and consistency—“those three words can win a lawsuit,” Mr. Lang continued.

There cannot be discrimination if a physician treats all employees the same. “But if you give one person a $10,000 raise and the other a $5,000 raise … everyone will know about it. When that person leaves, whether [they leave] voluntarily or not, they sue,” Mr. Lang said.

“And most attorneys work on a contingency fee, so there is no cost to the employee.”

Wage-hour audits are another fairness issue. “You need to have someone figure out if you are treating your employees correctly. Are they truly exempt from overtime?” Mr. Lang said. “Let's say you pay someone $60,000 per year. Are they entitled to overtime? It depends on their job description.”

Wage-hour audits are the No. 1 legal issue that companies face in the United States, Mr. Lang said. Beginning in 2001, the number of wage-hour class action lawsuits surpassed the number of class actions for race, sex, national origin, color, religion, and age in federal courts—combined.

Mr. Lang also addressed the perils of dating in the workplace. “I have three sexual harassment cases now based solely on a supervisor dating a subordinate,” he said. “What do you think a subordinate employee will do if they are fired? They will sue, and most likely they will win.”

Some employers have policies that address dating in the workplace. “What has recently become a trend that I cannot believe is a 'love contract,'” Mr. Lang said. Some companies allow workers to date but they have to inform the employer when a relationship develops. Also, they are required to sign a contract stating that they are not being coerced, he noted.

Once a year, hire an expert to train your office managers about harassment and discrimination, Mr. Lang suggested. “Why? It's an insurance policy,” he said.

An employee handbook with a specific process for making sexual harassment complaints is recommended. Complaints should be made to at least two people—one of each gender—listed in the handbook by job title instead of name. This will ensure that an employee has someone to talk with besides the person doing the alleged harassment.

A meeting attendee asked Mr. Lang about his fees. “I charge about $2,000–$2,500 to develop a new handbook or revise one. A 3-hour training once a year costs about $1,000,” Mr. Lang said. His rates as a law firm partner range from $250/hour to $350/hour. He also has trained associates who charge less per hour for consultation.

Another element of legal protection is, not surprisingly, “documentation, documentation, documentation,” Mr. Lang said. “But do not write down anything you do not want someone to read. This sounds like something your grandmother would tell you.”

Never assume your e-mail, text message, or instant message (IM) is not going to be exhibit No. 1 in a lawsuit, Mr. Lang said. “Good employment lawyers have great experts that will get e-mails and IMs. Do not assume they are gone after you delete them.”

Mr. Lang's last piece of advice was “know a good employment lawyer.”

MIAMI — Minimizing exposure to employee lawsuits—including sexual harassment and discrimination claims—begins with hiring the right employee for your office, a labor and employment attorney told a gathering of pediatricians.

Also, fairness and consistency are important. Always provide one office assistant the same raises, benefits, and time off as another. “Doctors' offices are small, and there are no secrets,” said Chad K. Lang, who practices labor law in Miami.

“I am here to help you deal with a commodity you deal with every day—your employees,” Mr. Lang said at a pediatric update conference sponsored by Miami Children's Hospital.

“They can be your greatest asset or your greatest nightmare.”

Laws concerning labor and employment are about much more than worker's compensation. The only law that may not apply to a small practitioner is the Family and Medical Leave Act, which only applies to staff with a minimum of 50 employees. Although federal law generally applies to firms or practices with 15 or more employees, discrimination law applies to those with only 5 employees.

Prevention is the best strategy. Mr. Lang recommends that you look under a microscope at every employment decision you make. He estimated that about 90% of all employee disputes are caused by 10% of employees.

Avoid general employment application forms; customize one with questions relevant to work in a medical practice, he said. Also, train interviewers to spot facial expressions that indicate lying or shading of the truth. “What if you find out 6 months later someone you hired was jailed for embezzlement? You need to know enough about employment law so you can recognize a red flag and know [when] to call someone to help.”

Fairness, documentation, and consistency—“those three words can win a lawsuit,” Mr. Lang continued.

There cannot be discrimination if a physician treats all employees the same. “But if you give one person a $10,000 raise and the other a $5,000 raise … everyone will know about it. When that person leaves, whether [they leave] voluntarily or not, they sue,” Mr. Lang said.

“And most attorneys work on a contingency fee, so there is no cost to the employee.”

Wage-hour audits are another fairness issue. “You need to have someone figure out if you are treating your employees correctly. Are they truly exempt from overtime?” Mr. Lang said. “Let's say you pay someone $60,000 per year. Are they entitled to overtime? It depends on their job description.”

Wage-hour audits are the No. 1 legal issue that companies face in the United States, Mr. Lang said. Beginning in 2001, the number of wage-hour class action lawsuits surpassed the number of class actions for race, sex, national origin, color, religion, and age in federal courts—combined.

Mr. Lang also addressed the perils of dating in the workplace. “I have three sexual harassment cases now based solely on a supervisor dating a subordinate,” he said. “What do you think a subordinate employee will do if they are fired? They will sue, and most likely they will win.”

Some employers have policies that address dating in the workplace. “What has recently become a trend that I cannot believe is a 'love contract,'” Mr. Lang said. Some companies allow workers to date but they have to inform the employer when a relationship develops. Also, they are required to sign a contract stating that they are not being coerced, he noted.

Once a year, hire an expert to train your office managers about harassment and discrimination, Mr. Lang suggested. “Why? It's an insurance policy,” he said.

An employee handbook with a specific process for making sexual harassment complaints is recommended. Complaints should be made to at least two people—one of each gender—listed in the handbook by job title instead of name. This will ensure that an employee has someone to talk with besides the person doing the alleged harassment.

A meeting attendee asked Mr. Lang about his fees. “I charge about $2,000–$2,500 to develop a new handbook or revise one. A 3-hour training once a year costs about $1,000,” Mr. Lang said. His rates as a law firm partner range from $250/hour to $350/hour. He also has trained associates who charge less per hour for consultation.

Another element of legal protection is, not surprisingly, “documentation, documentation, documentation,” Mr. Lang said. “But do not write down anything you do not want someone to read. This sounds like something your grandmother would tell you.”

Never assume your e-mail, text message, or instant message (IM) is not going to be exhibit No. 1 in a lawsuit, Mr. Lang said. “Good employment lawyers have great experts that will get e-mails and IMs. Do not assume they are gone after you delete them.”

