bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatrician's Role in Emergency Medical Services for Children
Authors:   Provisional Committee on Pediatric Emergency Medicine
Published: December 2021

To reduce the morbidity and mortality of critically ill and injured children, comprehensive care must be provided. This includes effective services and treatment from the onset of the illness or injury through definitive care. Pediatricians should counsel families not only about prevention of disease and injury but also about access to pediatric emergency care resources in their region. If the interval between recognition of illness and delivery of care is to be reduced to a minimum, a prehospital protocol must be established. Parents as well as prehospital care providers must be knowledgeable about their community's prehospital protocol for life-threatening illness or injury.

Primary care pediatricians need to establish networks with hospital-based pediatricians, emergency physicians, pediatric surgeons, and other pediatric medical and pediatric surgical specialists so that there is clearly assigned responsibility for provision of pediatric emergency care.1 When available, a pediatric surgeon should take charge of the child with multiple traumatic injuries. Optimally, the pediatric emergency care delivery system will be comprehensive and designed to meet the unique needs of children. The specific objectives of an emergency medical services for children (EMS-C) system should remain constant even though available resources may vary from region to region. For an EMS-C system to be most effective, practitioners need to develop the knowledge, skills, attitudes, and experience necessary to provide essential life support for ill and injured children.

Many regions currently have well-developed emergency medical services (EMS) systems with outstanding capability and sophistication but most have been designed to meet the needs of adults.2
SIDS or Murder?
Authors: DIMAIO VINCENT J. M.
Published: December 2021

To the Editor.—

It was with resignation that I read the paper by Oren et al1 about SIDS and familial occurrence. It is my opinion, as well as that of a number of other forensic pathologists to whom I showed the article, that the five deaths in group I of this article (infants born to families with two or more siblings who died of SIDS) are in all medical probability homicides by smothering. The individual clinical findings of these cases is not given, but from experience, I would say that one or more of these children in each family were brought to physicians and emergency rooms a number of times with a history of apneic episodes, that, if admitted, they never experienced these episodes in the hospital (unless they were alone with a parent), and that they were subsequently brought in dead after suffering a fatal apneic episode.
Newborn Screening for Sickle Cell Disease: Effect on Mortality
Authors: Vichinsky Elliott , Hurst Deborah , Earles Ann , Kleman Klara , Lubin Bertram
Published: December 2021

Newborn screening for sickle cell disease has been recommended as a method of decreasing patient mortality. However, its effectiveness in accomplishing this has not been reliably measured. To help determine the effectiveness, 10 years of experience in newborn screening have been summarized. The effects of early patient enrollment in a comprehensive treatment program on long-term morbidity and mortality are reported. From 1975 to 1985, 84,663 newborns were screened regardless of race or ethnic background. Bart's hemoglobin was present in 5%, hemoglobin AS in 2.6%, and hemoglobin AC in 0.75%. Excluding Bart's, approximately 3.6% of all newborns were carriers for hemoglobinopathy. Sickle cell disease occurred in 1:951 births (58 hemoglobin SS, 25 hemoglobin FSC, three hemoglobin S-β+-thalassemia, and three hemoglobin S-β°-thalassemia). In addition, one in every 4,233 newborns had a clinically significant thalassemia syndrome (eight hemoglobin FE, ten hemoglobin F only, two hemoglobin H). Compared with other newborn screening programs in California, (congenital hypothyroidism, 1:3,849; phenylketonuria 1:22,474, galactosemia 1:74,103), hemoglobinopathies are the most prevalent congenital disease. Eighty-one newborns with sickle cell disease were followed for 7.2 years. Patients experienced 513 hospitalizations, including 13 episodes of sepsis with or without meningitis and ten acute sequestration crises. The overall mortality rate for patients with sickle cell anemia diagnosed in the newborn period was 1.8%. In comparison, the clinical course of 64 patients with sickle cell anemia diagnosed after 3 months of age and followed for an average of 9.4 years was analyzed. Five of these patients died. In two of these, sickle cell anemia was diagnosed at the time of the death. Overall mortality rate in this group was 8%. In summary, the data indicate that newborn screening, when coupled with extensive follow-up and education, will significantly decrease patient mortality.
Combined Vaccine Against Measles, Mumps, Rubella, and Varicella
Authors: Brunell Philip A. , Novelli Valerio M. , Lipton Susan V. , Pollock Betsy
Published: December 2021

A combined measles, mumps, rubella, and varicella vaccine produced seroconversions for all four components similar to that found if measles, mumps, and rubella vaccine or live varicella vaccine were given separately. In addition, those exposed to varicella were completely protected or had only a mild rash. Moreover, the reaction rates were not increased if the vaccines were combined. The somewhat lower and delayed serologic response to live varicella vaccine as compared with the combined measles, mumps, rubella, and varicella may have been due to the small amount of varicella vaccine virus used or to its degree of attenuation. Persistence of antibody was observed 1 year postimmunization.
Low Affinity Antibody to Rubella Antigen in Patients After Rubella Infection in Utero
Authors: Fitzgerald Margaret G. , Pullen Gregory R. , Hosking Clifford S.
Published: December 2021

