bluuebunny/crossref_metadata_2025 huggingface dataset:
Hearing and Neurodevelopmental Outcome in Survivors of Persistent Pulmonary Hypertension of the Newborn
Authors: Marron Mary-Joan , Crisafi Maria A. , Driscoll John M. , Wung Jen-Tien , Driscoll Yvonne T. , James L. Stanley , Fay Thomas H.
Published: December 2021

Thirty-four infants who had a diagnosis of severe persistent pulmonary hypertension of the newborn at birth (alveolar-arterial oxygen difference > 600) were treated without paralysis or hyperventilation to induce alkalosis. All survived. Twenty-seven of these 34 eligible infants (79%) underwent neurologic, intelligence, and audiologic testing between 10 months and 6 years of age. Children who were younger than 1 year of age at the initial hearing test were retested after they reached 2 years of age. The average IQ was within the normal range (mean = 96.23). None had sensorineural hearing loss. Severe neurologic abnormalities were seen in 4 children, 3 of whom had been severely asphyxiated at birth (determined by biochemical criteria). Mild neurologic abnormalities were observed in 5 children. Two infants had bronchopulmonary dysplasia because they required supplemental oxygen for 29 and 66 days, respectively, and had abnormal chest roentgenograms; 1 patient takes intermittent doses of albuterol (Ventolin) and neither currently requires supplemental oxygen. This study of 27 infants with severe persistent pulmonary hypertension of the newborn suggests that conservative management without induced alkalosis or respiratory paralysis is accompanied by no sensorineural hearing loss and a good neurologic outcome.
Nickel Allergy From a Bed-Wetting Alarm Confused With Herpes Genitalis and Child Abuse
Authors: HANKS JOHN W. , VENTERS WANDA J.
Published: December 2021

The evaluation of vesicular genital rashes can be challenging for the pediatrician. The presence of an unusual genital rash should raise the concern of sexual abuse. In recent years awareness of child sexual abuse and its various presentations has increased through both lay and medical literature. When the possibility of sexual abuse arises, historical data may be difficult to elicit and can be misleading. The decision to investigate further may be based on the clinical appearance and location of the rash and the physician's level of suspicion.

In this setting, the differential diagnosis of genital rashes in children assumes tremendous importance.
INTRODUCTION
Authors: BROWN AUDREY K.
Published: December 2021

The Trustees of the Johnson and Johnson Institute for Pediatric Service (now The Johnson & Johnson Pediatric Institute) have, over the past 25 years, sponsored symposia on topics of major importance to the health and well-being of children. The subject of group day care for children was chosen for the symposium held October 4 and 5, 1991 at the Ritz Carlton Hotel in Arlington, Virginia. This choice was made, not only because the subject has been propelled into prominence by the dramatic recent changes in the pattern of family life and the role of women in our society, particularly the remarkable increase in the number of mothers working outside of the home, but because group day care was growing with little sense of direction. The Trustees felt that the quality of care would, to a large extent, shape the early development of the involved children, and that it is evolving with insufficient coordination among the disciplines essential to the development of child care settings of high quality. They felt that too little attention had been paid to the fact that the quality of care which was being substituted for maternal care demanded not only safe supervision, but also specific attention to the developmental needs of children at a time in life now recognized as perhaps the most developmentally critical. They felt it was time to bring together authorities in diverse disciplines, whose work impacted on this burgeoning field, to exchange information which could determine the future direction of child care by emphasizing those features in early care that enhance the child's full developmental potential.
A Decade of Medicaid in Perspective: What Have Been the Effects on Children?
Authors: Cartland Jenifer D.C. , Flint Samuel S. , McManus Margaret A.
Published: December 2021

This study of the Medicaid program analyzes changes in child recipients, costs, and service use during the 1980s to assess the effects of recent federal policy shifts and to project future costs for children. Data presented in this study are from the Health Care Financing Administration's Medicaid Statistical Report for the years 1979, 1985, and 1990, three time-points that demarcate major federal policy shifts. About half of all recipients added to the Medicaid program during the last decade were children; they comprised 14% of the total cost growth experienced by the program. In addition, the eligibility distribution of children receiving Medicaid shifted markedly over the last decade. In 1979, children receiving cash assistance comprised 90% of total child recipients; by 1990, this figure dropped to 72%. Future expansions to the Medicaid program are projected to cost less than the initial expansions. This is because the early expansions disproportionately served infants, who require more hospital services than older children. Despite the major changes in Medicaid eligibility for children during the 1980s, only limited cost shifts occurred in expenditures for children. Children continue to consume a small portion of the Medicaid budget. Congress should explore options for guaranteeing that their share of funding for services will be adequate. Moreover, since future expansions will be far less expensive than those already implemented, accelerating the phase-in process for all poor children may be a more financially feasible policy option than many policymakers anticipate, despite the fiscal hardships facing many states.
Report of the National Institute of Neurological Disorders and Stroke Workshop on Near Infrared Spectroscopy
Authors: Hirtz Deborah G.
Published: December 2021

A workshop about near infrared spectroscopy (NIRS), an emerging technology used to measure cerebral oxygenation and blood flow, was sponsored by the Developmental Neurology Branch, Division of Convulsive, Developmental, and Neuromuscular Disorders of the National Institute of Neurological Disorders and Stroke in Bethesda, MD, on March 31 and April 1, 1992. This was an international work-shop designed to bring together experts in the development of this technology with clinical researchers. Topics covered included the history and background of the development of NIRS technology, experimental models for the use of NIRS, clinical experience with NIRS in the neonate and the intrapartum fetus, and current key research issues with regard to technology and clinical use.

