bluuebunny/crossref_metadata_2025 huggingface dataset:
Development of a Population-specific Risk Assessment to Predict Elevated Blood Lead Levels in Santa Clara County, California
Authors: Snyder David Clayton , Mohle-Boetani Janet C. , Palla Barbara , Fenstersheib Martin
Published: December 2021

Objectives. To determine: (1) the prevalence of a blood lead level (PbB) of 10 µg/dL or greaterand 20 µg/dL or greater among children aged 6 to 72 months attending the Santa Clara County (SCC), California, public clinics, (2) risk factors for elevated PbB in this population, and (3) whether an SCC public clinic population-specific risk-assessment tool and a five-question lead poisoning questionnaire developed by the Centers for Disease Control and Prevention are useful for prospectively identifying children at higher risk for elevated PbB.

Methods. We tested for PbB 3630 children aged 6 to 72 months attending SCC public outpatient clinics between August 8, 1991, and September 1, 1992. We then conducted two matched case-control studies. Five local riskfactor questions were combined with the CDC's five-question lead poisoning questionnaire, and from May 1, 1993, to June 30, 1993, we conducted risk assessments on 247 children tested for PbB.

Results. Two hundred twenty-two of 3630 children (6.1%) had a PbB of 10 µg/dL or greater. Thirty-nine (1.1%) had a PbB at least 20 µg/dL. Seventy-nine percent of the children screened and 91.0% of the children with PbB at least 10 µg/dL were Hispanic. Twenty percent of Mexican-born Hispanic children had a PbB of 10 µg/dL or greater, versus 7% of U.S.-born Hispanic children. Several factors were associated with elevated PbB among Hispanic children. For identifying children with a PbB of at least 10 µg/dL, the sensitivity and predictive value negative for the CDC's "high risk" definition were 30% and 93%, respectively, whereas for the SCC population-specific high-risk definition, the sensitivity was 90% and the predictive value negative was 98%.

Conclusions. Hispanic children attending SCC public clinics have risk factors for elevated PbB that were not included in the CDC's lead poisoning questionnaire. Methods for prioritizing the frequency of lead screening may be improved by combining the CDC's questions with a population-specific risk assessment.
Hidden Risks: Early Discharge and Bilirubin Toxicity Due to Glucose 6-Phosphate Dehydrogenase Deficiency
Authors: MacDonald Mhairi G.
Published: December 2021

In the United States today it is common for a mother motherand her term newborn to leave the hospital at 12 to 48 hours postnatally. Current opinion varies widely regarding the desirability of this practice. Proponents of early discharge claim that it is safe and may be advantageous; opponents argue that detection of significant illness may be missed or delayed. Economic considerations often limit the choice of families and their physicians; as they fund progressively shorter hospital stays, managed care and health insurance companies constitute a major driving force toward earlier postpartum discharge.

The American Academy of Pediatrics (AAP)1,2 and the American College of Obstetricians and Gynecologists (ACOG) have published criteria to be met by early discharge candidates.2 These basic criteria include attendance at prenatal classes, instruction regarding common neonatal problems, uncomplicated term delivery, normal physical examination, thermal homeostasis, a negative Coombs test, demonstration of basic maternal skills, including successful infant feeding, and "physician-directed" follow-up within 48 to 72 hours after discharge.

NEONATAL MORBIDITY AND MORTALITY: RELATIONSHIP TO TIME OF DISCHARGE

Many neonatal problems do not become apparent for several days. However, the risks of early discharge remain poorly defined. Among published series of infants discharged early, mortality rates are low and not significantly different from those of control infants.3-6 Most studies have compared morbidity (rates of hospital readmission) between infants discharged early and late and have found similar rates of readmission between groups.7-9 There are few prospective, randomized studies; those that have been published have significant methodological flaws.3,10-16 For example, length of hospital stay varies, and length of stay and timing of follow-up overlap with control infants; study sample sizes are small, usually less than 100 per study.
Early Discharge: In the End, It Is Judgment
Authors: Kessel Woodie , Kiely Michele , Nora Audrey H. , Sumaya Ciro V.
Published: December 2021

"Early to bed and early to rise, Makes a man healthy, wealthy and wise," proclaimed Benjamin Franklin.1 Early warning, early detection, early periodic screening, diagnosis and treatment, early dismissal, early filing—the litany goes on. Indeed, early has always connoted an astuteness, a positive gain of some sort. Yet recent newspaper and magazine articles have challenged that adage by calling attention to observations of untoward consequences resulting from early discharge of newborns and their mothers from the hospital (Sugg DK. Giving moms, newborns more time in the hospital. Baltimore Sun. April 4, 1995:1; Cost cuts shrink hospital stays for children. The New York Times. May 6, 1995; Nordheimer J. Broad coalition fights insurer limits on hospital maternity stays. The New York Times. June 6, 1995; Lord M. Check in, deliver, go home. us News and World Report. December 5, 1994:98-100). In anticipation of the need to address those observations, the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration has taken the lead in assessing and tracking this issue nationally. This article describes the MCHB-supported investigations related to early discharge, including findings and recommending next steps.

