bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Inclusion of Beans in a Mixed Diet for the Treatment of Peruvian Children With Acute Watery Diarrhea
Authors: Alarcon Pedro , Montoya Ramon , Rivera Juan , Perez Fernando , Peerson Janet M. , Brown Kenneth H.
Published: December 2021

A double-masked clinical trial was conducted to assess the effects of inclusion of beans in a mixed diet for young Peruvian children with acute diarrhea. Dietary treatment consisted of either rice, beans, and vegetable oil (group RB, n = 25) or rice, soy-protein isolate, corn syrup solids, and vegetable oil (group RS, n = 21), each given in amounts up to 150 kcal/kg body weight per day immediately following rehydration therapy. The groups were generally similar at the time of admission, and there were no differences in the rates of treatment failure (8% in group RB, 14% in group RS; P = .65). Mean stool outputs were 83 ± 46 (SD) g/kg body weight in group RB and 71 ± 43 g/kg body weight in group RS on day 1, and these outputs consistently ranged from 25% to 40% greater in group RB than in group RS (P = .058). By contrast, the median duration of liquid stool excretion was substantially less in group RB than in group RS (60 vs 121 hours, P = .01). The fractional absorption of carbohydrate, fat, and total energy was significantly greater by children in group RS, but there were no differences in net apparent absorption of these nutrients because the children in group RB consumed significantly more of their assigned diet. Children in group RS gained significantly more weight during the whole period of observation (194 g vs 1 g, P = .047), but these differences could be entirely explained by the weight (and presumably fluid) changes on day 1. There were no consistent differences by dietary group in any of the other anthropometric indicators. It is concluded that despite moderate increases in stool output, the amount of beans offered in this study can be safely incorporated in a mixed diet for children with mild or moderately severe acute watery diarrhea.
INTRODUCTION
Authors: DANCIS JOSEPH , PARKS WADE
Published: December 2021

One of Saul Krugman's favorite photographs recalls the day in 1965 when he handed his predecessor at New York University, L. Emmett Holt, Jr., a copy of the Festschrift in his honor. Some 25 years later, it is our privilege to similarly honor Saul. It continues a long tradition at Bellevue Hospital. A Festschrift was dedicated to Abraham Jacobi, the first Director of Pediatrics, some 100 years ago. Tradition plays an important role in Saul Krugman's life and in the history of medicine in New York City.

New York hospitals have long been involved with the sequestration and care of patients with infectious diseases. In fact, many municipal hospitals were established because of epidemics of smallpox, measles, typhus, yellow fever, cholera, and typhoid fever. To protect the general population from infections arriving on ships, quarantine sites were established on islands in New York Harbor and the East River. These quarantine hospitals became the pest houses. The word "pest" derives from the first of the three great scourges of mankind: pestilence, famine, and war. As New York's municipal hospital system became better established, the pest houses evolved into infectious disease hospitals. The most famous of these was Willard Parker Hospital located on the East River on Manhattan's lower East side.

Saul was discharged from the Air Force in 1946 and joined an army of veterans seeking hospital training. Because of a delay in procuring a Pediatric residency at NYU-Bellevue, he took an interim position as resident physician at Willard Parker for six months. At the time all patients with infectious diseases in New York were funnelled into three specialty hospitals. Waves of children arrived at Willard Parker with scarlet fever, measles, pertussis, croup, and polio, filling wards to overflowing. Saul became an expert in infectious disease even before he began his pediatric residency! He maintained his affiliation with Willard Parker until it was closed 10 years later, signaling the end of an epoch as the result of medical advances. During those momentous years, Saul sharpened his clinical skills to an extraordinary degree, laying the groundwork for his future career in research and accumulating the experience that made the Krugman and Ward text, Infectious Diseases of Children, now in its 9th edition, an international success. The past 100 years has seen the conquest in this country of most of the dreaded infections that concerned us at the opening of the century. Saul Krugman participated in many of those advances. It is part of the irony of medical progress that, as we congratulate ourselves on our success, a new threat has emerged which will tax our energies and resources for many years to come. The frightening dimensions of AIDS will stalk the 21st century.
Head Injury in Very Young Children: Mechanisms, Injury Types, and Ophthalmologic Findings in 100 Hospitalized Patients Younger Than 2 Years of Age
Authors: Duhaime A. C. , Alario A. J. , Lewander W. J. , Schut L. , Sutton L. N. , Seidl T. S. , Nudelman S. , Budenz D. , Hertle R. , Tsiaras W. , Loporchio S.
Published: December 2021

Head injury in the youngest age group is distinct from that occurring in older children or adults because of differences in mechanisms, injury thresholds, and the frequency with which the question of child abuse is encountered. To analyze some of these characteristics in very young children, the authors prospectively studied 100 consecutively admitted head-injured patients 24 months of age or younger who were drawn from three institutions. Mechanism of injury, injury type, and associated injuries were recorded. All patients underwent ophthalmologic examination to document the presence of retinal hemorrhages. An algorithm incorporating injury type, best history, and associated findings was used to classify each injury as inflicted or accidental. The results confirmed that most head injuries in children younger than 2 years of age occurred from falls, and while different fall heights were associated with different injury types, most household falls were neurologically benign. Using strict criteria, 24% of injuries were presumed inflicted, and an additional 32% were suspicious for abuse, neglect, or social or family problems. Intradural hemorrhage was much more likely to occur from motor vehicle accidents and inflicted injury than from any other mechanism, with the latter being the most common cause of mortality. Retinal hemorrhages were seen in serious accidental head injury but were most commonly encountered in inflicted injury. The presence of more serious injuries associated with particular mechanisms may be related to a predominance of rotational rather than translational forces acting on the head.
Acute Pancreatitis in Children With Anticholinesterase Insecticide Intoxication
Authors: Weizman Zvi , Sofer Shaul
Published: December 2021

