bluuebunny/crossref_metadata_2025 huggingface dataset:
Sudden Death Associated With Biotinidase Deficiency
Authors: BURTON BARBARA K. , ROACH E. STEVE , WOLF BARRY , WEISSBECKER KAREN A.
Published: December 2021

To the Editor.—

We report a case of sudden death in a patient with presumed biotinidase deficiency and emphasize the importance of suspecting this diagnosis in patients who present with compatible clinical findings.

A nonconsanguineous couple was seen for genetic counseling following the death of their first child, a boy, at 23 months of age. A review of the history revealed that the child was normal until 5½ months of age when seizures developed which were eventually controlled with carbamazepine.
Intratracheal Suctioning in Sick Preterm Infants: Prevention of Intracranial Hypertension and Cerebral Hypoperfusion by Muscle Paralysis
Authors: Fanconi Sergio , Duc Gabriel
Published: December 2021

In a prospective nonrandomized study, using each baby as his or her own control, we compared intracranial pressure (anterior fontanel pressure as measured with the Digilab pneumotonometer), cerebral perfusion pressure, BP, heart rate, transcutaneous Po2, and transcutaneous Pco2 before, during, and after endotracheal suctioning, with and without muscle paralysis, in 28 critically ill preterm infants with respiratory distress syndrome. With suctioning, there was a small but significant increase in intracranial pressure in paralyzed patients (from 13.7 [mean] ± 4.4 mm Hg [SD] to 15.8 ± 5.2 mm Hg) but a significantly larger (P < .001) increase when they were not paralyzed (from 12.5 ± 3.6 to 28.5 ± 8.3 mm Hg). Suctioning led to a slight increase in BP with (from 45.3 ± 9.1 to 48.0 ± 8.7 mm Hg) and without muscle paralysis (from 45.1 ± 9.4 to 50.0 ± 11.7 mm Hg); but there was no significant difference between the two groups. The cerebral perfusion pressure in paralyzed infants did not show any significant change before, during, and after suctioning (31.5 ± 9.1 mm Hg before v 32.0 ± 8.7 mm Hg during suctioning), but without muscle paralysis cerebral perfusion pressure decreased (P < .001) from 32.8 ± 9.7 to 21.3 ± 13.1 mm Hg. Suctioning induced a slight decrease in mean heart rate and transcutaneous Po2, but pancuronium did not alter these changes. There was no statistical difference in transcutaneous Pco2, before, during, and after suctioning with and without muscle paralysis. Our data demonstrate that muscle paralysis in sick preterm infants can significantly minimize the increase in intracranial pressure and can stabilize the cerebral perfusion pressure without having any effect on the BP increase during suctioning.
Emergency Care of the Child
Authors: BUSHORE MARTHA
Published: December 2021

Optimal emergency care of the child requires a well-developed EMS-C system. The components are easy to identify. We need macroregions with institutions acknowledging their institutional capabilities for pediatric emergency care and supporting field triage and transfer agreements. We need highly educated and skilled prehospital care providers, from emergency medical technicians in the field to air and ground transport services with specialized pediatric transport teams. In addition to having an appropriate hospital emergency department attending physician staff, hospitals must develop networks of cooperation between emergency departments appropriate for pediatrics and childern's emergency care centers.

These centers strive for quality care through systematic record keeping, chart reviews, and audits identifying care deficiencies and appropriate remedies. Subsequent reviews document improved care. There are meetings of prehospital and hospital-based providers to discuss the management of challenging cases. Comprehensive pediatric emergency care involves integration of emergency stabilization patient care with community and hospital social services, patient education programs (such as Child Life), and comprehensive rehabilitation programs, as well as community accident prevention and basic life support programs.

As we strive to develop optimal emergency medical services for our country to best serve our people, comprehensive emergency care of children must have separate consideration from comprehensive emergency care of adults. If we are to assure optimal outcome for the life-threatened child, we need to continuously assess regional needs and capabilities and encourage optimal involvement of health care providers and institutions.
Cutaneous Necrosis Following a Spider Bite: A Case Report and Review
Authors: Alario Anthony , Price Gary , Stahl Richard , Bancroft Peggy
Published: December 2021

Several species of spiders indigenous to the United States can cause a painful and necrotic wound. Recognition of the characteristic clinical course is important to avoid potential complications. A case report and review are presented.
In Reply: The Circumcision Debate
Authors: WISWELL THOMAS E.
Published: December 2021

We read Dr Harkavy's letter with a great deal of interest. He addresses several important issues regarding our findings. Obviously, circumcision is not a randomly performed procedure. We have reviewed the records of all male infants from the first part of the current study and from our previous investigation. There were no differences in the two populations regarding socioeconomic status/military rank, race, or incidence of prematurity. The circumcised and uncircumcised groups were virtually indistinguishable. The presence of hypospadias was not a factor.
In Reply: Phototherapy Effect on the Incidence of Patent Ductus Arteriosus
Authors: ROSENFELD WARREN
Published: December 2021

