RESUMEN
From the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder--a randomized clinical trial of 579 children ages 7-9 years receiving 14 months of medication management, behavioral treatment, combination, or community care--the authors matched each African American and Latino participant with randomly selected Caucasian participants of same sex, treatment group, and site. Although Caucasian children were significantly less symptomatic than African American and Latino children on some ratings, response to treatment did not differ significantly by ethnicity after controlling for public assistance. Ethnic minority families cooperated with and benefited significantly from combination (multimodal) treatment (d = 0.36, compared with medication). This incremental gain withstood statistical control for mother's education, single-parent status, and public assistance. Treatment for lower socioeconomic status minority children, especially if comorbid, should combine medication and behavioral treatment.
Asunto(s)
Trastorno por Déficit de Atención con Hiperactividad/tratamiento farmacológico , Déficit de la Atención y Trastornos de Conducta Disruptiva/tratamiento farmacológico , Estimulantes del Sistema Nervioso Central/uso terapéutico , Etnicidad/estadística & datos numéricos , Metilfenidato/uso terapéutico , Cooperación del Paciente/estadística & datos numéricos , Niño , Método Doble Ciego , Femenino , Humanos , MasculinoRESUMEN
OBJECTIVE: To determine mean arterial pressure values during the first 24 hours for "stable" and "unstable" extremely low birth weight (ELBW) infants and to ascertain its association with perinatal factors. BACKGROUND: In ELBW infants, hypotension is diagnosed by nonspecific clinical signs together with reference arterial pressure values extrapolated from regression models or from scarce actual observations. DESIGN: Retrospective cohort study. METHODS: 101 ELBW (< or = 600 g) infants born in our medical center (1989-2000). Considered stable were 36 infants with umbilical cord hemoglobin > or = 14 g/dl who, although mechanically ventilated, had normal acid-base balance, no patent ductus arteriosus, had not received indomethacin, steroids, muscle relaxants, narcotics, were never treated for hypotension and survived at least 7 days. The remaining 65 infants constituted the unstable group. Arterial pressures were determined by oscillometry (OBP) and direct transducer readings through an umbilical line (MAP). All admission and 10% of the readings were by OBP; the remaining 1877 measurements were by MAP. RESULTS: Stable and unstable infants were similar in birth weight, demographics, history of chorioamnionitis, antepartum steroids, low Apgar scores, administration of epinephrine during resuscitation, and sepsis. Stable infants were different from unstable in gestational age (27+/-2 vs 25+/-2 weeks' gestational age [w GA]), history of preterm labor, preeclampsia, and neonatal mortality (22 vs 68%). Admission OBP (30+/-7 vs 29+/-10 Torr) were similar and 1-hour MAP were different (30+/-6 vs 27+/-7 Torr) between both groups. MAP for stable infants was higher throughout the 24 hours. Greater differences were noted between 3 and 6 hours when 34 of 65 unstable infants were treated for hypotension. Mean MAP and 10 percentile values for stable infants at 1, 3, 6, 12, and 24 hours were 30 (22), 31 (24), 32 (25), 34 (24), and 35 (28) Torr, respectively. MAPs did not correlate with birth weight, but they were lower among 19 stable infants < or = 26 w GA than among 17 stable infants > or = 27 w GA. History of preeclampsia, antenatal steroids, intratracheal epinephrine and cord hemoglobin did not influence MAP. Low 1-minute Apgar score and intracranial hemorrhage were associated with low MAP during the first day. CONCLUSION: There is a wide variation of GA among ELBW infants. MAPs increase with GA and with postnatal age. Shortly after birth, arterial pressures are similar for stable and unstable infants. Failure to increase MAP between 3 and 6 hours of life should create concern. MAP < or = 28 Torr at 3 hours of life is a reasonable, but not absolute, predictor of the need for hypotension treatment.