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n initial step toward improvingutcomes for preterm infants

Very preterm infants have poor neuro-cognitive outcomeselative to term infants for multiple reasons, including injury andltered brain development. However, a major societal challenge ishe consistent observation that poor outcomes correlate betterith socioeconomic status of the mother than with problems the

nfant may have had following delivery. Furthermore, prematu-ity is increased in disadvantaged populations. Intervention pro-rams are conceptually attractive, but have not been consistentlyuccessful. Koldewijn et al have now demonstrated that repeatedntensive interventions to improve self-regulatory competencefter birth improved developmental and behavioral assessmentst 6 months of age relative to a randomized group of controlnfants. It will be essential to determine if these benefits detectedt 6 months persist and contribute to improved long-term out-omes.

—Alan H. Jobe, MD, PhDpage 33

he fetal kidneyWith increasing sophistication of antenatal fetal ultra-

ound imaging, most anatomic abnormalities of the urinary tractre detected before delivery. An unfortunate consequence of this,owever, has been an increasing number of children with tran-ient anatomic variations which regress spontaneously and are ofo consequence. The major such finding is mild dilatation of theetal renal pelvis. Although a few fetuses with such a findingrove to have severe vesicoureteral reflux or ureteropelvic junc-ion obstruction, most are eventually proven to be normal.

In an effort to distinguish the types of fetal renal pelvicilatation which require careful post-natal follow up, a variety ofalculations have been suggested. In the current issue of Theournal, Leung et al from Hong Kong propose the use of thehydronephrosis index,” which divides the renal pelvic diametery the volume of the fetal bladder. This makes intuitive senseecause bladder dilatation is a common cause of renal pelvicilatation. The authors have developed a nomogram for thiseasurement at varying fetal ages.

This measurement is likely to be operator-dependent, andhese findings will need to be confirmed in other centers witharger numbers of pregnancies. Nonetheless, this line of inquiry

ay eventually help us to separate the occasional child withnderlying serious urinary tract anomaly from the bulk of chil-ren who are normal. This will save resources and certainly avoideedless parental stress.

—Thomas R. Welch, MDpage 116

he Journal of Pediatrics

arly rapid diagnostic viral tests in themergency department setting

Doan et al from Vancouver, British Columbia, performedprospective, randomized, controlled intervention trial of per-

ormance of multi-viral rapid diagnostic testing in children 3 to6 months of age brought to the emergency department (ED)ith febrile respiratory tract illnesses. Testing in the treatmentroup was performed at the time of triage (before evaluation byphysician), and results were recorded on the patient’s chart.utcomes assessed in the intervention and control groups wereD tests ordered, length of stay, prescription of an antibiotic,

nd then post-ED visit to a medical provider, performance ofncillary test(s), and prescription of an antibiotic. With 200hildren’s data analyzed, the only outcome measure significantlyffected by early, rapid testing was reduction in prescription of anntibiotic after ED discharge. It is possible that several caveats ofhe study design and performance “washed out” other potentialeneficial effects of early testing for a viral etiology of illness (eg,umber of test results not back before ED discharge in the

ntervention group, tests ordered by physician’s choice in theontrol group).

Multi-viral rapid testing (RSV, influenza, parainfluenza,nd adenovirus) confirmed viral etiology in � 60% of subjects inhis study. Even if the decrease in antibiotic prescriptions sub-equent to the ED visit was the only benefit of testing, it raisespossible new strategy in the battle against overuse of antibiotics.

—Sarah S. Long, MDpage 91

pidemiology of seizures in term infantsNewborn infants presenting with seizures are infrequent,

ut a major concern because of their long-term outcomes. In thisssue of The Journal, Glass et al provide precise estimates foreizure occurrence after term birth using a California data set ofver 2 million births. The incidence of seizures was about 1 per000 live births. The risks of newborn seizures were increased foraternal age over 40, maternal diabetes, deliveries at �42 weeks,

atastrophic deliveries, and maternal infection. This informationhould help alert pediatricians to infants who are at increased riskf seizures following term birth.

—Alan H. Jobe, MD, PhDpage 24

January 2009 A3