bluuebunny/crossref_metadata_2025 huggingface dataset:
Amused Not Saddened
Authors: NELSON DOUGLAS S.
Published: December 2021

In Reply.—

Ms Hammer's letter contains many important points with which I agree. Significant barriers to medical care exist for a large percentage of our population, and visits to an emergency department (ED) should be used as an opportunity to educate our patients. I believe that recognition of humor does not preclude delivery of appropriate (and even superior) health care. It is neither elitist nor callous to chuckle (usually along with the patient's parents) when something humorous occurs.
Cardiovascular Abnormalities in Children With Fragile X Syndrome
Authors: Crabbe Linda S. , Hornstein Lusia , Bensky Andrew S. , Schwartz David C.
Published: December 2021

It has been suggested by several authors that the prevalence of mitral valve prolapse and aortic root dilation is increased in individuals with the fragile X syndrome. The prevalence of these abnormalities in young children with fragile X has not been established. Sixteen boys and 1 girl 13 years or younger were studied. Only 1 child (6%) had the typical examination findings of mitral valve prolapse, although his echocardiogram was normal. From this study it appears that cardiac abnormalities in fragile X syndrome develop in late childhood and adolescence. It seems important to follow these children carefully so that these cardiac abnormalities can be documented when they do develop.
Long-term Results of Treatment With Low-Dose Fluoxymesterone in Constitutional Delay of Growth and Puberty and in Genetic Short Stature
Authors: Strickland A. L.
Published: December 2021

This prospective study was designed to assess growth response, side effects, other possible longterm effects, and final adult height in boys treated with the oral androgen, fluoxymesterone. From 1973 to 1984, eighty-two short boys (71 with constitutional delay of growth and puberty [CDGP] and 11 with genetic short stature [GSS]) were treated with daily oral doses of 2.5 mg of fluoxymesterone from 6 to 60 months. Final height assessment was made from 1989 to 1991. A group of 34 untreated boys (26 with CDGP and 8 with GSS) were also followed to assess the accuracy of the Greulich-Pyle and Bayley-Pinneau (GP-BP) and sexual maturity index height prediction methods. During treatment, each patient had a 1.7- to 2.5-fold increase in linear growth velocity. Accelerated velocity (over baseline) continued as long as the bone age was less than 14 years. No adverse androgenic effects (or undue acceleration of puberty) were observed. Final height exceeded pretreatment predictions for CDGP + GSS by 6.1 ± 3.5 (SD) cm (GP-BP) and 5.4 ± 3.2 cm (sexual maturity index). It is concluded that a daily oral dose of 2.5 mg of fluoxymesterone can be used to accelerate linear growth in boys with CDGP and GSS when needed to alleviate emotional problems secondary to slow growth and short stature without fear of compromising final adult height.
Neurobehavioral Profiles of Neonates Exposed to Cocaine Prenatally
Authors: Mayes Linda C. , Granger Richard H. , Frank Mary Ann , Schottenfeld Richard , Bornstein Marc H.
Published: December 2021

This study examined the effects of maternal cocaine use on performance on the Neonatal Behavioral Assessment Scale (NBAS). Cocaine-exposed newborns (n = 56) were compared with a non-cocaine-exposed group (n = 30) born to mothers with similar sociodemographic characteristics. Cocaine-exposed newborns showed significant reduction in birth weight but did not experience greater obstetric or postnatal complications. On neurobehavioral assessments using the NBAS, cocaine-exposed newborns showed significantly depressed performance on the habituation cluster but not on other NBAS clusters when differences in birth weight were controlled. In a sample of 30 cocaine-exposed newborns matched on birth weight, gestational age, and race to the 30 non-cocaine-exposed newborns, cocaine-exposed newborns continued to show depressed habituation performance. The significance of a selective effect of cocaine exposure on early habituation performance is discussed in terms of the implications for attentional regulation in the first year of life.
Influence of Thumb Sucking on Peer Social Acceptance in First-Grade Children
Authors: Friman Patrick C. , McPherson Keith M. , Warzak William J. , Evans Joseph
Published: December 2021

Chronic thumb sucking in school-age children may reduce peer social acceptance, an important contributor to social development. The influence of thumb sucking on social acceptance was assessed among 40 first-grade children, who were shown four slides of two 7-year-old children (one boy, one girl) in two poses (one thumb sucking, one not). After viewing each slide in their classrooms, the children answered 10 numerically weighted questions related to peer acceptance. To limit the possibility that the children would determine the girl and boy were the same in each pose, the slide presentation was counterbalanced across two sessions 1 week apart. Using a repeated-measures analysis of variance, the authors compared composite scores on each question for both poses. The results indicate that while in the thumb-sucking pose, the children were rated as significantly less intelligent, happy, attractive, likable, and fun and less desirable as a friend, playmate, seatmate, classmate, and neighbor than when they were in the non-thumb-sucking pose. These findings suggest that the risk of reduced social acceptance should be added to the list of potentially harmful effects of chronic thumb sucking in school-age children.
Failure of Cromolyn Sodium to Reduce the Incidence of Bronchopulmonary Dysplasia: A Pilot Study
Authors: Watterberg Kristi L. , Murphy Shirley ,   Neonatal Cromolyn Study Group
Published: December 2021