I am sure that Dr Rojas' observation of the shield depicted in our article led to his calculation of 40% loss of the available skin surface. This patient represented one of the earliest entered into the study. After our first few patients, the size of the shield was considerably decreased. In general, the size of shields for 1, 000-g patients is approximately 4 x 5 cm. We have measured the area of the chest and abdominal surfaces and compared this to the area of the shield. The area covered by the shield covered 17% to 25% of the trunk surface in patients we measured.
COMPREHENSIVE LIST OF CONTROLLED TRIALS IN PERINATAL MEDICINE
Authors: Student
Published: December 2021

The first comprehensive listing of controlled trials to have been assembled for any medical specialty has now been published. A Classified Bibliography of Controlled Trials in Perinatal Medicine 1940-1984. New York, Oxford University Press, 1986.
IS PREVENTION ALWAYS BETTER THAN CURE?
Authors: Student
Published: December 2021

A stitch in time saves nine, and is worth doing if the nine stitches will definitely have to be sewn. If, however, a hundred people have to have a stitch sewn into them to save one of them from having nine stitches, the proverb and the principle become more complex.
Prospective Appraisal of Complaints of Adverse Reactions to Foods in Children During the First 3 Years of Life
Authors: Bock S. Allan
Published: December 2021

To examine the natural history of adverse reactions to foods, 480 children were followed prospectively from birth to their third birthdays. Foods thought to be causing symptoms were evaluated by elimination of suspected foods, open challenges, and double-blind food challenges. Foods producing symptoms were reintroduced into the diet at 1- to 3-month intervals until the symptoms no longer occurred. Of the 480 children completing the study, 28% were thought to have symptoms produced during food ingestion, but in only 8% were these reactions reproduced (excluding fruit and fruit juices). During the first year of life 80% of the initial complaints occurred. The most striking finding was the brief duration during which reactions could be reproduced. The majority of foods were replaced in the diet within 9 months of their incrimination. A long list of foods was reported to produce many symptoms, but only a few foods reproducibly evoked gastrointestinal and skin symptoms, with respiratory symptoms being infrequent. Of great interest was that 75 children were reported to react to fruit or fruit juice, and 56 of these children had reproducible symptoms. This study has found that most food reactions occur during the first year of life, but rechallenge at regular intervals has shown that the food can be reintroduced into the diet by the third year without risk. Almost all reactions that were reproduced appear to be nonimmunoglobulin E mediated.
Breast Versus Bottle: Correlates of Adolescent Mothers' Infant-Feeding Practices
Authors: Joffe Alain , Radius Susan M.
Published: December 2021

Since the 1970s, breast-feeding as the preferred method of infant feeding has increased in overall popularity. However, certain populations, particularly poor, young, black, and less-educated women, have been slow to adopt this method. This prospective study was undertaken to identify factors relating to the choice of infant-feeding method among inner-city adolescents. Two hundred fifty-four pregnant adolescents completed a questionnaire supplying information regarding attitudes toward and knowledge about breast-feeding, social support, personal experience, and other variables hypothesized to correlate with their choice of infant-feeding method. Of the total sample, 17% said they were "probably" or "definitely" going to breast-feed their babies. Analyses revealed adolescents most likely to intend to breast-feed were those who perceived more benefits to breast-feeding, who desired more knowledge about it, who were themselves breast-fed, who reported supportive social environments, and who perceived relatively fewer barriers to breast-feeding their infants. Specific interventions based upon these findings are proposed. We conclude that adolescent mothers are interested in breast-feeding their babies and that interventions are feasible to increase breast-feeding within this population.
Carbamate Poisoning: The `Other' Insecticide
Authors: Garber Mark
Published: December 2021

A 16-month-old child who ingested rat poison, according to her parents, was noted to have signs of cholinergic poisoning. In the emergency department, the child was intubated and given atropine via the endotracheal tube until venous access was established. Phytonadione (vitamin K) and pralidoxime (2-PAM) Were also administered. The child recovered after an uneventful hospital course. The toxic agent was determined to be a carbamate insecticide, for which treatment with pralidoxime is considered controversial. Treatment of cholinergic poisoning due to unknown or mixed agents and poisoning caused by known carbamate insecticides are discussed.
Smoking Prevention: Behavioral Prescriptions for the Pediatrician
Authors: Perry Cheryl L. , Silvis Gregory L.
Published: December 2021

Pediatricians are important instigators of behavior change for the promotion of nonsmoking. Smoking is harmful to infants, children, and adolescents, and evidence is reviewed that passive smoking can have potent deleterious effects. Interventions with young adolescents based on social-psychologic theory have shown promise in changing smoking behavior and reducing smoking onset rates. Interventions are described, based on epidemiologic and etiologic data, that are appropriate for infants, children, adolescents, and parents. Interventions for parents should encourage cessation and the creation of a smoke-free environment for children. Interventions for children should emphasize the negative health effects of smoking and help them build an armamentarium against factors that promote experimentation with smoking. Interventions for adolescents should encourage them to remain nonsmokers in an environment of social pressure to smoke. The rationale for these strategies and methods of implementation in the pediatrician's office are described.
Safety Education in a Pediatric Primary Care Setting
Authors: Kelly Barbara , Sein Carmen , McCarthy Paul L.
Published: December 2021

