bluuebunny/crossref_metadata_2025 huggingface dataset:
Does Statistical Significance Equal Real Significance
Authors: HERSHER LEONARD
Published: December 2021

To the Editor.—

In what is probably the best-controlled study ever published on the controversial question of the effect of stressful life events in a family on childhood illness, Beautrais et al1 have demonstrated unequivocally that those events correlate positively with childhood morbidity.

The authors, however, grossly overinterpret the clinical importance of the results of their study. They state, for example, that "...the net effect of life events on child health was large ..." and that "... children from families experiencing 12 or more life events had ...six times the risk of hospital admission compared with children from families with three or fewer life events."
Early Termination of Breast-Feeding: Identifying Those at Risk
Authors: Loughlin Howard H. , Clapp-Channing Nancy E. , Gehlbach Stephen H. , Pollard John C. , McCutchen Thomas M.
Published: December 2021

In a private pediatric practice, 94 infants who were breast-feeding were followed for the first 2 months of life in order to define the frequency of cessation of breast-feeding and to identify factors that would predict mothers and infants at risk for early cessation.

At 8 weeks, 30% of the mothers had stopped nursing. Factors associated with cessation were: maternal lack of confidence in breast-feeding (P < .001); anticipated duration of nursing less than 6 months (P = .002); ratings by the nursery staff of infant's excessive crying (P = .007), infant's demanding personality (P = .007), trouble with féeding (P = .001), and future trouble with feeding (P = .004). Together, these factors predicted 77% of the mothers who terminated breast-feeding. Supplementing with formula before the 2-week office visit also led to termination of breast-feeding by 8 weeks (P = .006). This decision was frequently made without medical advice. Nearly 64% (14/22) of the mothers who added formula within the first 2 weeks did so without contacting the pediatric practice.
Effect of Formula Supplementation in the Hospital on the Duration of Breast-Feeding: A Controlled Clinical Trial
Authors: Gray-Donald Katherine , Kramer Michael S. , Munday Susan , Leduc Denis G.
Published: December 2021

To avoid methodologic pitfalls in previous observational studies linking formula supplementation in the hospital to early discontinuation of breast-feeding, a controlled clinical trial of restricted supplementation was conducted. In a pretrial sample of 621 newborns, a comparison of two "well-baby" nurseries found no differences in either hospital supplementation practices or the proportion of infants still being breast-fed at 4 or 9 weeks postpartum. Restriction of supplementation in one of the nurseries for the trial period (n = 781) did not result in higher breast-feeding rates at 4 or 9 weeks. There was, however, a slightly greater mean percent of birth weight lost in the restricted group (6.0% v 5.1%; P < .001). In examining the control group for evidence of an "observational" association, it was found that infants still breast-feeding at 4 or 9 weeks were far more likely to have been unsupplemented than those no longer being breast-fed. It thus appears that formula supplementation in the hospital is a marker, rather than a cause, of breast-feeding difficulty.
Bilirubin Photoisomerization in Premature Neonates Under Low- and High-Dose Phototherapy
Authors: Costarino Andrew T. , Ennever John F. , Baumgart Stephen , Speck William T. , Paul Mary , Polin Richard A.
Published: December 2021

Photoisomerization of native bilirubin to more polar configurational isomers (Z,E-bilirubin) and structural isomers (lumirubin) was studied in 20 premature infants with physiologic jaundice to determine the effect of low-dose (6 µW/cm2nm) v high-dose (12 µW/cm2/nm) phototherapy. Patients were assigned prospectively to receive either low- or high-dose treatment. Study groups were comparable with regard to birth weight, gestational age, and total bilirubin prior to the initiation of phototherapy. Treatment was administered with white light produced by a commercially available halogen-tungsten lamp. Dose was measured periodically during the study to ensure a uniform distribution of irradiance and constant exposure. Sera for photoisomers were obtained before initiation of treatment and at two, four, and eight hours. Photoisomers expressed as a percent of total bilirubin were determined using high-pressure liquid chromatography. Serum proportion of both configurational and structural isomers increased with the duration of phototherapy in both treatment groups. There was no significant difference between the percent of configurational isomers in low- and high-dose phototherapy groups. However, high-dose treatment produced a significantly higher proportion of the structural isomer lumirubin after four hours (0.7% low dose v 1.3% high dose, P < .05). These data confirm that phototherapy results in both configurational and structural isomerization of bilirubin in vivo. Furthermore, the previously described "dose" effect of phototherapy may be attributed to the production of the structural isomer, lumirubin.
Normotriglyceridemic Abetalipoproteinemia in Infancy: An Isolated Apolipoprotein B-100 Deficiency
Authors: Takashima Yoshiki , Kodama Tatsuhiko , lida Hisaya , Kawamura Masahiko , Aburatani Hiroyuki , Itakura Hiroshige , Akanuma Yasua , Takaku Fumimaro , Kawade Masaka
Published: December 2021