THE TECHNOLOGY

Near infrared spectroscopy is a new application of an existing technology which can provide information about changes in cerebral oxygen saturation, cerebral blood flow and volume, and oxygen utilization in the brain. The technology has been used for a long time to monitor hemoglobin, but only more recently for cytochrome oxidase. It involves the same basic principle used in the pulse oximeter, which uses light in the visible range to detect changes in finger arterial oxygen saturation. The method is based on the fact that light in the near infrared range (700 to 1000 nm) can pass through skin, bone, and other tissues relatively easily and that there are characteristic absorption bands of oxygenated and deoxygenated hemoglobin, and of the mitochondrial enzyme cytochrome oxidase (or cytochrome AA3) in the near infrared range.

When the near infrared beam is passed through tissue, a decrease in signal intensity results from the absorbance of the chromophores in the medium.
Relationship Between Periventricular Intraparenchymal Echodensities and Germinal Matrix-Intraventricular Hemorrhage in the Very Low Birth Weight Neonate
Authors: Perlman Jeffrey M. , Rollins Nancy , Burns Dennis , Risser Rick
Published: December 2021

The pathogenesis of the periventricular intraparenchymal echodense lesion (IPE) observed in association with germinal matrix-intraventricular hemorrhage (GM-IVH) in premature neonates is unclear. The objectives of this study were to determine (1) the temporal characteristics of GM-IVH and IPE, (2) the basic characteristics of the IPE, and (3) the relationship of clinical events, including surfactant administration, to IPE. One hundred twenty-four neonates of less than 1250 g birth weight were prospectively evaluated. IPE was defined as an echodensity greater than 1 cm in diameter by cranial sonography. Fifteen (12%) neonates developed IPE in association with GM-IVH (group 1); 33 neonates developed GM-IVH only (group 2) and 76 neonates without GM-IVH served as comparison group (group 3). IPE was essentially an asymmetrical lesion; both sides of cerebrum were equally affected. The lesion was diffuse in 9 neonates and focal in 5. IPE occurred both early, at 36 hours or before (n = 8), and later, ie, between 48 and 96 hours (n = 6). In one neonate IPE was diagnosed at autopsy. GM-IVH and IPE were noted simultaneously in neonate with the earlier onset IPE (diagnosed within 36 hours); GM-IVH preceded the IPE by 6 to 48 hours when the lesion was of a later onset. Surfactant was administered to 13 (87%) group 1, 24 (73%) group 2, and 35 (46%) group 3 neonates. Pulmonary hemorrhage developed in 9 (60%) of group 1, 3 (9%) group 2, and no group 3 neonates. Symptomatic patent ductus arteriosus occurred in 12 (75%) group 1, 15 (45%) group 2, and 15 (20%) group 3 neonates. The onset of symptoms associated with patent ductus arteriosus was earlier in group 1 vs group 2 or group 3 neonates, ie, 70 vs 172 hours. Nine (60%) group 1 neonates, 6 (18%) group 2, and 5 (7%) group 3 neonates died. The cranial sonogram was markedly abnormal in all 6 group 1 survivors. Stepwise polytomous logistic regression indicated that birth weight, gestational age, and emergent cesarean section were the best predictors of GM-IVH + IPE. These data indicate that (1) the large IPE observed with GM-IVH remains a major problem of the very low birth weight neonate, despite surfactant administration; (2) complications during labor that lead to emergent cesarean section appear to increase the risk for IPE; and (3) IPE was frequently associated with PH, but the precise mechanism(s) that link these two lesions are unclear. Attempts at prevention of IPE need to consider both perinatal and postnatal provocative factors.
Listening to, Parents
Authors: WOOD DAVID
Published: December 2021

In Reply.—

In our article entitled "Are Poor Families Satisfied With the Medical Care Their Children Receive?" we found that poor patients had a less satisfying experience communicating with the physician during a visit for their child. We suggested five potential barriers to communication between the patient (parent) and physician that may be more common when seeing poor patients (eg, inadequate reimbursement leading to less time, culture and language differences, practice setting limitations, etc). Unfortunately, in our non-system of care for the poor these barriers are commonly encountered by the physician and patient, making good communication much more difficult.
Exercise and Breast-Feeding: A Different Experience
Authors: WALLACE JANET P.
Published: December 2021

In Reply.—

Since the publication of our recent investigation of infant acceptance of postexercise breast milk,1 we have been pleased with the interest expressed by both the scientific and lay communities. Although the concerns of Drs Dewey and Lovelady are legitimate, we wish to make it clear that it would be unfortunate if our findings would discourage mothers from exercising in lactation. Our purpose was to investigate the legitimacy of reports from mothers who experienced nursing difficulties following exercise and to provide guidelines for successful lactation and exercise which is clearly vital for physiological and psychological well being of both the mother and the infant.
Saddened Not Amused
Authors: CHARNEY EVAN
Published: December 2021

