bluuebunny/crossref_metadata_2025 huggingface dataset:
Tobacco-Free Environment: An Imperative for the Health of Children and Adolescents
Authors:   Committee on Substance Abuse
Published: December 2021

1. Tobacco is a major health hazard to children and adolescents.

2. Maternal use of tobacco has significant adverse effects on pregnancy and fetal outcome.

3. Exposure to ETS has major effects on the health and psychosocial well-being of children.

4. Tobacco use by children is associated with chronic and recurrent medical problems as well as with increased risk for significant morbidity and mortality. Furthermore, tobacco use may be a marker for youth at risk for other behavioral problems.

5. Nicotine is an addicting substance and may serve as a gateway drug for the subsequent use of illicit substances.

6. Tobacco advertising is appealing to young people and may have a powerful effect in influencing them to begin tobacco experimentation.

7. A tobacco-free environment is an imperative for the health of children and adolescents.
Letter to the Editor
Authors: Theroux Mary C. , West David
Published: December 2021

We thank Drs Lopez and Urbansky for their comments. Their observation that the placebo group may have sufficiently biased the combined placebo/control group to account for the significant findings noted is reasonable, despite no significant differences being found between the placebo group and the control group.

Analysis of variance among the three groups was carried out for the objective outcome variables. Differences in mean heart rate changes and maximum heart rate changes remained significant, and differences between study versus control groups and study versus placebo groups were both found to be significant, accounting for multiple comparisons.
Red Book Recommendations on Ribavirin Challenged
Authors: Zucker Aaron R.
Published: December 2021

I am the Director of Pediatric Critical Care at Wyler Children's Hospital at the University of Chicago. Because I had personally witnessed problems when administering ribavirin for respiratory syncytial virus (RSV) lung disease, I became interested in learning about others' experiences with the drug. At that time, no studies particular to the drug's use in mechanically ventilated infants had been published, yet the 1991 Red Book stated that "infants who require mechanical ventilation because of severe RSV infection are those who may be most likely to benefit from ribavirin treatment."
Circumcision Questions
Authors: Setzer Nancy
Published: December 2021

The article by Wiswell and his colleagues is a sobering reminder of the potential gravity of complications associated with circumcision performed in boys after the neonatal period.1 As was noted in this article, over one third of complications are related to general anesthesia. After closer analysis of their statistics, however, these authors found an unusually large number of boys with malignant hyperthermia (2/476) compared with the usual incidence in pediatric patients, which is 1 in 15 000.2
Letter to the Editor
Authors: Harrison Helen
Published: December 2021

Dr Katcher brings up some important issues related to family diversity that were very much on the minds of the parents who drafted "The Principles for Family-Centered Neonatal Care.1 Rather than isolate these issues into separate principles, however, we chose to incorporate them throughout the document.

To address misunderstandings that arise from differences in the backgrounds of parents and staff, we have made a number of proposals including: active encouragement for families to discuss their views with caregivers, full parental access to relevant information, courses in communication for perinatal and neonatal prpfessionals, peer support in the neonatal intensive care unit, and systematic investigation into the issue of how parents with differing needs can best be served by various formats of information.
Why Change the Compression and Ventilation Rates During CPR in Neonates?
Authors:   Neonatal Resuscitation Steering Committee,   American Heart Association and American Academy of Pediatrics
Published: December 2021

The 1985 American Heart Association National Conference for Emergency Cardiac Care (ECC) recommendations for neonatal cardiopulmonary resuscitation included a chest compression rate of 120/minute accompanied by ventilation at a rate of 40 to 60/minute.1 There was no attempt to coordinate ventilation and compression. Rescuers providing chest compression and those providing ventilation were taught to perform their tasks independently, resulting in frequent simultaneous compression and ventilation. At the time, much of the available data indicated that simultaneous compression and ventilation (SVC-CPR) resulted in improved blood flow.2-6
Parental Monitoring and Peer Influences on Adolescent Substance Use
Authors: Steinberg Laurence , Fletcher Anne , Darling Nancy
Published: December 2021

Objective. To examine the joint influences of parental monitoring and peer influence on adolescent substance use over time.

Subjects. 6500 adolescents attending six high schools in Wisconsin and northern California.

Design. Longitudinal study.

Results. Parental monitoring was negatively associated with substance use, whereas the more involved an adolescent's peers were in substance use, the more likely he or she also was to use drugs and alcohol. Effects of monitoring and peer coercion were strongest for boys and girls at the transition into substance use, rather than at the transition from experimentation to regular use. The effect of parental monitoring on changes in adolescent substance use is mediated not so much by the nature of the adolescent's peer associates, but by its direct effect on the adolescent. Specifically, poorly monitored adolescents are more likely to use drugs, and drug-using adolescents seek out like-minded friends. Once an adolescent associates with drug-using peers, his or her own substance use approaches their level.