Gastrointestinal symptoms are commonly seen in anticholinesterase insecticide intoxication. A few studies in adults have demonstrated some evidence for pancreatic damage in this poisoning. To see whether this association exists also in children, we conducted a prospective study in 17 consecutive children with typical organophosphate and carbamate poisoning. On admission and following recovery, serum amylase, immunoreactive trypsin, glucose, calcium, urea, creatinine, and arterial blood gas values were determined and compared with those of age-matched control subjects. Acute pancreatitis was diagnosed in 5 subjects. They demonstrated significantly elevated (greater than mean + 2 SD) serum levels of both immunoreactive trypsin (914.0 ± 317.4 ng/mL, 159.9 ± 36.4 ng/mL, and 169.7 ± 41.2 ng/mL, respectively; P < .01) and amylase (448.0 ± 264.4 U/L, 152.8 ± 90.9 U/L, and 56.8 ± 26.3 U/L, respectively; P < .001; n = 4), compared with other patients and control subjects. Gastrointestinal symptoms were noted in all 5 subjects, with severe abdominal pain in 2. Such symptoms were evident in only 41% of the other 12 patients. Serum glucose levels were significantly elevated in these subjects compared with others (389.0 ± 66.2 mg/100 mL vs 180.4 ± 72.3 mg/100 mL; P < .01). None had hypocalcemia, renal dysfunction, or acidosis. All had complete recovery. It is concluded that acute pancreatitis is probably not rare in children with anticholinesterase insecticide poisoning. This may contribute to the development of gastrointestinal symptoms and hyperglycemia often observed in these patients.
Varicella in Pediatric Renal Transplant Recipients
Authors: Lynfield Ruth , Herrin John T. , Rubin Robert H.
Published: December 2021

As of November 1991, 8 of 83 children who had received renal transplants at Massachusetts General Hospital since January 1979 required admission for primary variceila. All 8 had cutaneous manifestations of disease, and 4 had evidence of visceral disease. Three of these 8 children received varicella zoster immune globulin (VZIG) after exposure to varicella; in the remaining children, exposure was not revealed until symptoms were present. All 8 children were treated with high-dose intravenous acyclovir. Two children died of complications of varicella infecfion, including 1 child who received VZIG on the day of exposure to varicella. Neither VZIG prophylaxis nor treatment with intravenous acyclovir offers complete protection against severe varicella infection to immunosuppressed children who have received organ transplants. A high priority should be given to the evaluation of alternative treatments, such as vaccination to the varicella virus, which could be administered to susceptible transplant candidates, preferably prior to transplantation.
Postneonatal Vitamin B6-Dependent Epilepsy
Authors: COKER STEVEN B.
Published: December 2021

Vitamin B6 acts as coenzyme in decarboxylation and transamination of amino acids. Pyridoxal phosphate is the coenzyme for a glutamic decarboxylase and γ-aminobutyric acid transaminase, enzymes necessary in production and metabolism of brain γ-aminobutyric acid. Vitamin B6 deficiency has been known to produce peripheral neuritis, dermatitis, anemia, and convulsions in infants.1 Administration of isonicotinic acid hydrazide may produce a vitamin B6-responsive neuropathy. Convulsions from vitamin B6 dependency occur despite normal vitamin B6 levels. These seizures, according to pediatric and neurological texts, occur immediately after birth up to 6 months.1-4

In 1985, Goutieres and Aicardi5 described three patients with atypical pyridoxine-dependent seizures with onset at 7 weeks, 5 days, and 4 months.
Attitudes of Expectant Fathers Regarding Breast-Feeding
Authors: Freed Gary L. , Fraley J. Kennard , Schanler Richard J.
Published: December 2021

Fathers participate in choosing the feeding method for their newborns. However they traditionally have not been included in most breast-feeding education programs. To examine expectant fathers' attitudes and knowledge regarding breast-feeding, we surveyed 268 men during the first session of their Childbirth education classes at five private hospitals in Houston, Texas. The study population was 81% white, 8% black, and 6% hispanic. Ninety-seven percent (n = 259) of the total were married. Fifty-eight percent (n = 156) reported that their spouses planned to breast-feed exclusively; several signficant differences existed between these men and those who reported plans for exclusive formula feeding. The breast-feeding group was more likely to believe breast-feeding is better for the baby (96% vs 62%; P < .0001), helps with infant bonding (92% vs 53%; P < .0001), and protects the infant from disease (79% vs 47% P < .001). The breast-feeding group was also more likely to want their partner to breast-feed (90% vs 13%; P < .0001) and to have respect for breast-feeding women (57% vs 16%; P < .0001). Conversely, those in the formula feeding group were more likely to think breast-feeding is bad for breasts (52% vs 22%; P < .01), makes breasts ugly (44% vs 23%; P < .05), and interferes with sex (72% vs 24%; P < .0001). The majority of both groups indicated breast-feeding was not acceptable in public (breast-feeding = 71%, formula feeding = 78%, P < .05). These data demonstrate misperceptions and a lack of education regarding breast-feeding in the formula feeding group and a lack of public acceptance in both groups. We conclude that fathers must be included in breast-feeding education programs. Confrontation of myths and misperceptions prenatally may help to overcome obstacles to the initiation of breast-feeding and to provide greater familial support for nursing mothers.
Treatment With Interferon Gamma Versus Interferons Alfa and Gamma in Children With Chronic Hepatitis B
Authors: Ruiz-Moreno Mercedes , Rúa Maria Jose , Moraleda Gloria , Guardia Leonor , Moreno Alberto , Carreño Vicente
Published: December 2021