BACKGROUND

The MCHB focus on length of hospital stay for newborns and their mothers began with an observation regarding rehospitalization of recently discharged newborns. Wallace et al of the San Diego County, CA, 1985 Cohort Infant Mortality Study Group,2 in work sponsored by the MCHB, reported that infants who died in the postneonatal period were significantly more likely to have been rehospitalized (excluding the hospitalization during which death occurred) than infants in the control group (surviving infants matched for plurality and month of birth).
Summary of Workshop: Early Discharge and Neonatal Hyperbilirubinemia
Authors: Catz Charlotte , Hanson James W. , Simpson Lisa , Yaffe Sumner J.
Published: December 2021

The National Institute of Child Health and Human Development and the Agency for Health Care Policy and Research convened a workshop addressing the issues related to early discharge and hyperbilirubinemia on March 28, 1995. Recent reports have suggested that a high proportion of hospital readmissions in the neonatal period are related to hyperbilirubinemia.1-3 In addition, a growing number of anecdotal reports have raised concern about a resurgence of kernicterus and other hyperbilirubinemia-related morbidity, much of which may be preventable with improved neonatal discharge practices, monitoring technologies, and/or new pharmacologic therapies.4

Cost-containment strategies, such as managed care, have resulted in a continued trend toward shorter lengths of stay for all hospitalizations in all age groups. As a part of this trend, early discharge of neonates has also become common. The potential effects of these policies on subsequent outcomes for neonates and their mothers have generated concern. (In fact, Maryland has recently passed, and other states have introduced, legislation mandating at least 2 days postnatal hospital care.5) In addition to hyperbilirubinemia, other health issues related to early discharge that have been identified were discussed. These are reviewed in this issue of Pediatrics.6 They include potential adverse effects on newborn screening, poor preparation for breast-feeding, inadequate surveillance of mothers and neonates for health problems in the postpartum/neonatal period, reduced opportunities for parent training in "at-risk" populations, disruption of immunization practices, and shifting of economic burdens to families and nonhospital-based providers.

The objectives of this workshop were: a) to review the present status of knowledge regarding hyperbilirubinemia requiring clinical intervention in the newborn and its prevention, and b) in the context of current practices, to begin outlining an agenda for research needs, practice guidance, and policy formulation related to morbidity and mortality associated with early discharge and neonatal jaundice.
Early Discharge, In the End: Maternal Abuse, Child Neglect, and Physician Harassment
Authors: Charles Seymour , Prystowsky Barry
Published: December 2021

In New Jersey, physicians were not consulted by home maintenance organizations (HMOs) before early discharge began. There was only the assurance that early discharge had gone well in California. In New Jersey it was quite different, for a spectrum of health problems soon became apparent. Moreover, obstetricians and pediatricians were repeatedly confronted by unhappy mothers who complained that they had been sent home uncomfortably soon. Anthony Caggiano, MD, President of the Obstetrical and Gynecological Society of New Jersey, points out that in 24 hours after delivery, many mothers are still in pain and are not ready to go home, physically or psychologically.
Hospital Stay for Healthy Term Newborns
Authors:   Committee on Fetus and Newborn
Published: December 2021

The timing of discharge of the mother and infant after birth was, until recently, a mutual decision between the physician and the mother. Discharge soon after birth began as a consumer-initiated movement and as an alternative to home delivery in the 1980s. Today, financial rather than family or medical considerations frequently drive the decision. Increasingly, insurers are refusing payment for a hospital stay that extends beyond 24 hours after an uncomplicated vaginal delivery,1 which has placed increasing pressure on physicians to discharge infants shortly after birth.

Few scientific data support the insurer's mandate. Several clinical studies have examined the effects of short hospital stay on infant outcomes.2-24 Unfortunately, these studies have methodologic flaws that make it difficult to draw definite conclusions,25 including their 1) retrospective nature, 2) lack of comparison groups, 3) insufficient sample sizes, and 4) study design.

The pediatrician's primary role is to ensure the health and well-being of the baby in the context of the family. It is within this context that this statement addresses the short hospital stay (< 48 hours of age) for healthy term newborns.

The hospital stay of the mother-infant dyad should be long enough to allow identification of early problems and to ensure that the family is able and prepared to care for the baby at home. Many cardiopulmonary problems related to the transition from an intrauterine to an extrauterine environment usually become apparent during the first 12 hours after birth.26 However, other problems, such as jaundice, ductal-dependent cardiac lesions, and gastrointestinal obstruction, may require a longer period of observation by skilled and experienced personnel.
Letters to the Editor
Authors: Groneck Peter
Published: December 2021

In agreement with other authors who have investigated the mechanisms of bronchopulmonary dysplasia (BPD), we have used Bancalari's definition in our recent publication.1,2 However, we certainly agree that from a clinical point of view it is much more appropriate to define the disease when clinical symptoms are present at a corrected age of 36 weeks, as recently stated by Merritt et al.3 Moreover, a more differentiated descriptive definition, as suggested by Weinstein et al,4 could be helpful for the comparison of pulmonary outcomes in clinical trials.
The Integrated School Health Center: A New Medical Home
Authors: McPherson-Corder Marilyn D.
Published: December 2021

