bluuebunny/crossref_metadata_2025 huggingface dataset:
Physician Communication with Children and Parents
Authors: Pantell Robert H. , Stewart Thomas J. , Dias James K. , Wells Patricia , Ross A. William
Published: December 2021

The way physicians communicate with patients has been shown to affect physiologic measurements, adherence to therapeutic regimens, and satisfaction with medical care. The purpose of this study was to document the content of medical interviews in routine pediatric visits and to identify demographic and situational characteristics that influenced the extent of communication between doctor and child. One hundred fifteen office visits to 49 physicians were videotaped and analyzed. Children studied were 4 to 14 years old with a mean age of 8.5 years. Verbal transactions were coded according to direction of communication, transaction type, and content category. Coder reliability for this system was 0.84. A considerable amount of the total communication, 45.5%, was between doctor and child. Doctors interacted differently with parents and children. More information about the current problem was obtained from children; physicians provided feedback primarily to parents. Parents received 4.4 times as much information as children about the nature and prognosis of a condition. The extent to which doctors talked to children in "substantive" areas was primarily associated with a child's age (r = .52, P < .001) but was partly influenced by family size (r = .20, P < .05) and family utilization (r = .22, P < .02). Race, socioeconomic status, type of problem, and previous encounter with the examining physician did not alter communication patterns. Boys were given more information than girls (6.5% vs 4.0%, P < .01). We suggest a theoretical framework for future investigation and teaching that identifies the child as an active participant in the medical process.
Cancer in Neonates: The Experience at The Children's Hospital of Philadelphia
Authors: Gale Gordon B. , D'Angio Giulio J. , Uri Antonia , Chatten Jane , Koop C. Everett
Published: December 2021

Among 22 neonates treated at the Children's Cancer Research Center of Philadelphia, 11 had neuroblastoma, which in two cases was widely metastatic. There were three infants with teratoma, three with sarcoma, three with leukemia, one with Wilms' tumor, and one with parotid carcinoma. Nine of eleven patients (82%) are long-term survivors following complete surgical excision of tumor, whereas only one of eight (13%) has survived following incomplete surgical excision. All three neonates with leukemia died. The overall two-year actuarial survival is 45% (10/22). The problems associated with treating neonates with chemotherapy, radiation therapy, or both are especially difficult because of the immaturity of the organs and structures. Surgical excision alone has been the treatment of choice for solid tumors. Chemotherapy or radiation therapy, when indicated, require careful monitoring for both acute toxicities and potential long-term morbidities.
Hyperphenylalaninemia Due to Dihydropteridine Reductase Deficiency: Diagnosis by Enzyme Assays on Dried Blood Spots
Authors: Arai Nobuhiro , Narisawa Kuniaki , Hayakawa Hiroshi , Tada Keiya
Published: December 2021

Enzymatic diagnosis of hyperphenylalaninemia due to a deficiency of dihydropteridine reductase (DHPR) has previously been made by assay on liver biopsy samples, cultured skin fibroblasts, cultured lymphoid cell lines, or peripheral leukocytes. These procedures have some disadvantages for the purpose of early diagnosis of the disease. A simple method of DHPR assay using erythrocytes or dried blood spots on filter papers is described. The mean DHPR activity erythrocytes of control subjects was 3.20 ± 0.70 (SD) nmoles/min/mg of hemoglobin, those of two patients were undetectable, and those of obligate heterozygotes for DHPR deficiency were approximately 50% of the mean control value. The assay on erythrocytes required only a 5-µl volume of whole blood for one test. The DHPR activities in dried blood spots on filter papers from 100 normal newborns were 5.77 ± 1.16 nmoles/min per 5-mm diameter disc; those from normal older infants, children, and adults were 3.37 ± 0.72 nmoles/min per disc; and those from two adolescent patients with DHPR deficiency were undetectable. No false-positive results were obtained. The stability of DHPR in dried blood on filter papers was enough to mail samples in an ordinary form to a specialist laboratory. The DHPR assay on erythrocytes of dried blood spots can be easily applied to all newborn infants with hyperphenylalaninemia detected using the Guthrie tests, and will facilitate the quick and confirmative detection of DHPR deficiency among them.
Eikenella corrodens Osteomyelitis
Authors: Polin Kenneth , Shulman Stanford T.
Published: December 2021

A 9-year-old boy developed osteomyelitis of the calcaneus following a puncture wound by a toothpick. Culture of the bone yielded a pure culture of Eikenella corrodens, an organism that is normally found in oral secretions. Recovery was complete following incision and drainage and antibiotic treatment with penicillins.
Percutaneous Insertion of Silastic Central Venous Catheters in Newborn Infants
Authors: Dolcourt Jack L. , Bose Carl L.
Published: December 2021

Percutaneous insertion of a very narrow (0.635-mm outside diameter) Silastic catheter for delivery of central hyperalimentation was performed on infants in the Newborn Intensive Care Center. Insertion of the catheter into the external jugular or basilic vein was successful in 15/17 (88%) infants, including four weighing less than 1,000 gm. Catheters remained in place for 446 patient-days (mean 24.8 ± 15.9 days). Culture-proven infection, thrombophlebitis, or caval obstruction did not occur. Percutaneously placed central Silastic catheters proved to be a safe and effective alternative to surgically placed catheters.
Use of Peripheral Intravenous Cannulas in Premature Infants: A Controlled Study
Authors: Batton Daniel G. , Maisels M. Jeffrey , Appelbaum Peter
Published: December 2021