This prospective, randomized, blinded clinical trial was conducted to test whether therapy with cromolyn sodium might decrease the incidence or severity of bronchopulmonary dysplasia when given to newborns with respiratory distress syndrome. Cromolyn (20 mg) or placebo was aerosolized to intubated newborns with respiratory distress syndrome every 6 hours, beginning on the first day of intubation. Patients were stratified by birth weight less than 1000 g and 1000 to 2000 g; primary outcome success was defined as survival to 30 days without oxygen dependence. Of 10 patients enrolled who were of less than 1000 g birth weight, there were no treatment successes, preventing outcome analysis. The study was discontinued after 28 patients of 1000 to 2000 g birth weight had been studied, at which time it had been found with 95% confidence, with a power of .80, that cromolyn sodium did not decrease by 50% the incidence of bronchopulmonary dysplasia. Severity of bronchopulmonary dysplasia was also similar, with 4 patients in the treatment group and 3 in the placebo group receiving mechanical ventilation at 30 days. Possible reasons for this study outcome include (1) a delivered dose too small to produce a clinical effect; (2) the start of therapy too late to prevent the onset of inflammation; (3) inadequate effect of cromolyn on polymorphonuclear cells in vivo; or (4) development of bronchopulmonary dysplasia through factors unaffected by the actions of cromolyn.
Sale of Individual Cigarettes: A New Development
Authors: ARCHBALD CHERYL
Published: December 2021

To the Editor.—

Each year, more people die as a result of cigarette smoking than from acquired immunodeficiency syndrome or crack/cocaine. As such, use and abuse of tobacco remains a serious health concern in our society. The fact that a recent study concluded that young children were as adept at recognizing Old Joe, the cartoon camel that promotes Camel cigarettes, as they were at identifying Mickey Mouse, vividly demonstrates the influence of one tobacco company on our children.
Developmental Issues in Foster Care for Children
Authors:   Committee on Early Childhood, Adoption, and Dependent Care
Published: December 2021

Pediatricians who provide care for children in foster care have a unique opportunity and a special responsibility to assess the totality of the child's experience and to be a sympathetic and objective advocate for the child.1 Many children in foster care have suffered repeated abuse and prolonged neglect and often have a myriad of unmet medical and mental health needs.2 However, paramount in the lives of these children is their need for continuity and a sense of permanence. Legal responsibility for establishing where these children will live and which adults will have custody of them rests jointly with the child welfare system and the judiciary. Pediatricians and other professionals with expertise in child development should participate actively as advisors to social workers and judges about the child's needs and best interests, especially in the context of placement and permanency planning.

Maintaining the integrity of distressed families by providing adequate support services is generally in the best interest of the child. Keeping families together, however, may not be best for all children. Alternatives based upon an assessment of the developmental needs of the children and the capabilities of the family to meet those needs must be given consideration. As a society we value the rights of the birth family, sometimes hold them to be inviolable, and presume that families are competent. This belief and a lack of resources for assessment, planning, and services have resulted in inaccurate assessment of the child's relationships with his/her family by social service agencies and courts.
Vitamin A Treatment of Measles
Authors:   Committee on Infectious Diseases
Published: December 2021

In spite of the availability of effective vaccines, measles continues to be a public health problem throughout the world. In 1990, the Centers for Disease Control received more than 27 672 reports of measles in the United States. Complications were reported in one third of infected children younger than 5 years of age.1 Of the 89 measles-related deaths in 1990, 55% occurred in children younger than 5 years old.

Several recent investigations have indicated that vitamin A treatment of children with measles in developing countries has been associated with reductions in morbidity and mortality. The World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF) issued a joint statement recommending that vitamin A be administered to all children diagnosed with measles in communities where vitamin A deficiency (serum vitamin A <10 µg/dL) is a recognized problem and where mortality related to measles is ≥1%. The recommended regimen is 100 000 IU by mouth at the time of diagnosis for infants younger than 12 months of age, and 200 000 IU for older children. In the presence of ophthalmologic signs of vitamin A deficiency, such as night blindness, Bitot's spots (grayish white deposits on the bulbar conjunctiva adjacent to the cornea) or xerophthalmia, the WHO recommends the dose be repeated in 24 hours and again 4 weeks later.2 Vitamin A is available in low-cost liquid formulations and is supplemented in infant formulas (2000 µ/L).

RATIONALE FOR VITAMIN A

Vitamin A is a necessary substrate for preserving epithelial cell integrity and in addition plays a role in immune modulation.1-3
Sepsis and Jaundice
Authors: JOHNSON ANDREW MYRON
Published: December 2021

To the Editor.—

Maisels and Kring1 have suggested that indirect hyperbilirubinemia as the only manifestation of bacteremia or sepsis in the newborn period is a rare event. Indeed, a previous study by Benaron and Bowen2 has shown that neonatal sepsis is associated with decreased maximal indirect bilirubin levels in newborns. The authors of that study suggested that bilirubin is consumed as an antioxidant in response to the release of oxidants by phagocytic cells. However, our own data suggest that the decrease may be at least in part due to more rapid maturation of the hepatic conjugating and excretory mechanisms for bilirubin secondary to the acute phase response (or "stress").3
Twins and HIV
Authors: GLOMB WM BRENDLE , WARD SALLY L. DAVIDSON , LEE STEVE S. , DURFEE MICHAEL J.
Published: December 2021