Parents of 171 children coming to the Yale-New Haven Hospital Primary Care Center for their 6-month checkup were randomized into an intervention group (n = 85) and a control group (n = 86). Parents in the intervention group received a three-part individualized course in child safety that required active parental participation. Parts 1, 2, and 3 were given at the 6-month, 9-month, and 12-month well-child visits, respectively. Parents in the control group received routine safety education as provided at well-child visits. The educational phase of the study was completed by 129 families, 65 in the intervention group and 64 in the control group. Safety knowledge, number of hazards in the home, and reported accidents were assessed by a "blinded" community health worker approximately 1 month after the 12-month well-child visit. A total of 109 home visits were made, 55 for the intervention group and 54 for the control group. Parental safety knowledge was assessed based upon pictorial hazard recognition. Of 13 possible hazards, the mean number of hazards recognized by the intervention group parents was 9.4 (n = 55) v 8.4 (n = 50) by the control group parents (t = 2.1, P < .05, two-tailed). A hazard score was determined for each family based on nine possible hazards observed at the home visit. The mean hazard score for the intervention group was 2.4 (n = 55 v 3.0 (n = 54) for the control group (t = 2.4, P < .02, two-tailed). Parentally reported accidents and accidents reported in hospital records were similar for both groups. Results of this study suggest that age-appropriate safety education that is repetitive and individualized and that requires active parental participation results in an increase in parental knowledge and an improvement in certain safety practices.
Acquired Immunodeficiency Syndrome and Adolescents: Knowledge, Beliefs, Attitudes, and Behaviors
Authors: Strunin Lee , Hingson Ralph
Published: December 2021

Adolescents are a group at high risk for exposure to acquired immunodeficiency syndrome (AIDS). Results of a random-sample survey of 860 adolescents 16 to 19 years of age, in Massachusetts indicate that many adolescents are still misinformed or confused about AIDS and AIDS transmission. Of the adolescent respondents, 70% said they were sexually active (having sexual intercourse or other sexual contact) but only 15% of them reported changing their sexual behavior because of concern about contracting AIDS, and only 20% of those who changed their behavior used effective methods. Of both sexually active and nonactive adolescents, 8% did not know that AIDS is transmitted by heterosexual sexual intercourse. Psychoactive drugs other than alcohol and marijuana had been used by 13% of those responding, and 1% reported injecting drugs. Of those psychoactive drug users, 8% did not know that AIDS can be transmitted by injecting drugs. There was no significant difference in knowledge between the sexually active and nonactive adolescents concerning sexual behavior and AIDS transmission or between the drug users and nonusers concerning drug use and AIDS transmission. The majority of respondents knew a relationship exists between AIDS and blood, and other body fluids, but knowledge of the mode of transmission was limited. Hence, many adolescents, including those in the highest risk subgroups of sexually active or psychoactive drug users, did not know what sexual and drug precautions are needed to prevent transmission of the virus. School systems and health care providers should systematically educate this population about AIDS to counter the current misinformation and confusion. Additional surveys of adolescents can help monitor whether misunderstandings can be reduced and knowledge of the means necessary to avoid transmission increased.
Neonatal Personpower
Authors: KATZMAN GERALD
Published: December 2021

To the Editor.—

There have been several attempts to define the person-power needs for neonatologists in the United States.1-3 The reports by Merenstein et al2 and the AAP Committee on Fetus and Newborn1 maintain that there is presently an adequate number of neonatologists, whereas in a 1981 editorial, Robertson3 predicted increasing shortages of neonatologists. Why the difference between the conclusions? My answer to this question is that the reports by Merenstein et al and the AAP used calculated ratios of neonatologists to live births or lengths of stay, whereas the Robertson editorial expressed concern about the critical care needs of the physiologically unstable neonate.
Cerebrospinal Fluid Endorphins and the Infant Apnea Syndrome
Authors: SOUTHALL DAVID P.
Published: December 2021

To the Editor.—

In his interesting paper (Pediatrics 1986;78:233-237), Orlowski states that one explanation for elevated levels of endorphins might be that they increase in response to the stress of a prolonged apneic episode. He rightly points out that elevated endorphin levels alone do not demonstrate a causal relationship to prolonged "abnormal" apnea. Unfortunately, he subsequently implied that, because the number of short, normally occurring, apneic pauses of 4 to 10 seconds in the group with high endorphin levels appear to be reduced in frequency by naloxone, this finding supports a primary role for endorphins in the genesis of abnormal apnea.
Cytomegalovirus and the Brain
Authors: CONBOY THOMAS J. , PASS ROBERT F. , BOLL THOMAS J.
Published: December 2021

In Reply.—

We agree with Ades et al that our study1 was not definitive in ruling out the possibility of intellectual impairment in children born with asymptomatic cytomegalovirus and said as much in our discussion, mentioning the relatively small sample size as one of several caveats. It is important to note that our study included only asymptomatic children with normal hearing in order not to confound the effects of hearing loss on intellectual performance with possible effects of the virus.
Steroid Effects on the Course of Abdominal Pain in Children With Henoch-Schonlein Purpura
Authors: ROSENBLUM NORMAN D. , WINTER HARLAND S.
Published: December 2021

Henoch-Schonlein purpura is a systemic vasculitis of unknown cause that is characterized primarily by abdominal pain, arthritis, and purpuric skin lesions. Abdominal pain is the most common gastrointestinal symptom, but intestinal bleeding and intussusception may occur. Previous studies have supported the use of steroids in managing the abdominal pain of Henoch-Schonlein purpura.1,2 Because there are no controlled trials using steroids in this disease, their value in affecting the intestinal lesions of Henoch-Schonlein purpura remains unknown. The purpose of this retrospective study was to assess the effect of corticosteroids on the outcome of abdominal pain in children with Henoch-Schonlein purpura.