A randomized, controlled study was done to determine whether a 25-gauge steel needle or a 24-gauge Teflon catheter was preferable for the administration of peripheral intravenous fluids and medications to premature infants. A total of 58 cannulas—28 steel needles and 30 catheters—were used in 34 infants. The needles remained in place for 15.4 ± 13.2 hours (mean ± SD) and the Teflon catheters for 49.5 ± 30.9 hours (mean ± SD). All of the steel needles had to be removed because of infiltration whereas only 17/30 (57%) of the catheters infiltrated. A local inflammatory reaction, which was not related to infection, occurred with 11/30 (37%) of the Teflon catheters. Following removal, Staphylococcus epidermidis was grown from the culture of 1/19 steel needles and 1/25 catheters. In both instances thin organism was thought to be a contaminant. Teflon catheters remain functional three times longer than steel needles with no apparent increase in complications. The use of these catheters, therefore, appears to be the preferred method for administering intravenous fluids to premature infants.
Public Law 94-142: Comments on the Pediatricians' Contribution from an Educator
Authors: Meyen Edward L.
Published: December 2021

Few professionals have as much to contribute to the education of children with handicaps as pediatricians. Certainly, the child's teacher falls heir to instructional responsibility, but the teacher's knowledge of development and learning behavior comes largely from the influence of pediatricians in the child development literature. The teacher is also dependent on the pediatrician to assure that students are healthy and as responsive as possible to instruction. The relationship between the classroom teacher and the pediatrician is often taken for granted. Most classroom teachers relate the role of the pediatrician to education only on those occasions when a student has a special health problem or in reference to scheduled health events, such as immunizations or physical examinations.
Molested Children
Authors: Levy Howard B. , Clauson Cheryl Y.
Published: December 2021

The article by Rimsza and Niggeman (Pediatrics 69:8, 1982) concerning the medical evaluation of sexually abused children was replete with precise, lucid, and well validated information. We were, however, somewhat perplexed by the use of the term "lax rectal tone." Although we can understand the need to access rectal trauma, the subjectivity of such a finding may peril its reliability and validity.

We recently reviewed our experience with sexually molested children at an inner city hospital.
Letter to the Editor
Authors: Weinberger Miles
Published: December 2021

The paper by Kraemer et al1 demonstrated the potential for theophylline toxicity in association with influenza B. This article adds to the previous literature demonstrating increased serum theophylline concentrations during maintenance dosage in association with prolonged febrile illnesses.2,3 The authors recommend appropriately that a serum theophylline measurement be performed when symptoms compatible with theophylline toxicity are observed. I would add to that recommendation the precaution that a subsequent theophylline dose not be given in the presence of nausea, vomiting, or unusual headache even if a serum concentration is not yet known.
Hyperprolactinemia and Delayed Puberty: A Report of Three Cases and Their Response to Therapy
Authors: Patton Mary L. , Woolf P. D.
Published: December 2021

Delayed puberty occurred in three patients (aged 15 to 22 years) with elevated prolactin levels. Despite the varying etiologies, their clinical presentations were marked by absence of galactorrhea, prepubertal genitalia (2/3), and short stature (1/3). Except for hyperprolactinemia, endocrinologic evaluation was normal in two patients. Bromocnptine restored prolactin levels to normal in all three patients, two of whom had prior transsphenoidal surgery, and resulted in initiation of menses in one girl and pubertal development in both boys. The 22-year-old male patient with the empty sella syndrome has progressed through puberty after the addition of oral testosterone.
Effect of Continuous Positive Airway Pressure on the Ventilatory Response to CO2 in Preterm Infants
Authors: Durand Manuel , McCann Ellen , Brady June P.
Published: December 2021

The effect of continuous positive airway pressure (CPAP) on the ventilatory response to CO2 in newborn infants is unknown. The CO2 response to 4% CO2 in air was studied in nine preterm infants without lung disease before and during administration of CPAP (4 to 5 cm H2O) delivered by face mask. Minute ventilation, tidal volume, respiratory frequency, and end-tidal Pco2 were measured, and the slope and intercept of the CO2 response were calculated. Respiratory pattern and changes in oxygenation were also analyzed by measuring inspiratory and expiratory time, mean inspiratory flow, mean expiratory flow, effective respiratory timing, endtidal Po2, and transcutaneous Po2. CPAP significantly decreased minute ventilation from 278.7 to 197.6 mL/mm/kg (P < .001). Tidal volume and respiratory frequency were also significantly decreased. The slope of the CO2 response during CPAP was not significantly different from the slope before CPAP (36 v 33 mL/min/kg/mm Hg, P > .1), but the intercept was shifted to the right (P < .001). The decrease in respiratory frequency was primarily due to a prolongation of expiratory time (P < .05). In addition, transcutaneous Po2 increased during administration of CPAP (P < .001). These findings indicate that: (1) CPAP significantly decreases ventilation in preterm infants without lung disease, affecting both tidal volume and respiratory frequency; (2) CPAP does not appreciably alter the ventilatory response to CO2; (3) the changes in respiratory frequency are primarily accounted for by a prolongation of expiratory time; (4) CPAP improves oxygenation.
Workshop on Effects of Otitis Media on the Child
Authors: Bluestone Charles D. , Klein Jerome O. , Paradise Jack L. , Eichenwald Heinz , Bess Fred H. , Downs Marion P. , Green Morris , Berko-Gleason Jean , Ventry Ira M. , Gray Susan W. , McWilliams Betty Jane , Gates George A.
Published: December 2021