Mr. Lang's last piece of advice was “know a good employment lawyer.”

MIAMI — Enhance your practice and patient care through collaboration with community resources for children, said Dr. Francis E. Rushton Jr.

“The role of the pediatrician in the community requires use of community resources in collaboration with other professionals, agencies, and parents,” he said. It “requires linkage of our services to other early childhood services in the community.” For example, a partnership between his pediatric practice and a local elementary school in South Carolina improved well-child visits. A greater number of well-child visits were completed and vaccinations administered, and there was a trend toward lower use of other health care services, compared with traditional well-child care.

“When you immerse yourself in community projects, you will learn a lot of what is out there. I [also] learned a lot about what was going on in the community by asking parents,” Dr. Rushton said. He links his patients to publicly funded services including school programs, health department services, and home visitor programs in Beaufort, S.C., where he is in private practice.

Awareness of community resources might save lives as well. “One of my partners had a mother who broke out crying at 4 months when screened [for depression], and she admitted she was suicidal.” Although not trained in suicide intervention, “as a community pediatrician, I have developed links outside my office that ultimately help my patients,” said Dr. Rushton, who is also chair of the Council on Community Pediatrics of the American Academy of Pediatrics.

Screen for maternal depression at the 2-week new baby visit, Dr. Rushton suggested at a pediatric update sponsored by the Miami Children's Hospital.

Collaboration is simply defined as “sitting down with other providers of services and coming up with something different than what you were doing before,” he said.

But collaboration is not always easy. For example, a local school system representative wanted to provide new parents with literature, which Dr. Rushton found redundant because he already gives a lot of material to parents. “So it got my bristles up. Then we realized neither one of us was meeting our goals—the school readiness scores were abysmal.” Things improved when they worked together.

The Well-Baby Plus program at Beaufort Elementary's child development center is another successful collaboration. “We provide all the shots out of our office,” Dr. Rushton said. “A public health service nurse helps my nurse give the shots.”

Dr. Rushton devised the program along with nurse practitioner Westley Byrne. Families with infants about the same age attend 90-minute sessions at the center. Anticipatory guidance is done at each visit, with literacy addressed around 6 months, poisoning at 9 months, discipline at 12 months, and toilet training at 15 months. Nutrition is addressed at all visits.

While a pediatrician performs a check-up on the infant, the parents can participate in a support group and learn about community health and social agency services.

In a study, 51 families in the “high intensity” program completed more visits, received more vaccinations, and had a trend toward fewer emergency department visits—“which is the way you can sell this program,” Dr. Rushton said.

A total of 94% of parents in the Well-Baby Plus program thought their well-child care helped them become better parents, as opposed to 76% of parents in a comparison group that received traditional preventive care. “Significantly more mothers remembered our advice about poisoning and discipline, with a trend toward more knowledge about nutrition and toilet training,” when asked 2 months after the appropriate anticipatory guidance, he said.

The American Academy of Pediatrics Council on Community Pediatrics provides a test of community skills for pediatricians (www.aap.org/sections/socp/compedsselfassessment.html

'When you immerse yourself in community projects, you will learn a lot' about what is out there. DR. RUSHTON

MIAMI — Enhance your practice and patient care through collaboration with community resources for children, said Dr. Francis E. Rushton Jr.

“The role of the pediatrician in the community requires use of community resources in collaboration with other professionals, agencies, and parents,” he said. It “requires linkage of our services to other early childhood services in the community.” For example, a partnership between his pediatric practice and a local elementary school in South Carolina improved well-child visits. A greater number of well-child visits were completed and vaccinations administered, and there was a trend toward lower use of other health care services, compared with traditional well-child care.

“When you immerse yourself in community projects, you will learn a lot of what is out there. I [also] learned a lot about what was going on in the community by asking parents,” Dr. Rushton said. He links his patients to publicly funded services including school programs, health department services, and home visitor programs in Beaufort, S.C., where he is in private practice.

Awareness of community resources might save lives as well. “One of my partners had a mother who broke out crying at 4 months when screened [for depression], and she admitted she was suicidal.” Although not trained in suicide intervention, “as a community pediatrician, I have developed links outside my office that ultimately help my patients,” said Dr. Rushton, who is also chair of the Council on Community Pediatrics of the American Academy of Pediatrics.

Screen for maternal depression at the 2-week new baby visit, Dr. Rushton suggested at a pediatric update sponsored by the Miami Children's Hospital.

Collaboration is simply defined as “sitting down with other providers of services and coming up with something different than what you were doing before,” he said.

But collaboration is not always easy. For example, a local school system representative wanted to provide new parents with literature, which Dr. Rushton found redundant because he already gives a lot of material to parents. “So it got my bristles up. Then we realized neither one of us was meeting our goals—the school readiness scores were abysmal.” Things improved when they worked together.

The Well-Baby Plus program at Beaufort Elementary's child development center is another successful collaboration. “We provide all the shots out of our office,” Dr. Rushton said. “A public health service nurse helps my nurse give the shots.”

Dr. Rushton devised the program along with nurse practitioner Westley Byrne. Families with infants about the same age attend 90-minute sessions at the center. Anticipatory guidance is done at each visit, with literacy addressed around 6 months, poisoning at 9 months, discipline at 12 months, and toilet training at 15 months. Nutrition is addressed at all visits.

While a pediatrician performs a check-up on the infant, the parents can participate in a support group and learn about community health and social agency services.

In a study, 51 families in the “high intensity” program completed more visits, received more vaccinations, and had a trend toward fewer emergency department visits—“which is the way you can sell this program,” Dr. Rushton said.

A total of 94% of parents in the Well-Baby Plus program thought their well-child care helped them become better parents, as opposed to 76% of parents in a comparison group that received traditional preventive care. “Significantly more mothers remembered our advice about poisoning and discipline, with a trend toward more knowledge about nutrition and toilet training,” when asked 2 months after the appropriate anticipatory guidance, he said.

The American Academy of Pediatrics Council on Community Pediatrics provides a test of community skills for pediatricians (www.aap.org/sections/socp/compedsselfassessment.html

'When you immerse yourself in community projects, you will learn a lot' about what is out there. DR. RUSHTON

MIAMI — Enhance your practice and patient care through collaboration with community resources for children, said Dr. Francis E. Rushton Jr.