PATIENTS AND METHODS
Congenital Pilar and Smooth Muscle Nevus
Authors: GVOZDEN ANDRE B. , BARNETT NANCY K. , SCHRON DEBORAH S.
Published: December 2021

Dermatologists and pediatricians are often consulted by parents and other health professionals about the prognosis, management, and aesthetic effect of congenital nevi. In this paper we review the literature and report two new cases of a recently described and possibly underdiagnosed form of congenital lesion, the pilar and smooth muscle nevus.

CASE REPORTS

Case 1

A 6-month-old girl was evaluated for a skin lesion present since birth on her left flank. At the time of examination, it consisted of a well-defined brownish blue, lightly pigmented, barely visible macule with coarse blond hair, 6 x 7 cm (Fig 1). Upon stroking, slight, transient erection of the hair was appreciated.
Infantile Spasms Due to Unilateral Cerebral Infarcts
Authors: ALVAREZ LUIS A. , SHINNAR SHLOMO , MOSHÉ SOLOMON L.
Published: December 2021

Infantile spasms are an age-specific seizure disorder that occur in infants with no known underlying disorder or prior neurologic insult (cryptogenic group) as well as in infants with a variety of genetic disorders or known prior neurologic insult (symptomatic group).1-8 The presence of infantile spasms is associated with a high incidence of developmental retardation (87%)3 even in previously normal infants.3,5-7 Although there are many contradictory studies, it is generally believed that the infants in the symptomatic group, especially those with abnormal findings on neurologic examination prior to the onset of the seizures, have a significantly higher incidence of mental retardation and epilepsy than the infants in the cryptogenic group.1-9
Chronic Interstitial Pneumonitis in a 3-Year-Old Child With Hypersensitivity to Dove Antigens
Authors: WOLF STEPHEN J. , STILLERMAN ALLAN , WEINBERGER MILES , SMITH WILBUR
Published: December 2021

Chronic interstitial lung disease is an uncommon clinical entity in childhood. The onset is frequently insidious with progressive tachypnea, dyspnea, cyanosis, clubbing, weight loss, and hypoxia. More than 100 different occupational and environmental agents have been identified as causes, although two thirds of cases are reported as idiopathic.1 Assessment can involve invasive procedures such as bronchoalveolar lavage and open lung biopsy. Treatment of the idiopathic forms includes use of corticostenoids and cytotoxic agents, and response is variable with progression to pulmonary fibrosis being a common end stage. In contrast to this grim prognosis, the similar clinical pattern associated with hypersensitivity pneumonitis, also identified as "extrinsic allergic alveolitis," can be rapidly reversed if the offending antigen is identified and eliminated.
Does This Work?
Authors: LUMLEY JUDITH
Published: December 2021

The published reports of uncontrolled trials have begun to include an emollient statement in the final paragraphs of the discussion, qualifying the conclusions by drawing attention to the need for these promising findings to be confirmed in a large randomized trial. At first sight, this seemed a hopeful sign, a predictor of imminent conversion to the laudable practice of randomizing the first patient, but gradually it became clear to me that the apparent change of attitude was not matched by any comparable change in behavior. New treatments, procedures, operations, diagnostic aids, and other interventions continue to follow the classic opening stages in the career of a medical innovation: from promising report through to standard procedure1 before the fundamental question—does this work?—has been answered.
Benign Epilepsy of Childhood: A Speculation and Its Ramifications
Authors: Freeman John M. , Tibbles John , Camfield Carol , Camfield Peter
Published: December 2021

Most children with generalized tonic-clonic seizures have a benign developmental disorder of seizure theshold that will be outgrown with or without treatment. Such children may have one or more infrequent seizures before adequate threshold is achieved. A small percentage of children will have frequent generalized seizures (epilepsy) due to brain damage or abnormality. Such patients require vigorous anticonvulsant therapy. However, for the children with "benign childhood epilepsy" treatment may be worse than the disease.
Varicella-Like Illness Caused by Live Varicella Vaccine in Children With Acute Lymphocytic Leukemia
Authors: Brunell Philip A. , Geiser Clementina F. , Novelli Valerio , Lipton Susan , Narkewicz Sarah
Published: December 2021

A varicella-like illness occurred in five of 52 children with acute lymphocytic leukemia following the administration of live varicella vaccine. Only one of the children required treatment with acyclovir. Virus isolated from two of the children was "vaccine-like" but differed slightly from the original vaccine strain when tested by restriction enzyme analysis. There did not appear to be a reversion to virulence because two of the household contacts who seroconverted had mild or subclinical infections. Vaccinees in whom this reaction developed tended to have a poor cellular immune response to varicellazoster virus.
Elemental Mercury Exposure Among Children of Thermometer Plant Workers
Authors: Hudson Paul J. , Vogt Richard L. , Brondum Jack , Witherell Linden , Myers Gary , Paschal Daniel C.
Published: December 2021