As a measure of the affinity of antirubella antibody, the resistance of the antibody to elution was used by increasing concentration of ammonium thiocyanate. The term affinity index has been used to define the molarity of thiocyanate which leads to a reduction of 50% of the initial density. The serum from a group of patients with intrauterine rubella was compared with the serum from a group of deaf children, some of whom could have rubella, and a group of controls with antibody following natural infection. The results show that the affinity index of patients with rubella is significantly lower than that of controls. The other deaf patients span the range of indices of the rubella and control groups suggesting that a number of those children could have deafness caused by intrauterine rubella.
Megaloblastic Anemia Characterized by Microcytosis: Imerslund-Grasbeck Syndrome With Coexistent α-Thalassemia
Authors: RUSSO CAROLYN L. , HYMAN PAUL E. , OSEAS RONALD S.
Published: December 2021

Imerslund-Grasbeck syndrome is a hereditary autosomal recessive condition of selective vitamin B12 malabsorption in the terminal ileum, resulting in chronic megaloblastic anemia.1,2 The purpose of this report is to describe a child with coincident Imerslund-Grasbeck syndrome and α-thalassemia, who also had a vitamin B12-sensitive microcytic anemia.

CASE REPORT

When R.S. was 15 months of age his mother reported that progressive anorexia and lethargy had developed. There was no history of chronic diarrhea, vomiting, frequent infections, or pica; there was no family history for blood dyscrasias.

R.S. was a black boy who weighed 8.3 kg (less than the fifth percentile); his length was 74 cm (less than the fifth percentile), and his head circumference was 45 cm (second percentile).
Commercialization of Children's Television and Its Effect on Imaginative Play
Authors:   Committee on Communications
Published: December 2021

Toy-based television programs, commonly known as program-length commercials, and television-activated toys exploit children as consumers. Of more urgent concern is their potential to promote violent and aggressive behavior, increase the intellectual passivity with which children view television, and inhibit imaginative play.1

Almost all of the 20 best selling toys on the market today are based on television programs. More than half of these toys have violent themes. Many glorify war. Clearly, the commercialization of children's television promotes violence as well as sales. It does little to entertain or educate our children.

Television-activated toys take the exploitation of program-length commercials one step further. These toys are activated by inaudible signals broadcast during a program. They are referred to as "interactive," but no descriptor could be more misleading. Although the television affects the toy and the child, no reciprocal interaction occurs.

Television-activated toys represent the third, and potentially most hazardous, phase in the commercialization of children's television. Initially, the promotion of toys on television was limited to commercials. After the toy was purchased, the child decided when and how to play with it. In the next phase, program-length commercials were developed to market toys and to show children how to play with them.

The development of television-activated toys almost completely eliminates the creative role of the child. Children need only to buy the toy; the television will play with it for them.

Parents should consider a child's playtime as an active, creative process that requires imagination. Television-activated toys interfere with this process.
What Is `Significant' and DTP Reactions
Authors: WILKINS JEANETTE
Published: December 2021

To the Editor.—

I read with interest the article by Hoffman et al.1 The authors conclude from this study that DTP immunization is not a significant factor in the occurrence of SIDS because only five (1.8%) of the case infants died within 24 hours of receiving the DTP vaccine. Their data are welcomed and provide convincing evidence that the DTP vaccine does not contain a potent toxin contributing to infant sudden death.

However, if one assumes that the adverse reaction to the DTP vaccine may result from an immunologic intravascular complexing of particulate antigen (whole-cell or disrupted pertussis organisms) with specific antibody to produce a Jarisch-Herxheimer reaction,2,3 then the adverse reaction may not occur within 24 hours of inoculation.
Fire-Setting Behavior in Individuals With Klinefelter Syndrome
Authors: MILLER MARVIN E. , SULKES STEPHEN
Published: December 2021

Klinefelter syndrome is a sex chromosome disorder with an incidence of approximately two per 1,000 male newborns.1 Eighty percent of individuals with Klinefelter syndrome are 47,XXY, whereas the other 20% have a variant sex chromosomal constitution with additional supernumerary X or Y chromosomes (ie, 48,XXXY, 48XXYY) or are mosaic.2 Individuals with Klinefelter syndrome have small testes which usually cannot produce sperm or normal amounts of testosterone. The results of this are infertility and undermasculinization. Behavioral and psychiatric problems are also common in individuals with Klinefelter syndrome and include personality disorder, reactive depression, schizophrenia, mental deficiency, sexual deviation, criminal behavior, and alcoholism.3
School Bus Seat Belts?
Authors: LAWS HARRY F.
Published: December 2021

To the Editor.—

The recently debated issue of whether or not to put seat belts on children riding school buses seems to be gaining momentum and attempts are being made to amass data supporting their usage on grounds of safety. My observation is that safety, although it is important, is not the most important issue today on school buses. Discipline, or lack thereof, is more of an issue. Data already exist to support the use of seat belts to improve children's behavior, and it would seem to me that recommending seat belts on school buses for that purpose makes much better sense and would be rapidly adopted by school officials! Perhaps we need to adjust the thrust of our argument!
Aspirin and Reye Syndrome
Authors: BARAL JIM
Published: December 2021