“The role of the pediatrician in the community requires use of community resources in collaboration with other professionals, agencies, and parents,” he said. It “requires linkage of our services to other early childhood services in the community.” For example, a partnership between his pediatric practice and a local elementary school in South Carolina improved well-child visits. A greater number of well-child visits were completed and vaccinations administered, and there was a trend toward lower use of other health care services, compared with traditional well-child care.

“When you immerse yourself in community projects, you will learn a lot of what is out there. I [also] learned a lot about what was going on in the community by asking parents,” Dr. Rushton said. He links his patients to publicly funded services including school programs, health department services, and home visitor programs in Beaufort, S.C., where he is in private practice.

Awareness of community resources might save lives as well. “One of my partners had a mother who broke out crying at 4 months when screened [for depression], and she admitted she was suicidal.” Although not trained in suicide intervention, “as a community pediatrician, I have developed links outside my office that ultimately help my patients,” said Dr. Rushton, who is also chair of the Council on Community Pediatrics of the American Academy of Pediatrics.

Screen for maternal depression at the 2-week new baby visit, Dr. Rushton suggested at a pediatric update sponsored by the Miami Children's Hospital.

Collaboration is simply defined as “sitting down with other providers of services and coming up with something different than what you were doing before,” he said.

But collaboration is not always easy. For example, a local school system representative wanted to provide new parents with literature, which Dr. Rushton found redundant because he already gives a lot of material to parents. “So it got my bristles up. Then we realized neither one of us was meeting our goals—the school readiness scores were abysmal.” Things improved when they worked together.

The Well-Baby Plus program at Beaufort Elementary's child development center is another successful collaboration. “We provide all the shots out of our office,” Dr. Rushton said. “A public health service nurse helps my nurse give the shots.”

Dr. Rushton devised the program along with nurse practitioner Westley Byrne. Families with infants about the same age attend 90-minute sessions at the center. Anticipatory guidance is done at each visit, with literacy addressed around 6 months, poisoning at 9 months, discipline at 12 months, and toilet training at 15 months. Nutrition is addressed at all visits.

While a pediatrician performs a check-up on the infant, the parents can participate in a support group and learn about community health and social agency services.

In a study, 51 families in the “high intensity” program completed more visits, received more vaccinations, and had a trend toward fewer emergency department visits—“which is the way you can sell this program,” Dr. Rushton said.

A total of 94% of parents in the Well-Baby Plus program thought their well-child care helped them become better parents, as opposed to 76% of parents in a comparison group that received traditional preventive care. “Significantly more mothers remembered our advice about poisoning and discipline, with a trend toward more knowledge about nutrition and toilet training,” when asked 2 months after the appropriate anticipatory guidance, he said.

The American Academy of Pediatrics Council on Community Pediatrics provides a test of community skills for pediatricians (www.aap.org/sections/socp/compedsselfassessment.html

'When you immerse yourself in community projects, you will learn a lot' about what is out there. DR. RUSHTON

Compliance with immunization recommendations goes beyond missed doses: Administration of vaccines before the recommended age and/or too close together may add to suboptimal coverage, according to data analysis by scientists from the Centers for Disease Control and Prevention in Atlanta.

Elizabeth T. Luman, Ph.D., and her associates conducted a nationally representative study of compliance with Advisory Committee on Immunization Practices (ACIP) vaccine recommendations (Am. J. Prev. Med. 2008;34:463–70).

“We knew that about one in five toddlers [was] missing a vaccination, but we were surprised that mistimed doses reduced coverage by another 10%,” Dr. Luman said in an interview. “In total, about one in four children aged 19–35 months [is] not current” on vaccinations.

Dr. Luman and her associates at the CDC's National Center for Immunization and Respiratory Diseases assessed 17,563 children aged 19–35 months. They used 2005 vaccination histories from the National Immunization Survey (NIS).

The estimated coverage with the 4:3:1:3:3 vaccination series incorporating all ACIP recommendations was 72%.

This is 9 percentage points lower than calculations based only on counting doses. Compliance was lowest with the DTaP and greatest with the poliovirus vaccine.

“It's important that children get all the recommended doses, but timing is important as well, so vaccines will be most effective,” said Dr. Luman. She and her associates stated that they had no relevant financial disclosures.

“The implication of this particular article is that if you did not vaccinate at the appropriate time, you're vulnerable to a particular disease,” Dr. John Bradley said in an interview. “We want people to get the vaccine in the recommended time slot if possible, but that is not to say that if you have to reschedule the appointment … that you are completely susceptible to that disease.” Dr. Bradley is a member of the American Academy of Pediatrics Committee on Infectious Diseases. The ACIP recommendations are developed in collaboration with the AAP and the American Academy of Family Physicians.

The researchers recognized that sometimes a vaccine cannot be given at the recommended time. “Administering a vaccination a few days early is preferred to missing the opportunity to vaccinate a child who is unlikely to return at the appropriate time,” the authors wrote. “However, the observance of both age-appropriate vaccination and sufficient time between doses in a series maximizes the immune response and the vaccine's efficacy.”

“Medical science doesn't know how much wiggle room we have. To give a week early or late—those studies have not been done,” said Dr. Bradley, who is also director of the division of infectious diseases at Children's Hospital and Health Center, San Diego.

“The timing of vaccines and boosters is based on a best guess of optimal timing” based on large-scale trials reviewed by the Food and Drug Administration. Dr. Bradley said he has no financial disclosures related to vaccines.

About 6% of children received at least one age-invalid vaccination in the 4:3:1:3:3 series.

Another 3% received at least one interval-invalid vaccination; this figure included 0.3% who received MMR immunization too soon following a varicella vaccination.

In addition, approximately 14% of children had a third dose of hepatitis B vaccine prior to the age of 6 months, the minimum valid age.

Limitations of the study include vaccination histories reported by vaccine providers identified through parents, as well as a lack of information regarding vaccine contraindications, including allergic reactions.