Thirty-five children with chronic hepatitis B were randomly assigned to three groups: group 1 (n = 12), untreated group 2 (n = 11), treated with 1 million units of Interferon gamma per square meter of body surface (MU/m2), three times a week for 24 weeks; and group 3 (n = 12), treated with interferon alfa at a dose of 5 MU/m2, three times a week for 12 weeks followed by 1 MU/m2 of interferon gamma with the same schedule. At the end of the treatment (6th month), hepatitis B virus DNA was negative in 16.5% of the control group, in 9% of the children treated with interferon gamma, and in 16.5% of those treated with interferons alfa and gamma. No child had lost the hepatitis B e antigen by this time. No basal differences in the serum hepatitis B virus DNA concentration among the groups were observed. At follow-up (15th month), viral genome was negative in 25% of the untreated children, in 36% of the group treated with interferon gamma, and in 41.5% of the children who had received interferons alfa and gamma. Hepatitis B e antigen was negative in 25% of the children who belonged to groups 1 and 3 and in 27% of the children treated with interferon gamma only. These data suggest that interferon gamma does not have a powerful antiviral effect on chronic hepatitis B in children. However, it is well tolerated.
Control of Hepatitis B: To Be or Not To Be?
Authors: HALL CAROLINE BREESE , HALSEY NEAL A.
Published: December 2021

The needs of children should not be made to wait.

—John F. Kennedy, 1963

The recent recommendations of the American Academy of Pediatrics (AAP) Committee on Infectious Diseases and the Immunization Practices Advisory Committee of the Centers for Disease Control to immunize all infants against hepatitis B virus (HBV) infection have engendered concerns and questions which should not eclipse the import and intent of these recommendations.1,2 Behind these statements lay much deliberation and expertise drawn from those in pediatrics, medicine, infectious diseases, and public health. The undeniable conclusions of both committees are that control of HBV infection and its consequences (1) is necessary, (2) requires a new approach, and (3) must include universal infant immunization and should include immunization of adolescents whenever resources permit.
Managed Care
Authors: CARTLAND JENIFER D. C. , YUDKOWSKY BETH K.
Published: December 2021

In Reply.—

Doctors Sapin and Laws raise fundamental concerns about our article that was recently published in Pediatrics.1 We feel that these concerns are addressed adequately in the paper, but we would like to take this opportunity to clarify our findings.

Dr Sapin argues that our study characterizes all managed care plans, such as the Kaiser Permanente Medical Care Program in which he practices, as having ineffective referral mechanisms. He holds that pediatricians at Kaiser experience "no barriers to appropriate referrals" and indicates that we did not stress this finding adequately.
Managed Care
Authors: ROBBINS KENNETH M.
Published: December 2021

To the Editor.—

At a time when many of us are trying to understand and evaluate the effects of the influence of managed care on medical practice, it was with significant dismay that I read the unscientific, anecdotal, and frankly inflammatory report that formed the second article in the February 1992 issue of Pediatrics.1

The article, based solely on a self-reporting physician survey, conduded that some managed care patients were denied benefits for some referrals and admissions (surprise!—that is what managed care is expected to do) and that some doctors didn't like having their decisions questioned (also no surprise).
Physicians' Interactions with Pharmaceutical Companies
Authors: PROCOPIO LAWRENCE
Published: December 2021

To the Editor.—

I was pleased to see Dr Margolis' article1 on the ethics of physician interactions with pharmaceutical companies that appeared in the December 1991 issue of Pediatrics. I applaud the author for making such a clear statement of his opinion. It is not often easy for physicians to escape the conflicts of interest which are, I believe, inherent in our fee-for-service system.

For my part, I often have conflicting thoughts about the ethics of accepting samples of medication from pharmaceutical company representatives.
Recognizing the Identifiers of Child Abuse as a Syndrome
Authors: RENZULLI FRANCESCO , CARDI ETTORE
Published: December 2021

To the Editor.—

This July marked the thirtieth anniversary of the well-known paper by Kempe et al,1 "The Battered Child Syndrome," which described two infants with traumatic lesions, malnutrition, and poor hygiene.