To the Editor.—

I read with interest the article by Orlowski et al.1 As a coauthor of the original article on Reye syndrome,2 and as the author of a relevant letter published in the New England Journal of Medicine,3 I was surprised that the authors did not review these previous submissions, in which it was stated that 11 of the 21 patients in the original study were given aspirin before the onset of their syndrome.
Treatable Dystonia Presenting as Spastic Cerebral Palsy
Authors: FINK JOHN K. , FILLING-KATZ MICHELE R. , BARTON NORMAN W. , MACRAE PAULA RAVIN , HALLETT MARK , COHEN WARREN E.
Published: December 2021

To the Editor.—

Cerebral palsy is a disorder with nonprogressive motor impairment that begins in early infancy and is characterized by spasticity or involuntary movements.1 It is classified according to the primary motor disturbance present (spastic, extrapyramidal, hypotonic, and mixed). Approximately 65% of patients with cerebral palsy have the spastic type.2 The term does not imply a specific cause. Prematurity, anoxia, infection, trauma, and metabolic or other pathologic processes may be responsible in individual patients.
Adverse Drug Reactions in Children Leading to Hospital Admission
Authors: Mitchell Allen A. , Lacouture Peter G. , Sheehan Jane E. , Kauffman Ralph E. , Shapiro Samuel
Published: December 2021

To provide information regarding pediatric hospital admissions prompted by adverse drug reactions, data were reviewed from an intensive drug surveillance program in which 10,297 patients admitted to diverse pediatric wards at four teaching and three community hospitals were systematically monitored. Among 3,026 neonatal intensive care unit admissions, 0.2% were prompted by adverse drug reactions; among 725 children with cancer, 22% of admissions were prompted by adverse drug reactions. Among 6,546 children with other conditions monitored on general medical and specialty wards at two teaching hospitals and on general pediatric wards at three community hospitals, 2% (131) of admissions were prompted by adverse drug reactions. Two patients (0.03%) died because of their reactions. The proportion of admissions prompted by drug reactions increased between infancy and 5 years of age and tended to be relatively stable thereafter. The drugs most commonly implicated in the admissions were phenobarbital, aspirin, phenytoin, ampicillin/amoxicillin, theophylline/aminophylline, trimethoprim-sulfamethoxazole, and diphtheria-pertussis-tetanus vaccine. Similar proportions of admissions were prompted by adverse drug reactions in teaching hospitals (2.1%) and in community hospitals (1.8%), and the drug groups implicated in these admissions were generally similar in the two settings. In contrast to adult populations, children with adverse drug reactions account for a small proportion of hospital admissions. Findings from this large, systematic study of pediatric admissions to teaching and community hospitals may serve as a baseline to which other pediatric facilities can compare their experience.
Systemic Vasculitis Associated With Eosinophilia and Marked Degranulation of Tissue Eosinophils
Authors: Fischer Thomas J. , Daugherty Cynthia , Gushurst Colette , Kephart Gail M. , Gleich Gerald J.
Published: December 2021

A 9-year-old girl had fever, life-threatening interstitial pneumonia, a vesicular skin rash, parotid and submandibular swelling, and marked blood eosinophilia (WBC count 47,000/µL, 39% eosinophils). Results of lung and skin biopsies showed vasculitis with intense eosinophil infiltration. Immunofluorescence analyses of these biopsies, as well as analysis of tissue from the parotid, lip, and trachea, showed striking deposition of eosinophil granule major basic protein associated with areas of tissue damage. Treatment with glucocorticoids and hydroxyurea produced clinical improvement. The association between tissue damage and deposition of the cytotoxic major basic protein suggests that the eosinophil contributed to the pathophysiology of this disease. Recognition of the capacity of the eosinophil to produce tissue damage can be helpful in the selection of therapy.
Levy-Hollister Syndrome
Authors: Kreutz Joseph M. , Hoyme H. Eugene
Published: December 2021

The Levy-Hollister syndrome is an autosomal dominant disorder characterized by lacrimal malformations, simple cup-shaped ears, hearing loss, hypodontia and enamel dysplasia, and upper limb malformations. Renal anomalies have been noted variably. Two families with this disorder have been described previously. Recently, a third family with the Levy-Hollister syndrome was evaluated. Unusual features present in this family included bilateral nasolacrimal duct fistulas, radial aplasia, and unusual dermal ridge patterns. Early recognition of this disorder should prompt investigation for renal anomalies and/or hearing loss. It should also lead to consideration of surgical attempts to correct the lacrimal abnormalities or conductive hearing loss, thereby reducing the long-term morbidity in affected patients.
Intrapartum Asphyxia and Cerebral Palsy
Authors: Freeman John M. , Nelson Karin B.
Published: December 2021

Signs of presumed hypoxia/asphyxia of the fetus are not uncommon and can be detected during labor, in the delivery room, and during the early neonatal period. Virtually no single sign or symptom has sufficient correlation to enable prediction of later cerebral palsy with a reasonable degree of medical certainty. To attribute cerebral palsy to prior asphyxia with reasonable certainty, there must be evidence that a substantial hypoxic injury occurred and that a sequence of events ensued which would prove the clinical impact of that hypoxic insult. Few cases of cerebral palsy meet these criteria.
Neonatal Extracorporeal Membrane Oxygenation
Authors: DONN STEVEN M.
Published: December 2021