To the Editor.—

We recently read the report of Thomas et al1 which suggested an association between twin gestation and human immunodeficiency virus (HIV) positivity in the offspring via vertical transmission. Dr Thomas speculated that there might be "an association between [maternal] drug use and twinning." She mentions that "the results of an analysis of 1988 birth certificates in progress at the New York City Department of Health suggests a higher incidence of twinning among women who mentioned narcotics use on the birth certificates."
Acetaminophen Hepatotoxicity After a Prolonged Ingestion
Authors: WALSON PHILIP D. , GROTH JOHN F.
Published: December 2021

To the Editor.—

The Rumack-Matthew nomogram has been useful in predicting hepatotoxicity following single, acute acetaminophen ingestions.1 We report a case of acetaminophen hepatotoxicity to emphasize the lack of predictive value of the nomogram if the ingestion occurs during a prolonged period.

A 16-year-old girl reportedly ingested between 7.5 and 10 g of acetaminophen during a 4-hour period (7:00 to 11:00 am). She vomited twice spontaneously between 11:00 am and 3:30 pm A serum acetaminophen concentration drawn at 3:15 pm was 114 mg/L.
Acetaminophen Hepatotoxicity After a Prolonged Ingestion
Authors: DART RICHARD C. , RUMACK BARRY H.
Published: December 2021

In Reply.—

Drs Walson and Groth are correct; the nomogram was designed to deal only with a single-point ingestion following a time interval sufficient to permit peak absorption.

It is critical to point out that current knowledge indicates continued dosing of N-acetylcysteine (NAC) (Mucomyst) very likely would have benefitted this patient. The reasons for this follow.

1. Smilkstein et al1 have reported previously that administration of NAC up to 24 hours after ingestion may have some, albeit reduced, benefits.
Health Insurance Differentials Among Minority Children With Chronic Conditions and the Role of Federal Agencies and Private Foundations in Improving Financial Access
Authors: McManus Margaret A. , Newacheck Paul
Published: December 2021

Minorities experience a disproportionate share of the financial barriers resulting from higher rates of uninsuredness and a greater reliance on Medicaid vs private insurance. As a result, health services use and patterns of expenditures vary markedly by race and ethnicity.1,2

National survey data reveal a rapid increase in the number of uninsured black and Hispanic persons between 1977 and 1987.3 The major factors contributing to this increase are (1) overall growth in the size of the minority population, especially Hispanics; (2) reductions in private insurance coverage; and (3) the lack of significant expansions in public programs, largely Medicaid (note: several Medicaid eligibility expansions affecting poor children occurred during and after 1987).

In 1987, 14% of white children younger than age 18 were uninsured compared to 22% of black children and 33% of Hispanic children (Cornelius LJ. Unpublished data). Black and Hispanic persons were more likely to rely on Medicaid as their primary financing source than were white persons.3 In 1987, 8% of white children were covered by Medicaid vs 38% of black and 28% of Hispanic children (Cornelius LJ. Unpublished data from the Agency for Health Care Policy and Research, 1992.). Despite Medicaid's importance as a financing source, low reimbursement rates have resulted in inadequate provider participation and corresponding access barriers.4,5

In comparison with white persons, minorities have less access to employer-based insurance benefits. Part of the reason lies in the types of jobs that are disproportionately held by minorities. Personal service and agricultural employers typically do not offer health insurance to their employees.
Multiculturalism, Chronic Illness, and Disability
Authors: Groce Nora Ellen , Zola Irving Kenneth
Published: December 2021

To gain at least an initial understanding of the underlying beliefs and attitudes in a cross-cultural situation, we believe that the three key points discussed in this paper should prove a significant point of departure:

1. Traditional beliefs about the cause of chronic illness or disability will play a significant role in determining family and community attitudes toward individuals with a disability and will influence when, how, and why medical input is sought.

2. The expectation of survival on the part of parents and community will have an effect on the amount of time, energy, and cooperation shown by family and community for the individual who has an impairment.16

3. The expectations by family and community for the social role(s) an individual with a chronic illness or disability will hold will affect a broad range of issues, including education, social integration, and independence.

Furthermore, although chronic illness and disability are often considered as issues distinct from the full range of problems encountered in society for immigrant and minority groups, in fact, these issues could not be more closely tied. The frequently discussed concerns within the ethnic and minority community about the role of the family, integration and acculturation, social articulation with the greater American society, stress, cross-cultural misunderstanding, and outright prejudice can all compound the problems encountered for the chronically ill or disabled individual in a multicultural society.
Cost-Effectiveness Analysis of Bicycle Helmet Subsidies in a Defined Population
Authors: Thompson Robert S. , Thompson Diane C. , Rivara Frederick P. , Salazar Angela A.
Published: December 2021

Objective. To examine the potential effects of bicycle safety helmet cost subsidy on bicycle head injury rates and costs.