“Health care providers, along with parents and vaccination programs, have done an outstanding job of increasing vaccination levels in the U.S.,” Dr. Luman commented. “But continued vigilance and improvements are needed to make sure that every child and every community [is] protected from these deadly diseases. Good communication between providers and parents can help increase parental awareness of the benefits of vaccination, and ensure that children are brought in for all their vaccinations at the right time.”

Compliance with immunization recommendations goes beyond missed doses: Administration of vaccines before the recommended age and/or too close together may add to suboptimal coverage, according to data analysis by scientists from the Centers for Disease Control and Prevention in Atlanta.

Elizabeth T. Luman, Ph.D., and her associates conducted a nationally representative study of compliance with Advisory Committee on Immunization Practices (ACIP) vaccine recommendations (Am. J. Prev. Med. 2008;34:463–70).

“We knew that about one in five toddlers [was] missing a vaccination, but we were surprised that mistimed doses reduced coverage by another 10%,” Dr. Luman said in an interview. “In total, about one in four children aged 19–35 months [is] not current” on vaccinations.

Dr. Luman and her associates at the CDC's National Center for Immunization and Respiratory Diseases assessed 17,563 children aged 19–35 months. They used 2005 vaccination histories from the National Immunization Survey (NIS).

The estimated coverage with the 4:3:1:3:3 vaccination series incorporating all ACIP recommendations was 72%.

This is 9 percentage points lower than calculations based only on counting doses. Compliance was lowest with the DTaP and greatest with the poliovirus vaccine.

“It's important that children get all the recommended doses, but timing is important as well, so vaccines will be most effective,” said Dr. Luman. She and her associates stated that they had no relevant financial disclosures.

“The implication of this particular article is that if you did not vaccinate at the appropriate time, you're vulnerable to a particular disease,” Dr. John Bradley said in an interview. “We want people to get the vaccine in the recommended time slot if possible, but that is not to say that if you have to reschedule the appointment … that you are completely susceptible to that disease.” Dr. Bradley is a member of the American Academy of Pediatrics Committee on Infectious Diseases. The ACIP recommendations are developed in collaboration with the AAP and the American Academy of Family Physicians.

The researchers recognized that sometimes a vaccine cannot be given at the recommended time. “Administering a vaccination a few days early is preferred to missing the opportunity to vaccinate a child who is unlikely to return at the appropriate time,” the authors wrote. “However, the observance of both age-appropriate vaccination and sufficient time between doses in a series maximizes the immune response and the vaccine's efficacy.”

“Medical science doesn't know how much wiggle room we have. To give a week early or late—those studies have not been done,” said Dr. Bradley, who is also director of the division of infectious diseases at Children's Hospital and Health Center, San Diego.

“The timing of vaccines and boosters is based on a best guess of optimal timing” based on large-scale trials reviewed by the Food and Drug Administration. Dr. Bradley said he has no financial disclosures related to vaccines.

About 6% of children received at least one age-invalid vaccination in the 4:3:1:3:3 series.

Another 3% received at least one interval-invalid vaccination; this figure included 0.3% who received MMR immunization too soon following a varicella vaccination.

In addition, approximately 14% of children had a third dose of hepatitis B vaccine prior to the age of 6 months, the minimum valid age.

Limitations of the study include vaccination histories reported by vaccine providers identified through parents, as well as a lack of information regarding vaccine contraindications, including allergic reactions.

“Health care providers, along with parents and vaccination programs, have done an outstanding job of increasing vaccination levels in the U.S.,” Dr. Luman commented. “But continued vigilance and improvements are needed to make sure that every child and every community [is] protected from these deadly diseases. Good communication between providers and parents can help increase parental awareness of the benefits of vaccination, and ensure that children are brought in for all their vaccinations at the right time.”

Compliance with immunization recommendations goes beyond missed doses: Administration of vaccines before the recommended age and/or too close together may add to suboptimal coverage, according to data analysis by scientists from the Centers for Disease Control and Prevention in Atlanta.

Elizabeth T. Luman, Ph.D., and her associates conducted a nationally representative study of compliance with Advisory Committee on Immunization Practices (ACIP) vaccine recommendations (Am. J. Prev. Med. 2008;34:463–70).

“We knew that about one in five toddlers [was] missing a vaccination, but we were surprised that mistimed doses reduced coverage by another 10%,” Dr. Luman said in an interview. “In total, about one in four children aged 19–35 months [is] not current” on vaccinations.

Dr. Luman and her associates at the CDC's National Center for Immunization and Respiratory Diseases assessed 17,563 children aged 19–35 months. They used 2005 vaccination histories from the National Immunization Survey (NIS).

The estimated coverage with the 4:3:1:3:3 vaccination series incorporating all ACIP recommendations was 72%.

This is 9 percentage points lower than calculations based only on counting doses. Compliance was lowest with the DTaP and greatest with the poliovirus vaccine.

“It's important that children get all the recommended doses, but timing is important as well, so vaccines will be most effective,” said Dr. Luman. She and her associates stated that they had no relevant financial disclosures.

“The implication of this particular article is that if you did not vaccinate at the appropriate time, you're vulnerable to a particular disease,” Dr. John Bradley said in an interview. “We want people to get the vaccine in the recommended time slot if possible, but that is not to say that if you have to reschedule the appointment … that you are completely susceptible to that disease.” Dr. Bradley is a member of the American Academy of Pediatrics Committee on Infectious Diseases. The ACIP recommendations are developed in collaboration with the AAP and the American Academy of Family Physicians.

The researchers recognized that sometimes a vaccine cannot be given at the recommended time. “Administering a vaccination a few days early is preferred to missing the opportunity to vaccinate a child who is unlikely to return at the appropriate time,” the authors wrote. “However, the observance of both age-appropriate vaccination and sufficient time between doses in a series maximizes the immune response and the vaccine's efficacy.”

“Medical science doesn't know how much wiggle room we have. To give a week early or late—those studies have not been done,” said Dr. Bradley, who is also director of the division of infectious diseases at Children's Hospital and Health Center, San Diego.

“The timing of vaccines and boosters is based on a best guess of optimal timing” based on large-scale trials reviewed by the Food and Drug Administration. Dr. Bradley said he has no financial disclosures related to vaccines.

About 6% of children received at least one age-invalid vaccination in the 4:3:1:3:3 series.

Another 3% received at least one interval-invalid vaccination; this figure included 0.3% who received MMR immunization too soon following a varicella vaccination.