We wish to draw attention to the fact that, simultaneously, in 1962, Rezza and De Caro,2 two Italian pediatricians, reported the case of an infant with inflicted physical injuries and malnutrition. Furthermore, the authors found that the infant had marked mental retardation, which regressed to a great extent in the course of a lengthy hospitalization.
New Federal Policy for Children With Special Health Care Needs: Implications for Pediatricians
Authors: Ireys Henry T. , Nelson Richard P.
Published: December 2021

Title V of the Social Security Act of 1935 established the nation's first categorical health care program for children: the Crippled Children's Service. In 1985, federal legislation changed the name of the Crippled Children's Service to the Program for Children With Special Health Care Needs. Four years later, new amendments to Title V dramatically altered the Program's mission. States are now required to spend 30% of the funds from the Maternal and Child Health Services block grant on children with special health care needs and to take specific steps toward improving the service system for these children and their families. The new mandate is the only current foundation of a national health policy for children with special health care needs. The 1989 law substantially broadens the mission of the state programs and explicitly recognizes that all children with a special health care need should have access to an appropriate, community-based system of care monitored by state Children with Special Health Care Needs agencies. In addition, states are now required to conduct needs assessments pertaining to these children, to foster local systems of care, and to ensure a high quality of community-based services. Understanding the implications of the new amendments is essential because pediatricians and other child health care professionals have key roles to play in implementing these new policies.
Parents' Views of Adolescent Health Issues
Authors: Fisher Martin
Published: December 2021

To determine how important the parents of teenagers consider adolescent health issues to be and the kind of involvement they would like from their schools and physicians, a questionnaire was sent to 1090 families with children attending two public high schools in a suburban community. The 438 parents who completed the questionnaire (40% response rate) indicated that their adolescents had a mean age of 16.2 years, 52% were male, 54% were in grades 11 and 12, and 70% received regular care from a pediatrician. Most parents considered substance use, sexuality, mental health issues, nutritional concerns, and general medical issues to be issues requiring attention nationally; many considered these issues to require attention locally; fewer considered these issues to require attention for their teenager's friends; and only some indicated these issues require attention for their own teenagers. More than 95% of respondents said parents should discuss these topics with their teenagers, more than 80% said they themselves did, and more than 85% said they wanted these issues discussed with their adolescents in school. Approximately three quarters of parents said that they would bring their adolescent to their regular doctor for management of these issues, expected that their physician would be comfortable with such care, and wanted their doctor to discuss these issues with their teenagers. Most, however, thought that their teenagers would tell them if they needed help for these problems (including substance use and sexuality-related issues), approximately half believed it would be okay for the doctor to manage these problems confidentially, and fewer than 40% said they would be willing to pay higher fees necessary for the extra time required to manage these issues. Although some of these parents may have underestimated the health care needs of their adolescents, this study indicates that most were interested in having involvement from their physicians and schools and were generally aware of the importance of these issues.
Above and Below the Threshold: Severity of Psychiatric Symptoms and Functional Impairment in a Pediatric Sample
Authors: Costello Elizabeth J. , Shugart Margaret A.
Published: December 2021

Pediatricians are sufficiently concerned about the importance of "subthreshold" mental health problems to have joined in the movement to create a Diagnostic and Statistical Manual of Mental Disorders for the primary care setting (DSM-PC), with the aim of establishing a set of criteria for disorders that do not meet the severity requirements of the American Psychiatric Association's current DSM. An element in the argument for a DSM-PC is that there is a high level of functional impairment and need for treatment in children with mental health problems below the DSM threshold. This was examined in 789 children aged 7 through 11 recruited sequentially from the pediatric clinics of a health maintenance organization, compared with 134 age-matched children seen in a psychiatric clinic. Of the pediatric patients, 22% had one or more clinical-level DSM-III diagnoses, and 42% had a threshold-level disorder, compared with 65% and 34%, respectively, of psychiatric patients. In the pediatric sample, most threshold, and all clinical-level disruptive behavior disorders were associated with significant levels of functional impairment. There was little evidence that emotional disorders (anxiety and depression), even at the clinical level, were associated with significant impairment. One implication of these results is that pediatricians can expect one child in five to have a clinical-level DSM disorder. A second is that intervention at low levels of disruptive behavioral symptomatology may be needed if significant functional impairment is to be avoided.
Microwave Heating of Infant Formula: A Dilemma Resolved
Authors: Sigman-Grant Madeleine , Bush Gloria , Anantheswaran Ramaswamy
Published: December 2021

Microwave heating of infant formula is a common practice despite concerns of infant scalding. Beyond the issue of physical safety, little is known about the effects on nutrient content of microwave heating of infant formula. Casein-predominant infant formula in 120- and 240-mL glass and plastic nursing bottles of varying colors were heated for 40 seconds and 60 seconds, respectively. Temperature profiling was monitored during the heating cycle. Analysis of riboflavin and vitamin C was made prior to and after heating. Topmost portions reached a mean temperature of 44.7 ± 1.7°C and 43.0 ± 2.4°C for all types of 240-mL and 120-mL bottles, respectively. Topmost temperatures were significantly hotter than temperatures reached at other sites. Routine mixing resulted in formula temperatures which could safely be fed to infants (35.4 ± 0.3°C and 33.9 ± 0.2°C for 240-mL and 120-mL bottles, respectively). There was no significant loss of either riboflavin or vitamin C. Protocols for microwave heating are given.
Growth and Development of Children Conceived by In Vitro Fertilization
Authors: Brandes Joseph M. , Itzkovits Joseph , Scher Anat , Sarid Miriam , Thaler Israel , Gershoni-Baruch Ruth
Published: December 2021