Design. Using empiric data on the incidence and costs of bicycle injuries to children, we examined the hypothetical effects of various bicycle helmet subsidies in a cost-effectiveness analysis. A hypothetical cohort of 100 000 5- through 9-year-olds was followed for 5 years after helmet cost subsidization. Sensitivity analyses were done of three different levels of safety helmet subsidy ($5, $10, $15), three discount rates (2%, 4%, 6%), 10 levels of safety helmet use ranging from 10% to 100%, and the occurrence or nonoccurrence of catastrophic head injuries.

Patients. Forty-three children 5 through 9 years of age and 27 children 10 through 14 years of age with head injuries due to bicycling were identified through emergency department surveillance of a population of 29 533.

Setting. Group Health Cooperative of Puget Sound, a large health maintenance organization.

Outcome measures. Bicycle head injuries prevented and the savings or costs associated with various subsidy, safety helmet use, and discount rates.

Results. Hypothetically, an increase in bicycle helmet use rates to 40% to 50% due to subsidies of $5 or $10 prevents 564 to 840 head injuries in a cohort of 100 000 5- through 9-year-olds over 5 years. Under these conditions and a 2% discount rate, cost savings ranging from $189 207 to $427 808 will result when catastrophic head injuries are included in the analysis.

Conclusion. Subsidization of bicycle safety helmets to achieve a cost of $14 to $20 per helmet and use rates of 40% to 50% will likely prove cost-effective. Empirical evidence from a Seattle campaign suggests that such helmet use rates are achievable.
Infants of Less Than 1250 Grams Birth Weight at Groote Schuur Hospital: Outcome at 1 and 2 Years of Age
Authors: Thompson Clare M. , Buccimazza Sandro S. , Webster Joanne , Malan Atties F. , Molteno Christopher D.
Published: December 2021

A prospective 2-year follow-up study of infants with birth weights of less than 1250 g was undertaken at Groote Schuur Hospital Neonatal Intensive Care Unit. For a 12-month period beginning July 1988, all live infants born at Groote Schuur Hospital or referred to the Neonatal Intensive Care Unit were included in the study cohort. The aim of the study was to document the morbidity, mortality, and neurodevelopmental outcome of these infants to 2 years of age.

Of 235 liveborn infants, 143 (61%) survived to discharge. One hundred twenty-six infants were born weighing less than 1000 g; 42% survived to discharge. One hundred nine infants weighed 1000 g or more at birth, and 83% survived to discharge. Better survival was documented for infants whose mothers attended antenatal care, who weighed more than 900 g, and who were of greater than 30 weeks' gestation. Eleven infants died in the first 6 months after discharge. One hundred six infants (83% of survivors) underwent Griffiths developmental testing and clinical assessment at 1 year of age. Ninety-six (91%) of these survivors were seen and tested at 2 years of age. Of the 106 infants assessed at 1 year of age, 6 infants had cerebral palsy, 6 were globally developmentally delayed without signs of cerebral palsy, and 1 infant showed significant motor delay with a normal developmental quotient. At 2 years of age 1 additional infant had cerebral palsy and 9 more infants are likely to be mentally retarded. At 2 years of age the major handicap rate was, therefore, 22% . Sixty-nine percent of surviving infants, and all but 1 of the infants with cerebral palsy, were underweight for gestational age at birth. There was a tendency for these underweight-for-gestational-age infants to score less well at 2 years of age. Infants who received ventilation and infants with a birth weight of less than 1000 g were not found to score less well than other infants in the cohort.
Birth Weight and Illness Severity: Independent Predictors of Neonatal Mortality
Authors: Richardson Dougbas K. , Phibbs Ciaran S. , Gray James E. , McCormick Marie C. , Workman-Daniels Kathryn , Goldmann Donald A.
Published: December 2021

Background. Low birth weight is a major determinant of neonatal mortality. Yet birth weight, even in conjunction with other demographic markers, is inadequate to explain the large variations in neonatal mortality between intensive care units. This variation probably reflects differences in admission severity. The authors have recently developed the Score for Neonatal Acute Physiology (SNAP), an illness severity index specific for neonatal intensive care, and demonstrated illness severity to be a major determinant of neonatal mortality.

Objective. To define the relative contributions of birth weight and illness severity to the risk of neonatal mortality and to identify other significant independent risk factors.

Methods. Logistic regression was used to analyze data from a cohort of 1621 consecutive admissions to three neonatal intensive care units (92 deaths), to test six alternative predictive models. The best logistic model was then used to develop a simple additive clinical score, the SNAP Perinatal Extension (SNAP-PE).

Results. These analyses demonstrated that birth weight and illness severity are powerful independent predictors across a broad range of birth weights and that their effects are additive. Below 750 g, there is an interaction between birth weight and SNAP. Other factors that showed independent predictive power were low Apgar score at 5 minutes and small size for gestational age. Separate derivation and test samples were used to demonstrate that the SNAP-PE is comparable to the best logistic model and has a sensitivity and specificity superior to either birth weight or SNAP alone (receiver-operator characteristic area .92 ± .02) as well as excellent goodness of fit.