The number of centers providing extracorporeal membrane oxygenation (ECMO) therapy to newborns with intractable respiratory failure has grown dramatically. The ECMO registry now includes 37 institutions in the United States,1 and there may be additional centers offering ECMO but not participating in the registry. To date, more than 1,400 patients have been treated with ECMO with a survival rate exceeding 80%. Widespread acceptance of ECMO therapy has been accomplished despite a paucity of controlled clinical trials2 and without the benefit of long-term follow-up of survivors. Initial fervor about neonatal ECMO has stemmed from the excellent survival statistics cited by most of the earlier investigators.2-4
Asthma
Authors: SMITH THOMAS F. , MELTON ALTON L.
Published: December 2021

To the Editor.—

We would like to applaud the letter by Plaut et al (Pediatrics 1988;81:174) urging that pediatricians not hesitate diagnosing asthma in children whose wheezing is eradicated by antiasthma medicines. Parents may be upset if some of the myths about asthma are not dispelled at the same time. However, parents of children referred to our medical center are often more upset to find that their pediatrician has been giving their child antiasthma medicines for years without calling it asthma.
Physician Reimbursement
Authors: COHEN GEORGE J.
Published: December 2021

To the Editor.—

In the excellent study of physician reimbursement by Hickson et al (Pediatrics 1987;80:344-350), there seems to be an implication that more health care visits than stated in the American Academy of Pediatrics' guidelines constitute excessive cost and perhaps unnecessary patient-doctor interaction. The suggestion that limiting compensation to just the visits in the guidelines might be a technique of cost control is really self-defeating. The authors have already demonstrated that more well-child visits decrease the number of emergency room visits, which are far more expensive.
Ribavirin Use Questioned
Authors: DASHEFSKY BARRY , WALD ELLEN R. , GREEN MICHAEL
Published: December 2021

To the Editor.—

The report by McMillan and colleagues1 of the nonpredictiveness of certain clinical and laboratory tests in determining the duration of hospitalization of patients with respiratory syncytial virus adds to our understanding of this important respiratory pathogen. However, we disagree with the authors' implied assumption that ribavirin therapy might be expected to shorten hospitalization and with their concluding recommendation "to institute aerosolized ribavirin therapy for essentially all infants with documented respiratory syncytial virus infection who require hospitalization."1(p26)
Ribavirin Use Questioned
Authors: MCMILLAN JULIA A. , WEINER LEONARD B.
Published: December 2021

In Reply.—

The concerns of Dashefsky et al regarding the validity of the studies that led to the FDA approval of aerosolized ribavirin for the treatment of patients with respiratory syncytial virus infection are well described in their critical review of those studies.1 We agree that none of those studies provided the kind of conclusive quantification of ribavirin's efficacy that should preclude further placebocontrolled trials. Nonetheless, ribavirin is on the market, and physicians who care for young infants hospitalized with respiratory syncytial virus infection must decide whether and when it should be used.
Physical Examination for Brain Injury
Authors: MARGOLIS PETER , NICHOLS VIRGINIA
Published: December 2021

To the Editor.—

Rivara et al (Pediatrics 1987;80:579-584) suggest that children without positive clinical findings following head trauma may still be at substantial risk for brain injury. In the abstract of their article, they state, "No clinical findings, alone or in combination, accurately identified all patients with abnormal findings on CT scan."(p579) In particular, the authors noted that, of 51 patients with a Glasgow Coma Scale of 13 to 15, 16 (31%) had abnormal CT findings.
Bilirubin, Intraventricular Hemorrhage, and Phenobarbital in Very Low Birth Weight Babies
Authors: Epstein Michael F. , Leviton Alan , Kuban Karl C. K. , Pagano Marcello , Meltzer Catherine , Skouteli Helen N. , Brown Elizabeth R. , Sullivan Kathleen F.
Published: December 2021

The relationships among serum bilirubin concentration on days 5 and 7, birth weight, the presence of intraventricular hemorrhage, and the receipt of phenobarbital were examined in a group of 232 newborns weighing <1,751 g who were intubated, mechanically ventilated by 12 hours after birth, and whose parents had given permission for a randomized trial of phenobarbital prophylaxis of intraventricular hemorrhage. The ratio of serum bilirubin concentration to birth weight (the bilirubin divided by birth weight index [BBI]) was used to examine the impact of 25 variables on a clinical guideline for therapy of hyperbilirubinemia in newborn infants. A linear regression model was used; the most powerful covariate was a birth weight <1.0 kg. The only other variable that reduced the BBI was phenobarbital receipt. The presence of intraventricular hemorrhage and ecchymoses had a significant influence increasing the BBI.
TrophAmine
Authors: HEIRD WILLIAM C.
Published: December 2021