In addition, approximately 14% of children had a third dose of hepatitis B vaccine prior to the age of 6 months, the minimum valid age.

Limitations of the study include vaccination histories reported by vaccine providers identified through parents, as well as a lack of information regarding vaccine contraindications, including allergic reactions.

“Health care providers, along with parents and vaccination programs, have done an outstanding job of increasing vaccination levels in the U.S.,” Dr. Luman commented. “But continued vigilance and improvements are needed to make sure that every child and every community [is] protected from these deadly diseases. Good communication between providers and parents can help increase parental awareness of the benefits of vaccination, and ensure that children are brought in for all their vaccinations at the right time.”

FORT LAUDERDALE, FLA. — More children with pneumonia are developing necrotizing pneumonia from a growing variety of infectious agents, including methicillin-resistant Staphylococcus aureus, according to a retrospective, 15-year study.

“Necrotizing pneumonia is real,” Dr. Andrew Colin said.

If a child has a persistent fever that does not respond to treatment for 3 or more weeks, along with pleural effusions suggesting community-acquired pneumonia, consider coexisting necrotizing pneumonia, he said.

Multiple organisms are playing a role, “including a lot of necrotizing pneumonias where we do not know the organism. These could be mycoplasma,” said Dr. Colin, director of the division of pediatric pulmonology, Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center in Florida.

Of 80 patients, 38 (48%) had positive cultures. Streptococcus pneumoniae was the predominant organism, although in the more recent years there was a variety of organisms responsible, most notably methicillin-resistant Staphylococcus aureus (MRSA), Dr. Colin said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Dr. Colin, along with Dr. Gregory Sawicki (the study's lead author) and associates, found an increasing incidence of necrotizing pneumonia from January 1990 to February 2005 at Children's Hospital Boston (Eur. Respir. J. 2008 Jan. 23 [Epub ahead of print]). Of 80 cases identified, there was 1 case during 1993–1994; 11 each during 1995–1996 and 1997–1998; 17 cases during 1999–2000; and 12 cases during 2001–2002.

“By the end of the study, years 2003–2004, we had 28 cases in one hospital, which is quite significant,” Dr. Colin commented.

A meeting attendee asked if children at greater risk for necrotizing pneumonia can be identified.

“We don't have large enough numbers to predict who will develop necrotizing pneumonia,” responded Dr. Colin, who is also professor of pediatrics at the University of Miami.

Necrotizing pneumonia presents with coexisting effusion in a majority of patients. In the study, 69 children (86%) had pleural effusion with a low pH (mean 7.08).

It is clinically challenging to differentiate the signs and symptoms of necrotizing pneumonia from the effusion, Dr. Colin said.

Computed tomography with contrast is the best way to diagnosis necrotizing pneumonia, Dr. Colin said. The imaging detects the characteristic features, the liquefaction and cavitation of lung tissue. Look for demarcation between lung and liquid lung, he suggested.

How to differentiate a lung abscess from liquid in the lung on the imaging was another meeting attendee question.

“The differential diagnosis is absolutely critical,” Dr. Colin said. On the CT scan, abscesses appear with thick walls, whereas necrotizing lungs have thin walls and will collapse in a couple of days, he replied. Also, “if you tap the two, the abscess will be positive in culture, the necrotizing lung will be negative.”

Although the lungs are often sterile with necrotizing pneumonia, “there are some bad bugs, so everyone gives antibiotics just in case.”

Dr. Colin advocated a conservative approach to prolonged chest tube drainage in patients who develop necrotizing pneumonia. In another of his studies, five of nine children with the condition developed bronchopleural fistulae after chest tube placement (Pediatr. Radiol. 1999;29:87–91). Three of these children had a surgical chest tube placed for an average of 7 weeks to treat persistent pneumothorax.

The longer drainage continues, the greater the risk of puncturing a lung. A bronchopleural fistula is a serious complication that can substantially lengthen a hospital stay and recovery time, he added.

“Despite the serious morbidity, massive parenchymal damage, and prolonged hospitalizations, long-term outcome following necrotizing pneumonia is excellent,” Dr. Colin and his coauthors wrote. In fact, all patients in the study had a complete clinical resolution within 2 months, he added.

“The good news is you do not have to resect damaged lungs—these young patients have a remarkable ability to recover.”

FORT LAUDERDALE, FLA. — More children with pneumonia are developing necrotizing pneumonia from a growing variety of infectious agents, including methicillin-resistant Staphylococcus aureus, according to a retrospective, 15-year study.

“Necrotizing pneumonia is real,” Dr. Andrew Colin said.

If a child has a persistent fever that does not respond to treatment for 3 or more weeks, along with pleural effusions suggesting community-acquired pneumonia, consider coexisting necrotizing pneumonia, he said.

Multiple organisms are playing a role, “including a lot of necrotizing pneumonias where we do not know the organism. These could be mycoplasma,” said Dr. Colin, director of the division of pediatric pulmonology, Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center in Florida.

Of 80 patients, 38 (48%) had positive cultures. Streptococcus pneumoniae was the predominant organism, although in the more recent years there was a variety of organisms responsible, most notably methicillin-resistant Staphylococcus aureus (MRSA), Dr. Colin said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Dr. Colin, along with Dr. Gregory Sawicki (the study's lead author) and associates, found an increasing incidence of necrotizing pneumonia from January 1990 to February 2005 at Children's Hospital Boston (Eur. Respir. J. 2008 Jan. 23 [Epub ahead of print]). Of 80 cases identified, there was 1 case during 1993–1994; 11 each during 1995–1996 and 1997–1998; 17 cases during 1999–2000; and 12 cases during 2001–2002.

“By the end of the study, years 2003–2004, we had 28 cases in one hospital, which is quite significant,” Dr. Colin commented.

A meeting attendee asked if children at greater risk for necrotizing pneumonia can be identified.

“We don't have large enough numbers to predict who will develop necrotizing pneumonia,” responded Dr. Colin, who is also professor of pediatrics at the University of Miami.

Necrotizing pneumonia presents with coexisting effusion in a majority of patients. In the study, 69 children (86%) had pleural effusion with a low pH (mean 7.08).

It is clinically challenging to differentiate the signs and symptoms of necrotizing pneumonia from the effusion, Dr. Colin said.