Conclusion. This simplified clinical score provides accurate mortality risk estimates for application in a broad array of clinical and research settings.
Spectrum of Limb Disruption Defects Associated With Chorionic Villus Sampling
Authors: BURTON BARBARA K. , SCHULZ CHARLENE J. , BURD LAURENCE I.
Published: December 2021

A number of recent publications have suggested an increased incidence of transverse limb anomalies,1,2 the hypoglossia-hypodactylia syndrome,1 and cavernous hemangiomas3 in infants born to mothers who had undergone chorionic villus sampling (CVS) in the first trimester of pregnancy. We previously reported 4 CVS-related cases of transverse limb anomalies2 and since have examined 10 additional cases. The purpose of this report is to describe the spectrum of abnormalities observed in these 14 cases. We believe that the findings in these patients support an association between CVS and limb abnormalities by demonstrating that the type of anomaly associated with CVS is a very specific one that is uncommonly observed in the general population.
Bone Mineral Content in Infants and Children With Chronic Cholestatic Liver Disease
Authors: Argao Eric A. , Specker Bonny L. , Heubi James E.
Published: December 2021

Objective. To assess bone mineral content (BMC) status and serum vitamin D metabolite levels of infants and children with chronic cholestatic liver disease. To determine if severity of bone disease in these patients correlates with serum vitamin D metabolite levels.

Methodology. We measured radial BMC with the use of a single-beam photon absorptiometer and serum vitamin D metabolite levels in 56 patients with chronic cholestasis seen at our institution from 1985 through 1991. Patients were divided into two groups according to age.

Results. In group 1 (n = 37; age 2 to 22 months), decreased levels of BMC were seen as early as the first few months of life, with sharp decline observed with increasing age (approaching 3 to 5 standard deviations [SD] below the mean, P < .0003). Older patients (group 2, n = 19; age 2 to 20 years) had BMC values which clustered between 2 and 4 SD below the mean throughout the age range. Although a downward trend also was noted with increasing age, this was not statistically significant. Despite correction for weight-age or height-age, BMC was decreased in most of these patients. No correlation between severity of osteopenia and serum levels of 25(OH)-vitamin D and 1,25(OH)2-vitamin D was observed in either infants or older children.

Conclusions. Decreased bone mineralization, as a complication of chronic cholestatic conditions, is a disease process that begins early in infancy, rapidly worsens with increasing age and hepatic dysfunction, and remains relatively stable in children with more stable liver disease.
Childhood Sexual Abuse Reported by Facilitated Communication
Authors: HOSTLER SHARON L. , ALLAIRE JANET H. , CHRISTOPH RICHARD A.
Published: December 2021

Facilitated communication remains an unproven and controversial strategy for nonspeaking children with developmental disabilities. It is possible that the process may be influenced by the facilitator. The evaluation of alleged sexual abuse reported by FC must include a full psychosocial history, complete physical examination for evidence of abuse, and the assessment of the child's communicative competence. The demonstration of communicative competence requires a strategy similar to that utilized with Carla. The successful documentation of the child's communication of general information should precede the pursuit of specific abuse issues.
Ambient Air Pollution: Respiratory Hazards to Children
Authors:   Committee on Environmental Health
Published: December 2021

Levels of many outdoor air pollutants decreased substantially after the passage of the Clean Air Act of 1970; however, levels of ozone, carbon monoxide, and particulate matter are still high enough to present hazards to children. Failure to meet the federal standards for these pollutants was a major force driving the adoption of the revised Clean Air Act of 1990. In addition, recent research indicates that acidic aerosols, for which there are no health-based standards, may be associated with adverse respiratory effects.

As an ambient air pollutant, ozone is formed by the action of sunlight on nitrogen oxides and reactive hydrocarbons (both of which are emitted by motor vehicles and industrial sources). Ozone levels therefore tend to be highest on warm, sunny days, which are conducive to outdoor activities. In many areas ozone concentrations peak in the midafternoon, when children are likely to be playing outside. It is important to distinguish ground-level ozone air pollution from stratospheric ozone depletion by chlorofluorocarbons. These issues are unrelated. Carbon monoxide, a product of incomplete combustion, is emitted mainly from cars and other mobile sources. Airborne particulate matter is a variable and complex mixture of natural materials and substances released from numerous industries, motor vehicles, residential wood burning, construction and demolition, and other sources. Acidic aerosols are traceable mainly to combustion of sulfur-containing fossil fuels and to reactions of photochemical free radicals with nitrogen dioxide.

Exposure to ambient air pollution in North America has been clearly associated with acute and subacute effects in epidemiologic investigations and in controlled exposure studies in environmental chambers.
Self-regulation of Energy Intake in Children, Questioned
Authors: SHEA STEVEN , BASCH CHARLES E. , CONTENTO ISOBEL , STEIN ARYEH D.
Published: December 2021

In Reply.—

Birch et al found a threefold difference in the magnitude of the coefficient of variation for energy intake at eating occasions compared to daily energy intake in a controlled setting,1 and we observed a similar threefold difference among children in their everyday environment.2 Dr Goldman points out that averaging individual measurements reduces the variability of the mean. It was for this reason that we used a statistical test to compare the observed coefficient of variation for the day's energy intake to the expected coefficient of variation for the day.
Practice Guideline for the Management of Infants and Children 0 to 36 Months of Age With Fever Without Source
Authors: Baraff Larry J. , Schriger David L. , Bass James W. , Fleisher Gary R. , Klein Jerome O. , McCracken George H. , Powell Keith R.
Published: December 2021

Study objective. To develop guidelines for the care of infants and children from birth to 36 months of age with fever without source.