During the past two decades, financial access to health care has improved for the very young, with emphasis on immunizations and medical care facilities for infants and mothers. Well-woman mandates, such as cancer detection and treatment programs, have improved the health of adult women. Even efforts to meet the needs of an ever-growing elderly population have improved. In contrast to expansions and improvements in care for the aforementioned populations, among others, there is still a population whose unmet medical needs have grown exponentially: school-age youth. Morbidity and mortality for todays school-age children are linked most often to complex behavior patterns and psychosocial risk factors. Prevention and treatment of these patterns and factors often require a multidisciplinary approach using educational and case management strategies; social, mental health, dental, and nutritional services; and traditional medical services. In recognition of the school as the focus of many communities and in recognition of this population's disproportionate drain on medical expenditures, current and projected, there has been a push for more monies to be spent on developing integrated school-based and school-linked clinics. These clinics should focus on meeting community needs and should emphasize coordination and cooperation between private and public agencies. If such efforts are not continued into the 21st century, this least-served population, which on the surface seems to be the healthiest, will be a major factor in the rising cost of care, particularly because they lacked a medical home while they were school age.
Impact of Prenatal Diagnosis on the Birth Prevalence of Neural Tube Defects, Atlanta, 1990-4991
Authors: Roberts Helen E. , Moore Cynthia A. , Cragan Janet D. , Fernhoff Paul M. , Khoury Muin J.
Published: December 2021

Objective. To determine the impact of prenatal diagnosis on the birth prevalence of neural tube defects (NTDs) in Atlanta during 1990 through 1991.

Methods. Live-born and stillborn infants with NTDs who were at least 20 weeks' gestation were ascertained by the Metropolitan Atlanta Congenital Defects Program (MACDP), a population-based birth defects registry. Prenatally diagnosed NTD-affected pregnancies were ascertained from the four perinatal centers and the three genetic laboratories operating in Atlanta during 1990 through 1991. Fetal death certificates were also reviewed for potential cases.

Results. During 1990 through 1991, MACDP ascertained 59 NTD cases, for a birth prevalence of 0.77/1000 live births. During this period, an additional 28 NTD-affected pregnancies were detected prenatally and terminated before 20 weeks' gestation. The adjusted NTD rate during 1990 through 1991, which includes prenatally diagnosed cases, was 1.13/1000 live births.

Conclusions. Prenatal diagnosis is making a substantial impact on the birth prevalence of NTDs in Atlanta. However, since NTD rates in Atlanta were 2 to 2.5 per 1000 live births in 1970, prenatal diagnosis and termination of pregnancy does not completely account for the declining rate of NTDs.
A Pacifier Increases the Risk of Recurrent Acute Otitis Media in Children in Day Care Centers
Authors: Niemelä Marjo , Uhari Matti , Möttönen Merja
Published: December 2021

Objective. To follow up a previous retrospective analysis in which we found the use of a pacifier to be a risk factor for recurrent acute otitis media (AOM).

Method. In the present prospective study, the occurrence of AOM and the use of a pacifier were recorded in 845 children attending day care centers during a 15-month period.

Results. More than three attacks of AOM occurred in 29.5% of the children younger than 2 years using pacifiers and in 20.6% of those not doing so (relative risk, 1.6; 95% confidence interval [CI], 0.6, 4.1); in children 2 to 3 years of age, the figures were 30.6% and 13.2%, respectively (relative risk, 2.9; 95% CI, 1.2, 7.3). Logistic modeling with adjustment for age and the duration of monitoring showed the occurrence of AOM to be associated with the time during which a pacifier was used. The use of a pacifier increased the annual incidence of AOM from 3.6 (95% CI, 2.5, 4.9) to 5.4 episodes (4.4, 6.6) in children younger than 2 years and from 1.9 (1.4, 2.5) to 2.7 (2.2, 3.3) in children 2 to 3 years of age. The population-attributable risk of AOM attacks due to the use of a pacifier was 176 attacks, ie, 459 to 635 attacks per year, in the youngest children and 69 attacks, ie, from 264 to 333 attacks per year, in those 2 to 3 years of age. It can be calculated that the use of a pacifier was responsible for 25% of the attacks in children younger than 3 years. Breastfeeding, parental smoking, thumb sucking, using a nursing bottle, and the social class of the family failed to show such strong associations with the occurrence of AOM.

Conclusion. We conclude that the use of a pacifier is a significant risk factor for recurrent AOM and suggest that pacifiers should be used only during the first 10 months of life, when need for sucking is strongest, and AOM is uncommon.
Ear Temperatures
Authors: Zempsky William T.
Published: December 2021

Recently there have been several articles published in the literature concerning the use of otic thermometers and the equivalence or lack thereof of these instruments to the current "gold standard" (ie, rectal thermometers).1-3 I'm sure the following case will add some lively banter to this debate! A 5-week-old infant was referred to the emergency department from his pediatrician's office for a "full sepsis evaluation." This previously healthy infant had been crying more than usual at home and a rectal temperature obtained by his parent was 102.5°F.
Annual Summary of Vital Statistics-1994
Authors: Guyer Bernard , Strobino Donna M. , Ventura Stephanie J. , Singh Gopal K.
Published: December 2021

Recent trends in the vital statistics of the United States continued in 1994, including decreases in the number of births, the birth rate, the age-adjusted death rate, and the infant mortality rate. Life expectancy increased slightly to 75.7 years. Only marriages reversed the recent trend with a slight increase in 1994. An estimated 3 979 000 infants were born during 1994, a decline of <1% from 1993. The birth rate was 15.3 live births per 1000 population, a 1% decline. These decreasing rates reflect a decline in the fertility rate to 67.1 live births per 1000 women aged 15 to 44 years. Final figures for 1993 indicate that fertility rates declined for all racial groups, by 1% for white women (to 65.4) and 3% for black women (to 80.5). The fertility rate for Hispanic women (106.9) was 84% higher than that for non-Hispanic white women and 31% higher than for non-Hispanic black women.

