Susan C. DonLevy

Implementing Pediatric Growth Charts into an Electronic Health Record System

Electronic health record (EHR) systems are increasingly being adopted in pediatric practices; however, requirements for integrated growth charts are poorly described and are not standardized in current systems. The authors integrated growth chart functionality into an EHR system being developed and installed in a multispecialty pediatric clinic in an academic medical center. During a three-year observation period, rates of electronically documented values for weight, stature, and head circumference increased from fewer than ten total per weekday, up to 488 weight values, 293 stature values, and 74 head circumference values (p<0.001 for each measure). By the end of the observation period, users accessed the growth charts an average 175 times per weekday, compared to 127 patient visits per weekday to the sites that most closely monitored pediatric growth. Because EHR systems and integrated growth charts can manipulate data, perform calculations, and adapt to user preferences and patient characteristics, users may expect greater functionality from electronic growth charts than from paper-based growth charts.

Effect of spironolactone-hydrochlorothiazide on lung function in infants with chronic bronchopulmonary dysplasia*

To test the hypothesis that spironolactone-hydrochlorothiazide (Aldactazide) will improve urine output and lung function in infants with bronchopulmonary dysplasia, we studied 21 hospitalized, spontaneously breathing, oxygen-dependent infants with chronic bronchopulmonary dysplasia. Infants were randomly assigned to receive either a 1:1 mixture of spironolactone and hydrochlorothiazide orally (n = 12) (3 mg/kg/day of both compounds) or no treatment (n = 9) for 6 to 8 days each. Dynamic lung compliance, total pulmonary resistance, and hemoglobin oxygen saturation were measured on the first and last days of each study period. Fluid intake and urine output were measured each day. Although the treatment significantly increased urine output, neither lung mechanics nor oxygenation were improved by the drug. The magnitude of the diuresis achieved with spironolactone-hydrochlorothiazide treatment was comparable to the diuresis achieved in a previous study of furosemide treatment (J Pediatr 1986:109;1034-9). Statistical analysis indicated that a type II error was an unlikely explanation for our failure to detect a beneficial effect. In three patients, doubling the oral dose did not improve lung mechanics or oxygenation. We speculate that diuresis per se is not responsible for lung function improvement during treatment with other drugs with diuretic properties.

Equations describing percentiles for birth weight, head circumference, and length of preterm infants

Objective:To describe growth of prematurely born infants and create a growth chart adequate to assess growth of infants with less than 29 completed weeks of gestation.Study design:Birth weight, head circumference and length measurements of 7425 liveborn preterm infants from 1985 to 1997 were retrieved from a longitudinal database maintained by the neonatology division. The 3rd, 5th, 10th, 15th, 25th, 50th, 75th, 85th, 90th, 95th and 97th percentiles of each measurement were determined and used for mathematical modeling.Results:Birth weight was described with an exponential function while head circumference and length were described with linear functions. A preterm growth chart for the 10th, 50th and 90th percentiles for birth weight, weight growth, head circumference and length was generated.Conclusion:The mathematical models of growth provide smooth representations of the percentiles across gestational ages.

Quantifying cerebral changes in adolescence with MRI and deformation based morphometry.

To identify and quantify structural changes in the maturing brain between childhood and adolescence.

Modeling brain tissue volumes over the lifespan: quantitative analysis of postmortem weights and in vivo MR images

Normative measurements of brain gray matter and white matter tissue volumes across the lifespan have not yet been established. The purpose of this article was to use mathematical modeling and analytical functions to demonstrate the growth trajectory of gray matter and white matter from age 0 to age 90. For each gender, brain weight functions were generated by utilizing existing autopsy data from 4400 subjects. Brain gray matter, white matter and lateral ventricular volumes were measured from 39 MR volumes of normal individuals. These were converted to weight by multiplying the tissue volumes by the specific gravity of that tissue. White matter volumes were described by a saturating exponential function, and the gray matter volume function was calculated by subtracting the white matter weight function from the brain weight function. For each gender, equations were generated for white matter and gray matter volumes as a function of age over the lifespan.