The plasma lipoproteins of a 1-year-old Japanese infant were studied because of malnutrition, severe decrease in plasma lipid level, and acanthocytosis. Plasma lipoprotein analysis revealed that low-density lipoproteins were deficient; however, low levels of triglyceride-rich lipoproteins were found in the plasma. On sodium dodecylsulfate (SDS) polyacrylamide gel electro-phoresis, apoprotein B-48 and a faint band corresponding to apoprotein B-100 were detected in the lipoprotein fraction of density < 1.006 g/mL when the infant was 6 months old. Apoprotein B-48 was more clearly detected after 1 year, but the band corresponding to apoprotein B-100 on the sodium dodecylsulfate gel electrophoresis had disappeared. The apoprotein B-48 content of the fraction with density < 1.006 g/mL was about 0.05 to 0.3 mg/dL. The patient's lipoproteins consisted mainly of high-density lipoproteins. These results suggest that the disorder in this patient is caused by apoprotein B-100 deficiency.
Bronchiolitis and Recurrent Wheezing
Authors: WELLIVER ROBERT
Published: December 2021

To the Editor.—

I read with interest the article by McConnochie and Roghmann on bronchiolitis and wheezing.1 I especially applaud the effort that extends epidemiologic studies of possible long-term effects of bronchiolitis to patients whose original illness was mild enough to permit outpatient management. The authors found a portion of recurrent wheezing following bronchiolitis that could not be explained by personal or family history of atopic illness, passive smoking, or any factor other than bronchiolitis itself.
Breaker's Back
Authors: BITHONEY WILLIAM G.
Published: December 2021

To the Editor.—

I wish to bring to the attention of Pediatrics readers a cause of back trauma among urban adolescents. In the Comprehensive Child Health Program, we recently saw a male adolescent who complained of lumbar back pain, relieved by rest and aggravated by bending over and by vigorous physical activity. He had also noted a mass about the size of an orange in the center of his back; he denied any history of trauma to the area.
Jean Seam Coccygodynia
Authors: STOSHAK MARCIE L. , MORTIMER EDWARD A.
Published: December 2021

To the Editor.—

We believe we have identified a new syndrome that may be of practical interest to those who care for adolescents. We present two case reports.

Case 1. This 14-year-old female student complained of low back pain and tenderness, which she had experienced for 2 months, since her return to school in September. On examination, there were no findings but the location of the pain was determined to be the coccyx. On questioning, she acknowledged wearing tight blue jeans with heavy reinforced seams to school.
Roentgenology and Malabsorption Syndromes
Authors: SMITH DAVID S.
Published: December 2021

To the Editor.—

The paper by Weizman et al1 in which radiologic manifestations observed in association with intestinal malabsorption syndromes are reevaluated is reminiscent of a similar concern in our department, some 40 years ago, that culminated in the paper, "The Roentgenologic Pattern of the Small Intestine in Infants and Children" by Henry Zwerling and Waldo E. Nelson.2 Naturally, I was not aware of their study until my association with Dr Nelson a few years later.

The stimulus for each of these studies was similar, viz, roentgenlogic demonstration of intestinal patterns that had been attributed to intestinal malabsorption (see references in each article) in children who had no clinical evidence of this disorder.
E-Ferol
Authors: PHELPS DALE L.
Published: December 2021

In Reply.—

Bowen and Johnson raise two issues regarding my commentary on E-Ferol. One is a technical misunderstanding, which I clarify below. The other issue, was my choice of title and its implications. My commentary was titled "E-Ferol: What Happened and What Now?" It is puzzling how this title could be misconstrued as intending "to comment on what went wrong to cause E-Ferol to be marketed for as long as it was." Bowen and Johnson further extrapolate from this to an incorrect and unsupported inference: "The implication of Phelps is that the Food and Drug Administration was unaware of this product when the contrary is true...." Neither the title nor the content of the commentary was meant to imply this.
Isolated Menses in Prepubertal Girls
Authors: Blanco-Garcia Matilde , Evain-Brion Danièle , Roger Marc , Job Jean Claude
Published: December 2021