To assess the physical and mental development of infants born after in vitro fertilization (IVF), we performed a general physical and developmental examination (Bayley and Stanford-Binet scales) on a cohort of 116 IVF children, conceived and born at our institution between February 1985 and March 1989, and on 116 non-IVF matched controls. Study and control groups were each composed of 66 singletons, 19 pairs of twins and 4 sets of triplets, whose age at examination ranged from 12 to 45 months. The developmental indices of IVF infants were within the normal range and did not differ from those of their matched controls. The indices were positively correlated to gestational age, birth weight, head circumference at birth and at examination, and mother's education. Mean birth weight, gestational age, and birth weight percentile of IVF infants were lower than the mean of the healthy population. Mean percentiles of weight and length at examination (mean age 22.4 months) were equally low but did not differ from those of the matched controls. However, mean percentiles of head circumference at birth and at examination compare well with the normal mean, both in IVF and control groups. Twins and triplets (IVF and controls) had significantly lower physical and mental indices as compared to singletons.
Screening for Fungal Endophthalmitis in Children at Risk
Authors: Enzenauer Robert W. , Levin Alex V. , Elder James E. , Morin J. Donald , Calderwood Stan
Published: December 2021

To evaluate the efficacy of screening ophthalmologic examinations in high-risk children, we reviewed the medical records for all patients hospitalized from 1985 through 1989 at The Hospital for Sick Children, Toronto, Ontario, who underwent ophthalmological consultation to rule out endogenous fungal endophthalmitis (n = 176). The patients were divided into groups: Group 1 (n = 47), those with deep-tissue fungal infection, and Group 2 (n = 129), those at risk for invasive fungal disease. Group 2 was subdivided further into two subgroups: Group 2a (n = 48), those with evidence of superficial fungal colonization (positive fungal culture) but no deep-tissue involvement, and Group 2b (n = 81), those with no evidence of fungal colonization (negative fungal culture). Of these 176 patients, 7 were diagnosed with endogenous fungal endophthalmitis: 6 from Group 1, 1 from Group 2a, and 0 from Group 2b. We found a significant association between the development of endogenous fungal endophthalmitis and the status of the fungal culture result (P < .005). The odds ratio indicated the risk of endogenous fungal endophthalmitis in Group 1 patients with deep-tissue infection was at least 19 times that of Group 2 at-risk patients. The risk of endogenous fungal endophthalmitis in Group 1 patients was at least 7 times that of Group 2a colonized patients and 12 times that of Group 2b patients with no positive fungal culture. Our study confirms the necessity of careful dilated ophthalmoscopic examination in patients with invasive fungal disease and suggests screening for those at-risk patients with superficial fungal colonization. Our results, however, do not document the value of routine ophthalmoscopic consultation in at-risk children without evidence of any fungal colonization.
Smooth Muscle Tumors in Children With Human Immunodeficiency Virus Infection
Authors: MUELLER BRIGITTA U. , BUTLER KARINA M. , HIGHAM M. COLLEEN , HUSSON ROBERT N. , MONTRELLA KAREN A. , PIZZO PHILIP A. , FEUERSTEIN IRWIN M. , MANJUNATH KALLANNA
Published: December 2021

Neoplastic disease is an increasing problem in adults with the acquired immunodeficiency syndrome (AIDS). Kaposi's sarcoma is the indicator disease in 9% and lymphoma in 3% of adult AIDS cases.1 Indeed, the estimated incidence rate of non-Hodgkin's lymphomas (NHLs) reaches almost 50% in adult patients who have survived for up to 3 years while receiving antiretroviral therapy and who have a CD4 count below 50 cells/mm3.2 Children with human immunodeficiency virus (HIV) infection have also been treated and followed up for an extended period of time, but a similar increase in the incidence of malignancies has not yet been described. Through December 1990, only 17 children with NHL and 1 child with Kaposi's sarcoma as AIDS-indicator disease have been reported to the Centers of Disease Control.1
Elevated Cord Human Chorionic Gonadotropin in Leprechaunism
Authors: SOLOMON ABBY L. , SHALWITZ ROBERT A.
Published: December 2021

Many of the distinguishing features of leprechaunism (Donohue's syndrome) suggest abnormalities of endocrine regulation. Prominent genitalia, rugation of the labioscrotal folds, polycystic ovaries, and precocious puberty are associated with leprechaunism,1 and these characteristics indicate possible pathology in the hypothalamic-pituitary-gonadal axis. In the few reported cases of leprechaunism in which this area has been evaluated, no consistent biochemical abnormalities have emerged. A review by Elders et al1 describes three cases in which baseline gonadotropin levels were normal, and gonadotropin-releasing hormone response in the one patient tested was normal.1 Szilagyi et al, however, reported a single case in which baseline luteinizing hormone was extremely elevated (385 mIU/mL) and did not respond to luteinizing hormone-releasing hormone, whereas baseline follicle-stimulating hormone was slightly elevated (13.0 mIU/mL) and had an exaggerated response to luteinizing hormone-releasing hormone.2
Meconium and Tracheal Aspiration
Authors: BULL DALE H. , SOLA AUGUSTO , WAKELEY ANN
Published: December 2021