Conclusions. Intervention efforts should include both parents and community-level efforts. Parental monitoring is an effective tool both in the prevention of drug use and in the amelioration of drug use.
Human Immunodeficiency Virus Infection/AIDS In Children: The Next Decade
Authors: Ammann Arthur J.
Published: December 2021

The next decade of HIV/AIDS must resolve critical issues. It will be necessary to probe deeply to examine what is currently known, identify what needs to be known, and find ways to solve the issues that must be confronted. How to best achieve solutions in a timely manner must also be determined. Seven priorities of major importance have been identified. There are others, and there will be new ones. Each issue is complex, but each one must be faced with the hope that solutions will be found. After 10 years, HIV infection is at risk of becoming institutionalized, bringing with it an acceptance of the issues as inherent to the disease. Patients look to the medical profession and scientific community to provide hope. But there are also significant educational, psychological, social, and public health issues that must be resolved. The first decade of AIDS consisted of recognition, diagnosis, and early treatment. If hope is to be brought to our children and their parents, the next decade must consist of the prevention and therapeutic control of HIV and its complications.
Estimating Neonatal Mortality Risk: An Analysis of Clinicians' Judgments
Authors: Stevens Sonya M. , Gray James E. , Richardson Douglas K. , McCormick Marie C. , Goldmann Donald A.
Published: December 2021

Background. Clinicians' estimates of mortality risk in the neonatal intensive care unit (NICU) have implications for patient triage, transfer, initiation and termination of life support, and allocation of medical resources. The accuracy of these judgments has not been studied, nor the differences between nurses and attending physicians.

Objectives. 1) evaluate the accuracy of subjective judgments of NICU unit mortality risk, 2) identify the key components of clinician judgments, 3) compare accuracy between attending physicians and nurses, and 4) examine the utility of combining an objectively computed risk and clinician judgments to improve predictions.

Methods. We obtained estimates of mortality risk on 544 admissions to two NICUs on the day of admission from the attending physician and primary nurse. These were compared with an objective computed mortality risk based on birth weight and the Score for Neonatal Acute Physiology (SNAP) using a linear judgment analysis model, as well as with actual outcomes.

Results. Physicians and nurses had good discriminating power with actual mortality rates ranging from 0% among low risk patients to 67% among those with the highest mortality estimates. Physicians had a tendency to overestimate mortality risk. Clinicians base their estimates on the same factors and similar judgment weights as the empiric mortality risk model (22% birth weight, 62% illness severity (SNAP), 13% low Apgar, and 3% for intrauterine growth restriction). Clinicians place additional emphasis on therapeutic as well as physiologic factors. When the computed risk and physician judgment were combined, both made significant contributions in a logistic mortality risk model.

Conclusions. Clinician judgments of mortality risk are fairly accurate and similar to an objective illness severity index. This simple method provides insight into clinical decision making and has important applications in improving direct patient care, appropriate allocation of medical resources, and medical training.
Children in Car Crashes: Analysis of Data for Injury and Use of Restraints
Authors: Johnston Carden , Rivara Frederick P. , Soderberg Robert
Published: December 2021

Objective. To determine the effect of car restraints on motor vehicle injury rates for children aged 0 to 14 years.

Methods. A probability sample of all police-reported car crashes in the United States in 1990 and 1991 was analyzed for injury rates of passengers aged less than 15 years in relation to restraint usage, age, and seating position.

Results. Optimal restraint usage (defined as car seats for children 0 to 4 years old and lap shoulder belts for children 5 to 14 years old) was 40%. The use of the car seat was 76% for infants (0 to 12 months old) and 41% for toddlers (1 to 4 year olds). The non use of a restraint was highest for 10 to 14 year olds (43%).

The rate of involvement in car crashes for all children was 21.4 (per 1000/yr). The highest rate was the 14 year olds with 29.6 followed by 2 year olds with 26.5.

Injury rates were 4.76 (per 1000/yr) for all children. The lowest rate was 2.91 for infants but increased to 4.78 for 3 year olds. The single strongest risk factor for injury was the non use of a restraint. (Adjusted odds ratio 2.7; 95% CI 2.4 to 3.0.) The risk factor for injury for the front seat was 1.5 (95% CI 1.4 to 1.7).

Use of the car seat reduced injuries by 60% for 0 to 4 year olds, whereas the lap shoulder harness was only 38% effective for 5 to 14 year olds (P ≤ .001) Injury rates of unrestrained 0 to 4 and 5 to 14 year olds were similar.

Conclusions. Greater involvement in car crashes and less use of car restraints explains the 64% higher rate of injury for 3 year olds than for infants. It is time to target the toddlers.

Restraints designed for adults are not as effective for the school age child as car seats are for the preschool child. A better restraint for the school age child should be designed and evaluated. Meanwhile, increased usage of current restraints must be encouraged, as they substantially reduce injuries.
Intellectual Impairment in Children of Women Who Smoke Cigarettes During Pregnancy
Authors: Olds David L. , Henderson Charles R. , Tatelbaum Robert
Published: December 2021

The acknowledgement section of the following two articles should have included the statement listed below:

Intellectual Impairment in Children of Women Who Smoke Cigarettes During Pregnancy. Pediatrics. 1994;93:221-227.

We thank Robert Chamberlin for serving as co-investigator on the original trial; John Shannon for his administrative support of the work; and Elizabeth Chilson, Diane Farr, Georgianna McGrady, Jacqueline Roberts, and Lyn Scazafabo for their work with the families enrolled in the program.
Rate of Weight Gain of Inpatients with Anorexia Nervosa Under Two Behavioral Contracts
Authors: Solanto Mary V. , Hertz Stanley , Jacobson Marc S. , Golden Neville H. , Heller Lenore
Published: December 2021

Objective. To ascertain the rate of weight gain of inpatients with anorexia nervosa under two behavioral contracts, differing in criterion weight gain required to earn increasing privileges.