Seventeen prepubertal girls 1 to 8 years of age were studied for the complaint of vaginal bleeding of apparent uterine origin. The bleeding was considered as isolated menses because it lasted two to five days and no other signs of sexual development or any detectable vaginal or uterine abnormalities were found. Eleven girls had two or more apparent menstrual periods, six experienced only one period. Height and bone age were not significantly different from normal. Laparoscopy or ultrasonography showed normal prepubertal uterine size, with either prepubertal ovaries or ovaries containing follicular cysts. Plasma gonadotrophins and their response to luteinizing hormone-releasing hormone were at prepubertal levels. Plasma estradiol level was significantly above the normal prepubertal range, suggesting transient ovarian activity and instability of the pituitarygonadal axis in these girls. Isolated menses occurred mainly during the months of September to January, thus leading us to speculate about possible seasonal variations of hormonal regulation.
Stability in Waking-Sleep States in Neonates as a Predictor of Long-Term Neurologic Outcome
Authors: Lombroso Cesare T. , Matsumiya Yoichi
Published: December 2021

Thirty-three full-term neonates were ranked blindly on a scale ranging from the least to the highest "risk" for future neurologic complications on the basis of available perinatal biographies, tests, and examinations performed during the newborn period. Four prolonged polygraphic-behavioral recordings were obtained one week apart beginning at ten days after birth. Five waking and sleep states were scored in each session as percentages of total observation time, giving a total of 20 scores for each baby to be subjected to analysis of variance. These measures also provided individual profile consistency or variability in maintaining waking-sleep states over the selected period of postnatal time. The whole cohort, except three infants who could not be followed adequately, was then reexamined periodically over a period ranging from 3 to 4 years (±6 months) for neurologic and developmental assessments. Except for two scores that produced a low level of statistical significance (P < .05), the other 18 scores were found to be not associated with long-term outcomes. Even the first two scores were not satisfactory discriminators for the outcome of the individual babies. However, when coefficients of concordance (W) were computed from each individual baby profile, significant statistics (P < .001) emerged to indicate good correlations between high or low W values in the newborn period and long-term outcomes. All 17 newborns who had W scores greater than 0.9 were found to be normal at follow-up regardless of the poor ranking given several of them during the newborn period. Among the 13 newborns who had W scores less than 0.9, 11 had a poor clinical outcome at follow-up, though several had been ranked initially as falling within the least "risk" group.
Coxsackievirus Group B Antibodies in the Ventricular Fluid of Infants with Severe Anatomic Defects in the Central Nervous System
Authors: Gauntt Charles J. , Gudvangen Richard J. , Brans Yves W. , Marlin Arthur E.
Published: December 2021

Ventricular fluids from four of 28 newborn infants who were initially seen with severe congenital anatomic defects in the central nervous system contained neutralizing antibody to at least one serotype of coxsackieviruses group B. Two of the four infants with anticoxsackieviruses group B antibody in the ventricular fluid did not have a detectable level of the same antibody(ies) in their serum. The ventricular fluid of one of the infants had immunoglobulin M neutralizing antibody directed against coxsackievirus B6. Of 11 mother-infant pairs that had neutralizing antibody to coxsackieviruses group B in both sera, nearly half had antibodies directed against more than one serotype. These data suggest the possibility of an association between congenital infections with coxsackieviruses group B and rare severe CNS defects.
Predicting Mortality in Low-Birth-Weight Infants with Pulmonary Interstitial Emphysema
Authors: Gaylord Mark S. , Thieme Rita E. , Woodall Diane L. , Quissell Barbara J.
Published: December 2021

Due to the high mortality associated with pulmonary interstitial emphysema in the low-birth-weight infant, a method was developed to predict the infants most at risk for death. This information will allow the discriminant selection of patients for future trials of an alternative method of mechanical ventilation, highfrequency ventilation. During a 3-year-period (July 1, 1979 through June 30, 1982), 70 infants were retrospectively analyzed to determine the clinical parameters important in predicting mortality. The infants at highest risk for death included those of younger gestational age, those with birth weight less than 1,500 g (95% of all mortalities), and those that developed pulmonary interstitial emphysema within the first 24 hours of life. Mortality sharply increased in the infants with birth weight less than 1,500 g whose ventilatory requirements exceeded a peak inspiratory pressure of 25 cm H2O on day 1. Morbidity was high in the survivors as evidenced by a 54% incidence of bronchopulmonary dysplasia. With multivariant analysis, it was possible to isolate the variables (birth weight and highest peak inspiratory pressure on day 1) most influential in predicting mortality and to construct a formula for predicting mortality in the infants with birth weight less than 1,500 g. With a subsequent prospective study of 30 infants, the predictive accuracy of the formula was established.
Decreased Specific Airway Conductance in Infant Apnea
Authors: Kao Lily C. , Keens Thomas G.
Published: December 2021