Because evidence of mercury exposure was found among workers of a mercury thermometer-manufacturing plant in March 1984, the Vermont Department of Health studied the workers' children for both exposure to mercury and evidence of mercury toxicity. The median urine mercury level of 23 workers' children was 25 µg/L. This was significantly higher than the level (5 µg/L) among 39 children randomly selected from nonworkers' households in the same community (P < .001). Mercury-in-air levels measured in workers' homes were higher than those measured in control homes. A significant correlation was found between the urine mercury levels of the workers' children and the urine mercury levels of their working parents. No child had frank mercury toxicity. No evidence of neurologic toxicity among exposed children was discovered by a pediatric neurologist who examined these and unexposed children without knowledge of their exposure status. This is the first report demonstrating mercury exposure in children of mercury workers. Although toxic effects of mercury were not demonstrated at these levels of exposure, children of mercury workers are at risk for mercury exposure and potential mercury toxicity.
Mucolipidosis Type IV: Clinical Spectrum and Natural History
Authors: Amir Naomi , Zlotogora Joel , Bach Gideon
Published: December 2021

The clinical spectrum and developmental features of mucolipidosis type IV, a recessive lysosomal storage disorder, are presented. The evaluation was based on information from the clinical charts and information obtained from the families of 20 patients between the ages of 2 to 17 years. The clinical manifestations of the disease, profound psychomotor retardation and visual impairment, appear during the first year of life. Definitive diagnosis is made by electron microscopy which reveals storage organelles typical of the mucolipidoses. This study details, for the first time, the heterogeneity of the ophthalmologic features, specifically as pertains to the age of onset, degree and clinical course of the corneal opacities, and the retinal involvement. Although the top developmental level was found to be 12 to 15 months in language and motor function, the course of the disease is protracted for some children, who show only a slight improvement, and others, little if any deterioration despite the early infantile onset of the disease. This presentation provides guidelines for the clinical diagnosis of mucolipidosis type IV.
Iron Deficiency Anemia and Iron Therapy Effects on Infant Developmental Test Performance
Authors: Lozoff Betsy , Brittenham Gary M. , Wolf Abraham W. , McClish Donna K. , Kuhnert Paul M. , Jimenez Elias , Jimenez Rafael , Mora Luis A. , Gomez Ivonne , Krauskoph Dina
Published: December 2021

The behavioral effects of iron deficiency and its treatment were evaluated in a double-blind randomized controlled community-based study of 191 Costa Rican infants, 12 to 23 months of age, with various degrees of iron deficiency. The Bayley Scales of Infant Development were administered before and both 1 week and 3 months after IM or oral administration of iron. Appropriate placebo-treated control infants were also tested. Infants with iron deficiency anemia showed significantly lower mental and motor test scores, even after considering factors relating to birth, nutrition, family background, parental IQ, and the home environment. After 1 week, neither IM nor oral iron treatments differed from placebo treatment in effects on scores. After 3 months, lower mental and motor test scores were no longer observed among iron-deficient anemic infants whose anemia and iron deficiency were both corrected (36%). However, significantly lower mental and motor test scores persisted among the majority of initially anemic infants (64%) who had more severe or chronic iron deficiency. Although no longer anemic, they still showed biochemical evidence of iron deficiency after 3 months of treatment. These persistent lower scores suggest either that iron therapy adequate for correcting anemia is insufficient to reverse behavioral and developmental disturbances in many infants or that certain ill effects are long-lasting, depending on the timing, severity, or chronicity of iron deficiency anemia in infancy.
ORAL HEALTH IN PEDIATRICS
Authors: BIGLER JOHN A.
Published: December 2021

Symposia on oral health in children have been all too few on pediatric programs. Although there have been numerous articles in the dental and public health journals, comparatively few have appeared in pediatric and other medical literature. When one considers that children are particularly vulnerable to dental caries and it is estimated that 92% of the population have some dental problems, the importance of this subject becomes evident.

There are not enough dentists in this country to take care of the problems. For this reason, prevention and control of dental caries becomes the responsibility of the physician as well as the dentist. It becomes even more an obligation than a responsibility because we as pediatricians assume care that makes for total child health.

With this in mind the pediatrician must keep abreast of the theories of dental caries initiation, its control and prevention. He should also recognize when children are getting proper dental care.
EFFECTS OF ACTH AND CORTISONE ON LEUKEMIA IN CHILDHOOD
Authors: SCHULMAN IRVING , LANMAN JONATHAN T. , LAXDAL OLIVER E. , HOLT L. EMMETT
Published: December 2021

The results of treatment of 14 children with leukemia with ACTH and cortisone have been presented. Complete laboratory and clinical remissions lasting 1 to 33 weeks were induced in six patients; incomplete remissions were induced in two others.

No favorable responses were encountered in terminal states, monocytoid leukemia, and granulocytic leukemia differentiated beyond the blast stage. No relationship could be demonstrated between refractoriness to the hormones and to antifolic acid therapy; patients completely refractory to one agent have shown complete response to the other.