Equations to support predictive automated postnatal growth curves for premature infants

Growth charts are used in pediatric medicine to plot anthropomorphic measurements over time, serving as a screen for diseases related to a patients nutritional and general health status. Whereas reference data for term infants are available from the Center for Disease Control, reference data for premature infants in a neonatal intensive care unit have not been established. Predictive curves for preterm patients, which are based on a patients postmenstrual age and anthropomorphic measurements at birth, cannot be easily implemented with traditional paper-based methods. Preterm growth charts can be generated in an electronic health record system, but doing so requires mathematical equations or computer-readable tables. This report examines published perinatal growth curves and presents equations for predicted postnatal weight, head circumference and length in preterm infants.

Defining the Expected Growth of the Preterm Infant

The infant mortality rate, defined as the number of children who die before 1 year of age per 1000 live births, has long been considered a measure of a population’s health. The subspecialty of pediatrics now known as neonatology and the Neonatal Intensive Care Unit (NICU) arose from efforts to decrease infant mortality. Access to neonatal intensive care has improved the survival rate of those infants with birth trauma, asphyxia, bacterial infections, and congenital anomalies. Additionally, the miniaturization of technology has made it possible to challenge the lower limits of viability by providing cardiopulmonary support to smaller and prematurely born infants. However, the incidence of low birth weight has not decreased and the incidence of preterm birth is continuing to increase. Providing the care to support the development of the extremely premature infant in an extrauterine environment is an ongoing challenge for all perinatal care providers. Pediatricians agree that nutrition and growth of prematurely born infants in the NICU should be similar to growth in utero. However, in utero nutrition requirements and growth are poorly defined. Multiple investigators have reported values for anthropometric measurements for premature infants, but the values are not coincident. This chapter compares the differences in recently defined growth patterns of preterm infants from 22 to 37 weeks gestation and describes differences in early growth patterns according to race and gender. Additional data are presented to describe the necessary caloric intake to support reasonable growth.

Are Perinatal Factors Predictive of Optimal School Age Outcome in the ELBW Infant? † 1241

The incidence of major developmental disabilities in the extremely low birth weight (ELBW) infant has remained stable despite dramatic improvement in survival. A subset of these children consistently overcome the odds, are neurologically intact, and demonstrate normal cognitive and academic skills. The purpose of this study is to identify perinatal predictors of optimal school age outcome in a sample of ELBW children. The study group consists of 257 surviving ELBW infants (<1001 grams) admitted to Vanderbilt University Hospital July 1982-July 1989. Information regarding presence of vision or hearing impairment, cerebral palsy, mental retardation, and school difficulty(need for special education or remedial resources after meeting school system eligibility criteria) at 7-9 yrs is available for 214 of 257 children (83%). The survivors were divided into three mutually exclusive subgroups: Group 1(n=66) is children with optimal outcome, no disability or school difficulty; Group 2 (n=71) is children with school difficulty, but no major difficulty; Group 3 (n=77) is children with any major disability. Data regardingobstetric risk (prenatal care, maternal smoking, presentation and mode of delivery, antenatal steroid administration, amnionitis, fetal heart rate tracing), neonatal course (birth weight, gestation, BPD, IVH, length of stay) and sociodemographics (race, gender, maternal age, education, marital status, social risk score) were analyzed by ANOVA and chi squares in relation to school age outcome for each of the three groups. The ELBW children with major developmental disability (Group 3) had significantly lower birth weight, shorter gestation, longer hospitalization, and more severe IVH than the remaining two thirds of the survivors in Groups 1 and 2 (p<0.05). However the children with optimal school age outcome (Group 1) and the children experiencing school difficulty (Group 2) did not differ significantly from each other on any of the obstetric, neonatal, or sociodemographic variables listed above, with the exception of gender. In our sample, the ELBW child spared major disability still has a 50% risk of experiencing school difficulty regardless of perinatal factors. If optimal outcome cannot be predicted by perinatal factors, then further research is important to identify mechanisms to reduce morbidity and promote optimal cognitive outcome in the rapidly growing population of ELBW survivors.

Is BPD or Duration of Oxygen Therapy a Predictor of School Difficulty in the Extremely Low Birth Weight Infant? † 863

Is BPD or Duration of Oxygen Therapy a Predictor of School Difficulty in the Extremely Low Birth Weight Infant? † 863