A disorder of respiratory control is the suspected etiology in a majority of infants with apnea. Although neurologic control of breathing has been evaluated in infants surviving an apneic episode, pulmonary mechanics have not been previously measured. Pulmonary mechanics were measured during sleep in ten infants with apnea, aged 45.4 ± 1.4 (SE) weeks postconception, and 13 control infants, aged 42.0 ± 0.8 weeks postconception. Infant apnea patients were defined as those having at least one episode of cyanosis, limpness, and apnea requiring vigorous stimulation or resuscitation to restore normal breathing, and in whom no treatable etiology could be found. Thoracic gas volume, airway resistance, and specific airway conductance were measured in an infant body pressure plethysmograph during quiet breathing. Dynamic pulmonary compliance was measured in six infants using an esophageal balloon. Specific airway conductance was decreased in infants with apnea compared with control infants (P < .05). Thoracic gas volume, airway resistance, and dynamic pulmonary compliance values were comparable with those of control infants. These data suggest that airway narrowing or abnormal control of airway tone during sleep may contribute to apnea in some infants.
Aseptic Meningitis Secondary to Metrizamide Lumbar Myelography in a 4½-Month-Old Infant
Authors: DiMario Francis J.
Published: December 2021

Although metrizamide has been used as a contrast agent for myelography for the past decade, there are few reports of its use in the pediatric population. Aseptic meningitis has rarely been reported as an adverse effect of metrizamide in adults. The first pediatric case of aseptic meningitis following lumbar myelography with metrizamide is reported.
Healing Rates of Treated and Untreated Bone Lesions in Histiocytosis X
Authors: Womer Richard B. , Raney R. Beverly , D'Angio Giulio J.
Published: December 2021

Evaluation of the response of histiocytosis χ to various forms of treatment is difficult, because presentation patterns are protean and the disease can be self-limited. A retrospective evaluation was made of the healing of 42 histiocytosis χ bone lesions, in 21 patients treated in variety of ways, using serial radiographs and a semiquantitative scoring system. Treatments included various combinations of surgery (simple biopsy or curettage), radiotherapy (200 to 1,200 centi-Gray [cGy]), chemotherapy (according to various protocols), and local steroid injection. Median times to a given degree of healing were similar across treatment groups and in untreated lesions. It was concluded that mode of treatment does not exert a strong influence on the rate of healing of histiocytosis χ bone lesions. Some healing should be apparent 4 months after diagnosis, but complete healing may take many months. Treatment of histiocytosis χ bone lesions is indicated only if intense pain or risk of fracture or deformity are present.
Burkitt-like Lymphoma in a Hemophilic Boy with Impaired Cellular Immunity
Authors: Aronis Sophia , Tzortzatou Fotini , Karaboulas Katherine , Tsiftis George , Madalenakis Katherine , Karpathios Themistoklis
Published: December 2021

Burkitt-like lymphoma was seen in a hemophilic boy with impaired cell-mediated immunity, of the type described in healthy hemophiliacs. The coexistence of two rare diseases, hemophilia and Burkitt's lymphoma in an immunosuppressed patient is suggestive of a blood-borne agent transmitted with factor VIII concentrates which might be an immune modifier and/or oncogenic at the same time.
Role of Soy-Based, Lactose-free Formula During Treatment of Acute Diarrhea
Authors: Santosham Mathuram , Foster Stephan , Reid Raymond , Bertrando Robert , Yolken Robert , Burns Barbara , Sack R. Bradley
Published: December 2021

A controlled study was conducted comparing the standard method of treating hospitalized infants with acute diarrhea (limited starvation) with the initiation of "early feeding" using a soy-based, lactose-free formula in infants of an American Indian tribe 12 months of age or younger. Forty-three patients, randomly assigned to group A, were given a soy-based, lactose-free formula four hours after hospitalization, and 44 patients, randomly assigned to group B, received standard therapy (food was withheld for the first 48 hours of hospitalization). After the first 48 hours, the same soy-based, lactose-free formula was given to the group B patients. Fluid intake and output of stool, urine, and vomitus were measured until the diarrhea resolved. Overall, group A patients showed less mean stool output (121 ± 129 (SD) mL/kg) than group B patients (299 ± 319 mL/kg) (P < .001). Furthermore, the duration of illness was significantly shorter in group A patients (54 ± 28 hours v 93 ± 56 hours) (P < .001). It was concluded that soy-based, lactose-free formulas can be safely used during the acute phase of diarrheal illness in infants and that their use shortens the duration of illness and decreases stool output in comparison with standard therapy.
Childhood Appendicitis: Factors Associated with Perforation
Authors: Brender Jean D. , Marcuse Edgar K. , Koepsell Thomas D. , Hatch Edwin I.
Published: December 2021