To the Editor.—

We share the concerns of Wiswell and Henley1 that the adoption of a selective approach to the management of meconium-stained newborns is premature and may increase the risk of such infants for serious sequelae of meconium aspiration syndrome (MAS). Their analysis was motivated by a recent proposal that delivery room intubation and suctioning of meconium-stained newborns be reserved for those neonates who are depressed and require positive-pressure ventilation.2 We acknowledge that the data presented by Wiswell and Henley are limited by their retrospective design, but nevertheless, we wish to point out one result contained in their review that was neither emphasized nor discussed.
Subspecialization Within Pediatric Practice: A Broader Spectrum
Authors: McCrindle Brian W. , Starfield Barbara , DeAngelis Catherine
Published: December 2021

This study was undertaken to describe subspecialty characteristics and practices of the population of pediatricians given the ongoing controversy regarding a projected manpower oversupply of general pediatricians. A questionnaire was mailed to a national random sample of 1620 United States physicians listed in the American Medical Association's Pysician Masterfile as being in office-based pediatric practice. The final response rate was 63%. Seventy percent of respondents designated their practices as "general pediatrics" versus 17% as "general pediatrics with a specific subspecialty interest" and 13% as "subspecialty practice." The general pediatricians with a specific subspecialty interest were intermediate in the proportion that had some training in a pediatric fellowship program (general pediatricians with a specific subspecialty interest, 63% versus general pediatricians, 14%, P < .0001, and pediatricians with a subspecialty practice, 92%, P < .0001) and that were certified in a pediatric subspecialty by the American Board of Pediatrics (general pediatricians with a specific subspecialty interest 16% versus general pediatricians, 2%, P < .0001, and pediatricians with subspecialty practice, 62%, P < .0001). They were also intermediate in the proportion involved in various academic pursuits. Their practices, however, more closely resembled general pediatricians than pediatricians with a subspeciality practice in their location, setting, associates, and commitment to primary care. They were more likely than general pediatricians to utilize or provide specialized tests or procedures. A large percentage of pediatricians incorporate subspecilaty elements into their general pediatric practices. Models of current and projected pediatric manpower supply need to be reassessed in light of this form of practice.
Value of Selective Pancreatic Angiography in the Evaluation of Hyperinsulinemic Hypoglycemia in Infancy
Authors: DODEK ANTON B. , SADEGHI-NEJAD AB
Published: December 2021

Transient hyperinsulinemic hypoglycemia of the newborn is relatively common and is seen frequently in infants of diabetic mothers.1 Erythroblastosis fetalis and Beckwith-Wiedemann syndrome are less common causes.2 By contrast, persistent hyperinsulinism is an uncommon cause of hypoglycemia in this age group.2 This form of hyperinsulinemia is often caused by nesidioblastosis, a diffuse disorder of the pancreas resulting from transformation of the pancreatic ductal tissue into insulin-producing islet cells, or rarely by an islet cell adenoma, a localized proliferation of the islets of Langerhans.2,3 In one review of 160 hyperinsulinemic infants, four adenomas were reported.4 Because an islet cell adenoma may be very small, attempts at diagnosis and localization by non-invasive techniques such as ultrasonography, computer tomography, and magnetic resonance imaging have usually been unsuccessful.
Carnation Marketing Practices
Authors: OSKI FRANK A.
Published: December 2021

In Reply.—

Congratulations. It is the first right thing Carnation Nutritional Products has done in this whole sorry affair.
Behavior Management of Pediatric Dental Patients
Authors:   AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON CHILD ABUSE AND NEGLECT, 1991 TO 1992, Krugman Richard D. , Bays Jan , Chadwick David L. , Levitt Carolyn J. , McHugh Margaret T. , Whitworth J. M.
Published: December 2021

To the Editor.—

It has been brought to the attention of The American Academy of Pediatric Committee on Child Abuse and Neglect that some dentists continue to use the hand-over-mouth technique with airway restriction (HOMAR) for behavioral management of pediatric patients. We have received two case reports of children who were adversely affected by this technique. One was left with bruises and petechiae and the other lost consciousness and bladder control.

The original literature on the hand over mouth (HOM) technique is alarming as it indicates that "once in a great while a patient's nostrils can be closed until he really needs air, as indicated by his color" and that 19 of 35 pediatric dentists surveyed in 1969 "felt it is permissible to completely close off a child's airway in special circumstances."
Naftifine (Naftin) in Pediatrics
Authors: RABINOWITZ LINDA G. , ESTERLY NANCY B.
Published: December 2021

To the Editor.—

We recently examined two children with tinea corporis who were unresponsive to naftifine therapy. Fungal cultures grew Trichophyton tonsurans and their clinical lesions subsequently cleared with clotrimazole. This experience and the presence of naftifine advertisements in Pediatrics (March 1992) prompted us to share information regarding this medication with fellow pediatricians.

Naftifine hydrochloride (Naftin) 1% cream, an allylamine antifungal agent, the first of its kind available in the United States, has been reported to be highly effective in the treatment of tinea pedis, tinea cruris, and tinea corporis.
Lupus Nephritis Study—Questions
Authors: RABINOVICH C. EGLA , COLBERT ROBERT A. , KREDICH DEBORAH W.
Published: December 2021

To the Editor.—

We read with great interest the article entitled "Lupus Nephritis: Prognostic Factors in Children" by McCurdy et al.1 The authors examined multiple factors as possible prognostic indicators of eventual tual renal failure in 90 children with lupus nephritis. This represents a large cohort of patients with pediatric lupus nephritis and the authors should be commended on their efforts. However, we feel it is important to point out some shortcomings of this study.