To the Editor.—

I was saddened to read the article by Douglas Nelson, "Humor in the Pediatric Emergency Department: A 20 Year Perspective" (Pediatrics. 1992;89:1089-1090). Although Dr Nelson did not intend "to ridicule our patients or their parents" by listing their malapropisms, that is exactly what his article does. It is one thing to recognize the occasional humor in a patient's confusion with medical terminology, quite another to enter those remarks in a notebook or publish them in a medical journal.
Effectiveness of Iron-Fortified Infant Cereal in Prevention of Iron Deficiency Anemia
Authors: Walter Tomas , Dallman Peter R. , Pizarro Fernando , Vebozo Luis , Peña Gloria , Bartholmey Sandra J. , Hertrampf Eva , Olivares Manuel , Letelier Angelica , Arredondo Miguel
Published: December 2021

Background. Iron deficiency continues to be a common problem among infants throughout the world. Iron-fortified formula is effective in preventing iron deficiency but the benefit of iron-fortified cereal is controversial.

Methods. We compared iron-fortified rice cereal to unfortified rice cereal in infants who were exclusively breast-fed for more than 4 months and to iron-fortified formula in infants who were weaned to formula before 4 months of age. The design was double blind in respect to the presence or absence of fortification iron in the cereal or formula and included 515 infants who were followed on the protocol from 4 to 15 months of age. Rice cereal was fortified with 55 mg of electrolytic iron per 100 g of dry cereal and infant formula with 12 mg of ferrous sulfate per 100 g of dry powder, levels approximating those in use in the United States. Measures of iron status were obtained at 8, 12, and 15 months. Infants with hemoglobin levels of <105 g/L were excluded from the study and treated.

Results. Consumption of cereal reached plateaus at means of about 30 g/d after 6 months of age in the formula-fed groups and 26 g/d after 8 months in the breast-fed groups; these amounts are higher than the 19-g/d mean intake by the 73% of infants who consume such cereal in the United States. Among infants weaned to formula before 4 months, the cumulative percentages of infants excluded for anemia by 15 months were 8%, 24%, and 4%, respectively, in the fortified cereal, unfortified cereal and formula, and fortified formula groups (P < .01 unfortified vs either fortified group; the difference between the two fortified groups was not significant). In infants breast-fed for more than 4 months, the corresponding values were 13% and 27%, respectively, in the fortified and unfortified cereal groups (P < .05). Mean hemoglobin level and other iron status measures were in accord with these findings.

Conclusion. Iron-fortified infant rice cereal can contribute substantially to preventing iron deficiency anemia.
Preventing Lead Poisoning in Kids: A Win-Win Opportunity
Authors: KARP HARVEY N.
Published: December 2021

To the Editor.—

For many, it is hard to believe that small amounts of lead pose a risk to children. In the February issue of Pediatrics, Dr Edgar Schoen cautioned physicians that the recent national focus on lead is overstated.1 Although Dr Schoen is correct that early lead studies were inadequately designed, he ignores later research which is well-designed and clearly implicates lead. In doing so, he seriously underestimates the hidden cost to our society of this pervasive toxin.
Use of Videotaping to Evaluate Pediatric Resident Performance of Health Supervision Examinations of Infants
Authors: McCormick David P. , Rassin Glennda M. , Stroup-Benham Christine A. , Baldwin Constance D. , Levine Harold G. , Persaud Donna I. , Wolf Wendy J.
Published: December 2021

Study objectives. To demonstrate reliability of a method for evaluating pediatric resident performance of health supervision examinations of infants using real patients and to evaluate pediatric resident performance of health supervision examinations of infants before and after an educational intervention consisting of a 6-month ambulatory rotation combined with video-assisted review of resident performance of the examination.

Design. Longitudinal cohort study in which all seond-year residents were enrolled. Residents' preintervention (baseline) videotapes were compared with postintervention videotapes. Each resident served as his or her own control.

Setting. University hospital pediatric resident continuity clinic.

Subjects. Sixteen second-year pediatric residents who were participating in a required 6-month ambulatory rotation.

Method and main results. Reliability study: Using a 51-item instrument derived from the American Academy of Pediatrics Guidelines for Health Supervision, trained raters blind to the sequence and dates of the videotaped health supervision examinations independently rated 44 resident encounters (a minimum of two raters per tape) and achieved good interrater reliability (κ = 0.80). Intervention study: After a 6-month ambulatory rotation which included resident-faculty reviews of preintervention videotapes, residents showed a 14% mean improvement in performance scores for the examination (P < .05).

Conclusions. The results indicate that videotaped health supervision examinations using real patients can be reliably evaluated by observational techniques in a continuity practice. A 6-month ambulatory block rotation coupled with video-assisted interactive review of examinations is associated with measurable improvement in resident performance on the postintervention test.
Fluticasone Propionate Aqueous Nasal Spray Is Safe and Effective for Children With Seasonal Allergic Rhinitis
Authors: Grossman Jay , Banov Charles , Bronsky Edwin A. , Nathan Robert A. , Pearlman David , Winder John A. , Ratner Paul H. , Mendelson Louis , Findlay Steven R. , Kral Kenneth M. , Field Elizabeth A. , Rogenes Paula R.
Published: December 2021

Introduction. Fluticasone propionate aqueous nasal spray, a new topical corticosteroid preparation, is effective when given as 200 µg once daily in patients (> 12 years of age) with seasonal allergic rhinitis.

