September 2013  Volume 163  Number 3 Copyright 2013 by Mosby Inc.

Height in chronic S hort stature is a common accompaniment of childhood-onset chronic kidney

disease (CKD). When recombinant human growth hormone (rhGH) became
kidney disease available, children with CKD were among the first and largest groups of children in
Thomas R. Welch, MD whom this agent was used. It clearly works, and the new generation of pediatric
nephrologists rarely sees the severe "renal dwarfism" that once was commonplace in
pediatric nephrology practice.
Of course, short stature is not necessarily bad for overall health per se. The argu-
ment for treating it in CKD always has been one of improved quality of life for
affected children. Although a reasonable suggestion, it never has been tested carefully.
In the current issue of The Journal, the Chronic Kidney Disease in Children Study
Group report careful assessment of quality of life, by both patients and their families,
in a large group of children with CKD followed for several years. This allowed for lon-
gitudinal assessment of quality of life during therapy with rhGH. The parents assess-
ments of quality of life in the social and physical domains were significantly improved
in children receiving rhGH; interestingly, the assessments of adolescents themselves
were not so positive.
These data are complicated and deserve very careful reading. Indeed, one may come
to more than one conclusion from them. In any case, this report represents the best
available data set addressing this problem.
Article page 736<

Outcomes of late
onset Candida sepsis
I nvestigators of the Eunice Kennedy Shriver National Institute of Child Health and
Human Development Neonatal Research Network, enrolled 1515 infants with
extremely low birth weight (ELBW; <1000 g) and suspected sepsis to investigate
in extremely low birth the relative importance of etiologic agent of sepsis on outcome. Ninety percent of
enrolled infants (1317/1515) were examined for neurodevelopmental outcome at 18
weight infants months of age. Investigators were able to compare outcomes for those suspected of
Sarah S. Long, MD sepsis who had proven Candida infection versus proven bacterial infection versus
no proven infection, as well as perform a post hoc comparison with a cohort of 864
ELBW infants concurrently enrolled in the registry who were not suspected of late
onset sepsis (LOS).
Neurodevelopmental impairment was found in 31% of ELBW infants with Candida
and 31% with non-Candida LOS and/or meningitis. Compared with infants in the
registry who had never been screened for sepsis, those with Candida infection were
more likely to have neurodevelopmental impairment (OR 1.83, 95% CI 1.01. 3.33
and P = .047). Dramatically increased mortality and disability following Candida
sepsis was apparent in infants with birth weight <750 grams50% mortality and
33% of survivors having neurodevelopmental impairment.
This study helps rectify discrepant findings in studies without the current
studys clear comparison groups. It also urges a better understanding of Candida
disease and prevention to optimize outcomes for this exquisitely vulnerable
population.
Article page 680<

613
 Predicting outcome I n this issue of The Journal, investigators from Spain report the use of clinical,
biochemical, and neuroimaging findings in the neonatal period in infants
of symptomatic with congenital cytomegalovirus (CMV) infection to predict long-term neurode-
CMV infection velopmental outcome. The strengths of the study are the performance of multiple
biochemical tests on the neonates cerebrospinal fluid (ie, neuron-specific enolase
Sarah S. Long, MD and b2-microglobulin, the latter of which is thought to be a reflection of local cell
turnover), neuroimaging studies, long-term follow-up to an average age of 8.7
years (range 19 months to 18 years), and extensive neurodevelopmental testing
(eg, cognitive, behavioral, motor, visual, auditory). Results show that adjusted
head circumference 2 SD below expected, cerebrospinal fluid b2-microglobulin
of $ 8 mg/L, or moderate to severe neuroimaging abnormalities, individually
and especially when combined, have excellent predictive value for moderate-
severe disability. These findings will not only aid clinicians but will better inform
clinical trials of potential therapies.
Article page 828<