The patients initially were seen between 1970 and 1983.
Birth Asphyxia Alters Neonatal Intestinal Motility in Term Neonates
Authors: Berseth Carol Lynn , McCoy Hila Helen
Published: December 2021

As an extension of an earlier study showing that manometry can identify preterm newborns at risk for feeding intolerance, the authors investigated whether abnormalities of intestinal motor activity underlie the feeding intolerance seen in asphyxiated newborns. Low-compliance perfusion manometry was recorded within the first postnatal week in 25 term neonates admitted consecutively for respiratory diseases. Eleven of these neonates were identified to have experienced birth asphyxia because three concurrent features were present: 1-minute Apgar score of less than 2; 5-minute Apgar score of less than 4; and recurrent seizures within the first 48 postnatal hours. The remaining 14 neonates, who did not have any of these three characteristics, were considered to be nonasphyxiated control neonates. Motor activity differed in nonasphyxiated and asphyxiated neonates during fasting and feeding. During fasting, asphyxiated neonates had less migrating activity than nonasphyxiated neonates. In addition, episodes of motor quiescence and clustered phasic activity were less well organized in asphyxiated neonates. Both groups of neonates displayed a change in motor activity in response to a feeding infusion; however, the response was initiated significantly sooner in asphyxiated than in control neonates. All of the 11 asphyxiated neonates were intolerant of enteral feedings during the first poststudy week, but no control neonate was feeding intolerant. Six of the asphyxiated neonates were reevaluated 1 to 2 weeks later. During this latter study, motor activity in these asphyxiated neonates was similar to that of nonasphyxiated neonates; 5 of 6 of these neonates subsequently tolerated enteral feedings. It is speculated that changes in motor activity underlie the feeding intolerance that asphyxiated neonates typically exhibit. Furthermore, manometrics may provide a direct method to monitor functional responsiveness of the intestinal tract to identify those neonates at risk for feeding intolerance and to guide feeding management in these neonates.
Impact of a Matched Term Control Group on Interpretation of Developmental Performance in Preterm Infants
Authors: Gross Steven J. , Slagle Terri A. , D'Eugenio Diane B. , Mettelman Barbara B.
Published: December 2021

One hundred twenty-four children who were born at 24 to 31 weeks' gestation and 124 term children matched in social background underwent serial developmental evaluations. The Bayley Mental Developmental Index at 6, 15, and 24 months and the McCarthy General Cognitive Index at 4 years were used to classify cognitive outcome for preterm children as normal (indices higher than 1 SD below the mean), mild-moderately delayed (indices between 1 and 2 SD below the mean), or severely delayed (indices ≥2 SD below the mean). Classifications based on norms derived from the performance of the term control group were compared with those based on published standardized test scores. The control group had substantially higher mean (±SD) Bayley Mental Developmental Indices at 6 (111 ± 11), 15 (114 ± 13), and 24 months (115 ± 21) than the published test mean (100 ± 16). Consequently, significantly more preterm children were classified as normal when the Bayley test mean was used than when the performance of the control group was used to define the normal range (84% vs 52% at 6 months, 82% vs 49% at 15 months, and 70% vs 47% at 24 months). Severe cognitive delays were infrequent when defined by test mean (6% to 11%) but two to three times greater when the control group scores were used. In contrast, the control group had a mean McCarthy General Cognitive Index at 4 years (102 ± 14) that was similar to the published test mean (100 ± 16). Thus, while the preterm group demonstrated a small decrease in mean cognitive scores between 2 and 4 years (Mental Developmental Index, 95 ± 19 and General Cognitive Index, 92 ± 15), this represented a significant improvement in performance relative to the 13-point fall in mean scores in the control group over this same period (115 ± 21 to 102 ± 14). These data highlight the importance of a control group to provide normative data for current populations of children and to provide a reference for comparing outcome over time using different testing instruments in the evaluation of high-risk children.
Delayed Recognition of Human Immunodeficiency Virus Infection in Preadolescent Children
Authors: Persaud Deborah , Chandwani Sulachni , Rigaud Mona , Leibovitz Eugene , Kaul Aditya , Lawrence Robert , Pollack Henry , DiJohn David , Krasinski Keith , Borkowsky William
Published: December 2021

Thirty-two (18%) of 181 children cared for at our institution who were infected with the human immunodeficiency virus type 1 (HIV-1) were first seen, and HIV was diagnosed, when they were 4 years of age and older. Initial complaints or diagnoses for these children included the following: hematologic disorders (5) (3 idiopathic thrombocytopenic purpura, 1 neutropenia, 1 anemia); recurrent bacterial infections (10); Pneumocystis carinii pneumonia (3); developmental delay (1); skin disorders (2) (1 genital wart, 1 chronic zoster); weight loss (3); malignancy (1); and nephropathy (1). Eight children were referred for evaluation because of maternal HIV-1 infection. The risk factors for HIV-1 infection included maternal/perinatal exposure (22), perinatal blood transfusion (6), blood transfusion during infancy (2), and sexual abuse (2). Ten (31%) of the 32 children have subsequently died. The longest survival from perinatal infection was 12 years. HIV-1 infection in children can result in a prolonged clinical latency and can masquerade as other pathologic conditions. The absence of clinical symptoms in older children at risk for HIV-1 infection should not deter HIV testing.
Kernicterus in Preterm Infants; Lest We Forget (To Turn on the Lights)
Authors: IVES N. KEVIN
Published: December 2021