Study objective. To evaluate the efficacy and safety of fluticasone propionate aqueous nasal spray in children aged 4 to 11 years with seasonal allergic rhinitis.

Study design. Multicenter, randomized, double-blind, placebo-controlled, parallel-group.

Patients. Two hundred fifty children aged 4 to 11 years with moderate-to-severe nasal symptoms, a positive skin test reaction to a late-summer or autumn allergen, a history of seasonal allergic rhinitis, and documentation of an unsatisfactory response to conventional treatment.

Interventions. Children were randomly assigned to receive fluticasone propionate, either 100 µg or 200 µg, or placebo, given by intranasal spray once daily in the morning for 14 days.

Measurements and results. Severity of nasal symptoms (obstruction, rhinorrhea, itching, and sneezing) was recorded on visual analog scales by investigators at weekly visits and by patients (or adult guardian) daily in the evening. According to investigator and patient ratings, both fluticasone propionate 100 µg/d and 200 µg/d lowered total nasal symptom scores when compared with placebo. Both dosages of fluticasone propionate were more effective than placebo on the basis of investigatorrated overall clinical evaluation of efficacy at the end of treatment, with significant improvement (as opposed to moderate or mild improvement, no change or worsening) noted in 21% to 29% of the active-treatment groups vs 9% in the placebo group. There were no significant differences between the two fluticasone propionate dosages in any efficacy measurement. Morning plasma cortisol concentrations and frequency of drug-related adverse events were similar in the fluticasone propionate and placebo groups.

Conclusion. In children as young as 4 years, 100 µg of fluticasone propionate aqueous nasal spray given once daily is as effective as 200 µg given once daily, the usual adult dose for the treatment of seasonal allergic rhinitis. Both fluticasone propionate dosages were well tolerated and neither dosage appears to interfere with the hypothalamic-pituitary-adrenal axis in children.
Oxygen Saturation and Breathing Patterns in Children
Authors: Poets Christian F. , Stebbens Valerie A. , Samuels Martin P. , Southall David P.
Published: December 2021

Objective. To obtain information on breathing patterns and oxygenation in children.

Design. Overnight tape recordings of arterial oxygen saturation (Sao2 Nellcor N200 in beat-to-beat mode), photoplethysmographic waveforms, and breathing movements in 70 healthy children (mean age 8.0 years, range 2 through 16). Analysis of recordings for pauses in breathing movements of ≥4 seconds (apneic pauses), for episodes in which Sao2 fell to ≤90% (desaturations) and, only during the state of regular breathing, for baseline Sao2 heart rate, and respiratory rate.

Results. Both baseline heart rate and respiratory rate decreased with increasing age (r = –.7 and –.3, respectively, P < .01). Baseline Sao2 was similar to that previously observed in infants (median 99.5%, range 95.8 to 100, 5th centile 96.6%). Every recording showed apneic pauses, with a frequency that did not vary consistently with age (median 7.7/h, range 0.6 to 25.5). One hundred nineteen apneic pauses in 43 recordings lasted for 15 to 19.9 seconds, and 23 lasted for ≥20 seconds (longest 28.8 seconds). The number of episodic falls in Sao2 to ≥90% decreased with age (r = –.3, P < .01); such episodes were found in 47% of children aged 2 through 6 years, but in only 13% of those aged 12 through 16 years. The 95th centile for desaturation frequency in the total group was 0.6/h. In six episodes in four patients, Sao2 fell to ≤80%.

Conclusions. Apneic pauses, some of which can last for more than 20 seconds, are a normal phenomenon in healthy children and adolescents, but only a small minority of apneic pauses affect blood gas homeostasis. Information concerning oxygenation may be more relevant to our understanding of the maturation of respiratory control than the recording of breathing signals alone.
Questions About Electrographic Seizures in Newborns
Authors: SCHER MARK S.
Published: December 2021

In Reply.—

I would like to thank Drs Scheller and Sotero for their comments regarding our retrospective study of electrographic seizures in neonates. As we have previously reviewed,1 there are several unresolved issues with respect to the reported incidence and diagnostic criteria of neonatal seizures. Diagnostic inaccuracies with respect to both the underestimation as well as overestimation of seizures still exist. Healthy patients with suspicious movements or encephalopathic infants with abnormal movements reflective of a brain disorder may occur independent of seizures.
BLOOD OF LOVED ONES IS NO SAFER THAN GENERAL SUPPLY, STUDY FINDS
Authors: L. J. F.
Published: December 2021

SAN FRANCISCO, Nov. 11 (AP)—Blood donated by family members and friends is more likely to carry hepatitis and some other diseases than is blood from anonymous donors, a Government study has found...

The study, financed by the National Institutes of Health, is the first large-scale examination of the safety of directed donations, Mr. Williams said. It involved examination of the records of 1,099,341 donations by 699,702 donors in Los Angeles, Oklahoma City, Detroit, San Francisco and the Baltimore-Washington area.

One screening test showed that 2.6 percent of donations from friends and relatives were infected with hepatitis B, compared with 1.8 percent of blood-bank donations, Mr. Williams said.