GOALS, DEFINITIONS, AND CLASSIFICATION OF OTITIS MEDIA

—Charles D. Bluestone, MD

The goal of this Workshop was to assess current knowledge concerning the effects of otitis media on the child. Experts in pediatrics, infectious disease, otolaryngology, audiology, speech, linguistics, and psychology met in Chicago on Aug 25, 1982 to participate in this Workshop. A summary of the discussions is presented here. Otitis media is broadly defined as an inflammation of the middle ear without reference to etiology or pathogenesis.1 Otitis media with effusion is an inflammation of the middle ear in which a collection of liquid (i.e., middle ear effusion) is present in the middle ear space (no perforation of the tympanic membrane is present). Atelectasis of the tympanic membrane, which may or may not be associated with otitis media, is defined as either collapse or retraction of the tympanic membrane. Acute otitis media implies a rapid and short onset of signs and symptoms lasting approximately 3 weeks. From 3 weeks to 3 months, the process may be resolving or subacute. If middle ear effusion persists beyond 3 months, the condition is classified as chronic otitis media with effusion. Many terms have been used for acute otitis media, such as "suppurative," "purulent," or "bacterial" otitis media; however, a "serous" effusion may also have an acute onset. Otitis media with effusion unaccompanied by signs and symptoms of acute inflammation has also had a plethora of other names: "serous," "secretory," "nonsuppurative," and "glue ear" have been the most commonly used.

EPIDEMIOLOGY AND NATURAL HISTORY OF OTITIS MEDIA
Kasai Procedure and Vitamin E
Authors: SOKOL RONALD J. , HEUBI JAMES E. , BALISTRERI WILLIAM F.
Published: December 2021

To the Editor.—

The recent article by Burgess et al1 provides practitioners with encouraging data regarding the developmental outcome of children who have undergone the Kasai procedure for treatment of extrahepatic biliary atresia. The overall mean developmental quotient (DQ) was surprisingly normal, although in long-term survivors the DQ was somewhat lower. The gross motor development of these children, however, fell into the low-normal to delayed range after 8 months of age. Long-term survivors were noted to have a "lack of coordination and inaccuracy in performing gross motor tasks."
Obstructive Sleep Apnea and Its Therapy: Clinical and Polysomnographic Manifestations
Authors: Frank Yitzchak , Kravath Richard E. , Pollak Charles P. , Weitzman Elliot D.
Published: December 2021

Obstructive sleep apnea syndrome was studied in 32 children, aged 2 to 14 years, in the sleep-wake disorders center at Montefiore Hospital and Medical Center during the years 1977 to 1980. All children under-went all-night polysomnograms; 17 of these children had surgery to relieve airway obstruction and seven had a repeat polysomnographic study 4 to 6 weeks following the surgery. There was a significant improvement in the number of obstructive apneas and in other apnea indices following surgery. There was no significant effect on the durations and the proportions of the various sleep stages, on sleep efficiency, or on the number of awakenings.
Verapamil: An Effective Calcium Blocking Agent for Pediatric Patients
Authors: Porter Co-burn J. , Garson Arthur , Gillette Paul C.
Published: December 2021

Verapamil is a slow-channel calcium-blocking agent that has been released recently by the Food and Drug Administration for treatment of cardiac dysrhythmias in all age groups. Its primary action is to slow conduction in the atrioventricular node, thereby abolishing those types of supraventricular tachycardia using the atrioventricular node as a part of the reentry circuit or slowing the ventricular rate in someone with atrial flutter. Other investigations have shown that it is likely to relieve left ventricular outflow obstruction in patients with hypertrophic obstructive cardiomyopathy. Because of its potential widespread usefulness in the pediatric population, all pediatricians should be more aware of how it is used and the potential hazards. The methods of administration and treatment of overdoses as well as indications for usage, contraindications, and adverse reactions will be explained.
Long-Term Outcome of Children with Severe Head Trauma and Prolonged Coma
Authors: Mahoney William J. , D'Souza Bernard J. , Haller J. Alex , Rogers Mark C. , Epstein Melvin H. , Freeman John M.
Published: December 2021

Forty-six children with significant head trauma who remained in coma more than 24 hours were the subjects of this long-term outcome study. Twelve (38%) died. The average length of coma in the 34 survivors was 15.5 days. Follow-up ranged from 9 months to 4 years (mean 21 months). Twenty-nine percent of the survivors were normal at follow-up. An additional 53% had mild cognitive or behavioral problems, but 61% of these had evidence of similar problems prior to the injury. Nine percent of survivors had motor residua but normal intellect. Nine percent had severe intellectual and motor problems. Children less than 2 years of age had a worse outcome. Despite severe injury and prolonged coma after head trauma, most children do well. Intensive medical and surgical care increases the rate of survival and does not result in a large number of severely disabled survivors.
Counterimmunoelectrophoresis of Urine for Diagnosis of Bacterial Pneumonia in Pediatric Outpatients
Authors: Turner Ronald B. , Hayden Frederick G. , Hendley J. Owen
Published: December 2021