Watchko and Oski have a reputation for stimulating debate on the topic of neonatal jaundice. As scriptwriters of "Vigintiphobia: a one-act play,"1 they questioned the `standard practice' applied to the management of jaundice in otherwise healthy term infants. In the current issue of Pediatrics2 they again court controversy by turning their attention to treatment thresholds and the risk of kernicterus in jaundiced preterm infants.

We are provided with a thoroughly researched historical review of the risk of kernicterus in the preterm infant from 1950 to the 1990s. The story is presented as a journey of experience from the pre-intensive care era, through the so-called `low bilirubin kernicterus era' (1965 through 1982), to the present.
Single Daily Bottle Use in the Early Weeks Postpartum and Breast-Feeding Outcomes
Authors: Cronenwett Linda , Stukel Therese , Kearney Margaret , Barrett Jane , Covington Chandice , Del Monte Kristen , Reinhardt Robert , Rippe Laurie
Published: December 2021

A prospective study of breast-feeding mothers was undertaken to determine the effects of limited bottle use and infant temperament on breast-feeding outcomes. White, married, primigravida women who were committed prenatally to breast-feeding for at least 6 weeks (n = 121) were randomly assigned to one of two groups: a planned bottle group that would offer one bottle daily between the second and sixth weeks postpartum and a total breast-feeding group that would avoid bottles during the same period. Group assignment had no effect on the occurrence of breast-feeding problems, on mothers' achievement of 90% of their prenatal breast-feeding duration goals, or on weeks to weaning across the study period. At 6 months postpartum, 59% of the planned bottle group and 69% of the total breast-feeding group were still breast-feeding. No main or interactive effects of infant temperament on breast-feeding outcomes were found.
Gastric Juice, Drugs, and End-Tidal Carbon Dioxide Detectors
Authors: BHENDE MANANDA S. , THOMPSON ANN E.
Published: December 2021

To the Editor.—

Since publishing our article "Utility of an End-Tidal Carbon Dioxide Detector During Stabilization and Transport of Critically Ill Children (Pediatrics. 1992;89:1042-1044), it has been brought to our attention,1 and we also have observed that contamination of the end-tidal CO2 detector with gastric acid causes permanent yellow discoloration of the detector. The same is true of direct contact of the detector with resuscitation drugs (epinephrine, atropine, lidocaine).1 Such discoloration has not been observed with deep intratracheal drug administration.2,3
Money Alone Won't Do It
Authors: MILLER C. ARDEN
Published: December 2021

In Reply.—

Dr David Copeland rightfully emphasizes that family-oriented social supports and interventions, necessary and beneficial as they may be, are unlikely to compensate fully for the social dysfunction that results from unwanted childbearing. Approximately 12% of childbearing in the US is unwanted, about every eighth newborn. Another 27% of births are mistimed, wanted but not just now.1 The trend in unwanted childbearing has moved upward by about 29% since 1982. This is the same period when public funding of contraceptive services was diminished by one-third and when access to abortion was constrained.2
Lack of Money—Barrier to Immunization
Authors: ANDERSON RON J.
Published: December 2021

In Reply.—

I reviewed the letter from Drs Zimmerman, Giebink, and Street concerning our article authored by Shulte et al (Pediatrics. 1991;87:204-207) which studied patterns of referral for immunization in Dallas County, Texas. We believe their comments are insightful and agree that financial barriers are a major reason that these children are referred. Their experience documents a financial gradient from the uninsured to the Medicaid to the fully insured population as concerns treatment or referral decisions from primary care physicians.
Lead Ingestion and X-rays
Authors: MATTE THOMAS D. , BINDER SUE , McELVAINE MICHAEL D. , COPLEY CHARLES C. , DE UNGRIA ESTILITA G.
Published: December 2021

In Reply.—

We agree with Dr O'Connor's assertion that radiopaque foreign bodies seen on abdominal radiographs of children with pica are not necessarily leaded paint chips. However, we consider it reasonable to infer that essentially all of the densities noted in the lead-poisoned children whose records we reviewed were, in fact, leaded paint chips.1 For the great majority of lead-poisoned children in St. Louis, deteriorated leaded paint is found in their primary residence or in other residences the children frequent.
Is the Denver II Developmental Test Worthwhile?
Authors: ADESMAN ANDREW R.
Published: December 2021

To the Editor.—

The recent study by Glascoe et al1 assessing the accuracy of the Denver II is undoubtedly the first of many which will look at the clinical utility of this new, unvalidated developmental screening instrument. I am writing to express concerns about the methodology of this study and, more importantly, to express caution regarding use of the Denver II as a screening test prior to its validation.

Glascoe et al examined the accuracy of the Denver II using several different approaches to test interpretation and found that it generally led to overreferral.