Design. Follow-up comparison of cohorts receiving different interventions.

Setting. Eating disorders service, operating on a general adolescent medicine unit.

Patients. Patients admitted consecutively who met the following criteria: (1) weight at least 15% less than that expected for age, sex, and height; (2) female gender; (3) absence of chronic medical illness; (4) hospital stay of at least 28 days. Twenty-two patients meeting these criteria were treated between July 1987 and October 1988, when contract 1 was in effect. This cohort of patients was compared with a group of 31 patients, also meeting the these criteria, who were treated between November 1988 and December 1991, when contract 2 was in effect.

Interventions. The behavioral contract, signed by the patient on admission, specifies the minimum 4-day weight gain necessary to earn increasing ward privileges, such as use of phone, frequency of visits, etc. Contracts 1 and 2 differed only in the 4-day weight gain criterion: 0.8 lb (0.36 kg) and 1.2 lb (0.55 kg), respectively.

Results. The results of analysis of covariance, with admission weight as the covariate, revealed a significant interaction between contract and day, such that patients receiving contract 2 gained weight more rapidly (0.36 lb/d) than those receiving contract 1 (0.20 lb/d). There was no confounding difference between groups in the use of psychotropic medication, and no complications of refeeding in either group.

Conclusion. Increasing the 4-day criterion weight gain from 0.8 to 12 lb in a behavioral contracting intervention was associated with a significant increase in the rate of weight gain, without an accompanying increase in complications of refeeding. This result simultaneously: (a) provides support for the efficacy of behavioral contracting and (b) reveals malleability in the rate of gain based on the targeted gain specified in the contract.
SUICIDAL ATTEMPTS AMONG OLDER ADOLESCENTS: PREVALENCE AND CO-OCCURRENCE WITH PSYCHIATRIC DISORDERS
Authors: Andrews Judy A. , Lewinsohn Peter M.
Published: December 2021

The prevalence of suicidal attempts and ideation and the co-occurrence of attempts with psychiatric disorders were examined in a community sample of 1710 older adolescents. Structured interviews using rigorous diagnostic criteria were conducted in two annual assessments. Lifetime prevalence of attempts was 7.1% and ideation was 21.1%. Almost 90% of those who attempted also evidenced suicidal ideation. Suicide attempts occurred in conjunction with depressive, substance use, and disruptive behavior disorder but not with panic disorders. Results indicate that risk factors for an attempt are the following: being female, from a home without a father, poor education of the father, previous attempts, suicidal ideation, and mental disorders.
Unexpected Death Due to Acute Airway Obstruction in Daycare Centers
Authors: Byard Roger W.
Published: December 2021

Sudden collapse due to acute upper aerodigestive tract obstruction in infants and young children is most often caused by ingested food or toy parts.1,2 Although attention has been previously drawn to the different pattern of food asphyxiation in children compared with adults,2 the following two cases taken from the autopsy files of the Adelaide Children's Hospital over a 20-year period demonstrate particular risk factors associated with young children eating in daycare centers.

CASE REPORTS

Case 1

A 19-month-old healthy boy was eating a sausage happily in a daycare center when last observed by a caretaker who was then absent for several minutes.
The Pediatrician's Role in Helping Children and Families Deal With Separation and Divorce
Authors:   Committee on Psychosocial Aspects of Child and Family Health
Published: December 2021

Each year over 1 million children experience divorce, but many pediatricians may only learn of this agonizing crisis from their patient's behavioral reaction or if the family, as a consequence of the divorce, moves to a different community. Since the average length of marriages that end in divorce is just under 7 years, many of the children affected are young. The combination of out-of-wedlock births and divorce will result in 61% of all children living with a single parent.1,2

Divorce may be a solution to a discordant marriage and any decrease in intrafamilial hostility may be constructive; however, for many children, the tensions continue and the entire divorce process is a long, searing experience. Divorce is the termination of the family unit, and, like termination of any important relationship, it is often characterized by painful losses.3 Approximately half of all children do not see their father after divorce and few have spent a night at their father's home in the past month.4

The divorce itself is usually only the first of a series of major changes in the lives of affected children. Their sense of loss is ongoing and may re-emerge especially on holidays, birthdays, special school events, and when attempting to integrate multiple new family relationships.

The custodial parent may have to start work or work longer hours, the family may have to move to a new community, and there may be secondary losses of relatives, local friends, and a familiar school. The family home may have to be sold.
Letter to the Editor
Authors: Helbock Harold J.
Published: December 2021

I acknowledge the reports referenced by Drs Reynolds and Hanna.1,2 These presentations indeed raised the issue of adrenal insufficiency in ill premature infants. Given the limits of space I deleted reference to the Portland Group's abstract when I added their full publication.3 For the same reason, other references were included only as required by the text. I regret and apologize for any inadvertent discourtesy resulting from my choice of references.