Thirty-eight pediatric outpatients with pneumonia were studied by counterimmunoelectrophoresis for the presence of Haemophilus influenzae type b or pneumococcal antigenuria. Of the 38 patients eight (21%) hadH influenzae type b antigenuria and two (5%) had pneumococcal antigenuria. H influenzae, type b antigenuria was detected more frequently in patients <2 years of age than in older children. Urine counterimmunoelectrophoriesis appears to be a useful tool for the etiologic diagnosis of bacterial pneumonia and should facilitate further studies of the epidemiology, pathogenesis, and clinical spectrum of this disease.
Increased Risk of Gallstones in Children Receiving Total Parenteral Nutrition
Authors: Roslyn Joel J. , Berquist William E. , Pitt Henry A. , Mann Linda L. , Kangarloo Hooshang , DenBesten Lawrence , Ament Marvin E.
Published: December 2021

Twenty-one children receiving long-term total parenteral nutrition were prospectively evaluated for the presence of gallstones. Using ultrasonography, nine children (43%) were found to have cholelithiasis, and five have since undergone cholecystectomy. Only children with ileal disorders or previous resection developed stones. In the select group of patients with ileal disorders or previous resection, the prevalence of stones was 64%, nearly twice that which has been observed in similarly defined adults not receiving total parenteral nutrition. Data from this study suggest that the prolonged administration of parenteral nutrition significantly enhances the risk of gallstone formation already imposed by a previous ileal resection or disorder. Periodic ultrasonograms provide a safe and accurate means of monitoring high-risk patients during and after prolonged total parenteral nutrition therapy.
Clinical-Echocardiographic Correlations in Acute Rheumatic Fever
Authors: Vardi Pnina , Markiewicz Walter , Weiss Yael , Levi Josef , Benderly Abraham
Published: December 2021

Thirty-three children with acute rheumatic fever were studied using echocardiography to characterize heart involvement in this disease. Among 26 subjects with a first episode of acute rheumatic fever, 18 had a clinical diagnosis of carditis and six had heart failure. Heart failure usually resulted from valvular incompetence rather than from myocardial failure in these patients. Conversely, among seven subjects with recurrent rheumatic fever, five had a clinical diagnosis of carditis and four had heart failure. Severe left ventricular dysfunction noted on echocardiography probably contributed significantly to the appearance of heart failure in two of these four subjects. Ten patients were initially believed not to have carditis: a diagnosis of mitral valvulitis was made in two of these ten on the basis of the results of the echocardiographic examination. Echocardiography, which provides important information on the cardiac status of patients with acute rheumatic fever, may help in assessing the prognosis and may be useful in the therapy of these patients.
Reversible Reduction in Renal Function During Treatment with Captopril
Authors: COLAVITA RICHARD D. , GAUDIO KAREN M. , SIEGEL NORMAN J.
Published: December 2021

Captopril is known to be effective for the control of hypertension in adults.1,2 Several recent reports have described the efficacy of this drug in children3,4 and neonates.5 Side effects include neutropenia, proteinuria, rashes, ageusia, hypotension, and hyperkalemia. Farrow and Wilkinson6 described a case of reversible renal failure during therapy with captopril in a young woman with severe hypertension secondary to renal artery stenosis. However, renal failure is not a well-appreciated side effect of this drug and has not been described previously in a pediatric patient during treatment with captopril. We report two cases in which a reversible decline in renal function occurred in children being treated with captopril.
Decreased Prostacyclin Levels in Sickle Cell Disease
Authors: LONGENECKER GESINA L. , MANKAD VIPUL
Published: December 2021

To the Editor.—

Mehta and Albiol1 recently reported grossly elevated plasma levels of the antiplatelet prostanoid, prostacyclin, in sickle cell disease (SCD), and proposed this as the (a) mechanism whereby platelet function in this disorder suppressed. The latter has been reported by others2 and was confirmed by Mehta and Albiol, but is not a universal finding.3 Our data concerning prostacyclin levels in SCD differ dramatically.4 Using serum derived from whole blood treated with indomethacin (a modification of the method of Patrono et al5 for thromboxane B2), with radioimmunoassay (RIA) (New England Nuclear) for the prostacyclin metabolite, 6-keto-PGF1α, levels (picograms per milliliter) occurred in the order:
Effect of Serum Hyperosmolality on Opening of Blood-Brain Barrier for Bilirubin in Rat Brain
Authors: Bratlid Dag , Cashore William J. , Oh William
Published: December 2021

The effect of hyperosomolality on the blood-brain barrier for bilirubin was studied in rats. Hyperbilirubinemia was induced in the chronically catheterized rat by infusion of bilirubin at a rate of 30 mg/kg/h for three hours. After two hours of bilirubin infusion, three levels of hyperosmolality were induced by bolus of urea at three different doses: 50, 75, and 100 mmol/kg, respectively. The serum osmolality rose from 297 mosm/L in the control group to 345, 383, and 400 mosml/L in the three respective groups. No significant differences were found between the groups in levels of total or free serum bilirubin, serum albumin, blood pH, and blood gases. A significant dose relationship was found in both brain bilirubin and brain albumin content with reference to the serum hyperosmolality. The results indicate that hyperosmolality causes opening of the blood-brain barrier for bilirubin in the rat. It may be speculated that this adverse phenomenon (hyperosmolality) may play a role in the pathogenesis of kernicterus in infants whose serum bilirubin levels are below the range of saturated bilirubin binding capacity.
Is There an Increased Risk of Haemophilus influenzae Septicemia in Children with Sickle Cell Anemia?
Authors: Powars Darleen , Overturf Gary , Turner Ernest
Published: December 2021