Computed tomography with contrast is the best way to diagnosis necrotizing pneumonia, Dr. Colin said. The imaging detects the characteristic features, the liquefaction and cavitation of lung tissue. Look for demarcation between lung and liquid lung, he suggested.

How to differentiate a lung abscess from liquid in the lung on the imaging was another meeting attendee question.

“The differential diagnosis is absolutely critical,” Dr. Colin said. On the CT scan, abscesses appear with thick walls, whereas necrotizing lungs have thin walls and will collapse in a couple of days, he replied. Also, “if you tap the two, the abscess will be positive in culture, the necrotizing lung will be negative.”

Although the lungs are often sterile with necrotizing pneumonia, “there are some bad bugs, so everyone gives antibiotics just in case.”

Dr. Colin advocated a conservative approach to prolonged chest tube drainage in patients who develop necrotizing pneumonia. In another of his studies, five of nine children with the condition developed bronchopleural fistulae after chest tube placement (Pediatr. Radiol. 1999;29:87–91). Three of these children had a surgical chest tube placed for an average of 7 weeks to treat persistent pneumothorax.

The longer drainage continues, the greater the risk of puncturing a lung. A bronchopleural fistula is a serious complication that can substantially lengthen a hospital stay and recovery time, he added.

“Despite the serious morbidity, massive parenchymal damage, and prolonged hospitalizations, long-term outcome following necrotizing pneumonia is excellent,” Dr. Colin and his coauthors wrote. In fact, all patients in the study had a complete clinical resolution within 2 months, he added.

“The good news is you do not have to resect damaged lungs—these young patients have a remarkable ability to recover.”

FORT LAUDERDALE, FLA. — More children with pneumonia are developing necrotizing pneumonia from a growing variety of infectious agents, including methicillin-resistant Staphylococcus aureus, according to a retrospective, 15-year study.

“Necrotizing pneumonia is real,” Dr. Andrew Colin said.

If a child has a persistent fever that does not respond to treatment for 3 or more weeks, along with pleural effusions suggesting community-acquired pneumonia, consider coexisting necrotizing pneumonia, he said.

Multiple organisms are playing a role, “including a lot of necrotizing pneumonias where we do not know the organism. These could be mycoplasma,” said Dr. Colin, director of the division of pediatric pulmonology, Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center in Florida.

Of 80 patients, 38 (48%) had positive cultures. Streptococcus pneumoniae was the predominant organism, although in the more recent years there was a variety of organisms responsible, most notably methicillin-resistant Staphylococcus aureus (MRSA), Dr. Colin said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Dr. Colin, along with Dr. Gregory Sawicki (the study's lead author) and associates, found an increasing incidence of necrotizing pneumonia from January 1990 to February 2005 at Children's Hospital Boston (Eur. Respir. J. 2008 Jan. 23 [Epub ahead of print]). Of 80 cases identified, there was 1 case during 1993–1994; 11 each during 1995–1996 and 1997–1998; 17 cases during 1999–2000; and 12 cases during 2001–2002.

“By the end of the study, years 2003–2004, we had 28 cases in one hospital, which is quite significant,” Dr. Colin commented.

A meeting attendee asked if children at greater risk for necrotizing pneumonia can be identified.

“We don't have large enough numbers to predict who will develop necrotizing pneumonia,” responded Dr. Colin, who is also professor of pediatrics at the University of Miami.

Necrotizing pneumonia presents with coexisting effusion in a majority of patients. In the study, 69 children (86%) had pleural effusion with a low pH (mean 7.08).

It is clinically challenging to differentiate the signs and symptoms of necrotizing pneumonia from the effusion, Dr. Colin said.

Computed tomography with contrast is the best way to diagnosis necrotizing pneumonia, Dr. Colin said. The imaging detects the characteristic features, the liquefaction and cavitation of lung tissue. Look for demarcation between lung and liquid lung, he suggested.

How to differentiate a lung abscess from liquid in the lung on the imaging was another meeting attendee question.

“The differential diagnosis is absolutely critical,” Dr. Colin said. On the CT scan, abscesses appear with thick walls, whereas necrotizing lungs have thin walls and will collapse in a couple of days, he replied. Also, “if you tap the two, the abscess will be positive in culture, the necrotizing lung will be negative.”

Although the lungs are often sterile with necrotizing pneumonia, “there are some bad bugs, so everyone gives antibiotics just in case.”

Dr. Colin advocated a conservative approach to prolonged chest tube drainage in patients who develop necrotizing pneumonia. In another of his studies, five of nine children with the condition developed bronchopleural fistulae after chest tube placement (Pediatr. Radiol. 1999;29:87–91). Three of these children had a surgical chest tube placed for an average of 7 weeks to treat persistent pneumothorax.

The longer drainage continues, the greater the risk of puncturing a lung. A bronchopleural fistula is a serious complication that can substantially lengthen a hospital stay and recovery time, he added.

“Despite the serious morbidity, massive parenchymal damage, and prolonged hospitalizations, long-term outcome following necrotizing pneumonia is excellent,” Dr. Colin and his coauthors wrote. In fact, all patients in the study had a complete clinical resolution within 2 months, he added.

“The good news is you do not have to resect damaged lungs—these young patients have a remarkable ability to recover.”

FORT LAUDERDALE, FLA. — Although some children with sleep-disordered breathing experience significant cognitive deficits, not all do, and identification of those at risk remains a clinical challenge, according to a sleep medicine expert.

There is a wide range in individual susceptibility, Dr. David Gozal said. “A child can have a mild [sleep] disturbance and be affected or have severe sleep apnea and be unaffected cognitively.” Together with apnea severity and environmental factors, individual differences in susceptibility complete the triple-risk model of obstructive sleep apnea morbidity, said Dr. Gozal, professor and vice chair of research, department of pediatrics, University of Louisville (Ky.).

In general, increased apnea severity is associated with greater impairments in cognition. For example, Dr. Gozal and colleagues found significant neurocognitive deficits with higher apnea/hypopnea index (AHI) scores in snoring children (J. Sleep Res. 2004;13:165–72).

With increases in AHI severity, a child's IQ can decrease, Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. For children with an AHI of 5 or more, for example, there is average loss of 6–8 IQ points. “If you are born with an IQ of 100, that can be the difference between going to college or not.”