We agree that it is important to recognize adrenal abnormalities in the small premature infant.
Capillary Refill
Authors: Vernon Donald D. , Dean J. Michael
Published: December 2021

We are writing to comment on the article by Gorelick et al, "Effective Ambient Temperature and Capillary Refill in Healthy Children" (Pediatrics 1993;92:699-702) and, in particular, the accompanying editorial by Barth (Pediatrics 1993;92:723-724). It is hardly surprising that capillary refill time is affected by ambient temperature or that it is an imperfect indicator of tissue perfusion. We hope that their intention was not to imply that clinical assessment of perfusion is a useless endeavor, however.
GENETIC STUDY OF RDS
Authors: Floros Joanna
Published: December 2021

Blood specimens are needed for genetic studies of the surfactant protein genes. We would like to receive specimens from prematurely born infants with and without RDS. We are particularly interested in specimens from families that exhibit familial tendency for RDS and specimens from twin or multiple births with and without RDS.
PREVENTION OF NEURAL TUBE DEFECTS
Authors: L. J. F.
Published: December 2021

On the basis of increasing evidence, including the preliminary report of Czeizel and Dudas' Hungarian study,1 the U.S. Public Health Service released an advisory on September 11 stating,

In order to reduce the frequency of NTDs [neural-tube defects] and their resulting disability, the United States Public Health Service recommends that: All women of childbearing age in the United States who are capable of becoming pregnant should consume 0.4 mg of folic acid per day for the purpose of reducing their risk of having a pregnancy affected with spina bifida or other NTDs. Because the effects of higher intakes are not well known but include complicating the diagnosis of vitamin B12 deficiency, care should be taken to keep total folate consumption at <1 mg per day, except under the supervision of a physician.2
Pediatric Resident Attitudes About Technologic Support of Vegetative Patients and the Effects of Parental Input—A Longitudinal Study
Authors: Rubenstein Jeffrey S. , Unti Sharon M. , Winter Robert J.
Published: December 2021

Objective. To evaluate the change over time of attitudes about withdrawal of care from hopelessly ill children among a cohort of pediatric residents.

Design. Prospective data collection via surveys.

Setting. A pediatric residency program in a children's hospital.

Subjects. Pediatric residents beginning training in 1987 and 1988; 29 residents completed the study.

Interventions. Study participants completed a structured case-oriented questionnaire yearly from June 1988 through the completion of their residency training. The withholding of vasoactive agents or cardiopulmonary resuscitation, and the withdrawal of intravenous fluids, nutrition, or mechanical ventilation were the specific therapeutic options presented for a patient in a persistent vegetative state. The effects of time (further training) and parental wishes on resident decisions were assessed.

Measurements and main results. No resident wanted to provide intensive care to a child in a persistent vegetative state who was in respiratory failure; all residents would withhold vasoactive agents and CPR from such a child. At the conclusion of training, most (97%) would withdraw mechanical ventilation. A minority would withdraw intravenous (IV) fluids (41%) or nutrition (35%). Residents became more willing to withdraw IV fluids from these patients (0/16 vs 6/16; P = .03) and to withhold or withdraw therapies in general (P = .03) over the course of their training. All of this change occurred over the first year of training. Parental wishes altered treatment plans for these patients significantly, both when parents desired additional treatment (P < .0001), and when parents wanted treatment stopped (P = .04). The residents' level of training had no effect on responses to parents' therapeutic requests.

Conclusion. Although exposure to level of care issues occurs throughout pediatric residency training, almost all changes in trainees' attitudes occur during the first year. Efforts to promote effective learning and coping should be concentrated in this period.
Intensive Care Treatment Decisions: The Roots of Our Confusion
Authors: Clark Frank I.
Published: December 2021

Background. Decisions to withdraw or withhold treatment from infants and children are continuing concerns. Physicians voice confusion over perceived legal requirements. This confusion may lead to overtreatment of patients. Recent evidence suggests legal concerns still shape physician treatment decisions.

Objective. This study was undertaken to determine if the legal standard governing these medical decisions was clearly stated.

Design. Conventional legal research was performed. Because the 1984 Federal Child Abuse Amendments require these issues to be resolved by state laws, statutes of the 50 states and the District of Columbia were reviewed to ascertain if they would support a charge of child abuse for the inappropriate withdrawal of life-support from a child. An electronic legal database was queried for all cases involving withdrawal of life-support in children since 1984; the cases were analyzed to determine if judges were applying the federal legal standard.

Results. Current child abuse reporting laws would support the federal standard in all 50 states and the District of Columbia. Six reported withdrawal cases were identified; none applied the federal standard. There is an emerging state legal standard that is flexible and subjective and allows a quality of life analysis because it is based on parental authority. This standard conflicts with the federal standard.

Conclusions. The current law is unclear because two competing legal standards coexist; physicians cannot simultaneously meet both standards. Choosing to apply the state legal standard in clinical medical practice should support families in times of stress and relieve physicians of the burden of considering who is potentially overtreated.
Screening for Lead Poisoning in an Urban Pediatric Clinic Using Samples Obtained by Fingerstick
Authors: Schonfeld David J. , Cullen Mark R. , Rainey Petrie M. , Berg Anne T. , Brown David R. , Hogan James C. , Turk David S. , Rude Catherine S. , Cicchetti Domenic V.
Published: December 2021

Objective. To assess the false positive rate of blood (BPb) determinations on sample obtained by fingerstick from children screened in an urban clinic.