The risk of Haemophilus influenzae septicemia/meningitis to children who have sickle cell anemia (SS) has been determined to be greater than that seen among normal infants. Of ten bacteriologically proven cases, eight episodes of infection were observed among 234 children with sickle cell anemia (645 person-years), who were less than 5 years of age. There was one case per 69 infants with sickle cell anemia who were less than 18 months old and one case per 36 children with sickle cell anemia between 19 and 59 months of age. Unexpectedly, two infections occurred among 224 children (824 person-years), aged 5 to 9 years; both died. Contrary to the rapid clinical course of pneumococcal infections in children with sickle cell anemia H influenzae septicemia was regularly heralded by a greater than 24-hour prodrome of upper respiratory tract infection, low-grade fever, and otitis media. Three (30%) preventable deaths occurred. Antibiotic therapy for the febrile child with sickle cell anemia must be predicated on the known 400-fold increased risk of pneumococcal septicemia in those less than 5 years old and the fourfold risk of H influenzae septicemia in those less than 9 years of age.
Elevation of cAMP Levels in Cerebrospinal Fluid of Patients with Neonatal Meningitis
Authors: Lin Ching-Yuang , Ishida Makoto
Published: December 2021

The cyclic 3',5'-adenosine monophosphate (cAMP) concentrations in the cerebrospinal fluid of 20 children with neonatal bacterial meningitis and aseptic meningitis were measured by radioimmunoassay method. The cAMP levels were found to be significantly elevated above control levels (P < .01) during the acute phase in most of the patients. In the convalescent stage the cAMP concentration was decreased but levels remained significantly elevated (P < .01) in patients with complications. During the acute phase, the cAMP levels were higher in neonatal bacterial meningitis than in aseptic meningitis (P < .01). The results suggest that cAMP is a sensitive indicator of transient cellular metabolic disturbance in the brain and may be used to monitor the course of neonatal meningitis.
An Outbreak of Clostridium difficile Necrotizing Enterocolitis: A Case for Oral Vancomycin Therapy?
Authors: Han V. K.M. , Sayed H. , Chance G. W. , Brabyn D. G. , Shaheed W. A.
Published: December 2021

During a 2-month period, 13 infants in this neonatal intensive care unit developed necrotizing enterocolitis, increasing the prevalence in inborns from 5.2 to 20.5/1,000 live births. Fifty-seven perinatal and neonatal factors, many of which have previously been associated with necrotizing enterocolitis, were compared between the infants with necrotizing enterocolitis and 17 unaffected inborn control infants admitted concurrently. Clostridium difficile cytotoxin was detected in the stools of 12 affected infants (92.3%) in comparison with two control infants (11.8%) (P < .001), and the organism was isolated in eight affected neonates (61.5%) compared to none of the control infants (P < .001). The outbreak was terminated upon institution of oral vancomycin therapy in cases and infant contacts, and strict antiinfective measures in the neonatal intensive care unit. This indicates an etiologic role of C difficile in the outbreak. Oral vancomycin in the management of necrotizing enterocolitis was assessed by therapeutic response, drug levels, and occurrence of side effects. Oral vancomycin therapy is indicated in necrotizing enterocolitis outbreaks in units where C difficile is endemic.
Intracranial Tuberculomas in a Child: Computed Tomographic Scan Diagnosis and Nonsurgical Management
Authors: Tyler Beverly , Bennett Harvey , Kim Joon
Published: December 2021

Despite great strides in screening and detection of tuberculosis, urban areas still harbor many children with this disease. The case of a child with probable intracranial tuberculomas who was medically treated with antituberculous therapy and followed with frequent computed tomographic (CT) scans is reported. Despite older textbooks that espouse surgery as the treatment for intracranial tuberculomas, it is suggested that in the era of CT scanning, they should be treated the same as other focal CNS infections. Surgery should be reserved for medical failure or deteriorating conditions.
Temperature, Mitochondria, and Reye's Syndrome
Authors: EL-MALLAKH RIF S.
Published: December 2021

To the Editor.—

Mitochondrial failure, manifest by changes in mitochondrial enzyme activity1-3 and morphology,4-5 is central to Reye's syndrome (RS).6 Although it has been variously hypothesized that the mitochondrial changes are secondary to an exogenous toxin,7-12 or an intrinsic mitochondrial defect,6 the actual cause remains obscure.

Electron microscopic studies have shown sweelling and loss of cristate in mitochondria of patients with RS. It is interesting that very similar changes occur in Trypanosoma cruzi.13-16

T cruzi is an extracellular/intracellular protozoan parasite which causes Chagas' disease.17
The Irresponsible Expert Witness
Authors: CARSTENSEN EARL J.
Published: December 2021

To the Editor.—

I read with great interest Brent's article. "The Irresponsible Expert Witness: A Failure of Biomedical Graduate Education and Professional Accountability (Pediatrics 1982;70:754-762). Although I am not one of the itinerant expert witnesses of low professional calibre, I have been called upon as an expert witness on two separate occasions. This experience, coupled with reflection upon various readings from multidisciplines, evokes an intellectual and emotive fear at the shortcomings of our judicial process.
The Irresponsible Expert Witness
Authors: BRENT ROBERT L.
Published: December 2021

In Reply.—

Many of the points that Turetsky makes are summarized in a paper entitled "Litigation-Produced Pain, Disease and Suffering."1 I can add little to the eloquence of Turetsky and Carstensen, except to point out that one must be able to document concerns and be careful not to air complaints that may be emotional or anecdotal, unless identified as such.