At any AHI level in the study, however, there were children without any cognitive deficit, again pointing to the individual variability, said Dr. Gozal, who is also a respiratory/sleep physiologist in the division of sleep medicine at Kosair Children's Hospital Research Institute, also in Louisville.

Specifically, significantly higher impairments in phonological processing, visual and auditory attention, and social problems were found among children with an AHI greater than 5, compared with those scoring 5 or less. High scorers also had significantly worse thought problems, delinquent or oppositional behavior, aggressiveness, externalizing of problems, and deficits in verbal comprehension ability.

In another study of 297 poorly performing first graders, there was a 6- to 9-fold increase in sleep apnea, compared with the general population (Pediatrics 1998;102:616–20).

The good news is that apnea treatment reversed some learning deficits. Some parents thank Dr. Gozal for improvements in their children's ability to learn following adenotonsillectomy.

In terms of potential misdiagnosis, there is some overlap between children with attention-deficit/hyperactivity disorder (ADHD) symptoms and those with obstructive sleep apnea (OSA) who demonstrate intrinsic daytime sleepiness. These patients can benefit from stimulant treatment, Dr. Gozal said.

The diagnosis of sleep apnea may be completely overlooked, since these patients improve with stimulants, similarly to children with ADHD who also are intrinsically sleepy. However, children with a formal diagnosis of ADHD-inattentive type who are not sleepy will be more likely to improve with addition of a norepinephrine reuptake inhibitor to treat their prefrontal cortex executive dysfunction, he said.

The way a child lives affects the way the sleep-disordered breathing affects them, Dr. Gozal said. “Physical activity is actually protective of our children when they have sleep apnea.” For example, a walk in the park 30 minutes per day, 5 days a week, can prevent the onset of morbid consequences of apnea. In addition, higher home literacy levels are associated with a lesser likelihood of learning and behavioral deficits among children with sleep apnea, he said.

Given such individual variability in risk of adverse cognitive outcomes in these children, Dr. Gozal and his associates are searching for a prognostic marker. They found that elevated plasma C-reactive protein levels, an indicator of increased systemic inflammation, might indicate children with OSA are at greater neuro-cognitive risk (Am. J. Respir. Crit. Care Med. 2007;176:188–93).

They assessed 278 children and found high-sensitivity C-reactive protein (hsCRP) levels almost triple among children with cognitive deficits, compared with those without. Participants were 5- to 7-year-old children recruited from the community.

The mean hsCRP was 0.48 plus or minus 0.12 mg/dL in children with OSA and cognitive deficits, compared with 0.21 plus or minus 0.08 mg/dL in children with the condition and normal cognitive scores. This difference was statistically significant.

“We show in a community-based study of snoring and nonsnoring school-aged children, that children with OSA have increased levels of hsCRP and also exhibit decreased cognitive performances compared with control children,” Dr. Gozal and his associates wrote. “Furthermore, hsCRP levels are significantly increased among patients with OSA and cognitive dysfunction, and this phenomenon persists even when after the severity of OSA is matched for the two cognitive function groups. Thus, hsCRP variation emerges as a predictive measure of risk for OSA-induced cognitive deficits in children.”

FORT LAUDERDALE, FLA. — Although some children with sleep-disordered breathing experience significant cognitive deficits, not all do, and identification of those at risk remains a clinical challenge, according to a sleep medicine expert.

There is a wide range in individual susceptibility, Dr. David Gozal said. “A child can have a mild [sleep] disturbance and be affected or have severe sleep apnea and be unaffected cognitively.” Together with apnea severity and environmental factors, individual differences in susceptibility complete the triple-risk model of obstructive sleep apnea morbidity, said Dr. Gozal, professor and vice chair of research, department of pediatrics, University of Louisville (Ky.).

In general, increased apnea severity is associated with greater impairments in cognition. For example, Dr. Gozal and colleagues found significant neurocognitive deficits with higher apnea/hypopnea index (AHI) scores in snoring children (J. Sleep Res. 2004;13:165–72).

With increases in AHI severity, a child's IQ can decrease, Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. For children with an AHI of 5 or more, for example, there is average loss of 6–8 IQ points. “If you are born with an IQ of 100, that can be the difference between going to college or not.”

At any AHI level in the study, however, there were children without any cognitive deficit, again pointing to the individual variability, said Dr. Gozal, who is also a respiratory/sleep physiologist in the division of sleep medicine at Kosair Children's Hospital Research Institute, also in Louisville.

Specifically, significantly higher impairments in phonological processing, visual and auditory attention, and social problems were found among children with an AHI greater than 5, compared with those scoring 5 or less. High scorers also had significantly worse thought problems, delinquent or oppositional behavior, aggressiveness, externalizing of problems, and deficits in verbal comprehension ability.

In another study of 297 poorly performing first graders, there was a 6- to 9-fold increase in sleep apnea, compared with the general population (Pediatrics 1998;102:616–20).

The good news is that apnea treatment reversed some learning deficits. Some parents thank Dr. Gozal for improvements in their children's ability to learn following adenotonsillectomy.

In terms of potential misdiagnosis, there is some overlap between children with attention-deficit/hyperactivity disorder (ADHD) symptoms and those with obstructive sleep apnea (OSA) who demonstrate intrinsic daytime sleepiness. These patients can benefit from stimulant treatment, Dr. Gozal said.

The diagnosis of sleep apnea may be completely overlooked, since these patients improve with stimulants, similarly to children with ADHD who also are intrinsically sleepy. However, children with a formal diagnosis of ADHD-inattentive type who are not sleepy will be more likely to improve with addition of a norepinephrine reuptake inhibitor to treat their prefrontal cortex executive dysfunction, he said.

The way a child lives affects the way the sleep-disordered breathing affects them, Dr. Gozal said. “Physical activity is actually protective of our children when they have sleep apnea.” For example, a walk in the park 30 minutes per day, 5 days a week, can prevent the onset of morbid consequences of apnea. In addition, higher home literacy levels are associated with a lesser likelihood of learning and behavioral deficits among children with sleep apnea, he said.