A retrospective study was performed to identify factors associated with perforation in 150 children with acute appendicitis. The children's parents were interviewed about the nature and timing of care, family history of appendicitis, and history of abdominal pain episodes, and the children's medical records were reviewed. Delay in treatment—the interval between first recognized symptoms of abdominal pain and surgery—was most predictive of perforation. A treatment delay of more than 36 hours was associated with a 65% or greater incidence of perforation. Mean delay for the group with perforation of the appendix was 66.7 hours compared with 35.8 hours for the group having appendicitis without perforation (P < .01). Mean professional delay was significantly longer in the group with perforated appendicitis than in the group having appendicitis without perforation (P < .01), but mean parental delay was not. Children aged 1 to 4 years and those aged 5 to 8 years had a 74% and 66% incidence of perforation, respectively, compared with a 30% to 42% incidence in older children (P < .01). Age had a significant effect upon perforation even when adjusted for delay in treatment. Other factors associated with perforation were family history of appendicitis, social class, advice given by the first health professional contacted, and the presence of fecaliths. When all factors were considered simultaneously by using logistic regression techniques, delay in treatment, age, and absence of a family history of appendicitis were all significant predictors of perforation.
Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients
Authors:   Committee on Drugs,   Section on Anesthesiology
Published: December 2021

The goals of sedation and general anesthesia in the ambulatory patient are: (1) patient welfare; (2) control of patient behavior; (3) production of positive psychological response to treatment; and (4) return to pretreatment level of consciousness by time of discharge.

DEFINITION OF TERMS

Terms used in this document are defined as follows:

Pediatric patients: Includes all patients who are infants, children, and adolescents less than age of majority.

Must or shall: Indicates an imperative need and/or duty; as essential or indispensable; mandatory.

Should: Indicates the recommended manner of obtaining the standard; highly desirable.

May or could: Indicates freedom or liberty to follow a suggested or reasonable alternative.

Conscious sedation: Conscious sedation is a minimally depressed level of consciousness that retains the patient's ability to maintain a patent airway independently and continuously, and respond appropriately to physical stimulation and/or verbal command, eg, "Open your eyes." For the very young or handicapped individual, incapable of the usually expected verbal responses, a minimally depressed level of consciousness for that individual should be maintained. The caveat that loss of consciousness should be unlikely is a particularly important part of the definition of conscious sedation, and the drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.

Deep sedation: Deep sedation is a controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused, which may be accompanied by a partial or complete loss of protective reflexes, including the ability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal command.
To Tube or Not to Tube: That Continues to Be the Question
Authors: TEELE DAVID W. , ROSNER BERNARD , KLEIN JEROME O.
Published: December 2021

In Reply.—

We appreciate Chamberlin's thoughtful comments about the associations between otitis media with effusion and development of speech and language and his concern about results that are statistically significant but may not be "clinically significant." We share his view that measurements of the sequelae of disease should include those that are meaningful to the child.

We reported results of tests of speech and language that indicated that children who had spent many days with middle ear effusion during the first years of life scored significantly lower than did children who had not spent such time.
Subsequent Pregnancy in Mothers of Infants with Congenital Heart Disease
Authors: Rubin Judith D. , Ferencz Charlotte
Published: December 2021

Pregnancy rates for mothers of infants with conotruncal cardiac malformations and mothers of healthy control infants were compared for a 3-year period. Mothers of infants who died of congenital heart disease had the highest pregnancy rates, followed by control mothers, and then by mothers of surviving infants with congenital heart disease. Comparison in relation to the number of living children showed similar subsequent pregnancy rates for mothers of deceased infants with congenital heart disease and mothers of control infants, but lower rates for mothers of surviving infants with congenital heart disease. "Replacement" of a deceased infant occurs frequently, apparently in order to achieve a desired family size, whereas decreased reproduction in families of living infants with congenital heart disease may reflect the psychosocial and economic impact of the continuing care of a child with severe heart disease.
Pediatric Manpower Recommendations
Authors:   Committee on Pediatric Manpower
Published: December 2021

The quality of pediatric care available to children in the United States remains a source of concern. The cost and accessibility of care, the education and training of pediatricians, and the numbers of pediatricians and other health care professionals who serve children affect the quality of care significantly.

The GMENAC (Graduate Medical Education National Advisory Committee) Report1 strongly suggested a coming "glut" of physicians and recommended reductions in the numbers of students in medical schools in the United States, severe restriction on the number of graduates of foreign medical schools entering practice in the United States, and reevaluation of the need to train nonphysician health care providers at current levels. More recent information confirms the GMENAC projections of a serious physician surplus.