It may be of interest that I received more than 200 personal letters regarding the article on the irresponsible expert witness2; these letters came directly to the Jefferson Medical College and not to the Pediatrics editorial office.
Effect of Frequent Breast-Feeding on Early Milk Production and Infant Weight Gain
Authors: De Carvalho Manoel , Robertson Steven , Friedman Arnold , Klaus Marshall
Published: December 2021

To investigate the effects of frequency and duration of breast-feeding on infants' milk intake and weight gain, two groups of mother-infant pairs were studied during the first month after delivery. Mothers in the control group (n = 24) nursed their infants on a 3- to 4-hour schedule. Those in the experimental group (n = 20) were encouraged to nurse frequently. During the first 14 postpartum days, all mothers recorded the length and time of each breast-feeding. On the 15th and on the 35th postpartum day, milk intake per feeding for 24 hours and infant weight gain from birth were measured. During the first 2 weeks after delivery, mothers in the experimental group nursed more frequently (9.9 v 7.3 feedings per 24 hours; P <.0001). On day 15, their infants took more milk (725 v 502 mL/24 h; P <.0002), and had gained more weight from birth (561 v 347 g; P < .02). On day 35, although mothers in the experimental group were still nursing more frequently (9.8 v 6.8 feedings per 24 hours; P <.01), milk intake and weight gain from birth were not significantly different.
Suctioning in the Preterm Infant: Effects on Cerebral Blood Flow Velocity, Intracranial Pressure, and Arterial Blood Pressure
Authors: Perlman Jeffrey M. , Volpe Joseph J.
Published: December 2021

The relationship of suctioning to changes in the cerebral circulation was studied in 35 premature newborn infants. The objectives of the study were to determine whether important alterations occur in cerebral hemodynamics with suctioning and whether such alterations relate to systemic hemodynamic events. A transcutaneous Doppler technique was used to measure blood flow velocity in the anterior cerebral arteries. A prominent increase in cerebral blood flow velocity was documented in nearly all patients. Accompanying the increase in cerebral flow velocity was a marked increase in blood pressure; thus, the increased cerebral flow velocity appeared to reflect directly changes in systemic hemodynamic events. Also accompanying the increase in cerebral flow velocity was a marked increase in intracranial pressure. These data suggest potentially deleterious effects of suctioning in the preterm infant at risk for the occurrence of intraventricular hemorrhage and raise questions regarding the advisability of routine suctioning of such infants.
Cerebral Infarction Related to Neck Position in an Adolescent
Authors: Hope Ellen E. , Bodensteiner John B. , Barnes Patrick
Published: December 2021

A 16-year-old boy developed a left occipital lobe infarction after falling asleep with his head extended and rotated to the left. He was found to have an anomalous cerebrovascular system, in which the entire blood supply to the left occipital cortex derived from the right vertebral artery. It has been shown that vertebral artery flow can be compromised by physiologic degrees of extension of the neck and rotation of the head to the opposite side. To our knowledge, this is the only reported case of cerebral cortical infarction due to temporary arterial obstruction of the vertebral artery during physiologic hyperextension of the neck and rotation of the head. All previous cases attributed to this mechanism have been brainstem, cerebellar, or cervical spinal cord involvement with thrombosis of the vessel in question. Anomalies of the cerebrobasilar vascular system may place these individuals in jeopardy during otherwise harmless physical activities.
Congenital Hydrocephalus Due to Prenatal Intracranial Hemorrhage
Authors: Jackson J. Craig , Blumhagen Joel D.
Published: December 2021

A 3,400-g female neonate with a large head, widened sutures, and full fontanels at the time of her delivery by cesarean section is described. Imaging with ultrasound and computed tomography at 24 and 36 hours of age showed findings typical of hydrocephalus caused by intraventricular hemorrhage occurring several days or more prior to birth. There was no direct evidence of any predisposing vascular lesion or coagulopathy. Such a phenomenon has not been previously reported.
The Pediatrician's Role in Discipline
Authors:   Committee on Psychosocial Aspects of Child and Family Health
Published: December 2021

With declining availability of extended family to support and advise young parents and with the growing numbers of single-parent families, the pediatrician is increasingly consulted about the behavioral management of children and especially about appropriate discipline. Discipline means "to impart knowledge and skill to" rather than corporal punishment.

The emotionally mature adult is a disciplined person, able to postpone pleasure appropriately, tolerate discomfort when necessary, and be assertive without being hostile. Such abilities are learned over time and the process begins in earliest childhood.

As the human newborn matures physiologically and neurologically and as his care givers gradually impose limits in relation to feeding, toileting, or sleeping, the child's biologic rhythms become more regular and adapt to family routines. Signals of discomfort, such as crying and aimless thrashing of limbs, are modified and abandoned as the infant acquires memories of past relief of distress provided by the environment (parents).