In Reply.—

The purpose of the study reported in the paper1 to which Zlotkin refers was to evaluate the efficacy of a new parenteral amino acid mixture (ie, TrophAmine) with respect to maintaining "normal" plasma amino acid concentrations and promoting nitrogen retention in low birth weight infants. Because the study was not a controlled trial in which this amino acid mixture was compared with another mixture, a concerted effort was made to avoid drawing conclusions or stating claims regarding the efficacy of this amino acid mixture relative to other mixtures.
Peptic Ulcer Disease in Children: Etiology, Clinical Findings, and Clinical Course
Authors: Drumm Brendan , Rhoads J. Marc , Stringer David A. , Sherman Phillip M. , Ellis Lynda E. , Durie Peter R.
Published: December 2021

The records of all children with peptic ulcer disease at the Hospital for Sick Children were retrospectively evaluated, excluding neonates, throughout a 5-year period. Only cases with a definite ulcer crater identified either at endoscopy or at surgery were included. There were 36 patients, 20 boys and 16 girls. Duodenal ulcers were more common than gastric ulcers (2.8:1). Ages ranged from 3 months to 17 years, with a mean age of 10 years. Patients were reviewed with respect to etiology of peptic ulcer disease, age when first examined, initial symptoms, and clinical course. Patients were divided into two groups, those with primary (n = 19) and those with secondary (n = 17) peptic ulcer disease. All peptic ulcers in patients younger than 10 years of age were secondary in nature. Secondary ulcers occurred generally in association with a severe underlying illness (11/17), and many ulcers necessitated emergency surgery because of perforation and/or severe hemorrhage (8/17). None of these patients had chronic or recurrent symptoms. In contrast, in children with primary peptic ulcer disease, initial symptoms were more benign. Most patients had abdominal pain and only one required emergency surgery. Children with primary duodenal ulcer disease had a high incidence of recurrent symptoms (67%), however, with surgery for intractable disease necessitated in 40%. Single-contrast barium meals were found to be unreliable in establishing a diagnosis of peptic ulcer disease, particularly cases of gastric ulcer disease.
Ontario Child Health Study: Patterns of Ambulatory Medical Care Utilization and Their Correlates
Authors: Woodward Christel A. , Boyle Michael H. , Offord David R. , Cadman David T. , Links Paul S. , Munroe-Blum Heather , Byrne Carolyn , Thomas Helen
Published: December 2021

Data from a large epidemiologic survey of Ontario children 4 to 16 years of age are presented concerning the frequency and correlates the use of ambulatory medical care services during a 6-month period in which a universal, first-dollar health insurance plan was used. Patterns of use of ambulatory medical care are described for three settings: doctor's offices, emergency rooms, and hospital outpatient departments. A group of children who are frequent users of ambulatory medical care (defined as using three or more services in 6 months) consumed nearly two thirds of all services. Two regression equations are presented—one predicting use/nonuse of ambulatory medical care and the other predicting the total number of visits for medical care. Although only a small proportion of the variance in use/nonuse and amount of use was explained, the major determinant of both ambulatory medical care use and frequency of use was the child's physical health status as perceived by the parent. Younger child, urban area of residence, the number of chronic medical problems of the child, and higher level of maternal education also contributed to the explanation of use v nonuse. Among ambulatory medical care users, high users were more likely to be described as having mental health problems and have parents who had been treated for "nerves." Family size and socioeconomic variables were not important factors in use, suggesting that universal health insurance reduces some barriers to ambulatory medical care for children.
Stairway Injuries in Children
Authors: Joffe Mark , Ludwig Stephen
Published: December 2021

Children frequently injure themselves falling down stairways, but the characteristics of these injuries are not well described. A total of 363 consecutive patients seen in a pediatric emergency department were studied. The majority of patients had minor superficial injuries. Bony injuries occurred in 7% of patients. Head and neck injuries occurred in 73% of patients, extremity injuries, which were predominantly distal, in 28%, and truncal injuries in 2%. Children younger than 4 years of age were more likely to sustain head trauma than children older than 4 years of age (P < .005). Injury to more than one body part occurred in only 2.7% of patients. Children who fell down more than four steps had no greater number or severity of injury than those who fell down less than four steps (P = .67). Patients were admitted to hospitals in 3% of cases. No patient had life-threatening injuries and no patients required intensive care. When multiple, severe, truncal, or proximal extremity injuries are noted in a patient who reportedly fell down stairs, a different mechanism of injury should be suspected.
Improving the Quality of Expert Witness Testimony
Authors: BRENT ROBERT L.
Published: December 2021

Although various groups in our society have bemoaned the increasing frequency of negligence litigation and its concomitant costs, there has been an absence of any coordinated approach to solve this serious economic and social problem. Many physician groups, including our own American Academy of Pediatrics,1 have made attempts at tort reform. In my own earlier writings I suggested numerous alterations in the present system of tort law that I believed would improve the overall fairness of the system and decrease the excessive number of nonmeritorius law suits, not only in the medicolegal arena but in the whole area of negligence litigation.2,3
Prevention of Lead Poisoning in Children—An Issue for Both Developing and Industrialized Countries
Authors: GUTHRIE ROBERT
Published: December 2021

To the Editor.—

This is in response to two articles1,2 concerning lead exposure in fetuses and children. Recent evidence has begun to document the threat to the human species of prenatal, as well as postnatal, exposure to low levels of blood lead concentration. Studies in Australia3 and the United States4-6 have described the problem for industrialized countries, and reports from England7,8 and the United States and Kuwait9 have produced evidence for developing countries.