The GMENAC recommendations are sensitive issues which affect the lives of many deeply motivated men and women who are eager to serve as physicians. It is important to note that foreign medical graduates are included among leading pediatricians in our country. Their contributions are outstanding, and some provide care in underserved The diversity of this group has enriched not only medicine but our entire culture. Unhappily, severe restrictions on the ability of those educated in medical schools overseas to establish practices in the United States would tarnish the potential of the "American Dream." Nevertheless, with a limited demand for physicians, it is also clear that, in the future, for every foreign medical graduate whose dream of medical practice in the United States is fulfilled, there will ultimately be one highly qualified United States medical graduate for whom it is denied.
Hunger Debate
Authors: GRAHAM GEORGE G.
Published: December 2021

In Reply.—

The letter from Meyers and Spivak is disheartening: its vituperative tone suggests that they really believe what they are saying. They question the author's right to criticize the Massachusetts Nutrition Survey because it is "unpublished in the medical literature and...inaccesible...." I would hate to have to hold my breath until it appeared in a serious peer-reviewed journal and I dare say that, having been released with great fanfare via press conference to the national media, many more pediatricians (and legislators and ordinary citizens) will have heard its claims than will ever read this correspondence.
Status of Pediatric Pain Control: A Comparison of Hospital Analgesic Usage in Children and Adults
Authors: Schechter N. L. , Allen D. A. , Hanson K.
Published: December 2021

A chart review was conducted of the records of 90 children and 90 adults, randomly selected and matched for sex and diagnosis, to investigate analgesic usage. Four diagnostic categories (hernias, appendectomies, burns, and fractured femurs) at two hospitals were examined. Results revealed that adults received an average of 2.2 doses of narcotics per day, whereas children received 1.1 (P = .0001). Significant differences in dosing were noted between the diagnostic categories. Diagnoses associated with a longer hospital stay showed a greater discrepancy between narcotic usage in children and adults. Hospital differences were also significant (P = .004) with more doses per day administered at the urban hospital than the rural one. Infants and young children were less likely than older children to have narcotics ordered for them, but, if ordered, frequency of administration was similar for all children. Our study demonstrates that children and adults with the same diagnoses are treated differently as regards narcotic administration. Further research is necessary to determine whether these results represent a difference in pain tolerance in children or a lack of recognition of their discomfort.
Metolazone and Furosemide Therapy for Edema
Authors: GARIN EDUARDO H. , RICHARD GEORGE A.
Published: December 2021

To the Editor.—

In his report, Dr Arnold1 concludes that the combination of furosemide and metolazone offers a useful and effective oral therapy in most children with edema resistant to furosemide. In our opinion, pitfalls in patient selection and methodology cast doubts on his conclusions.

Dr Arnold defines furosemide resistance as no clinical response after a dose of 2 to 4 mg/kg/d of furosemide. However, the inclusion of patients who did not respond to 2 mg/kg/d seems inappropriate because: (1) 2 mg/kg/d has been considered the initial dose to treat these types of patients2 and (2) some of these patients may have responded to higher doses of furosemide (3 or 4mg/kg/d).
Endotracheal Tube Placement in Infants
Authors: HELLER RICHARD M. , COTTON ROBERT B.
Published: December 2021

In Reply.—

We agree with Dr Bloch that auscultation is a primary tool for determinig appropriate position of an endotracheal tube. However, experience in a busy neonatal intensive care unit has shown that, even with careful auscultation, endotracheal tubes still become inappropriately positioned, often with serious consequences. Our experience has been that the illuminated endotracheal tube provides a clear indication of depth of penetration when asymmetric lung disease may cause auscultatory findings to be equivocal.

Dr Goldenring raises the important point that the cost of the illuminated endotracheal tube is under evaluation at the present time, and as soon as information concerning pricing is available, I will make this information available to the readership of Pediatrics.
Zinc Deficiency and Edema
Authors: GOLDEN MICHAEL H. N. , GOLDEN BARBARA E.
Published: December 2021

To the Editor.—

Kumar and Anday1 describe three premature infants presenting with edema and hypoproteinemia—the classical signs of kwashiorkor—between 5 and 9 weeks of age. Such cases are not uncommon in developing countries. Kumar and Anday's patients had low plasma zinc concentrations (43, 37, and 42 µg/dL). On this basis the authors claim that edema and hypoproteinemia is a clinical presentation of zinc deficiency not previously reported.