Given such individual variability in risk of adverse cognitive outcomes in these children, Dr. Gozal and his associates are searching for a prognostic marker. They found that elevated plasma C-reactive protein levels, an indicator of increased systemic inflammation, might indicate children with OSA are at greater neuro-cognitive risk (Am. J. Respir. Crit. Care Med. 2007;176:188–93).

They assessed 278 children and found high-sensitivity C-reactive protein (hsCRP) levels almost triple among children with cognitive deficits, compared with those without. Participants were 5- to 7-year-old children recruited from the community.

The mean hsCRP was 0.48 plus or minus 0.12 mg/dL in children with OSA and cognitive deficits, compared with 0.21 plus or minus 0.08 mg/dL in children with the condition and normal cognitive scores. This difference was statistically significant.

“We show in a community-based study of snoring and nonsnoring school-aged children, that children with OSA have increased levels of hsCRP and also exhibit decreased cognitive performances compared with control children,” Dr. Gozal and his associates wrote. “Furthermore, hsCRP levels are significantly increased among patients with OSA and cognitive dysfunction, and this phenomenon persists even when after the severity of OSA is matched for the two cognitive function groups. Thus, hsCRP variation emerges as a predictive measure of risk for OSA-induced cognitive deficits in children.”

FORT LAUDERDALE, FLA. — Although some children with sleep-disordered breathing experience significant cognitive deficits, not all do, and identification of those at risk remains a clinical challenge, according to a sleep medicine expert.

There is a wide range in individual susceptibility, Dr. David Gozal said. “A child can have a mild [sleep] disturbance and be affected or have severe sleep apnea and be unaffected cognitively.” Together with apnea severity and environmental factors, individual differences in susceptibility complete the triple-risk model of obstructive sleep apnea morbidity, said Dr. Gozal, professor and vice chair of research, department of pediatrics, University of Louisville (Ky.).

In general, increased apnea severity is associated with greater impairments in cognition. For example, Dr. Gozal and colleagues found significant neurocognitive deficits with higher apnea/hypopnea index (AHI) scores in snoring children (J. Sleep Res. 2004;13:165–72).

With increases in AHI severity, a child's IQ can decrease, Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. For children with an AHI of 5 or more, for example, there is average loss of 6–8 IQ points. “If you are born with an IQ of 100, that can be the difference between going to college or not.”

At any AHI level in the study, however, there were children without any cognitive deficit, again pointing to the individual variability, said Dr. Gozal, who is also a respiratory/sleep physiologist in the division of sleep medicine at Kosair Children's Hospital Research Institute, also in Louisville.

Specifically, significantly higher impairments in phonological processing, visual and auditory attention, and social problems were found among children with an AHI greater than 5, compared with those scoring 5 or less. High scorers also had significantly worse thought problems, delinquent or oppositional behavior, aggressiveness, externalizing of problems, and deficits in verbal comprehension ability.

In another study of 297 poorly performing first graders, there was a 6- to 9-fold increase in sleep apnea, compared with the general population (Pediatrics 1998;102:616–20).

The good news is that apnea treatment reversed some learning deficits. Some parents thank Dr. Gozal for improvements in their children's ability to learn following adenotonsillectomy.

In terms of potential misdiagnosis, there is some overlap between children with attention-deficit/hyperactivity disorder (ADHD) symptoms and those with obstructive sleep apnea (OSA) who demonstrate intrinsic daytime sleepiness. These patients can benefit from stimulant treatment, Dr. Gozal said.

The diagnosis of sleep apnea may be completely overlooked, since these patients improve with stimulants, similarly to children with ADHD who also are intrinsically sleepy. However, children with a formal diagnosis of ADHD-inattentive type who are not sleepy will be more likely to improve with addition of a norepinephrine reuptake inhibitor to treat their prefrontal cortex executive dysfunction, he said.

The way a child lives affects the way the sleep-disordered breathing affects them, Dr. Gozal said. “Physical activity is actually protective of our children when they have sleep apnea.” For example, a walk in the park 30 minutes per day, 5 days a week, can prevent the onset of morbid consequences of apnea. In addition, higher home literacy levels are associated with a lesser likelihood of learning and behavioral deficits among children with sleep apnea, he said.

Given such individual variability in risk of adverse cognitive outcomes in these children, Dr. Gozal and his associates are searching for a prognostic marker. They found that elevated plasma C-reactive protein levels, an indicator of increased systemic inflammation, might indicate children with OSA are at greater neuro-cognitive risk (Am. J. Respir. Crit. Care Med. 2007;176:188–93).

They assessed 278 children and found high-sensitivity C-reactive protein (hsCRP) levels almost triple among children with cognitive deficits, compared with those without. Participants were 5- to 7-year-old children recruited from the community.

The mean hsCRP was 0.48 plus or minus 0.12 mg/dL in children with OSA and cognitive deficits, compared with 0.21 plus or minus 0.08 mg/dL in children with the condition and normal cognitive scores. This difference was statistically significant.

“We show in a community-based study of snoring and nonsnoring school-aged children, that children with OSA have increased levels of hsCRP and also exhibit decreased cognitive performances compared with control children,” Dr. Gozal and his associates wrote. “Furthermore, hsCRP levels are significantly increased among patients with OSA and cognitive dysfunction, and this phenomenon persists even when after the severity of OSA is matched for the two cognitive function groups. Thus, hsCRP variation emerges as a predictive measure of risk for OSA-induced cognitive deficits in children.”

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC.

“We are starting to see more and more cases of dengue fever,” Dr. Christian C. Patrick said at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas in October, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records in December revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The Aedes aegypti mosquito that spreads this disease is now found throughout central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a Jan. 9, 2008, commentary in JAMA (2008;299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus (Asian tiger mosquito), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote.

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days) with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC.

“We are starting to see more and more cases of dengue fever,” Dr. Christian C. Patrick said at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas in October, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records in December revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The Aedes aegypti mosquito that spreads this disease is now found throughout central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a Jan. 9, 2008, commentary in JAMA (2008;299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus (Asian tiger mosquito), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote.

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days) with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC.

“We are starting to see more and more cases of dengue fever,” Dr. Christian C. Patrick said at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas in October, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records in December revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The Aedes aegypti mosquito that spreads this disease is now found throughout central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a Jan. 9, 2008, commentary in JAMA (2008;299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus (Asian tiger mosquito), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote.

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days) with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.