Donations from friends and family members were also more likely to be contaminated with hepatitis C, syphilis and a virus HTLV-1, that can cause cancer.
Nutrition and Behavior: The Legend Continues
Authors: Accardo Pasquale , Lindsay Ronald
Published: December 2021

The study of the impact of the artificial sweetener, aspartame, on behavior and cognition in children with attention deficit disorder by Shaywitz et al1 will not make national or even regional headlines. It will most certainly not be recognized in the more sensational tabloid press; neither will it receive any notice from the electronic information media. The silence that will greet these results is even more puzzling in the face of the decade of effort and the tens of thousands of dollars that were invested in the project. The reasons for ignoring this excellent example of the scientific method as applied to a subject of great topical interest to the population at large would also seem to go beyond the simple fact that negative studies are inherently less exciting and less conclusive.
YOUTHS SET HOMELESS MAN AFIRE IN SUBWAY
Authors: L. J. F.
Published: December 2021

A 31-year-old homeless man was seriously injured early yesterday after four teen-agers set him on fire as he lay sleeping in a Bronx subway station, the transit police said. A 25-year-old man on his way to work grabbed a fire extinguisher from a token booth and doused the flames.

The victim, whose name was not released, was listed in critical condition at Bronx Municipal Hospital Center with burns over 75 percent of his body...

Fourteen homeless people were set on fire from January through April in the city's subways, the transit police said. One of them died.
Woman Confesses in Deaths of Children
Authors: L. J. F.
Published: December 2021

Waneta E. Hoyte said her five children died because they cried.

"In a signed confession, she said she smothered her children, Erik, James, Julie, Molly and Noah, because their screaming made her feel useless.

"It was the thing that caused me to kill them all because I didn't know what to do for them," Mrs. Hoyt said in a confession taken by investigators hours before her arrest last week on five counts of murder.

The statement, one of two provided to investigators by Mrs. Hoyt, transformed what had been a textbook case of so-called crib death of her five children more than 20 years ago into another kind of family cataclysm: an unthinkable crime..." Mrs. Hoyt now renounces the confession. She now claims she signed the statements only to stop questioning by police.
Do Young Boys With Fragile χ Syndrome Have Macroorchidism?
Authors: Lachiewicz Ave M. , Dawson Deborah V.
Published: December 2021

Objective. Macroorchidism is one of the most well-described clinical characteristics of men with fragile χ syndrome, but little information has been available regarding macroorchidism in prepubertal boys with fragile χ. The purpose of this study was to learn whether macroorchidism is a characteristic of fragile χ syndrome in prepubertal boys.

Methods. Clinical assessments were performed on 73 boys, 2.2 to 10.2 years, in whom fragile χ either had been diagnosed or who had been referred for fragile χ evaluations because of developmental delays. As part of these assessments, we measured testicular volumes using Prader orchiometer beads to find out if macroorchidism occurs before the onset of puberty.

Results. From 2.2 through 7 years, boys with fragile χ have significantly larger mean testicular volumes than boys without fragile χ, but macroorchidism (≥4.0 mL or ≥2 times normal) only occurred in 1 of 27 boys with fragile χ. From 8 to 10 years, all our patients with fragile χ had clinically enlarged testicles (≥3.75 mL), and 7 of 9 boys with fragile χ had macroorchidism (≥4.0 mL). The testicular volumes of control subjects were all ≤3.0 mL.

Conclusions. These findings suggest that macroorchidism occurs in some prepubertal boys with fragile χ, but in this series it did not occur until age 6 and usually did not occur until after age 8.
Camphor Revisited: Focus on Toxicity
Authors:   Committee on Drugs
Published: December 2021

This Policy Statement was retired April 2013.

This commentary updates a previous AAP statement developed by the Committee on Drugs concerning camphor.1 The original commentary reflected the level of concern among pediatric practitioners and poison centers about the toxicity of camphor. Since the original statement, the Food and Drug Administration (FDA) has recognized camphor as a safe and effective topical antitussive, analgesic, anesthetic, and antipruritic agent.2 Following the approval process in 1983, the FDA required that the concentration of camphor in products not exceed 11%.2 Higher concentrations were not more effective and could cause more serious adverse reactions if accidentally ingested. Most reported camphor-related fatalities involved agents containing a concentration greater than 11%.

Ingestion of potentially toxic substances by children is related to the availability of a product in their environment. Camphor remains widely available (Table). The toxicity of camphor when inappropriately used is well documented.3-6 Ingestion is the most common route of potentially toxic exposure, with rapid onset of toxic effects. The risk of toxicity relates to both the concentration of camphor in the ingested product and the rate of absorption of camphor into the body.

From 1985 through 1989, 32 362 human exposures to camphor were reported to the American Association of Poison Control Centers.7-11 From 1985 through 1989, life-threatening toxicity occurred in 33 children as the result of camphor ingestion. During this period, there were no Childhood deaths as the result of camphor ingestion. In 5 cases, the products ingested contained more than 11% camphor even though they had been discontinued in 1983. In 14 cases, the products contained between 10% and 11% camphor.
Utilization of Prenatal Diagnosis For Cystic Fibrosis Over the Past Seven Years
Authors: Jedlicka-Köhler Ilse , Götz Manfred , Eichler Irmgard
Published: December 2021

Objective. First trimester prenatal diagnosis (PD) by DNA analysis for cystic fibrosis (CF) has been available for parents of affected children since May 1986.