We reported2 a clear association between "nutritional" edema and a low plasma zinc concentration in 1979; our subsequent experience has confirmed that edema of this type is always associated with a low plasma zinc concentration, as indeed Kumar and Andays' cases demonstrate.
New Abuse of Ipecac
Authors: CZAJKA PETER A. , RUSSELL STEVEN L.
Published: December 2021

In Reply.—

We agree with the statements of Drs Ente and Penzer on the chronic abuse of ipecac syrup, namely, that chronic ipecac syrup abuse may produce myocardial injury, that chronic ipecac syrup abuse by persons with anorexia nervosa should be more widely recognised, and that ipecac syrup should remain a nonprescription drug. These issues were beyond the scope of our article (Pediatrics 1985;75:1101-1104) that addressed the effects of single doses of ipecac syrup. Although Drs Ente and Penzer do not advocate restricting the sale of ipecac syrup to limit its abuse, others recently have promoted in news reports the reclassification of ipecac syrup so that a prescription is required for purchase.
Committee Statement on Nutrition Corrected
Authors: SILVERIO JOHN
Published: December 2021

To the Editor.—

I have read with interest the statement of the Committee on Nutrition entitled "Nutritional Needs of Low-Birth-Weight Infants" (Pediatrics 1985;75:976-986).

In the section, "Commercial Formulas for LBW Infants," reference 65, which refers to a paper showing adequate growth and metabolic stability obtained with our Preemie SMA, is erroneously given as reference 45. The other two references that refer to competitive formulas are correct.

Unfortunately, this gives the wrong impression that Preemie SMA has not been shown to be associated with "adequate growth and metabolic stability."
Controversies in the Management of Acute Idiopathic Thrombocytopenic Purpura: A Survey of Specialists
Authors: Dubansky A. Stephen , Oski Frank A.
Published: December 2021

A total of 322 physicians, Board-certified in pediatric hematology, responded to a survey designed to determine several aspects of their management of children with acute idiopathic thrombocytopenic purpura. The survey demonstrates that, in practice among specialists, a controversy exists as to whether or not bone marrow examination needs to be performed, and how often corticosteroids should be prescribed. Seventy-four percent of practitioners would perform the bone marrow examination, whereas 26% would not do so. Forty-six percent of responders prescribe steroids more than half the time, whereas 54% prescribe steroids less than half the time. The questionnaire ascertained the reasons why physicians performed marrow aspirations and prescribed steroids.
Early Enteral Feeding Does Not Affect the Incidence of Necrotizing Enterocolitis
Authors: Ostertag S. G. , LaGamma E. F. , Reisen C. E. , Ferrentino F. L.
Published: December 2021

To begin to determine the optimal time for initiating enteral feedings, 34 sick, very low birth weight infants were prospectively selected from all neonates of less than 1,500 g (N = 116) and randomly divided into two groups. Infants were fed either on day 1 (early) or 7 (late) of life, according to a feeding protocol which included parenteral nutrition and a scheduled progression from sterile water to 2.5% dextrose, half-strength, and finally full-strength formula over seven days. The incidence of necrotizing enterocolitis and subsequent hospital course were compared. Initiating enternal feedings on day 1 did not significantly increase the incidence of necrotizing enterocolitis, produce a clustering of cases, or induce an earlier onset of necrotizing enterocolitis. The overall incidence of necrotizing enterocolitis in sick, very low birth weight neonates was 29% (5/17) and 35% (6/17) in the early and late groups, respectively, compared with 4.2% (2/47) in minimally sick, very low birth weight neonates. No significant differences between groups were seen in obstetrical complications, birth weight, gestational age, Apgar scores, presence of patent ductus arteriosus or intraventricular hemorrhage, use of umbilical catheterization, and respiratory or oxygen requirements. Infants fed enterally from day 1 did show a significantly higher energy and protein intake during the second week of life. These data show that providing dilute, early enteral calories does not adversely affect the incidence of necrotizing enterocolitis.
Relationship Between Childhood Blood Lead Levels and Stature
Authors: Schwartz Joel , Angle Carol , Pitcher Hugh
Published: December 2021