As the infant becomes more mobile, he or she will initiate contacts with the environment; some of the potentially dangerous contacts include electric cords and plugs, peanuts, or valuable bric-abrac. Actions must be taken to protect the infant or toddler: the use of safety plugs or removal of the danger, signals of "No," or physical removal of the child to a "safer" area. Some persistent, active children pose a real discipline challenge to their parents; other children are quite adaptable and "easy." And just as children vary in their behaviors, some parents find it difficult to say "No"; some parents are neglectful; and still others are overly restrictive, controlling, and harsh.
The Transfer of Drugs and Other Chemicals into Human Breast Milk
Authors:   Committee on Drugs
Published: December 2021

In this statement, lists of the pharmacologic agents transferred into human breast milk and their possible effects on the infant or on lactation if known are provided (Tables 1 to 4). The fact that infant but indicates that there are no reports in the literature. These tables should assist the physician in counseling a patient regarding breast-feeding when the patient has a condition for which a drug a pharmacologic agent does not appear on the lists is not meant to imply that it is not transferred into breast milk or that it does not have an effect on the is medically indicated.

These reports have been obtained from a search of the medical literature. Because methodologies used to quantitate drugs in breast milk continue to improve, current information will require continuous updating of the tables. Brand names are listed at the end of the tables in accordance with the 4th Edition AMA Drug Evaluation. The reference list is not inclusive of all articles published.

Physicians who encounter adverse effects in infants fed breast milk due to exposure to drugs that are not included here are urged to document the effects in a communication to the Committee on Drugs of the American Academy of Pediatrics in Evanston. Such communication should include: the generic and brand name of the drug; the maternal dose and mode of administration; the concentration of the drug in breast milk and maternal and infant blood in relation to time of ingestion; the age of the infant; and the method used for laboratory identification.
Changes in Infant Morbidity Associated with Decreases in Neonatal Mortality
Authors: Shapiro Sam , McCormick Marie C. , Starfield Barbara H. , Crawley Barbara
Published: December 2021

Neonatal mortality and morbidity among infants surviving to 1 year of age in eight geographic areas have been compared to determine whether recent decreases in mortality have affected the risk of infants having congenital anomalies or developmental delay. Mortality was obtained from birth and death records in 1976 and either 1978 or 1979; morbidity through home interviews with mothers of random samples of infants and developmental observations on the children. It is concluded that the decrease in mortality was not offset by increases in children with defects. Neonatal mortality decreased by 18% in this 2- to 3-year period; risk of congenital anomalies or developmental delay (all types combined) declined by 16% among the surviving infants. The reduction in risk was concentrated in the minor congenital anomalies or developmental delay category; the proportion of children with severe or moderate congenital anomalies or developmental delay did not change. Decreases occurred at every birth weight including the very low birth weights of 1,500 g or less, a subgroup with especially high mortality and morbidity resulting from perinatal events.
Use of Age Cutoff Policies for Adolescents in Pediatric Practice: Report from the Upper Midwest Regional Physician Survey
Authors: Resnick Michael David
Published: December 2021

Increased pediatric participation in the health and medical care of adolescents has been encouraged over the last several years, both through the redefinition of the age range of pediatric practice by the American Academy of Pediatrics, and by the 1978 Task Force Report on Pediatric Education. Whereas the Task Force Report enunciated a framework for pediatric leadership in adolescent medicine, little is known about the extent to which adolescents are actually included in pediatric practice. Based upon the findings of the 1980-1981 Upper Midwest Regional Physician Survey, the use of age "cutoff" policies for adolescents is explored. The various types of such policies are examined, in addition to reasons for their use and non-use, the characteristics of pediatricians who include and exclude adolescents from their practice, exceptions made to adolescent age limits, differential enforcement by patient and physician gender, and anticipated changes in cutoff policies in light of projected demographic changes for infants, children and youth, and physician supply.
Campylobacter Infection
Authors: SHULMAN STANFORD T. , MOEL DONALD
Published: December 2021

To the Editor.—

Chamovitz et al1 recently reported the occurrence of hemolytic-uremia syndrome with evidence of Campylobacter jejuni infection in both a mother and daughter. Although they indicated that there were no previous reports of the association of this enteric pathogen with hemolytic-uremic syndrome, we must point out the report of Denneberg et al,2 who noted this association in 1982.

In addition, we have recently treated a 22-month-old white girl with classic hemolytic-uremic syndrome who had bloody diarrhea as an early symptom.
A Death in the Family: The Pediatrician's Role
Authors: Brent David A.
Published: December 2021

The loss of a parent or sibling can have a profound effect on the psychosocial development of the surviving child. The pediatrician, by virtue of his or her longitudinal involvement with children, is in a unique position to provide anticipatory guidance for the family in which such a loss has taken place. This article reviews children's cognitive understanding of death, the distinction between normal and pathologic grief, and the impact of the loss of a parent or sibling on the course of family relations and the development of the children involved. Some of the common problems that may be manifest in children subsequent to such a loss, together with appropriate interventions, are outlined. Most situations can be best handled by the pediatrician, but criteria for seeking psychiatric consultation are provided.
Nervous System-Specific Enolase in Serum as a Marker for Neuroblastoma
Authors: Ishiguro Yukio , Kato Kanefusa , Ito Takahiro , Nagaya Masahiro , Yamada Noboru , Sugito Tetsuyuki
Published: December 2021