Method. From a single fingerstick (N = 1573), blood was collected in a capillary tube for determining lead concentration (CPb) by graphite furnace and an additional sample was absorbed onto a filter paper for determining lead concentration (FPb) by atomic absorption spectrophotometry with Delves cup. Zinc protoporphyrin (ZPP) was measured immediately and a confirmatory venous lead (VPb) specimen was obtained at the same visit if the ZPP was ≥35 µg/dL (0.6 µmol/L); children with either a CPb or FPb ≥15 µg/dL (0.7 µmol/L) were later recalled for determining VPb.

Results. For the 172 children who had a VPb on the same day as the screening tests, the false positive rates (95% confidence intervals) at a lead threshold of 15 µg/dL (0.7 µmol/L) were: CPb, 13.5% (6.7-20.3); FPb, 19.1% (11.8-26.4). Analyses using all 679 screens with a paired venous specimen (mean delay between screen and venous testing = 30 days) yielded much higher false positive rates (CPb, 31.3%; FPb, 46.0%).

Conclusions. Screening for lead poisoning is feasible within an urban pediatric clinic by direct measurement of lead concentration in blood samples obtained by fingerstick. The false positive rate that can be obtained is acceptable given the precision of measuring BPb concentration. Practitioners using a staged screening protocol may incorrectly attribute a higher false positive rate to the screening tests, when much of the error may be due to the temporal variability of BPb resulting from both biologic variability in BPb concentration and intermittent exposures.
Developmental Dysplasia of the Hip
Authors: Aronsson David D. , Goldberg Michael J. , Kling Thomas F. , Roy Dennis R.
Published: December 2021

Objective. The definition and early treatment of congenital dysplasia of the hip are controversial. The purpose of this study was to discuss the reasons for changing the acronym to developmental dysplasia of the hip (DDH) and to address its early detection and treatment.

Design. This multicenter study was designed to provide an updated assessment of the definition, pathologic anatomy, prevalence, etiology, natural history, early detection, and treatment of DDH.

Results. DDH more accurately describes the condition previously termed congenital dysplasia of the hip. The disorder is not always present at birth (congenital) and an infant may have a normal neonatal hip screening examination and subsequently develop a dysplastic or dislocated hip. Developmental dysplasia encompasses the wide spectrum of hip problems seen in infants and children. Physicians should understand that a normal neonatal screening examination does not assure normal hip development. The diagnosis of developmental dysplasia is made by physical examination. The Ortolani and Barlow maneuvers were designed to detect a subluxatable, dislocatable, or dislocated hip in the neonatal period. In the older child, limited abduction becomes a more reliable sign. The examination is variable depending on the type of dysplasia and changes with growth. The ultrasound is proving to be a sensitive tool in confirming the diagnosis in newborns and infants from birth to 4 months of age. The ultrasound is also valuable in older infants in terms of documenting that the dysplasia is responding to treatment. However, the ultrasound depends on an experienced sonographer and, in some cases, may be too sensitive, resulting in overtreatment. After 3 to 4 months of age, an anteroposterior pelvis radiograph can confirm the diagnosis.

Conclusions. All newborns should have a neonatal hip screening physical examination. After screening, the hips should be re-examined during health examination visits at 2 weeks, 2 months, 4 months, 6 months, 9 months, and 1 year of age. If any question arises during these visits or if there are associated risk factors, we recommend an ultrasound if the infant is <4 months of age or an anteroposterior pelvis radiograph if >4 months of age.
Poison Centers, Poison Prevention, and the Pediatrician
Authors: Lovejoy Frederick H. , Robertson William O. , Woolf Alan D.
Published: December 2021

The first poison centers were established in the United States in the early 1950s, stimulated by an American Academy of Pediatrics' survey of office-based pediatric practices which ascertained that its members had no place to turn for ingredient information on medications and household products.1 With the help of the Academy, pediatrician Dr. Edward Press, the Illinois Department of Health, and several community hospitals, the first poison center emerged. Over the subsequent 40 years, remarkable progress has occurred in the fields of clinical toxicology, poison control, and poison prevention. Yet despite these accomplishments, challenging clouds are appearing on the horizon which threaten these gains. This commentary, by the authors who have viewed and participated in a large part of the history of this progress, will focus on these major accomplishments with an emphasis on (a) poison prevention utilizing the pre-event (primary prevention), (b) the event (secondary prevention), and (c) the postevent (tertiary prevention) model.2
CHILDREN OF PEOPLE WITH SOMATIZATION DISORDER
Authors: Livingston Richard
Published: December 2021

Objective: The author investigated psychopathology, suicidal behavior, child abuse, somatization, and health care utilization in 34 children with a parent who has somatization disorder (SD-P) and two comparison groups: 41 children with a somatizing parent (SOM) (fewer symptoms than required for diagnosis of SD-P), and 30 pediatrically ill controls (CON). Method: Child and parent versions of the Diagnostic Interview for Children and Adolescents were scored for diagnosis and symptom counts in specified categories. Medical records were obtained and abstracted. Results: Children of SD-P had significantly more psychiatric disorders and suicide attempts than did children of SOM or the CON. SD-P and CON had significantly more unexplained physical symptoms that SOM. SD-P showed a trend toward more hospitalizations and experienced significantly more maltreatment. Conclusions: Children of SD-P are at significant risk in several respects. Clinical implications of these findings include a need for awareness and cooperation among general psychiatrists, primary care physicians, and child and adolescent psychiatrists to facilitate detection and treatment of these children's problems.
Disseminated Histoplasma capsulatum in a Patient with Hyper IgM Immunodeficiency
Authors: Hostoffer Robert W. , Berger Melvin , Clark Holly T. , Schreiber John R.
Published: December 2021