Although repeated remissions may be induced by hormone therapy, increasing resistance to the drugs tends to develop. While permanent benefit has not been obtained, ACTH and cortisone constitute valuable additions to the therapy of leukemia.
Eye Injuries in Childhood
Authors: Grin Trudi R. , Nelson Leonard B. , Jeffers John B.
Published: December 2021

A 3-year survey was conducted of all children with eye injuries admitted to Wills Eye Hospital to determine demographic, etiologic, and prophylatic factors. There were 278 cases, representing 22% of all ocular injuries in children requiring admission. The frequency of childhood ocular injuries is high, often resulting in serious visual impairment. Many of these injuries are preventable. The causes of pediatric eye injuries and preventive measures are discussed.
Partial Exchange Transfusion in Term, Polycythemic Neonates: Absence of Association With Severe Gastrointestinal Injury
Authors: Hem Herman A. , Lathrop Susan S.
Published: December 2021

Partial exchange transfusion is often used to treat neonatal polycythemia. Concern about the risk of necrotizing enterocolitis following the procedure has recently been raised. We report a retrospective analysis of 185 term, polycythemic neonates who received partial exchange transfusion. No evidence of severe gastrointestional injury was found. The technique for partial exchange transfusion we report consists of removal of blood from the umbilical vein with reinfusion of a commercial plasma substitute through a peripheral vein. Based on our data and a literature review, we offer suggestions for future conduct of partial exchange transfusion in polycythemic neonates.
Parental Health Beliefs as a Cause of Nonorganic Failure to Thrive
Authors: Pugliese Michael T. , Weyman-Daum Michelle , Moses Nancy , Lifshitz Fima
Published: December 2021

Parental misconceptions and health beliefs concerning what constitutes a normal diet for infants is reported as a cause for failure to thrive. There were seven patients (four boys, three girls), 7 to 22 months of age, who were evaluated for poor weight gain and linear growth. They were only consuming 60% to 94% of the recommended caloric intake for age and sex. The children's caloric intake had been restricted by their parents. They were concerned that the children would become obese, develop atherosclerosis, become junk food dependent, and/or develop eating habits that the parents believed were unhealthy. The parents instituted diets consistent with health beliefs currently in vogue and recommended by the medical community for adults who are at risk for cardiovascular disease. These diets caused the infants to experience inadequate weight gain and have a decreased linear growth rate. With nutritional counseling, all food restrictions were removed, the caloric intake was increased to 94% to 147% of the recommended intake for age. The weight gain rate increased significantly (P< .05) from 0.1 ± 0.1 kg/mo to 0.4 ± 0.3 kg/mo, and the linear growth rate increased significantly (P) from 0.4 ± 0.4 cm/mo to 1.0 ± 0.6 cm/mo within 3 months of therapy. Exaggerated concerns about excessive food intake in childhood and/or concern about the sequelae of eating an improper diet has resulted in this entity of failure to thrive due to parental health beliefs.
Health Services for California's Foster Children: Current Practices and Policy Recommendations
Authors: Halfon Neal , Klee Linnea
Published: December 2021

The organization and delivery of health services to children in foster care was investigated in 14 California counties in 1985. Foster care administrators, child welfare workers, foster parents, and health care providers responded to questionnaires and structured interviews performed by two pediatricians knowledgeable about the child welfare system. The organization of health services demonstrated a high degree of variability between counties. Although some counties initially evaluate all dependent children using specific protocols and examinations sites, more often services were poorly organized, fragmented, and had few safeguards to ensure delivery of appropriate health care. Use of recommended Early Periodic Screening Diagnosis and Treatment services was also variable, and counties could not provide documentation of use rates by foster children. Even less consistent was the performance of routine initial mental health assessments. Financial disincentives, fewer available providers, difficulties in obtaining and using Medicaid-reimbursed services, and fragmentation of services were frequently identified as barriers to access. To improve the organization and delivery of services, access barriers must be diminished, services must be better organized and integrated, and new financing mechanisms must be developed. Specific policy recommendations are presented.
Does Developmental Content Influence the Effectiveness of Anticipatory Guidance?
Authors: Dworkin Paul H. , Allen Deborah , Geertsma M. Alex , Solkoske Leslie , Cullina Joseph
Published: December 2021

We conducted a prospective, controlled study to evaluate the value of discussing developmental stages with mothers while providing anticipatory guidance during health maintenance visits. Eighty-three inner city mothers and their healthy, first-born infants were recruited within three days of birth and randomly assigned to either a control or intervention group. All mother-infant pairs were seen by the same pediatric provider for health maintenance visits when the infants were 2 weeks, 2 months, 4 months, and 6 months of age. At each visit, anticipatory guidance for all mothers included discussions of such age-appropriate issues as nitrition, safety, sleep, and common problematic behaviors. For the 39 intervention group mothers, the basis for such information was explained through age-specific discussions of affective, cognitive, and physical development. Dependent variables measured after the 6-month visit included maternal-infant interaction; maternal perceptions of infant temperament, family adaptation and adjustment, and satisfaction with the infant's behavior and development; and maternal satisfaction with pediatric services. Analyses of variance demonstrated no significant effect of treatment group on any of the outcome measures. These results do not support the importance of routinely discussing developmental stages during anticipatory guidance and suggest that specific, age-appropriate issues may be discussed without emphasizing the developmental basis for such information.
Prepubertal Female Genitalia: Examination for Evidence of Sexual Abuse
Authors: Herman-Giddens Marcia E. , Frothingham Thomas E.
Published: December 2021