Serum levels of nervous system-specific enolase (αγ form plus γγ form) were determined in 18 patients with neuroblastoma and in 40 control infants by means of a sandwich enzyme immunoassay method specific to the γ subunit (or 14-3-2 protein) of enolase isozymes. Levels in patients with neuroblastoma were elevated (mean, 70.3; range, 6.2 to 330.0 ng/mL) when compared with those of control subjects (4.3 ± 1.7 ng/mL). Most of the patients (6/7), whose serum nervous system-specific enolase level increased more than 100 ng/mL, died within 1 month. Serial measurements in patients with neuroblastoma receiving various therapies have revealed that there was a good correlation between serum nervous system-specific enolase levels and the course of the disease. These results indicate that the nervous system-specific enolase in serum may be a valuable marker for therapeutic monitoring of patients with neuroblastoma, as reported recently in patients with small-cell carcinoma of the lung.
The Hypermobility Syndrome
Authors: Biro Frank , Gewanter Harry L. , Baum John
Published: December 2021

The hypermobility syndrome has been recognized as a definitive diagnostic entity among children referred to a Pediatric Arthritis Clinic with musculoskeletal complaints. The diagnosis of hypermobility was made by the ability of the patients to perform at least three of the following maneuvers: (1) extension of the wrists and metacarpal phalanges so that the fingers are parallel to the dorsum of the forearm; (2) passive apposition of thumbs to the flexor aspect of the forearm; (3) hyperextension of elbows (≥10 degrees); (4) hyperextension of knees (≥10 degrees); (5) flexion of trunk with knees extended so palms rest on the floor. Of 262 patients, 15 (5.7%) referred to an arthritis clinic between January 1979 and July 1981 were subsequently determined to have hypermobility as the basis for their rheumatic complaints. Three of these 15 had concomitant juvenile arthritis. The presenting complaint of pain was most often localized to the knees, hands, and fingers. Arthritis and elevated ESRs were not seen except in the three patients who had concomitant juvenile arthritis. All patients responded to physicial therapy and nonsteroidal analgesic anti-inflammatory drugs. This is an entity not sufficiently well recognized as a source of musculoskeletal complaints in the United States. It will usually respond well to reassurance and symptomatic therapy.
Reducing the Toll of Injuries in Childhood Requires Support for a Focused Research Effort
Authors:   Committee on Research,   Committee on Accident and Poison Prevention
Published: December 2021

Injury is the leading cause of death and disability in childhood and early adult life. Trauma represents the largest loss of potential years of life1 and burdens the nation with enormous costs in terms of human suffering and disability, lost productivity, and medical services.2 In 1977, deaths from unintentional injuries ("accidents") accounted for nearly half of all deaths of children aged 1 to 14 years.3 Nonfatal, unintentional injuries, which are estimated to outnumber fatalities by 100 to 1,4 frequently result in permanent disability. Fatal inflicted injury (homicide) is a large and growing pediatric problem.5 Nonfatal child abuse and neglect affect more than 500,000 children per year,6 resulting in a progressive burden for its victims and society.

If those who are young are to be protected from life-threatening injury, a quickened pace of progress in injury care and prevention is needed. Efforts to build Emergency Medical Services were begun in the 1970s, but these services are not yet widely developed.2 Advances in other aspects of critical care for the injured have also evolved slowly. In the area of injury prevention, considerable progress has been made in the development of ways to understand and control childhood injury; this is evident by the reductions in certain types of childhood injury. The most notable successes have been the reduction of poisoning and flame burns as causes of death and disability in childhood.7,8 Important theoretic advances have been (1) the elimination of the term "accident," which suggests chaotic and random effects, and its replacement with the notion of "injury," which suggests the transfer of physical or chemical energy to a victim; (2) recognition that the types of interventions most likely to succeed are ones that require infrequent participation by the potential victim and his family (or none at all); and (3) awareness that different types of measures are needed to prevent different types of injury.9
Amiodarone in Control of Sustained Tachyarrhythmias in Children with Wolff-Parkinson-White Syndrome
Authors: SHAHAR ELI , BARZILAY ZOHAR , FRAND MIRA , FEIGL AMI
Published: December 2021

The Wolff-Parkinson-White syndrome in children is often associated with rapid supraventricular tachyarrhythmias.1-4 Commonly, these arrhythmias are of brief duration and respond promptly to conventional medications. In some patients, however, cardiovascular compromise and even circulatory collapse may supervene due to a prolonged arrhythmia resistant to various pharmacologic agents. The wide spectrum of medications, such as digoxin, quinidine, propranolol, and verapamil, used in order to control and prevent these arrhythmias in children with Wolff-Parkinson-White syndrome indicates lack of optimal therapy.1-4 Surgical interruption of the accessory pathway has also been undertaken.5

Recent experience with amiodarone hydrochloride, a relatively new antiarrhythmic drug, has shown favorable effects in adult patients with Wolff-Parkinson-White syndrome and recurrent arrhythmias following failure of traditional medications.6-9
Foot Dermatitis in Children
Authors: Weston Janet A. , Hawkins Kathleen , Weston William L.
Published: December 2021

Redness and scaling of the feet in prepubertal children is likely to represent a skin disease other than tinea pedis. If the dermatitis involves the dorsum of the feet, allergic contact dermatitis is a likely cause. In this study, 8/19 (42%) children with involvement of the dorsum of the feet had clinically relevant positive patch tests related to shoe allergens. All who avoided the allergens remained free of disease on a 2-year follow-up examination. Those children with dermatitis on the weight-bearing surface of the foot (juvenile plantar dermatosis) did not have positive patch tests (P = .15).