Participants and setting. An expert panel of senior academic faculty with expertise in pediatrics and infectious diseases or emergency medicine.

Design and intervention. A comprehensive literature search was used to identify all publications pertinent to the management of the febrile child. When appropriate, meta-analysis was used to combine the results of multiple studies. One or more specific management strategies was proposed for each of decision nodes in draft management algorithms. The draft algorithms, selected publications, and the meta-analyses were provided to the panel, which determined the final guidelines using the modified Delphi technique.

Results. All toxic-appearing infants and children and all febrile infants less than 28 days of age should be hospitalized for parenteral antibiotic therapy. Febrile infants 28 to 90 days of age defined at low risk by specific clinical and laboratory criteria may be managed as outpatients if close follow-up is assured. Older children with fever less than 39.0°C without source need no laboratory tests or antibiotics. Children 3 to 36 months of age with fever of 39.0°C or more and whose white blood cell count is 15 000/mm3 or more should have a blood culture and be treated with antibiotics pending culture results. Urine cultures should be obtained from all boys 6 months of age or less and all girls 2 years of age or less who are treated with antibiotics.

Conclusion. These guidelines do not eliminate all risk or strictly confine antibiotic treatment to children likely to have occult bacteremia. Physicians may individualize therapy based on clinical circumstances or adopt a variation of these guidelines based on a different interpretation of the evidence.
Effect of Antibiotic Therapy and Etiologic Microorganism on the Risk of Bacterial Meningitis in Children with Occult Bacteremia
Authors: Baraff Larry J. , Oslund Scott , Prather Mark
Published: December 2021

Objective. To quantify the effect of antibiotic therapy on the probability of subsequent bacterial meningitis in children with fever without source treated as outpatients.

Design. Bayesian meta-analyses.

Reports included. All reports of the organism-specific prevalence of occult bacteremia in children with fever without source treated as outpatients, and the organism-specific prevalence of subsequent meningitis in children with occult bacteremia initially treated as outpatients stratified by type of antibiotic therapy.

Results. The mean probabilities of subsequent meningitis in children with occult bacteremia were 9.8%, 8.2%, and 0.3% in the no antibiotic, oral antibiotic, and parenteral antibiotic therapy groups, respectively. All cases of bacterial meningitis in children with occult bacteremia treated with oral antibiotics were due to Haemophilus influenzae. There were no cases of culture-positive bacterial meningitis in 139 bacteremic children treated with ceftriaxone (mean probability, 0.3%; 95% confidence interval, 0.0% to 1.5%). The mean probabilities of bacterial meningitis in a child with fever without source treated as an outpatient without antibiotics were: Streptococcus pneumoniae, 0.21%; and H influenzae, 0.06%.

Conclusions. Antibiotic therapy is effective in preventing meningitis in children at risk of occult bacteremia.
Blue Rubber Bleb Nevus Syndrome: Case Report and Review of the Literature
Authors: MOODLEY MANIKUM , RAMDIAL PRATISTADEVI
Published: December 2021

In 1860 Gascoyen1 reported the association of cutaneous and intestinal lesions with gastrointestinal bleeding in a man with anemia and numerous cavernous hemangiomas of the skin. This association did not receive much clinical attention until 1958, almost a century later, when William Bennet Bean described a condition with similar findings and coined the term "blue rubber bleb nevus syndrome" (BRBNS), a name that seems aptly chosen because the "cutaneous hemangiomas have the feel and look of rubber nipples.2" The syndrome is usually present from birth or early childhood, but adult presentations have also been reported.3 The pathogenesis of this condition is unknown.
More to Be Learned From Crigler-Najjar Patients
Authors: HANSEN THOR WILLY RUUD
Published: December 2021

To the Editor.—

In a recent study by Galbraith et al,1 the use of tin-mesoporphyrin in two patients with the Crigler-Najjar type I syndrome is described. The feasibility of this kind of treatment is documented, and the authors' comments on the size of the total-body bilirubin pool as well as their calculations on bilirubin production and clearance in these patients are illuminating.

Personally, I am intrigued as much by aspects of the case reports, about which the authors do not comment, probably because these aspects are outside the focus of their paper.
Superiority of Oral Agar and Phototherapy Combination in the Treatment of Neonatal Hyperbilirubinemia
Authors: Caglayan Suat , Candemir Halil , Aksit Sadik , Kansoy Savas , Asik Sezin , Yaprak Isin
Published: December 2021

Objective. To determine the value of oral agar in the treatment of neonatal hyperbilirubinemia and to compare it with two other treatment modalities: phototherapy alone and phototherapy plus oral agar.

Methods. Two hundred eight jaundiced full-term newborns were divided into four groups. They were given either phototherapy alone, phototherapy plus oral agar, oral agar alone, or no treatment (control group). The changes in the serum bilirubin values were determined and the results were compared statistically, mainly using analysis of variance.

Results. In all three therapy groups, the time required to reduce the bilirubin level to either 15 mg/dL or to 10 mg/dL was significantly shorter than that required by the control group. Although oral agar was found to be as effective as phototherapy, the most significant decrease in bilirubin level was in the combination group.