Immunodeficiency with hyper immunoglobulin M (IgM) (dysgammaglobulinemia type I) was first described in 1961.1 It is defined by low or absent serum levels of immunoglobulin G (IgG) and immunoglobulin A (IgA) but elevated or normal levels of IgM and immunoglobulin D.2 An intrinsic B cell class switching defect had been implicated as the pathophysiology.3,4 There is also strong evidence to suggest that a T cell defect, the absence of a T cell ligand for the CD4O antigen on B cells may be the underlying immunologic abnormality.5,6 Additionally, there is clinical evidence that these patients develop infections common to individuals with T cell defects such as Pneumocystis carinii,7 cryptococal meningitis and sepsis, (unpublished personal experience) Cryptosporidium,8 and Giardia lamblia.9
The Inconspicuous or "Disappearing" Penis
Authors: Little James R.
Published: December 2021

I see that male genitalia are once again conspicuous in the pages of the Green Journal.1-3 I was horrified to read and see what is happening to young males in the Phoenix area, as described in the article by Bergeson et al.1 Their primary care pediatricians are threatened with litigation. All for a common, normal developmental phenomenon, whose only treatment should be simple reassurance.

I first became aware of this "problem" 15 or 20 years ago when an occasional father would show up for the 9- or 12-month well-child visit.
Questions About Adolescent Gestational Age and Birth Weight
Authors: Rees Jane M. , Bach Carol M.
Published: December 2021

We are writing to express our concerns about accepting the conclusions of Stevens-Simon et al, published in the December 1993 issue of Pediatrics,1 without further examination of the study description. Chief among these concerns is the analysis of pregnancies ending in preterm deliveries along with full term pergnancies. Evidence was not given to indicate that the pattern and rate of weight gain in these two groups was the same, whereas rate, in fact, has been shown to differ.2
SURVEY OF FATALITIES FROM SKIN TESTING AND IMMUNOTHERAPY, 1985 TO 1989
Authors: Fischer Thomas J.
Published: December 2021

Purpose of the Study. This study was a survey of fatalities from skin testing and immunotherapy performed by the American Academy of Allergy and Immunology (AAAI) for the period 1985 to 1989. (An initial study dating from 1959 to 1984 was reported by Lockey in 1987 (J Allergy Clin Immunol. 1987;79:660).)

Methods. Questionnaires were sent to all members of the AAAI and ACAI requesting reports of any fatalities known to have been associated with skin testing or immunotherapy. An extensive clinical history of these fatalities was obtained and reviewed.

Findings. Seventeen fatalities were associated with immunotherapy from 1985 to 1989 (in this same period, no fatalities were reported with skin testing). The mean age of the patients who died was 36 years; 69% were female. Of note, four patients were 18 years of age or younger. Of the patients who died, 76% had asthma, and most were reported to have had factors associated with increased severity. High allergic sensitivity was reported by 71%; 36% reported prior systemic reactions. Additional factors associated with fatalities were: changing to a new vial of extract (5), dosing error or inappropriate dose adjustment (5), allergen season (3), symptoms before injection (4), no waiting after injection (2), and home injection (1). The authors note that the annual fatality rate for administration of allergen extracts in the United States remains low: one fatality per 2 million doses, but that additional educational efforts to reduce the fatality rate are needed.

Reviewer's Comments. The observation that 76% of the fatalities occurred in patients with asthma is similar to the observation that patients who die from stinging insect hypersensitivity and food-induced anaphylaxis are more likely asthmatics.
INFLUENCE OF GRASS POLLEN IMMUNOTHERAPY ON CELLULAR INFILTRATION AND CYTOKINE EXPRESSION DURING ALLERGEN-INDUCED LATE-PHASE CUTANEOUS RESPONSES
Authors: Nimmagadda Sai , Spahn Joseph
Published: December 2021

Purpose of the Study. The mechanism by which immunotherapy (IT) provides its beneficial effects are poorly understood. This study examines the effects of grass pollen IT on cellular infiltration and cytokine mRNA expression during allergen induced late phase cutaneous responses.

Methods. Forty subjects were enrolled in this double blind, placebo controlled study to receive twice weekly injections of either a standardized grass pollen extract or placebo. Once maintenance was reached, injections were administered monthly for 9 months. Skin biopsies following intradermal infection with Timothy extract were performed prior to and following IT. Monoclonal antibody staining was used to detect surface markers on lymphocytes. In situ hybridization was used to identify cells expressing cytokine mRNA.