Between 1991 and 1993, birth rates for teenage mothers remained virtually unchanged, and abortion rates have steadily declined, suggesting that teenage pregnancy rates are levelling off. The number and proportion of births to women over age 30, however, continued to rise. The rate of births to all unmarried women (45.3 per 1000 in 1993) has been stable for 3 years. Prenatal care utilization improved in 1993; 79% of women initiated care in the first trimester and <5% had delayed care or no care. Improvements occurred among nearly all racial and ethnic groups. Reported smoking during pregnancy declined to 15.8% in 1993 from 16.9% in 1992. The proportion of babies delivered by cesarean section was 21.8% in 1993, a 2% decrease from 1992. Between 1992 and 1993, the rate of low birth weight (LBW) rose slightly to 7.2%, while very low birth weight (VLBW) remained stable at 1.3%. Most of the increase in LBW occurred among white infants and reflected, primarily, an increase in the proportion of multiple births. The black/white ratio in LBW continued to increase to more than two-fold with the largest difference recorded among term and postterm infants. Age-adjusted death rates in 1994 were lower for heart disease, malignant neoplasm, pulmonary diseases, other accidents, and homicides. The age-adjusted death rate for human immunodeficiency virus disease Continued to rise to 15.1 in 1994. The infant mortality rate declined 4% in 1994, to 7.9 per 1000, the lowest rate ever recorded in the United States. The decline was primarily in neonatal mortality. Among the states, Massachusetts (5.4) and Washington (5.7) had the lowest rates. The overall national trend appears to be related to declines in respiratory distress and sudden infant death syndrome deaths. Over the next 25 years, the number of children in the United States is expected to rise by only 10 million, and the composition of the child population will become more ethnically and radally diverse.
Neurological Correlates of Fetal Cocaine Exposure: Transient Hypertonia of Infancy and Early Childhood
Authors: Chiriboga Claudia A. , Vibbert Martha , Malouf Renée , Suarez Maria S. , Abrams Elaine J. , Heagarty Margaret C. , Brust John C. M. , Hauser W. Allen
Published: December 2021

Objective. To assess whether prenatal cocaine exposure has any long-term effects on neuro-development.

Design. A prospective cohort study with examiners blind to drug exposure and human immunodeficiency virus (HIV) status.

Subjects. Of 144 high-risk infants enrolled in a perinatal HIV neurodevelopmental study, 119 (83%) infants with both neurological and urine toxicology measures were followed up to age 24 months.

Methods. Neurological and developmental assessments were analyzed at 6-month intervals grouped according to the presence of cocaine in urine toxicology: 51 infants were cocaine-positive. Adjusted odds ratios (ORs) and 95% confidence interval (CI) were obtained by logistic regression equations that adjusted for perinatal variables, including measures of fetal growth, gestation, HIV status, and infant toxicology results.

Setting. Harlem Hospital Center from 1988 to 1992.

Results. At age 6 months, 21 of 51 (41%) cocaine-positive children exhibited hypentonia of any type (hypertonic tetraparesis, hypertonic diparesis, and hypertonic hemiparesis) compared with 17 of 68 (25%) cocaine-negative infants (OR = 2.1, CI = 1.0-4.6). Cocaine-positive infants were four times more likely to show hypertonic tetraparesis (HTP) than cocaine-negative infants (OR = 4.0; CI = 1.5-10.8). The association remained significant in multivariate analyses. Hypertonia, consistent with cerebral palsy, diminished over time in both groups. In 97% of affected infants hypertonia resolved by 24 months. Arm hypertonia abated first; leg hypertonia remained in some children up to age 18 months. No differences in development scores between cocaine-positive and cocaine-negative were noted at any age interval. However, among cocaine-positive infants those with early HTP showed significantly lower mean developmental scores at 6 and 12 month compared to infants without HTP.

Conclusion. Cocaine positivity urine toxicology at birth is associated with hypertonia during infancy. Such cocaine-induced effects are usually symmetrical, transient, and the majority of exposed children outgrow hypertonia by 24 months of life. Among cocaine-positive infants, HTP may be a marker for later developmental impairments.
The Effects of HIV on Cognitive and Motor Development in Children Born to HIV-Seropositive Women With No Reported Drug Use: Birth to 24 Months
Authors: Gay Caryl L. , Armstrong F. Daniel , Cohen Donna , Lai Shenghan , Hardy Marjorie D. , Swales Thomas P. , Morrow Connie J. , Scott Gwendolyn B.
Published: December 2021

Objective. This study documents delays in the mental and motor functioning of infants perinatally infected with human immunodeficiency virus (HIV) while controlling for confounding effects of prenatal drug exposure, ethnicity, socioeconomic status, and maternal separation and death.