What is particularly disturbing is that the blood levels of prenatal as well as postnatal exposure that have produced permanent deficits in the CNS of children are not much greater than the blood levels found in most of us living in modern, industrialized society.
Ultrasound Screening of Healthy Infants for Urinary Tract Abnormalities
Authors: Steinhart Jacob M. , Kuhn Jerald P. , Eisenberg Bernard , Vaughan Russell L. , Maggioli Albert J. , Cozza Thomas F.
Published: December 2021

The purpose of the study was to determine the incidence of silent but significant urinary tract abnormalities that might be detected by screening renal ultrasound studies of apparently healthy infants. Of 437 babies studied, six were found to have uropathology severe enough to warrant surgery for an incidence of 1.37% or one of every 73 babies studied.
Decreased Neonatal Serum Bilirubin With Plain Agar: A Meta-Analysis
Authors: Kemper Kathi , Horwitz Ralph I. , McCarthy Paul
Published: December 2021

Neonatal jaundice is one of the most common problems leading to prolonged hospitalization of the newborn. Therefore, an effective low-risk, low-cost therapy reducing hospitalization is highly desirable. Plain dried agar, an extract of seaweed, is low cost and low risk; it can bind bilirubin in the gut, decreasing its enterohepatic circulation, thereby decreasing serum levels. Because of conflicting conclusions in the studies of agar's effectiveness in the prevention and treatment of neonatal jaundice, a meta-analysis of their methodologies was done. Criteria for assessing prospective controlled therapeutic trials of agar were established in six areas: hypothesis and clinical outcome, patient selection, treatment group allocation, therapeutic maneuver, use of cotherapies, and data analysis. Nine prospective clinical trials of agar therapy were evaluated using these six criteria. The seven studies with negative conclusions regarding agar's efficacy failed to meet the criteria in several categories: patient selection, therapeutic maneuver, use of cotherapies, or data analysis. All of the studies, including the positive studies, were at risk for biased treatment allocation. Although the pooled data analysis suggests that prophylactic agar treatment is associated with reduced peak serum bilirubin levels, this observation must be interpreted cautiously in light of heterogenous patient populations and the methodologic problems described. Based on this meta-analysis, agar therapy for neonatal jaundice can neither be recommended nor rejected. The methodologic analysis gives clear guidance for future research concerning the effectiveness of agar in treating neonatal jaundice and provides a model for mete-analysis of other prospective trials in pediatrics.
Carbon Monoxide Poisoning Due to Automobile Exposure: Disparity Between Carboxyhemoglobin Levels and Symptoms of Victims
Authors: SANCHEZ RICARDO , FOSARELLI PATRICIA , FELT BARBARA , GREENE MARY , LACOVARA JANIS , HACKETT FAITH
Published: December 2021

An unresponsive 27-month-old black girl was brought to the Johns Hopkins pediatric emergency room. For the prior 45 to 50 minutes, she had been the middle passenger in the backseat of a car that had been traveling from Washington, DC, to Baltimore. The car was described as "an old heap of junk" by an adult passenger who also reported that the car's heater was turned on with all of the windows closed except for the ajar driver's window, throughout the trip. The two other children in the backseat reported that the patient had repeatedly climbed down to the floor and back up to the seat during the trip; about 15 minutes before arrival, she had fallen asleep.
Congenital Absence of the Hymen Only a Rumor?
Authors: JENNY CAROLE
Published: December 2021

In Reply.—

The letter from Mor and Merlob in which they note that all of their large group of infants examined for congenital malformations had hymens1 reinforces the fact that congenital absence of the hyman occurs rarely, if at all. If one were to recalculate confidence intervals using their data pooled with the data from our study done in Seattle,2 the expected frequency of congenital absence of the hymen in the population that could allow the inspection of 25,068 and 1,131 infants without finding the malformation would range from .00011 to 0 at the 95% confidence level.

The data from Mor and Merlob's group help put the myth that girls are often born without hymens to rest!
Pediatric Residencies: Differences Between 1959/1960 and 1984/1985
Authors: Bryke Christine R. , Tunnessen Walter W. , Scully Thomas J. , Oski Frank A.
Published: December 2021

Patient contact data, collected by two first-year pediatric residents, separated in time by 25 years, were compared, and it is concluded that pediatric residency has undergone major changes throughout the past quarter century. Pediatric training has increased in length and includes more female residents. The overall intensity of patient care pediatric residents provide has increased. Children with chronic disorders that were often lethal conditions 25 years ago now make up a large portion of pediatric admissions to teaching hospitals.
Peripheral Aneurysms in Children—A Link to Trauma
Authors: BAGWELL CHARLES E. , CAFFEE H. HOLLIS , TALBERT JAMES L.
Published: December 2021

Evaluation of soft tissue masses is a common component of pediatric practice and usually includes adenopathy v soft tissue neoplasia in the differential diagnosis. Recent experience with a young child referred for an enlarging axillary mass, which was found to be an aneurysm of the axillary artery, illustrates the natural history ofthis uncommon lesion and its frequent association with trauma in the pediatric population.