Methods. In a prospective study 37 couples with a single child affected by CF were investigated. Fathers and mothers were interviewed simultaneously, and their attitudes towards further childbearing and potential utilization of PD ascertained. Parental answers were treated as one. A 7-year follow-up allowed comparison between intended and actual behavior.

Results. At the time of the interview, 16 parents (43%) were determined to have further children. Nineteen parents (51%) said they would certainly or probably utilize PD in case of pregnancy. Their predominant reason for favoring PD was the strong desire to have a healthy child (47%). Among the 18 rejectors (49%) the fear of an unsolvable conflict in case of an affected fetus prevailed (39%). Twenty-four pregnancies actually occurred in 18 families. Utilization of PD was arranged in five (21%) and finally performed in four (17%) cases.

Conclusion. Availability of PD does not substantially change the reproductive behavior of parents of children with CF. Reasons for this were multifactorial, with anticipated difficulty in deciding to continue or terminate pregnancy being predominant.
Excessive Infant Crying: A Controlled Study of Mothers Helping Mothers
Authors: Wolke Dieter , Gray Pat , Meyer Renate
Published: December 2021

Objective. To determine the efficacy of behavioral management counseling in the treatment of persistent, excessive infant crying (>3 hours per day).

Design. Two treatments, one no treatment control group. Infants were group-matched according to baseline fuss/cry levels, sociodemographic, and infant variables. Treatments were carried out sequentially by the same counselors.

Setting. Telephone counseling by volunteers (mothers) of CRY-SIS, a national support group for the parents of crying infants.

Patients and interventions. Sequential sample of 27 mother-infant pairs receiving treatment 1 (Tr1, empathy: talking through the problem), 21 receiving treatment 2 (Tr2, behavioral management: specific care taking suggestions) and 44 receiving no treatment (C, controls). Infants were between 1 to 5 months of age.

Measurements and results. Mother-infant pairs had a pretreatment baseline assessment and a posttreatment follow-up (3 months after baseline) using 1-week diaries. Total fuss/cry duration reduced significantly more in the behavioral management group (by 51%) than the empathy group (37%) or the control group (35%). This was mainly due to significantly reduced evening fussing/crying in Tr2 (67%) compared with Tr1 (45%) and C (42%). No differences in total number of fuss/cry bouts/day were found. However, the number of fuss/cry bouts reduced significantly more in the evening in Tr2 (by 55%) compared with Tr1 (27%) and C (32%). Behavioral management mothers evaluated the same counselors as more sympathetic, knowledgeable, and understanding. Tr2 was also perceived by mothers to have helped them more in reducing the crying problem, coping with the infant, and improving the relationship with their infant than Tr1. No effects of treatment on infant difficult temperament were found.

Conclusions. Behavioral management was more effective in reducing fussing/crying than spending time with the mother talking through the problem or just waiting for spontaneous remission. Treatment by suitably but briefly trained lay counselors is an inexpensive and successful treatment option.
A Program to Limit Donor Exposures to Neonates Undergoing Extracorporeal Membrane Oxygenation
Authors: Rosenberg Ellen M. , Chambers Linda A. , Gunter Jean M. , Good Joseph A.
Published: December 2021

Objective. Extracorporeal membrane oxygenation (ECMO) has dramatically improved the survival of neonates with life-threatening respiratory and cardiac failure. However, ECMO requires numerous transfusions with significant risks. This study evaluated the effects of changing transfusion practices and blood component management on blood donor exposures in neonatal ECMO.

Design. A 3-year retrospective chart review of all neonatal ECMO patients from December 1989 through November 1992 was undertaken. During this 3-year period, transfusion practices and blood product preparation were altered twice to reduce blood donor exposures. The use of apheresis platelets and fresh frozen plasma (FFP), and preserving the expiration date on packed red blood cells (PRBCs) through the use of a sterile connecting device, allowed multiple transfusions from individual donor components. In addition, education of the ECMO physicians was focused on standardizing and reducing transfused volumes.

Sixty-four surviving neonatal patients (91.4%) were evaluated. Five patients had excessive bleeding and were excluded from analysis. The remaining 59 patients were divided into three protocols based upon the transfusion practice at the time of their ECMO course. Protocol 1 received PRBCs less than 5 days of age, volume-reduced platelet concentrates, and standard FFP units up to 24 hours after thawing. Changes in transfusion practice for protocol 2 included extended outdate for PRBCs to 10 days, and using single donor apheresis platelet aliquots. The third protocol entailed the use single donor apheresis FRP aliquots in addition to the protocol 2 changes.

Results. Total PRBC transfusion volumes (721 ± 406 ml for protocol 1, 637 ± 172 ml for protocol 3) and associated blood donor exposures (5 ± 2.1 for protocol 1, 3.9 ± 0.9 for protocol 3) did not change substantially over the reviewed period. However, FFP transfusion volumes (478 ± 170 ml for protocol 1, 274 ± 63 ml for protocol 3), FFP-related donor exposures (4.5 ± 1.6 for protocol 1, 1.2 ± 0.4 for protocol 3) and platelet-related donor exposures (4.6 ± 3.6 for protocol 1, 2.5 ± 1.5 for protocol 3) were reduced progressively and significantly from protocol 1 to protocol 3 (P < .01, Tukey's B test adjusted for multiple comparisons). The total number of donor exposures per patient while on ECMO was decreased from 14.1 in protocol 1 to 10.0 in protocol 2 to 7.5 in protocol 3 (P < .01).