Methods. The cognitive and motor development of 126 infants born to nondrug-using, HIV-seropositive Haitian women was assessed at 3-month intervals through 24 months of age using the Bayley Scales of Infant Development. By 18 months of age, 28 of the infants were diagnosed as HIV-infected, and the 98 uninfected infants served as a control group. The infected and uninfected infants did not differ with respect to mean gestational age, birth weight, ethnicity, or rates of maternal separation and death.

Results. By 3 months of age, the mean mental and motor scores of the infected infants were significantly lower than those of the uninfected controls. Furthermore, the initial differences between the two groups increased over time, as many of the infected infants became increasingly delayed. Although the infected infants tended to perform more poorly than the uninfected infants, nearly one third of the infected infants exhibited relatively normal cognitive development and half demonstrated relatively normal motor development.

Conclusions. Over the first 24 months of life, the mean rate of development of HIV-infected infants is significantly slower than that of noninfected infants born to seropositive mothers. This occurs even when the effects are not confounded with those of prenatal drug exposure.
Voiding After Neonatal Circumcision
Authors: Perlmutter Deborah F. , Lawrence Janet M. , Krauss Alfred N. , Auld Peter A. M.
Published: December 2021

Objective. To determine whether it is necessary to delay discharge of newly circumcised male neonates to observe voiding.

Subjects and Methods. A prospective study was conducted in 1992 and 1993 of 51 healthy male, newly circumcised neonates between 0 and 10 days of age. The neonates were observed for the time of first voiding after circumcision was performed.

Results. All neonates voided after circumcision at a mean age of 5.3 ± 2.5 hours, and there were no complications noted in the study population.

Conclusion. Healthy male infants who are circumcised without obvious complications can be expected to void, and it is unnecessary to delay hospital discharge to make this observation.
Inhaled Nitric Oxide for Persistent Pulmonary Hypertension of the Newborn: Implications and Strategy for Future "High-Tech" Neonatal Clinical Trials
Authors: Stark Ann R. , Davidson Dennis
Published: December 2021

Five large clinical trials are in progress in the United States and Canada examining the efficacy and safety of inhaled nitric oxide (iNO) for persistent pulmonary hypertension of the newborn (PPHN) and severe respiratory failure in near-term and term infants. A large trial in France that includes premature infants is also under way. Neonatologists have shown great interest in the use of iNO as a selective pulmonary vasodilator, but in the United States and perhaps elsewhere, widespread application of this treatment outside of study sites will have to await completion of clinical trials. At the current pace, we expect it will take several years to enroll an adequate number of patients to address relevant outcome end-points.
A Simple Maneuver to Provoke Benign Neonatal Sleep Myoclonus
Authors: Alfonso Israel , Papazian Oscar , Aicardi Jean , Jeffries Howard E.
Published: December 2021

Benign neonatal sleep myoclonus (BNSM) is characterized by: (1) neonatal onset, (2) myoclonic jerks occurring only during sleep, (3) abrupt and consistent cessation with arousal, (4) absence of concomitant electroencephalographic seizures, and (5) good outcome.1 The myoclonic jerks may be partial, multifocal, or generalized,1-11 with a frequency of 1 to 15 per second,1,3,9 and they do not stop with restraint.12 BNSM occurs in neurologically healthy neonates, usually disappears before 6 months of age, 2-7,9 and requires no treatment.1-11 Antiepileptic drugs are not effective in BNSM.1-11 Nevertheless, 35% of reported neonates with BNSM were treated with antiepileptic drugs before establishing the correct diagnosis.1-11
Health Supervision for Children With Turner Syndrome
Authors:   Committee on Genetics
Published: December 2021

This set of guidelines is designed to assist the pediatrician in caring for the child in whom the diagnosis of Turner syndrome has been confirmed by karyotype. Although the pediatrician's first contact with the child is usually during infancy, occasionally the pregnant woman who has been given the prenatal diagnosis of Turner syndrome will be referred for advice. Therefore, these guidelines offer advice for this situation as well.

Turner syndrome, as used here, refers to a condition in which there is short stature and ovarian dysgenesis in females because of the absence of a normal second sex chromosome. Nonchrornosomal gonadal dysgenesis is excluded. The birth prevalence of Turner syndrome has been estimated to be from 1:2000 to 1:5000 female live births. About 1% to 2% of all conceptuses have a 45,X chromosome constitution. Of these, the majority (99%) spontaneously abort, usually during the first trimester of pregnancy. With the more frequent use of ultrasound, it is recognized that some pregnancies with a fetal 45,X chromosome constitution progressing into the second trimester are associated with nuchal cysts, severe lymphedema, or hydrops fetalis. These pregnancies are associated with a high frequency of fetal death.