Findings. Both patient groups were matched for age, disease severity, and duration. Thirty-seven patients (17 placebo, 20 active) completed the study. The treated group had a significant decrease in symptoms, medication use, and size of the immediate and late phase reaction (LPR) after intradermal allergen injection upon completion of the IT. Skin biopsy cell counts from actively treated subjects obtained after subcutaneous allergen challenge showed a significant decrease in T helper and eosinophil cell numbers compared to the placebo group. Increases in the expression of CD25 and HLA-DR (markers of T cell activation) were seen in the treatment group. No differences in amount of HA and IL5 mRNA-expressing cells (TH2) were noted, but there was an increase in IFN-γ and IL2 mRNA expressing cells (ie, TH1) in the actively treated group. A significant correlation was noted between the size of the LPR and the numbers of CD4+ cells in the placebo group.
TERFENADINE-KETOCONAZOLE INTERACTION: PHARMACOKINETIC AND ELECTROCARDIOGRAPHIC CONSEQUENCES
Authors: Goldsobel Alan B.
Published: December 2021

Ketoconazole alters the metabolism of terfenadine in normal men and women. This results in accumulation of the parent drug, and is associated with significant prolongation of QTc. This drug combination should be avoided.
A COMMUNITY-BASED STUDY OF THE EPIDEMIOLOGY OF ASTHMA. INCIDENCE RATES, 1964 TO 1983
Authors: Kamada Alan
Published: December 2021

A higher incidence and earlier onset of asthma occurs in males and the increase in overall incidence from 1964 to 1983 occurred only in children and adolescents.
IDENTIFICATION, CHARACTERIZATION AND FUNCTIONAL ROLE OF PHOSPHODIESTERASE ISOZYMES IN HUMAN AIRWAY SMOOTH MUSCLE
Authors: Hopp Russell
Published: December 2021

Purpose of the Study. Theophylline, a widely used bronchodilator, has been traditionally thought to exert its effect by inhibiting phosphodiesterase (PDE), which increases cAMP levels. It has become apparent that there are actually five different PDE isozymes, each encoded by a different gene or gene family. It may be possible to selectively target the lung PDE isozyme using specific inhibitors for the pulmonary smooth muscle type of PDE. The specific type of airway smooth muscle PDE isozyme, the effect of specific PDE inhibitors, individually or additively, and regional differences in PDE enzyme types was the focus of this study.

Methods. Human trachea was obtained from brain-dead subjects, processed within 24 hours by separating the muscle from surrounding tissues, and homogenized. Human lung was similarly obtained and processed, with the ultimate isolation of individual bronchial smooth muscle from several generations of bronchial diameters. PDE isozyme separation was performed by using a combination of DEAE-Sepharose and calmodulin-Sepharose affinity chromatography.

Results. Trachael smooth muscle contained all five PDE isozymes. Using specific inhibitors of each PDE isozyme, inhibitors of PDE type III were >PDE Type IV which were >PDE type III, respectively, as bronchial smooth muscle relaxants. This bias toward Type III and IV PDE was found in large and small bronchial preparations. Inhibitors of PDE III and IV acted synergistically, and PDE III inhibitors assisted beta-agonist-induced relaxation.

Reviewer's Comments. If the only action of theophylline is its' effect on PDE, drugs that do a better job of blocking specific PDE isozyme(s) in bronchial smooth muscle should be developed.
A SPECIFIC ENDOTHELIN-1 ANTAGONIST BLOCKS INHALED ENDOTHELIN-1-INDUCED BRONCHOCONSTRICTION IN SHEEP
Authors: Kobayashi Roger
Published: December 2021

Purpose of the Study. Endothelin (ET) is a potent bronchoconstrictor. The study was designed to determine the functional activity and specificity of a new ET-1 antagonist in the airways of conscious sheep.

Methods. Fourteen conscious ewes (passive female specimens) had measurements of airway mechanics determined by several methods. Aerosol delivery was by a medical nebulizer with dosimeter aerosolizing ET-l, ET-l antagonist, carbachol, or control peptides. Protocol I determined concentration-response curves to inhaled ET-1 and ET-3 measuring lung resistance before and immediately after increasing ET concentrations. Subsequently, the protective effect of ET-1 antagonist to ET-1-induced bronchospasm was studied. Protocol II determined the effect of increasing concentrations of ET-l antagonist on bronchoconstriction and on protection against ET-1-induced bronchoconstriction. The specificity of protection of ET-1 antagonist was further studied against carbachol- and LTD4-induced bronchoconstriction.

Results. Both inhaled ET-1 and ET-3 caused concentration-dependent increases in lung resistance, but ET-1 was 400-fold more potent. Pretreatment with ET-1 antagonist produced marked inhibition of ET-1-induced bronchoconstriction (P value less than .001). ET-3 antagonist also provided a small but significant protection against ET-1-induced bronchospasm. None of the control peptides provided any protection. ET-1 antagonist had no effect on carbachol- or LTD4-induced bronchoconstriction suggesting receptor specificity. Increasing doses of ET-1 antagonist was safe, however at very high concentrations, there was some suggestion of bronchoconstriction (indicating that some irritant effect may exist).

Reviewer's Comments. ET-1 is a newly described, potent bronchoconstrictor and has been measured in bronchial lavage fluid from asthmatics. ET-1 appears to act on specific receptors as ET-1 antagonist effectively blocks the affect of ET-1 but not the bronchoconstrictive activity of LTD4 and carbachol.
HOW USEFUL DO PARENTS FIND HOME PEAK FLOW MONITORING FOR CHILDREN WITH ASTHMA?
Authors: Bell Thomas
Published: December 2021

Purpose of the Study. This study seeks to assess the actual utility of the home peak flow meter (PFM).

Methods. In a clinic where all children aged over 5 years receive a peak flow meter, 50 consecutive outpatients' families were given a questionnaire to explore the knowledge of the family consequent to the use of the PFM and their assessment of its utility.