Conclusions. The efficacy of phototherapy in decreasing the serum bilirubin level in neonatal hyperbilirubinemia can be augmented with the use of oral agar. Oral agar can also be used as a single agent for the treatment of neonatal hyperbilirubinemia, since it is as effective as phototherapy.
Randomized Controlled Trial of Three Interventions in the Management of Persistent Crying of Infancy
Authors: Parkin Patricia C. , Schwartz Clive J. , Manuel Betty Ann
Published: December 2021

Objectives. The objective of this study was to evaluate the effectiveness of three methods in the management of infantile colic.

Methods. Healthy infants with persistent crying were randomly assigned to one of three groups for a 2-week period. All groups received an assessment and reassurance from a pediatrician and support from a public health nurse. Group 1 also received counseling regarding specific management techniques. Group 2 also received a car-ride simulation device. Group 3 acted as a control. Mothers completed crying diaries and preintervention and postintervention anxiety questionnaires.

Results. Thirty-eight mother-infant pairs were enrolled. Combining all three groups, there was a 24% reduction in daily hours of crying (P = .01) and a 18% improvement in maternal anxiety (P < .001), but no significant difference among groups.

Conclusions. The natural history of persistent crying of infancy is improvement over time. These specific interventions proved no better than reassurance and support alone in decreasing daily hours of crying and maternal anxiety.
Severe Varicella Associated With Steroid Use
Authors: Dowell Scott F. , Bresee Joseph S.
Published: December 2021

Objective. To evaluate whether corticosteroid use is associated with severe varicella.

Design. The odds of corticosteroid exposure were compared among 35 children with severe varicella and 10 000 control subjects.

Results. Five (26.3%) of 19 case patients without known immunosuppression had received steroids within 30 days prior to the onset of their rash compared with 20 of the 10 000 control subjects (0.2%), giving an odds ratio of 178 (95% confidence interval 59 to 541). If 16 case patients with leukemia or other known immunosuppressive conditions were included, the odds ratio was larger (odds ratio 420, 95% confidence interval 189 to 935). Of the 13 case patients whose dosage was recorded, 7 received less than the equivalent of 2 mg/kg per day of prednisone. The timing of the steroid use in those who had severe varicella clustered within the incubation period for the virus.

Conclusions. Systemic corticosteroid use appears to increase substantially the risk of severe or fatal varicella. The timing of corticosteroid exposure, in addition to dose and duration, may be an important factor in determining vulnerability. Further studies are needed to determine whether short-course, low-dose, or inhaled steroids are associated with similarly increased risk. Physicians should be aware that varicella-susceptible patients receiving corticosteroids are at considerably increased risk for severe varicella and should consider how to counsel their patients.
Child-Rearing Practices and Nursing Caries
Authors: Serwint J. R. , Mungo R. , Negrete V. F. , Duggan A. K. , Korsch B. M.
Published: December 2021

Objective. To determine which child-rearing practices are associated with nursing caries.

Design. Cross-sectional study.

Setting. Hospital-based general pediatric clinic.

Participants. Sequential sample of 110 healthy children aged 18 to 36 months.

Outcome measures. Feeding practices of children, limit-setting issues, and familial dental health were determined by maternal interview. Nursing caries were diagnosed by dental examination.

Results. Nursing caries were found in 22 (20%) of the children. Ninety percent of children with and without caries were bottle-feeding at 12 and 18 months of age. Ninety-one percent of children with caries and 84% without were still drinking a nighttime bottle at 18 months (P = .33). The mothers of children with caries were found to have fewer years of education, 8.9 vs 10.8 years (P = .02), and were more likely to have eight or more cavities, 55% vs 19% (P = .002). More infants in the caries group had been breast-fed, 72% vs 46% (P = .02), although length of breast-feeding was similar, 5.4 vs 6.7 months. Fewer children with caries drank fluoridated tap water 27% vs 54% (P = .05), but there were no differences in topical fluoride use, dental hygiene practices, or visits to the dentist.

Conclusions. These findings fail to substantiate a straightforward relationship between child-rearing practices and nursing caries and suggest that well-designed prospective studies are need to clarify the etiology of early caries.
Effect of Bundling and High Environmental Temperature on Neonatal Body Temperature
Authors: Cheng Tina L. , Partridge J. Colin
Published: December 2021

Objective. The effect of bundling and ambient heat on newborn body temperature has not been systematically studied. It was hypothesized that bundling and warm environments can elevate the newborn's temperatures to the range that would prompt clinical concern of neonatal sepsis.

Methods. Twenty well, term newborns more than 1 day old were assigned to the control group (one blanket; 24.0°C room) or the experimental group (five blankets and hat; 26.6°C room). Continuous rectal probe temperatures were monitored over a 2½hour period.

Results. There were 8 control and 12 experimental newborns. The mean change in rectal temperature after 2½ hours was -0.04°C (SD ± 0.23) in control newborns and + 0.56°C (SD ± 0.12) in the treatment group (P < .0001, t test). Temperatures in the treatment group rose, after an initial half-hour lag, at a linear rate of 0.27°C per hour without a plateau. Two newborns reached 38.0°C, a rectal temperature that may raise concern of infection.