PHENOTYPE

Pediatricians are most familiar with the clinical findings that prompt the diagnosis in children, namely, short stature and the classic Turner syndrome features such as lymphederna, webbed neck, low posterior hair line, and cubitus valgus. A wide range of clinical abnormalities may be found (Table 1). Turner syndrome, however, is not always accompanied by distinctive features and most often is not diagnosed in infancy.
Clonidine and Sudden Death
Authors: Maloney Michael J. , Schwam Jeffrey S.
Published: December 2021

Clonidine is used by pediatricians and child psychiatrists for tics, Tourette's syndrome, and attention deficit disorder with hyperactivity (ADHD) with aggressive behavior. However, recent evidence of sudden death and cardiac toxicity associated with clonidine raises concern about the widespread use of this medication.

There are three unpublished cases where the combination of clonidine and methylphenidate has been associated with unexplained sudden death in children ages 7,8, and 9 years (Frenia M.L., personal communication, September 21, 1995, Drug Surveillance and Information, Boehringer Ingelheim Pharmaceuticals).
Screening for Congenital Adrenal Hyperplasia: The Delfia Screening Test Overestimates Serum 17-Hydroxyprogesterone in Preterm Infants
Authors: Saedi Saad Al , Dean Heather , Dent William , Stockl Elizabeth , Cronin Catherine
Published: December 2021

Objective. To compare 17-hydroxyprogesterone (17-OHP) levels measured by quantitative serum radioimmunoassay (RIA), including an extraction step, and by screening fluoroimmnoassay (FIA) on blood spots in preterm infants.

Methods. Subjects were 39 healthy infants born at less than 31 weeks' gestational age. Each infant had weekly blood sampling, and RIA and FIA were performed on each sample.

Results. Two hundred twenty-seven samples were taken at 28 to 41 weeks' postconceptional age. Mean ± SD 17-OHP measured by RIA was 11.4 ± 11.1 nmol/L (0.4 ± 0.4 µg/dL), and decreased over time. Mean ± SD 17-OHP measured by FIA was 38.96 ± 37.3 nmol/L, greater than 17-OHP (RIA). Log(δFIA-RIA) was inversely related to postconceptional age (R2 = .39).

Conclusion. Screening FIA of blood spots overestimates levels of 17-OHP in preterm infants and should not be used to determine the likelthood of congenital adrenal hyperplasia in this population. We have abandoned FIA screening for congenital adrenal hyperplasia in infants weiging less than 1500 g.
Practice-based Outcomes Research: Crucial, Feasible, and Neglected
Authors: Avorn Jerry
Published: December 2021

The article from the Vermont-Oxford Neonatal Network1 in this issue of Pediatrics comparing two surfactant preparations represents an important case study of a central issue in contemporary medicine: the need for rigorous, even-handed evaluation of competing therapies. Even at a time in which patients and payers are expecting ever-higher standards for clinical outcomes, and policymakers and insurers are demanding more and more stringent cost containment, the American health care system lacks a coherent mechanism for assembling and analyzing the data needed to meet these goals. For pharmacologic therapies, the Food and Drug Administration (FDA) prefers that mew agents be tested against placebos whenever possible, unless this would result in harm to experimental subjects.
Extralobar Pulmonary Sequestration Masquerading as a Congenital Pleural Effusion
Authors: Boyer Joseph , Dozor Allen , Brudnicki Adele , Slim Michel , Paliotta Marco , Kwark Hyun Ellen
Published: December 2021

Congenital pleural effusions are uncommon. The majority of cases are due to chylothorax, hydropsfetalis, and infection. Effusions of this nature are, for the most part, self-limited. When these factors are eliminated, an extensive evaluation seeking uncommon causes needs to be performed. We present a rare case of a congenital unilateral pleural effusion due to an extralobar sequestration with pulmonary lymphangiectasia.

CASE REPORT

M.T. was a female born to a 35-year-old woman G1P0 at 34 weeks gestation by caesarean section as a result of fetal bradycardia. The mother developed gestational diabetes and hypertension during pregnancy, requiring insulin, nifedipine, and methyldopa. A third trimester ultrasound performed at 29 weeks gestation revealed a left pleural effusion.
Vocal Cord Paralysis as a Presentation of Intrauterine Infection With Varicella-Zoster Virus
Authors: Randel Randy C. , Kearns Donald B. , Nespeca Mark P. , Scher Colin A. , Sawyer Mark H.
Published: December 2021

The association of maternal varicella-zoster virus (VZV) infection during pregnancy and congenital anomalies has been previously reported.1,2 Pregnancies complicated by maternal VZV infection have resulted in asymptomatic infants, the fetal varicella syndrome, and otherwise asmptomatic infants with herpes zoster. We report an infant who presented with bilateral vocal cord paralysis.

CASE REPORT

This 3 kg, white female infant was the product of a term gestation to a 29-year-old gravida 4, para 3, therapeutic abortion (TAB) 1 single female who received prenatal care. The mother tested negative for hepatitis B surface antigen and was rapid plasma reagent nonreactive. Pregnancy was complicated by maternal cannabis use.
Postexposure Prophylaxis of Varicella in Children With Leukemia by Oral Acyclovir
Authors: Ishida Yasushi , Tauchi Hisamichi , Higaki Aki , Yokota-Outou Yoshiko , Kida Kaichi
Published: December 2021

In the August 1993 issue of Pediatrics, Asano et al presented the successful experience in postexposure prophylaxis of varicella for healthy children by oral acyclovir (ACV).1 They discussed that postexposure prophylaxis by oral ACV has not been examined in immunocompromised patients. We experienced three children with acute lymphoblastic leukemia (ALL) exposed to varicella and tried postexposure prophylaxis by oral ACV with informed consent of their parents.