Experience with more than 375 cases of possible sexual abuse has taught us that much work still needs to be done in understanding normal prepubertal female anatomy and interpreting findings in sexual abuse cases. Because pediatric clinicians are often called upon to assess possible sexual abuse victims, knowledge of what is known and how best to examine the genitalia of a young girl is essential. Two cases are discussed that involve normal and abnormal anatomy. Examination techniques for adequate visualization include proper tension and timing with the spreading of the labia in the supine position, the knee-chest position, and lateral traction on the buttocks while lying flat on the abdomen to look for anal relaxation. The hymen, contrary to common notion, is often a slack, thick, folded, stretchable tissue which may persist after digital or penile penetration. Findings secondary to sexual abuse are often subtle. Acute tears or bruising are rare because force is seldom a part of the sexual acts committed against a child. A vaginal opening of greater than 5 mm is not common and may indicate vaginal penetration with a finger, object, or penis. An "intact" hymen does not necessarily preclude vaginal penetration. Lack of physical evidence never rules out abuse because many sexual acts leave no physical findings.
Gross and Fine Motor Development in 47,XXY and 47,XYY Males
Authors: Salbenblatt James A. , Meyers Deborah C. , Bender Bruce G. , Linden Mary G. , Robinson Arthur
Published: December 2021

Neuromuscular deficits described in early childhood as motor awkwardness or slow movements are still clinically present in school-aged boys with XXY and XYY sex chromosome aneuploidy. A control group of 14 boys (6 to 19 years of age) and 14 XXY and four XYY boys (6 to 15 years of age), identified by newborn screening, were blindly evaluated by a physical therapist. The Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) was administered and a clinical rating of neurologic status and sensory-motor integration was assigned. On the motor proficiency test, the XXY boys had significantly lower mean scores for upper limb coordination, speed and dexterity, and on gross motor and battery composites. The neuromuscular status of the aneuploid boys was deficient, with hypotonia, apraxia, primitive reflex retention, and problems with bilateral coordination and visual-perceptual-motor integration. This mild to moderate dysfunctional sensory-motor integration, as well as previously described auditory-processing deficits and dyslexia, contributed to school performance below that expected from their cognitive potential.
Transepidermal Water Loss During Sleep in Infants at Risk for Sudden Death
Authors: Kahn A. , Van de Merckt C. , Dramaix M. , Magrez P. , Blum D. , Rebuffat E. , Montauk L.
Published: December 2021

To search for excessive sweating during sleep in infants considered at risk for sudden infant death syndrome (SIDS), we studied 258 infants during one night. There were 134 normal infants (controls), 85 siblings of SIDS victims (siblings), and 39 infants who survived an apparent life-threatening event (ALTE) with no cause found for the incident. Mean postnatal ages were between 10 and 16 weeks. Transepidermal water evaporation rate was measured from the forehead using an evaporimeter during one night's polygraphic sleep recording. Measurements were made before feedings, during the first part of the night, and evaporation rate values were expressed as grams per square meter of body surface area per hour. In the three groups of patients evaporation rates were significantly lower during rapid eye movement (REM) sleep, compared with values measured during quiet wakefulness or nonrapid eye movement (NREM) sleep. Infants with an ALTE had significantly higher evaporation rate values during NREM sleep than the two other groups (20.1 ± 1.93, 11.3 ± 0.68, and 11.5 ± 0.98 for the ALTE, control, and sibling infants, respectively). The differences were not related to age, sex, weight, or rectal temperature. During NREM sleep, evaporation rate values greater than 25 mg/m2/h were seen in 10/190 (5.3%) of the asymptomatic infants and in 11/36 (30.6%) of the infants with an ALTE. The results are in agreement with reports in the literature of repeated night sweating in infants who eventually died of SIDS. Although we are unable to conclude why evaporation rate values are higher in the ALTE group than in the two other groups, we cannot exclude that it reflects differences in autonomous system activity. Further studies are needed to establish whether at least a subgroup of infants at higher risk for SIDS have increased transcutaneous water evaporation rates during NREM sleep and whether its measurement could contribute to risk prediction for SIDS.
Infant Death Rates Among the Poor and Nonpoor in Kentucky, 1982 to 1983
Authors: Spurlock Carl W. , Hinds M. Ward , Skaggs Joseph W. , Hemandez Calixto E.
Published: December 2021

The mortality rates of infants born in Kentucky during 1982 and 1983 were analyzed to determine whether there were differences between poor and nonpoor infants. We used computer matching with the Social Insurance Food Stamp files and with the Aid for Families With Dependent Children files to define poor and nonpoor Kentucky resident families. The crude death rate for poor infants was 13.7/1,000 births, and the nonpoor death rate was 10.8/1,000 births. After adjusting for several important variables, we found that the poor infant was at a significantly greater risk for death than the nonpoor infant but only during the postneonatal period (relative risk 2.04, P = .0003). Some differences by sex and race were noted. Sudden infant death syndrome and infections were largely responsible for the poor infants' higher postneonatal mortality risk.
Circumcision
Authors: THOMPSON ROBERT S. , THOMPSON DIANE C.
Published: December 2021