Conclusions. We conclude that the changes in blood bank component selection and management as well as physician practice were effective in substantially reducing ECMO-related transfusion volumes and the resulting donor exposures.
MOUNTING SENSE OF JOB MALAISE PROMPTS MORE HEALTH-CARE WORKERS TO JOIN UNIONS
Authors: L. J. F.
Published: December 2021

In search of job security and a voice in health-care reform, a growing number of workers at hospitals, nursing homes, and rehabilitation facilities are joining labor unions.

Hospital workers filed 158 petitions for union elections in 1993, up from only 19 in 1989, according to a study by Management Science Associates, Inc, a labor consulting firm. And unions won 58% of health-care elections in 1993—the highest win rate in the industry since 1984, according to Modern Health Care, an industry journal.
The Febrile Infant
Authors: McCarthy Paul L.
Published: December 2021

There have now been three large prospective studies of febrile infants published within the past 3 years.1-3 Each reports on over 500 patients. Two of the reports, that of Baskin et al1 and that of Jaskiewicz et al,3 in the current issue of Pediatrics, focus on infants meeting low-risk criteria for serious bacterial illness. These two studies ask the question: "If the febrile infant meets these selected low-risk criteria, then with what degree of diagnostic certainty can the examining physician rule out a serious illness?" Statistically, this index of diagnostic certainty is termed negative predictive value. Jaskiewicz et al studied 511 low-risk febrile infants and used 437 of these patients to calculate negative predictive value, which was 98.9%.
Lead Questionnaire Not Always Efficient
Authors: Kazal Louis A. , Bullock Patricia W.
Published: December 2021

Tejeda et al found the lead risk assessment questionnaire to be an effective screening method for identifying increased lead levels in their population.1 However, as Drs Gellert and Wagner pointed out in the same issue of Pediatrics,2 depending on the prevalence of elevated lead levels, screening may not even be necessary. Therefore, using this questionnaire may be inappropriate in certain populations.

In Arizona, Medicaid requires that physicians screen with these questions at 6, 9 to 12, 15 to 18, 24 to 36, and 48 to 60 months of age.
Postnatal Growth Preceding Sudden Infant Death Syndrome
Authors: Brooks John G. , Gilbert Ruth E. , Flemming Peter J. , Berry Peter J. , Golding Jean
Published: December 2021

Objective. To compare postnatal growth preceding the sudden infant death syndrome (SIDS) with that of age matched controls.

Design. Retrospective case-control study. Each SIDS victim was matched with two controls on date of parental interview, postnatal age, and neighborhood. Clinical and demographic data were collected by parental interview and by review of medical records, and interval body weights were obtained from health visitors' records.

Study population. All infants dying of SIDS between 1 May, 1987 and 30 April, 1989 in a geographically defined region consisting of four health districts in Avon and North Somerset in southwest England. Seventy-eight of the 99 SIDS victims and 139 of 156 control infants were included in the final analysis.

Results. There was no significant difference between SIDS victims and the controls in either of the two indices of postnatal growth which were analyzed. The mean growth rates (± 1 SEM) between birth and the last live weight (age equivalent weight for control infants) were 27.1 ± 1.0 g/day for the SIDS cases and 28.3 ± 1.5 g/day for the control infants. The mean growth rate (± 1 SEM) between the last two live weights were 31.5 ± 2.9 and 24.9 ± 2.1 g/day for the SIDS and control infants, respectively. Stratification of the infants by sex, gestational age, maternal smoking during pregnancy, breast versus bottle feeding, or age at death, did not result in any significant differences between SIDS and controls in either of the indices of postnatal growth rate. The 20 SIDS cases which were excluded from the final analysis did not differ from 78 whose data was analyzed, with regard to established SIDS risk factors, age at death, or postmortem weight.

Conclusions. No difference was found between the postnatal growth of SIDS victims and that of age matched control infants.
VIOLENT EVENTS REPORTED BY NORMAL URBAN SCHOOL-AGED CHILDREN: CHARACTERISTICS AND DEPRESSION CORRELATES
Authors: Freeman Linda N. , Mokros Hartmut , Poznanski Elva O
Published: December 2021

Objective: This paper reports data on the prevalence of morbid thoughts of death or injury and the experiences of violence for a sample of 6 to 12 year old urban school children and examines the relationship of these thoughts and experiences to the child's emotional health. Method: Fifty-seven of the sample of 223 children who attended the same inner-city school described violent events occurring to themselves, a relative or friend. All children were interviewed and assessed on the Children's Depression Rating Scale-Revised (CDRS-R). Results: Significantly higher CDRS-R sum scores, indicating the presence of suspected depression or of clinical concern, were recorded for the 57 children reporting experiences with violence. As well, the subgroup of 57 children were significantly more distressed by specific symptoms of low self-esteem, weeping, and worries about death or injury. Conclusions: Finding so many children reporting violent events occurring in their homes and community and that these children's experiences of violence were associated with emotional disturbances such as depression, dysphoric mood, low self-esteem, and excessive fears and worries about death or injury suggests the need for routine examination of the history of exposure to violence in the evaluation of inner-city children.
PUBLIC DEPOSITION OF HYPOTHESES, BEFORE DOING THE STUDIES
Authors: Student
Published: December 2021

Most papers do not carry at the end of the introduction a clear-cut hypothesis that is about to be tested, and when they do no-one can be sure that the words were not written when the data were already in...