[See Table in PDF file]

The characteristics of the patients are listed in the Table.
Early Prediction of the Development of Microcephaly After Hypoxic-Ischemic Encephalopathy in the Full-term Newborn
Authors: Badawi Nadia , Kurinczuk Jennifer J. , Blair Eve , Keogh John , Stanley Fiona
Published: December 2021

We read with interest the article by Cordes et al.1 This article raises an important issue concerning assumptions made with respect to the significance of intrapartum and neonatal observations. The population of infants studied was 54 full-term newborns born after uneventful pregnancies and diagnosed as having acute hypoxic-ischemic encephalopathy (HIE) that was intrapartum in origin. The underlying assumption of this diagnosis was that if there is no obvious antenatal cause of abnormal neonatal neurological signs, then any suboptimal intrapartum observation identifies the pathology as being intrapartum in origin.
Identification of Children At Risk for Lead Poisoning: An Evaluation of Routine Pediatric Blood Lead Screening in an HMO-Insured Population
Authors: Haan Mary N. , Gerson Marianne , Zishka B. Anne
Published: December 2021

Objectives. To estimate the prevalence of elevated blood lead levels in children receiving well-care checkups; and to evaluate the effectiveness of certain key risk factors in detecting children at higher risk for elevated blood lead levels.

Design. Cross-sectional study.

Setting. Two facilities of the Kaiser Permanente Medical Care Program (KPMCP) health maintenance organization (HMO), northern California region.

Patients. Six hundred thirty-six children, aged 12 to 60 months, who were seen at four KPMCP facilities in two subregions for a well-care checkup from September 1991 through August 1992.

Interventions. Blood samples were collected from each child and analyzed for lead content. Participating parents completed a questionnaire that included questions recommended by the Centers for Disease Control and Prevention (CDC) about the child's and the parents' lead exposure via home, workplace, and hobbies.

Results. Ninety-six percent of the children had blood lead levels under 10 µ/dL. Blood lead levels declined with increasing age and were higher for black children compared with whites. Age of residential housing, mother's education, and residence in an old house with peeling paint had low sensitivity and positive predictive value for identifying children with blood lead levels over 10 µ/dL.

Conclusion. Universal routine screening for elevated blood lead levels in children in an employed, HMO-insured population is not warranted on grounds of prevalence. Responses to CDC questions do not effectively identify high-risk children in this population.
Evaluation of Clinical Competence: The Gap Between Expectation and Performance
Authors: Joorabchi Bahman , Devries Jeffrey M.
Published: December 2021

Objective. To evaluate a 3-year experience with the Objective Structured Clinical Examinations (OSCEs) and to compare faculty expectations with resident performance.

Design. Descriptive analysis of measures of resident performance.

Setting. Community-based pediatric residency program in Michigan.

Participants. One hundred twenty-six pediatric residents at all levels of training.

Methods. The three examinations consisted of 36 to 42 5-minute stations, testing skills in physical examination, history, counseling, telephone management, and test interpretation. A committee of faculty and chief residents predetermined minimum pass levels for each resident level. Results were compared with other indices of resident performance.

Results. There was evidence for content, construct, and concurrent validity, as well as a high degree of reliability. However, 40% to 96% of residents scored below the minimum pass levels for their levels. In each examination, third-year residents had the highest failure rates, yet they scored well on the American Board of Pediatrics in-training examination and on their monthly clinical evaluations. Furthermore, for residents at all levels, the scores reflecting application of data were significantly lower than those assessing data gathering.

Conclusions. The gaps between expectations and performance, and between data gathering and application, have important implications for institutional educational philosophy, suggesting a shift toward more clinically oriented and learner-directed strategies in the design of instructional and evaluation methods.
Tuberculosis Infection in Human Immunodeficiency Virus—Positive Adolescents and Young Adults: A New York City Cohort
Authors: Hoffman Neal D. , Kelly Colleen , Futterman Donna
Published: December 2021

Objectives. Adolescents with human immunodeficiency virus (HIV) infection are at increased risk for tuberculosis (TB), underscoring the importance of early identification of TB infection. The goals of this study were to assess the factors associated with the completion of evaluations for TB in a cohort of HIV-positive adolescents and young adults and to describe the prevalence of Mycobacterium tuberculosis infection and adherence to antituberculous treatment regimens.

Methods. A retrospective chart review was done for all HIV-positive adolescents and young adults, ages 13 to 21 years (n = 49), seen in a comprehensive care program from January 1991 through December 1992. Data collected included CD4 cell count, HIV clinical status, living situation, substance use history, and the completion of an annual evaluation for TB infection. The evaluation consisted of a tuberculin skin test (Mantoux test), using an intraepidermal injection of 0.1 mL of 5 tuberculin units of purified protein derivative (PPD) and a simultaneous Merieux multitest anergy panel. Chi-square analysis was used to assess the association between the completion of the evaluation for TB and both living status and substance use.