Chorioamnionitis and
neurodevelopment
T he association between clinical and/or histological chorioamnionitis and poor neu-
rodevelopmental outcomes or death in newborns has been debated, with multiple
positive and negative studies in the literature. This association for preterm birth
Alan H. Jobe, MD, PhD perhaps is even more controversial. As more is learned about the types of infections
that are associated with premature delivery, any interpretation of an outcome relative
to a simple diagnosis of chorioamnionitis is inadequate. Some pregnancies are compli-
cated by chronic and indolent infections with single or multiple organisms not nor-
mally considered to be pathogenic, and others result in preterm deliveries with clear
pathogens. Inflammation-associated preterm labor may be primarily from the endo-
metrium and minimally involve the fetus, or the fetus may mount a systemic inflam-
matory response.
In this issue of The Journal, Salas et al carefully characterized and graded cord
inflammation to better identify the severity of the inflammation for a large number
of preterm deliveries. They report that a severe fetal inflammatory response was
associated with death or a poor neurodevelopmental outcome in preterm infants.
The logical association between fetal exposure to inflammation and brain injury be-
comes apparent with a better assessment of the inflammation. No doubt adverse
outcomes will associate with specific organisms, the duration of the fetal exposure,
and characteristics of the fetal and maternal inflammatory responses. Much more
needs to be learned about how to assess fetal risks to better direct the timing of
delivery.
Article page 652<

Association of asthma
and herpes zoster
T he incidence of asthma and herpes zoster (HZ) rose concurrently at the end of the
20th century. Investigators took advantage of the setting of Olmstead County,
Minnesota, where medical care is virtually self-contained, to perform a popula-
in children tion-based epidemiologic study to explore whether HZ was associated with asthma.
The study was performed before substantial use of varicella vaccine, and no case
Sarah S. Long, MD had received systemic corticosteroid in the three months prior to HZ. Twenty-three
percent of cases of HZ had asthma compared with 12.6% of matched controls
(aOR: 2.09, 95% CI 1.24-3.52; P = .006). The authors provide arguments about why
detection bias is likely not responsible for their finding. They conclude that asthma
may be an unrecognized risk factor for reactivation of nonairway-related latent
VZV infection and speculate that altered cell-mediated innate immune response could
be the biologic link.
Article page 816<

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 Screening contacts T he household contacts of physically abused children are at increased risk of non-
accidental injury. However, there are no current guidelines for screening such
of physically contacts, and current practice varies among institutions. In this issue of The Journal,
abused children Lindberg et al report a prospective study of 1918 contacts of 1196 children referred for
evaluation of possible abuse in 20 US centers. The authors identified injuries or dis-
Robert W. Wilmott, MD closures of abuse in 9.4% of contacts and found that recommended screening proce-
dures, such as skeletal survey, neuroimaging, interviews, and physical examination of
contact children, often were not performed. The authors conclude that, despite a high
risk of injury, completion of screening in contacts of potentially abused children is
poor and that current practices should be re-evaluated.
Article page 730<

Best practices for

controlling multidrug-
I n this issue of The Journal, Cantey et al describe the occurrence and control of a noso-
comial outbreak of multidrug-resistant Klebsiella pneumoniae infection/colonization
in the neonatal intensive care unit (NICU) at Parkland Memorial Hospital, Dallas,
resistant microbes Texas. Following septicemia of the index case and two additional fatal cases of infec-
tion within 48 hours, a multidisciplinary team (ie, medical, administrative, support-
in the NICU ive, and environmental services) formulated a multidimensional control and
Sarah S. Long, MD investigation plan. Although single interventions were not studied, the rapid success
of meticulous implementation of multiple standard infection control and prevention
practices (eg, staffing, spacing, cohorting, auditing cleaning effectiveness, auditing
hand hygiene beyond washing/gelling, frequent microbiologic screening of infants)
stands as an example of best practices.
This report is particularly useful because the outbreak occurred after good practices
of antibiotic stewardship, including minimal use of broad-spectrum antibiotics and
mitigation, without closing the NICU to new admissions or performing microbiologic
sampling of healthcare personnel.
Article page 672<

September 2013 615