There is a strong case for public deposition of hypotheses, lodged in advance of execution of a study.
Clinical and Pharmacokinetic Evaluation of Long-Term Therapy With Didanosine in Children with HIV Infection
Authors: Mueller Brigitta U. , Butler Karina M. , Stocker Vicki L. , Balis Frank M. , Pizzo Philip A. , Brouwers Pim , Husson Robert N. , Lewis Linda L. , Jarosinski Paul , Venzon David
Published: December 2021

Background. Didanosine has demonstrated promising antiviral activity and a tolerable toxicity profile in short term studies. We describe a cohort of HIV-infected children who were treated for a prolonged period of time with didanosine.

Methods. Children (6 months to 18 years of age) with symptomatic HIV infection or an absolute CD4 count < 0.5 x 109 cells/L, received oral didanosine at doses between 20 mg/m2 to 180 mg/m2 every 8 hours. Clinical, immunological, and virological parameters were assessed at least every 2 months. The pharmacokinetics of didanosine were evaluated in 85 patients.

Results. Previously untreated children (n = 51) and children who had received prior antiretroviral therapy (n = 52) were enrolled in the study (median time on study 22.6 months; range 2 to 48). The long-term administration of didanosine was well tolerated and no new toxicities were observed. The absolute CD4 count increased by ≥ .05 x 109 cells/L in 28 of 87 (32%) of patients after 6 months of therapy. Responses were also sustained in 41% of these children after 3 years of therapy. Children entering the study with a CD4 count >0.1 x 109 cells/L (n = 51) had a marked survival advantage (P = .00002) with an estimated survival probability after 3 years of 80% compared to 39% for children with lower CD4 counts. Although the area under the curve of didanosine increased proportionally with the dose, there was considerable interpatient variability at each dose level. There was no apparent relationship between surrogate markers of clinical outcome and plasma drug concentration.

Conclusions. Didanosine was well tolerated with chronic administration, and toxicities were uncommon and usually reversible. In 41% of patients, the CD4 count increased and was maintained at the higher level even after years of treatment.
Guidelines for Expert Witness Testimony in Medical Liability Cases(S93-3)
Authors:   Committee on Medical Liability
Published: December 2021

The American Academy of Pediatrics joins with other medical organizations in emphasizing the obligation of objectivity when its members respond to requests to serve as expert witnesses in the judicial system. Regardless of the source of the request, such testimony ought to embody the relevant facts and the expert's knowledge, experience, and best judgment regarding the case. At the same time, the Academy reiterates that it cannot condone participation of its members in legal actions in which their testimony will impugn some performances that clearly fall within the accepted standards of practice or, conversely, will endorse some obviously deficient practices.

The role of an expert witness in a medical liability case is to testify to the standards of care in a given case, and to explain how the defendant did or did not conform to those standards. An expert witness may be asked to testify as to whether a deviation from the standard of care caused the injury. Expert witnesses are also called upon to help an attorney determine if a case has merit, and in several states attorneys are required by law to consult an expert before a suit is filed. Because experts are relied upon to help courts and juries understand the "standards of practice" as applicable to a given case, care must be exercised that such "expert testimony" does not narrowly reflect the experts' views about applicable standards to the exclusion of other acceptable and perhaps more realistic choices. The standards of care for generalists may not necessarily be the standards of care for subspecialists.
The Frequency, Level, and Distribution of Fecal Contamination in Day-Care Center Classrooms
Authors: Laborde Danielle J. , Weigle Kristen A. , Weber David J. , Sobsey Mark D. , Kotch Jonathan B.
Published: December 2021

Children in day care are at higher risk of infectious diarrhea than those who remain at home.1,2 Diarrhea in day care centers (DCCs) is propagated through the fecal-oral route,3,4 a mode of transmission that is enhanced by fecal contamination. Knowledge of the pattern and degree of fecal contamination in DCC classrooms can identify important sources of enteropathogens to be targeted by hygienic interventions. This study was undertaken to qualitatively and quantitatively describe fecal contamination in DCC classrooms and to determine the relative stability of patterns of contamination across time.

Fecal coliforms occur in large numbers in human feces and can be presumptively identified on differential culture media. Each discrete colony represents a bacterial cell originally present on the surface that was sampled. In principle, the number of fecal coliforms rather than the frequency of positive samples reported in previous DCC studies5,6 should more accurately reflect enteropathogen characteristics of infectious dose and survival in the environment. Therefore, fecal contamination was measured by the number of viable fecal coliforms recovered from environmental surfaces and the hands of children and DCC staff members. The distribution of fecal contamination was described in terms of coliform presence and coliform density (counts) for individual classroom sites.

METHODS

Fecal contamination was measured during two prospective studies in North Carolina. In study 1, 13 Cumberland County DCCs served as controls during a hygienic intervention trial and were sampled from April 1989 to March 1990; in study 2, 25 Research Triangle Area DCCs were sampled between January and August 1991.