To the Editor.—

Wiswell et al,1 in 1985, and Wiswell and Roscelli,2 in 1986, report three retrospective cohort studies (Tripler, Brooke, and all Army hospitals) in which the association of circumcision status (circumcised v noncircumcised) and subsequent hospitalizations for urinary tract infection in the first year of life is evaluated. Cases appear to have been determined from examination of available hospital discharge data and the diagnosis confirmed by suprapubic bladder tap or catheterization. The authors report a ten- to 20-fold increase in hospitalized urinary tract infections among noncircumcised boys in the first year of life.
Lawn Darts Peril Underlined
Authors: AMOURY RAYMOND A.
Published: December 2021

To the Editor.—

Drs Tay and Garland stated in their abstract (Pediatrics 1987;79:261-263), "Serious head injuries secondary to lawn darts have not been reported." In 1984, we reported a similar injury due to a lawn dart in the Annals of Emergency Medicine (1984;13:484-486). I concur with the authors that lawn darts are potentially dangerous.

When the cause of a head injury has been identified as a lawn dart, it is most important to proceed with a CT scan, as the authors indicated.
Is Moderate Drinking During Pregnancy Associated With an Increased Risk for Malformations?
Authors: Mills James L. , Graubard Barry I.
Published: December 2021

The relationship between heavy drinking during pregnancy and congenital malformations is well known; however, whether moderate or light drinking is teratogenic is controversial. This prospective birth defects study collected information from 32,870 women about alcohol consumption during the first trimester of pregnancy. Total malformation rates were not significantly higher among offspring of women who had an average of less than one drink per day (77.3/1,000) or one to two drinks per day (83.2/1,000) than among nondrinkers (78.1/1,000). An increased risk as small as 12% in the group averaging less than one drink per day and 45% in those averaging one to two drinks per day would most likely have been detected if it were present. Likewise, major malformations were not increased in these drinking groups. Examining malformations by organ system and individual defect revealed that sex organ malformations and all genitourinary malformations increased significantly (P < .05) with increasing alcohol consumption. These findings suggest that alcohol, at the levels usually consumed during pregnancy, is not a significant cause of malformations. Nonetheless, the possibility that there are some malformations for which no safe drinking level exists requires additional investigation.
Familial Occurrence of Sudden Infant Death Syndrome and Apnea of Infancy
Authors: Oren Joseph , Kelly Dorothy H. , Shannon Daniel C.
Published: December 2021

We sought to determine the outcome of infants born to families with multiple victims of sudden infant death syndrome (SIDS) and/or apnea of infancy. Seventy-three infants, born to families who had two or more previous siblings who had either died of SIDS or who were monitored at home for apnea of infancy or for abnormal results on polysomnogram and/or pneumogram recording, were prospectively monitored. The infants underwent polysomnogram and pneumogram recording and were subsequently monitored at home with a cardiorespiratory monitor. All episodes of apnea were immediately reviewed. Thirteen infants (18%) had subsequent severe episodes of apnea and five other infants (7%) died during a subsequent episode. All deaths occurred in families who had two or more SIDS victims. The outcome for the 17 infants who were half siblings was similar to the outcome for full siblings. Clinical data of the infants and results of evaluation were not predictive of outcome.
α-Fetoprotein Screening
Authors:   Committee on Genetics
Published: December 2021

The Committee on Genetics of the American Academy of Pediatrics endorses the following guidelines for maternal α-fetoprotein screening, developed by the American Society of Human Genetics.1

Before maternal serum α-fetoprotein (MSAFP) screening is started, the following minimal criteria should be met.

1. Adequate physician/health professional education: The objective of this education is to assure that physicians and other health care professionals understand the nature and range of severity of each of the detectable conditions and anomalies, the objectives of screening and testing, the importance of timing and reporting the low predictive value of test results, and the follow-up procedures and counseling.

2. Access to a qualified MSAFP and amniotic fluid α-fetoprotein laboratory: Criteria for quality control in these laboratories are detailed in the full statement.

3. Adequate facilities and personnel for follow-up of abnormally high or low MSAFP values: Counseling, level I and level II sonography, amniocentesis, and qualitative amniotic fluid acetylcholin-esterase assay should be available.

4. Adequate patient education: Information should be provided on the nature of the defects detectable by MSAFP screening, on confirmatory procedures, and on the options available should an abnormal result be confirmed.

The optimal time for MSAFP screening is between 16 and 18 weeks of gestation.

The common MSAFP screening protocol would include: first serum specimen evaluation, second serum specimen evaluation (if indicated), counseling, ultrasonography, amniocentesis, amniotic fluid α-fetoprotein testing (acetylcholinesterase and fetal blood evaluation), karotyping.

Once the program is underway, physician's offices, laboratories, and referral centers should have staff available who can answer questions concerning procedures related to MSAFP screening.