Conclusions. Bundling and warm environments can elevate newborn body temperature to the "febrile" range in this age group. Physicians treating neonates with elevated temperature should ask about bundling and environmental conditions to differentiate endogenous from exogenous "fevers."
Effects of Calcium Disodium Versenate (CaNa2EDTA) Chelation in Moderate Childhood Lead Posioning
Authors: Markowitz Morri E. , Bijur Polly E. , Ruff Holly , Rosen John F.
Published: December 2021

Background. For children with asymptomatic moderate lead poisoning (Blood lead level [BPb] 25 to 55 µg/dL [1.21 to 2.66 µmol/L]), treatment with the chelating agent calcium disodium versenate (CaNa2EDTA) is recommended for all those children with a BPb level >45 µg/dL (2.17 µmol/L) and for those with a BPb level of 25 to 44 µg/dL (1.21 to 2.13 µmol/L) who also have a positive lead mobilization test. However, controlled studies demonstrating its efficacy at inducing a sustained reduction in BPb level or lead-related toxicity have not been performed in children with moderate lead poisoning. This study assesses the relationship between CaNa2EDTA chelation and measures of lead burden and toxicity in children with moderate lead poisoning.

Methods. Two hundred one children with moderate lead poisoning were enrolled. Sequential changes in BPb concentrations, bone lead level as measured by Lα-x-ray fluorescence, and lead-induced toxicity as assessed by erythrocyte protoporphyrin levels were determined over a 7-week period. From this group, children with a positive lead mobilization test received CaNa2EDTA chelation therapy.

Results. Children with positive lead mobilization tests had on average higher initial BPb, bone lead, and erythrocyte protoporphyrin concentrations. The chelated children decreased approximately 4.7 µg/dL (0.23 µmol/L), 41 corrected net counts, and 24 µg/dL (0.46 µmol/L) more than the unchelated children on BPb, bone lead, and erythrocyte protoporphyrin values, respectively. However, children with higher initial levels decreased the most, whereas children with lower initial levels showed the least decline, with or without treatment. When the initial values on the measures were controlled analytically, or when subgroups matched on initial levels were compared, there were no significant differences between the chelated and unchelated children.

Conclusions. The apparent effectiveness of CaNa2EDTA at reducing lead burden and toxicity is no longer observed when the pretreatment levels are considered. The findings suggest that sufficient doubt about CaNa2EDTA efficacy now exists to warrant a randomized controlled trial of chelation therapy in moderately lead-poisoned children. However, until such studies are performed, it would be premature to withhold chelation treatment on the basis of this study alone.
Midline Cervical Cleft
Authors: MADDALOZZO JOHN , FRANKEL ANDREW , HOLINGER LAUREN D.
Published: December 2021

The congenital midline cervical cleft represents a rare developmental abnormality that is not widely reported in the pediatric literature.1 Usually the lesion is initially evaluated by a pediatrician or other primary care physician who misinterprets the deficit as a branchial cleft deformity or thyroglossal duct cyst. Although developmentally related to these disorders, the congenital midline cleft represents a distinct anomaly that should be recognized at initial examination. The parents can then be appropriately counseled about the implications and further management decisions that are peculiar to this disorder. We have recently treated five cases of congenital midline cervical cleft at the Children's Memorial Hospital, Chicago, IL.
Consent for Medical Services for Children and Adolescents
Authors:   Committee on Pediatric Emergency Medicine
Published: December 2021

Major societal changes affecting the provision of child health care have occurred over the last few decades. In the area of emergency services, consent for medical treatment is an important issue. The purpose of this statement is to outline major considerations involving consent and provide the physician with practical guidelines concerning this issue.

Today fewer than one third of children live in two-parent families in which only the father works outside the home.1,2 Because of foster care placement, or temporary or permanent arrangements with relatives or friends, parents may not be available to give consent for treatment of their children.3-6

Unaccompanied minors may seek medical attention in any one of a number of locations. Some go to the emergency department, 14% of which have no policy regarding consent for the care of these patients.7 Unaccompanied minors younger than 18 years of age account for 3.4% of all emergency department visits.7 Twenty-two states and the District of Columbia now have laws concerning the "mture minor." Most other states have provisions in which competent minors may arrange for care involving contraceptives, pregnancy, abortion, sexually transmitted diseases, drug and alcohol abuse, and psychiatric disorders.8

The dilemma for emergency physicians and practicing pediatricians alike is whether to follow a strict interpretation of the law or to adopt a more practical approach. Clearly, consent is not required in life- or limb-threatening emergencies,8,9 although the definition of emergency varies from state to state. However, in most instances, only routine care, not emergency care, is needed. As a result, many physicians fear charges of battery or litigation should their judgement regarding treatment be questioned.8
SIDS and Homicide
Authors: REESE ROBERT M.
Published: December 2021

In Reply.—

Drs Bass and Hass cite the progress being made in the training of scene-investigators and this is desirable. No one would disagree that there is a great need for improved, standardized death-scene investigation by competent and objective personnel in all cases of sudden unexpected death in children. The additional need, as pointed out in the article,1 is for Child Death Review Teams in all jurisdictions,2-5 providing interdisciplinary in-depth investigation of all aspects of the unexpected death.