Results. Thirty-one (63%) of 49 patients completed evaluations for TB. Of the 31 completed evaluations, 18 were assessed by clinic staff on site, and 13 were assessed by other medical or trained nonmedical observers through community networking efforts. Neither homelessness nor illicit substance use were factors in the completion of the evaluation. Six (19%) of the 31 patients had positive PPD skin test results. Three had medical histories and chest radiographs suggesting active TB, and all were hospitalized for at least 2 weeks. Two had positive cultures for M tuberculosis, although the third also responded clinically to antituberculous therapy. All three were otherwise asymptomatic for HIV infection, with only moderately depressed CD4 cell counts. All three were homeless and used crack cocaine. After the initial treatment as inpatients, none completed treatment within the prescribed time period.

Conclusions. The completions of the evaluations for TB were greatly facilitated by community networking, but innovative strategies to enhance both screening and treatment programs, such as training youth service providers in the community to read PPD skin tests, expansion of directly observed therapy services, and youth-centered programs for housing and substance use, need further development. The high prevalence of TB in the cohort underscores the need for providers to increase efforts to identify cases of TB infection among adolescents and young adults and to incorporate HIV risk assessment, counseling, and testing into their practices routinely.
WHERE IS THE SANCTITY OF LIFE?
Authors: Student
Published: December 2021

How much do we really value the lives of children? . . .I know most people value their own child's life, but what about other people's children? On the basis of what I've seen, in the South Bronx, it's hard to believe we love these children. The physical degradation of their neighborhood, the chaotic and dysfunctional medical care we give them, the apartheid school system we provide them, the poisons we pump into their neighborhood by putting every kind of toxic-waste incinerator in their neighborhood, all that together does not give me the impression we value their lives.
How Accurately Can Bruises Be Aged in Abused Children? Literature Review and Synthesis
Authors: SCHWARTZ ARI J. , RICCI LAWRENCE R.
Published: December 2021

Unlike the severe abuse that was reported in early child abuse literature, more moderate injuries comprise 60% of physical child abuse. These less-severe abuse cases, many with limited, ill-defined bruising, may be more difficult to diagnose than a severe case with multiple-system injury or a child with specific, clearly imprinted bruising. Additionally, as the US Supreme Court observed, "Child abuse is one of the most difficult crimes to detect and prosecute in large part because there often are no witnesses except the victim.

Estimates of ages of bruises along with the aging of other injuries such as fractures and brain trauma may offer the only way to associate an injury with a particular perpetrator. Yet, as an aid to child abuse diagnosis and perpetrator identification, visual aging of bruises remains an inexact science, despite recent composite charts that suggest otherwise.

Even though it has been stated that it is not possible to age bruises accurately based on color, these opinions have not been represented in the child abuse literature. The study of Langlois and Gresham, to date the only research-based study of bruise aging by appearance, has not yet been cited in the medical literature (Science Citation Index search, August 1994).

The available literature does not permit the estimation of a bruise's age with any precision based solely on color. Even for the practitioner to state, as Wilson suggests, that a particular bruise is "consistent with" a specific age implies a level of certainty not supported by the literature.

Bruises may be described as "older" if yellow, brown, or green are present, but practitioners should note the limitations of bruise age analysis. Of course, the practitioner must continue to describe the size, shape, location, and color of each bruise accurately. This is best done by written description and drawings along with careful photographic representation. Photographs of a bruise, however, depending on available light and technique, may not represent color accurately. A standard color wheel in the photograph may help.

Future research should focus on a number of questions. A study of the aging of bruises, using contusions of known age and history-blinded examiners, could determine how accurate clinical estimates are. Interobserver reliability may also be assessed in such a study. The study of Langlois and Gresham should be repeated to confirm or to refute their findings. A photographic sequence of various bruises from appearance to resolution would give researchers and clinicians a reference of possible colors in different-aged bruises for standardized description.

The estimated age of a bruise should never be the sole criteria for a diagnosis of child abuse, but, rather, one component of a comprehensive assessment that incorporates a careful history of the injury, past medical history, family history, associated risk factors, a detailed physical examination, and appropriate laboratory testing.
In Reply: Condom Availability for Youth: A High-risk Alternative
Authors: BEACH ROBERTA K.
Published: December 2021

The letters from Drs Trivelli and Colliton provide an opportunity to emphasize the recommendations in the American Academy of Pediatrics (AAP) policy statement on "Condom Availability for Youth," which were specifically developed to support the AAP's strategic goal to promote adolescent healthy lifestyles. During the 3 years that this statement was researched, reviewed, modified, and ultimately approved as policy, many of the issues raised by Drs Trivelli and Colliton were thoroughly discussed. We appreciate the opportunity to comment on them now.
CONFIDENCE INTERVALS, NOT P VALUES
Authors: Student
Published: December 2021

To evaluate the extent of prediction error we must discard hypotheses testing in favor of estimation ...

The use of confidence intervals as summaries of the effect of an intervention enables the correct conclusions to be drawn from meta-analyses; reliance on whether a P value is more or less than 0.05 is a dangerous way of making decisions ...