CASE REPORT

A 45/12-year-old boy had a 3-month history of an enlarging right axillary mass. Although the child remained asymptomatic, gradual enlargement of the mass was described. The parents could recall no history of injury to the affected extremity (including arterial puncture for blood gas analysis) but, when questioned further, did describe transient discomfort several months previously when an adolescent sibling had grabbed him suddenly by the upper arm while running alongside and lifted him from the ground when he tripped and fell.
Black Child Care Practices in the Midwest
Authors: WALBURN JOHN N. , PERGAM JEANNETTE M. , PERRY SAMUEL H. , JENSEN JANE
Published: December 2021

A recent incident involving a shocked first-year pediatric resident who observed a black teenage mother chewing part of a tuna sandwich and feeding the resultant "mush" to her 8-month-old infant stimulated us to look for documentation of various child-rearing practices that were familiar to us from our work with mothers of various ethnic groups.

There is ample literature describing cultural beliefs about disease causation and cure; however, we could find little that described day-to-day parenting behaviors. We surveyed 68 black child care providers in Omaha, concerning their knowledge and use of child-rearing practices for infants (Table).

METHODS

A questionnaire approved by the University of Nebraska Medical Center Institutional Review Board was administered nonrandomly to black care givers by personnel in our pediatric clinics or by public health nurses during home visits.
Pediatric Guidelines for Infection Control of Human Immunodeficiency Virus (Acquired Immunodeficiency Virus) in Hospitals, Medical Offices, Schools, and Other Settings
Authors:   Task Force on Pediatric AIDS
Published: December 2021

Acquired immunodeficiency syndrome (AIDS), the most severe manifestation of infection with the human immunodeficiency virus (HIV), has been diagnosed in more than 900 children younger than 13 years of age throughout the United States as of May 1988, 77% of whom were infected in utero or perinatally secondary to maternal infection. Risk factors for maternal infection include intravenous drug abuse or sexual contact with partners who are intravenous drug abusers or bisexual. The remainder of children, including a high proportion of hemophiliacs, have been infected by blood or clotting factor infusion between 1979 and 1985. In addition, adolescents have acquired infection through sexual activity and intravenous drug use, as well as transfusion of contaminated blood or blood factors.

The criteria for diagnosis of AIDS in children differ in some ways from those for adults, and the most recently published diagnostic criteria (Morbidity Mortality Weekly Report, Aug 14, 1987) include the expanded spectrum of disease, such as recurrent bacterial infections and encephalopathy, as well as including children with presumptive diagnosis of AIDS-associated diseases such as lymphpoid interstitial pneumonitis. There is no accurate estimate of the numbers of infected asymptomatic children or of infected children with milder symptoms that do not meet the criteria for the diagnosis of AIDS. Although most cases of pediatric HIV infection have been identified in New York City, Newark, Miami, and Los Angeles, cases are appearing in other locations. Thus, HIV infection in childhood is becoming more widespread, but in many states it is still rare.

Because the cause of AIDS is a virus transmissible from human to human, pediatric health care workers must adjust infection control guidelines to meet this new threat.
MEDLINE Off-line—A Better Way?
Authors: MENKE JAMES A. , MCCLEAD RICHARD E.
Published: December 2021

In Reply.—

We can only agree with Desch and Johnson's comments, particularly regarding the rapid changes that are occurring in the on-line database industry. We also agree that for the novice the use of the Grateful Med program in conjunction with the National Library of Medicine's database is probably the best method. However, for those who are not novices or for those who plan to do a great deal of searching, BRS Colleague may be more appropriate.
Medicating Children With Attention Deficit Disorder
Authors: WIENER JERRY M.
Published: December 2021

To the Editor.—

I read the position statement by the American Academy of Pediatrics, Committees on Children With Disabilities and Drugs (Pediatrics 1987;80:758-760) regarding medication for children with attention deficit disorder. It is encouraging that the American Academy of Pediatrics has undertaken to bring this information to its membership; it is disappointing that, in discussing evaluation and treatment, there was no acknowledgment of any role for the child psychiatrist, even though the vast majority of research into diagnosis and treatment has been done by child psychiatrists and published in the psychiatric literature.
Medicating Children With Attention Deficit Disorder
Authors: COHEN HERBERT J.
Published: December 2021

In Reply.—

The AAP Committee on Children With Disabilities concurs with several of the issues raised by Dr Wiener. We note the need for counseling for children with ADHD and clearly support referrals to child psychiatrists when these children need psychiatric help. We also agree that working with the family represents a major component of the treatment of children with ADHD.