Findings. Eighty-four percent of the 50 respondents were familiar with key PFM parameters for their child, and 70% rated the PPM as very useful, another 28% as useful, and one patient as useless. Eighty-eight percent found the PPM useful during an attack of asthma; 46% as useful in assessing the response to bronchodilator therapy. A finding in a small number (20%) of detecting asthma in asymptomatic patients, is also of significance.

Conclusion and Comments. These findings support the usefulness of the PPM in home management of asthma in children. There remains some debate over whether its use should be stressed for asthma attacks and asymptomatic patients; some feel that patients should be taught to assess how asthma interferes with their daily life to best judge asthma's need for treatment. This study would have been more useful if such a group had been compared to the PFM group. I personally find that patients are increasingly technology-oriented and use the PFM in the home management of asthma.
PHARMACOKINETICS AND PHARMACODYNAMICS OF BAMBUTEROL, A LONG-ACTING BRONCHODILATOR PRO-DRUG OF TERBUTALINE, IN YOUNG AND ELDERLY PATIENTS WITH ASTHMA
Authors: Kamada Alan
Published: December 2021

A significant difference in the disposition of bambuterol is present between young and elderly asthmatics. This observation and the necessity for dosage adjustments requires further study in elderly asthmatics. Biochemical changes were not considered clinically significant. Bambuterol appears to offer the possibility of once-daily therapy in asthmatics.
SENSITIVITY, SPECIFICITY, AND PREDICTIVE VALUE OF PHYSICAL EXAMINATION, CULTURE, AND OTHER LABORATORY STUDIES IN THE DIAGNOSIS DURING EARLY INFANCY OF VERTICALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS INFECTION
Authors: Pacheco Susan E. , Shearer William T.
Published: December 2021

Purpose of the Study. To determine the HIV vertical transmission rate in an unselected group of infants born to HIV-infected mothers, and to examine the sensitivity, specificity, and positive and negative predictive values of physical examination and diagnostic laboratory studies (HIV culture, serum quantitative immunoglobulins and HIV-1 p24 antigen) in the diagnosis of HIV infection.

Study Population. A group of 142 infants referred solely because they were born to HIV-infected mothers were selected for this study.

Methods. Epidemiological and clinical data were obtained retrospectively from the Baylor Pediatric AIDS Clinical Trials Group HIV Infection Registry and medical records. The information recorded included results of physical examination and diagnostic laboratory tests (HIV culture, serum quantitative immunoglobulins, and HIV-1 p24 antigen). HIV cultures were performed according to a consensus protocol developed for the National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group.

Results. Of 142 infants whose HIV infection status was known at the time of the study, 17 (20%) had confirmed infection, and 68 (80%) had seroreverted with no evidence of infection. All HIV-infected infants were at least 3 months old when abnormal physical exam findings became apparent (lymphadenopathy and hepatosplenomegaly), but similar findings were noted in an equal number of HIV-uninfected infants. All infected infants available were HIV culture positive by 6 months of age (16/16). There was no positive cultures reported in the infants who seroreverted (32/32). Elevated immunoglobulins (IgG, IgA, IgM) were present by 6 months of age in a high percentage of infected infants. Nearly one-half of the uninfected infants had elevated immunoglobulin levels during the first 6 months of life, but in 50% of the cases it was IgG alone.
RAPID SEROLOGIC TESTING WITH IMMUNE-COMPLEX-DISSOCIATED HIV p24 ANTIGEN FOR EARLY DETECTION OF HIV INFECTION IN NEONATES
Authors: Church Joseph
Published: December 2021

The ICD p24 antigen assay is a rapid, relatively simple serologic test that is likely to be of value in the early diagnosis of HIV infection in neonates.
DEVELOPMENT AND SIGNIFICANCE OF ZIDOVUDINE RESISTANCE IN CHILDREN INFECTED WITH HUMAN IMMUNODEFICIENCY VIRUS
Authors: Church Joseph , Paul Mary E. , Shearer William T.
Published: December 2021

In HIV-infected children ZDV-resistant HIV strains are associated with diminished drug efficacy and more rapid disease progression.
DEFICIENT EXPRESSION OF A B CELL CYTOPLASMIC TYROSINE KINASE IN HUMAN X-LINKED AGAMMAGLOBULINEMIA
Authors: Abernathy-Carver Katherine J. , Liu Andrew
Published: December 2021

Purpose of the Studies. X-linked agammaglobulinemia (XLA) is a humoral immunodeficiency characterized by recurrent bacterial infections. Affected males lack mature B cells and serum immunoglobulins of all isotypes. They have a normal number of pre-B cells in the bone marrow, which suggests a defect in the pathway of B cell development. These two research groups sought to identify the gene and protein product responsible for this disorder.

Findings. Both groups, using different methodologies, successfully identified the mutant gene on the X chromosome, and characterized the defective protein product in a total of 10 XLA patients. The protein is a cytoplasmic tyrosine kinase. Other tyrosine kinases are known to play a critical role in signal transduction pathways that stimulate cell growth and differentiation.

Reviewers' Comments. These papers represent a major breakthrough in the understanding of XLA. More research is needed to explain how this defective protein results in this disorder. However, this opens the door for prenatal diagnosis and possible gene therapy in the future.