The selection of drugs such as methylphenidate over antidepressants represents our attempt to focus treatment on the use of this drug for ADHD itself.
Neonatal Back Transport: Clinical Outcomes
Authors: Lynch Terese M. , Jung August L. , Bose Carl L.
Published: December 2021

The convalescent course of 55 infants transported from a Level III hospital back to the community hospitals from which they were originally transported was compared with the course of 58 infants who convalesced in the tertiary center nurseries. The events in their prenatal course and acute neonatal course were similar, thus making comparisons of their convalescent course possible. Weight gain was greater among the transported infants for infants with birth weights ≥2,000 g and comparable if birth weight was <2,000 g. Transported infants received fewer transfusions than their nontransported counterparts. Tolerance of feedings, the occurrence of apnea and bradycardia, and use and discontinuance of supplemental oxygen were similar in both groups. Major new health problems occurred in 27% of all subjects, 20% of transported infants and 32% of nontransported infants. Readmission to the tertiary center or a change in status to more intensive care in the tertiary center occurred in 10% of all infants, 7% of transported and 14% of nontransported infants. It was concluded that convalescing infants often presented new clinical problems, in similar numbers and severity whether convalescing in the tertiary center or after back transport to community hospitals. Community hospital care givers were considered alert to these new problems and to have provided appropriate care, including retransfer to the tertiary center when necessary.
Bronchoscopic Findings in Infants Treated With High-Frequency Jet Ventilation Versus Conventional Ventilation
Authors: Kercsmar Carolyn M. , Martin Richard J. , Chatburn Robert L. , Carlo Waldemar A.
Published: December 2021

To identify tracheobronchial abnormalities associated with assisted ventilation, 40 infants with respiratory distress syndrome randomized to receive either short-term (48 hours) conventional or high-frequency jet ventilation were studied. Flexible fiberoptic bronchoscopy (n = 13) was performed and/or clinical and radiographic assessments were used to evaluate for laryngeal, tracheal, and bronchial lesions. There was no bronchoscopic evidence of necrotizing tracheobronchitis after either high-frequency jet ventilation (n = 8) or conventional ventilation (n = 5). Laryngotracheomalacia and nodular vocal cords were the most common abnormalities noted, and they occurred with equal frequency in both groups. Study infants who were not bronchoscoped had no clinical or radiographic evidence of tracheal or mainstem bronchial obstruction. One patient did have microscopic evidence of necrotizing tracheobronchitis at autopsy, however. It is concluded that short-term treatment of respiratory distress syndrome with high-frequency jet ventilation may be performed without undue risk of tracheobronchial injury.
Cocaine Use During Pregnancy: Prevalence and Correlates
Authors: Frank Deborah A. , Zuckerman Barry S. , Amaro Hortensia , Aboagye Kwabena , Bauchner Howard , Cabral Howard , Fried Lise , Hingson Ralph , Kayne Herbert , Levenson Suzette M. , Parker Steven , Reece Hilary , Vinci Robert
Published: December 2021

Cocaine use during pregnancy was assessed by interviews and urine assays obtained prenatally and immediately postpartum from 679 urban women enrolled in prenatal care. Of these, 17% were found to have used cocaine at least once during pregnancy. Eight percent had urine assays positive for cocaine metabolites using the enzyme-mediated immunoassay technique with a cutoff of 300 ng/mL of benzoylecgonine. Of the cocaine users, 24% denied use at the time of the interview and were identified solely by urine assay. Cocaine users were significantly (P < .01) less likely than nonusers to be married, Hispanic, or black born outside of the United States and were less well nourished. Users reported significantly (P < .01) more sexually transmitted diseases, prior low birth weight infants, spontaneous and elective abortions, and greater use of alcohol, cigarettes, marijuana, opiates, and other illicit drugs during pregnancy. Because cocaine use is correlated with many potential risk factors, large sample sizes and multivariate statistical techniques are needed to determine whether cocaine use during pregnancy poses an independent risk for adverse neonatal outcomes.
Thrombocytopenia and Human Immunodeficiency Virus in Children
Authors: Ellaurie Maadhava , Burns Edward R. , Bernstein Larry J. , Shah Kiran , Rubinstein Arye
Published: December 2021

Thrombocytopenia occurs in 13% of children with symptomatic human immunodeficiency virus (HIV) infection. The clinical and laboratory course of 19 children infected with HIV with thrombocytopenia is described. Bone marrow aspirates showed normal to increased numbers of megakaryocytes. Levels of antiplatelet antibodies were increased in 80% of the children and circulating immune complexes were found in 74%. Clinically significant hemorrhage leading to anemia occurred in five patients, and CNS bleeding led to a fatal outcome in an additional three children. Spontaneous remission of thrombocytopenia occurred in three of the 19 subjects. High-dose IV γ globulin was effective in increasing the platelet counts of six of 15 patients (40%) but resulted in a sustained remission in only one subject. Oral prednisone was effective in increasing the platelet count of two thirds of those whose platelet counts could not be controlled by IV γ-globulin. Bleeding manifestations were eliminated in all patients whose platelet counts increased significantly. Of the 11 children whose counts increased either spontaneously or as a result of therapy, eight remain alive (72%). In contrast, all of the eight patients whose platelet counts did not improve have died. Thrombocytopenia in children with HIV disease is engendered by immune mechanisms and is a major cause of morbidity and mortality. High-dose IV γ-globulin and/or corticosteroids are temporarily effective in increasing the platelet count and reducing bleeding in about half of thrombocytopenic patients and are recommended for use. The ability to respond to therapy correlates with improved survival.