The second National Health and Nutrition Examination Survey, 1976 to 1980, incorporated medical history, physical examination, anthropometric measurements, dietary information (24-hour recall and food frequency), laboratory tests, and radiographs. In linear regressions of adjusted data from 2,695 children aged 7 years and younger, 91% of the variance in height, 72% of the variance in weight, and 58% of the variance in chest circumference were explained by six variables: age, race, sex, blood lead level, total calories or protein, and hemetocrit or transferrin saturation level. Variables that did not significantly improve the models predicting growth included family income, degree of urbanization, serum albumin, copper, iron, and zinc levels, dietary carbohydrate, fat, calcium, potassium, phosphorus, vitamin A, vitamin C, niacin, riboflavin, and thiamine. The highly significant correlation of blood lead level with growth does not contradict the established association of childhood deprivation with increased lead exposure and with nutritional deficiences known to enhance lead absorption. Blood lead level may also represent a composite marker for unidentified genetic, ethnic, environmental, and sociocultural variables, other than race, sex, and nutrition, that affect growth. However, the correlation of stature, particularly height, with blood lead levels in the range of 5 to 35µg/dL is so statistically significant that it merits investigation in other surveys and consideration of the multiple biologic mechanisms by which low-level lead exposure could impair the growth of children.
Diarrhea Associated With Adherent Enteropathogenic Escherichia coli in an Infant and Toddler Center, Seattle, Washington
Authors: Paulozzi Leonard J. , Johnson Kathleen E. , Kamahele Lawrence M. , Clausen Carla R. , Riley Lee W. , Helgerson Steven D.
Published: December 2021

During November 1983, the Seattle-King County Department of Public Health investigated an outbreak of diarrhea associated with enteropathogenic Escherichia coli, serogroup 0111:K58, in an infant and toddler day-care center. Of the 25 children in the center, ranging in age from 4 to 30 months (median age 11 months), diarrhea occurred in 14 characterized by watery, greenish stools. The median duration of diarrhea was 12 days. Two of the ill children were hospitalized because of severe dehydration. Stool cultures from the children diagnosed initially did not yield the common bacterial pathogens, parasites, or rotavirus. Stool cultures from 11 of 14 ill children and two of 11 well children (P <.005), however, yielded an E coli serogroup, 0111: K58, which was not invasive or toxigenic by standard tests. The source of the organism was not identified. Although this organism has been recognized as a cause of diarrhea in newborn nurseries, this is the first published report of a documented outbreak of enteropathogenic E coli-induced diarrhea in a day-care center in the United States.
Growth and Development of Preterm Infants With Respiratory Distress Syndrome and Bronchopulmonary Dysplasia
Authors: Meisels Samuel J. , Plunkett James W. , Roloff Dietrich W. , Pasick Patricia L. , Stiefel Gilbert S.
Published: December 2021

This study examines the growth and development of 37 preterm infants, 20 with respiratory distress syndrome and 17 with bronchopulmonary dysplasia. The groups were balanced by sex, parity, family configuration, and socioeconomic status and were studied at either 12 or 18 months after hospital discharge. Findings indicate that infants with bronchopulmonary dysplasia are at greater risk for growth retardation in their second year than infants with respiratory distress syndrome. Furthermore, results from cognitive, sensorimotor, and language measures (the Bayley, Uzgiris-Hunt, and Receptive-Expressive Emergent Language scales) demonstrate that infants with bronchopulmonary dysplasia perform significantly less well than infants with respiratory distress syndrome. The group performance of the infants with respiratory distress syndrome suggests that their developmental scores are comparable to those of average, healthy full-term infants of the same age. In contrast, the group of infants with bronchopulmonary dysplasia performed in the low-average to delayed range. Moreover, regression analyses show that type of respiratory illness explains more of the variance in cognitive outcomes than such neonatal factors as birth weight or gestational age. Thus, this study demonstrates that infants with bronchopulmonary dysplasia are at high risk for developmental problems in their second year, and that the contribution of bronchopulmonary dysplasia to explanations of differential cognitive outcomes cannot be reduced to between-group differences in perinatal status.
Electrocardiogram of the Premature Infant at 1 Year of Age
Authors: Walsh Edward P. , Lang Peter , Ellison R. Curtis , Zierler Sally , Harned Herbert S. , Miettinen Olli S.
Published: December 2021

ECGs were examined from 461 premature infants at 1 year of age. Data from those without a history of bronchopulmonary dysplasia were generally similar to published norms for healthy 1-year old infants. History and persistence of residual lung disease were reflected in the ECG by a high prevalence of findings suggestive of right ventricular hypertrophy. Clinically significant patent ductus arteriosus during the neonatal period did not influence the 1-year ECG findings. The data expand the published experience with follow-up ECGs from premature infants and suggest that the ECG may be a useful tool in follow-up of chronic residual lung disease in this population.
YES/NO VERSUS HOW MUCH?
Authors: Student
Published: December 2021

The distribution between science and technology may be ascribed to the questions which they ask. . . the key question which defines a scientific inquiry is, "does my theory fit the facts?," and this. . .requires the answer "yes" or "no." Technological work rarely asks a question of this kind. Its questions almost always involve "how much?," and the answers have to be quantitative. Statistically speaking, the technologist is more interested in estimation than in testing significance.
Carbonic Anhydrase II Deficiency Syndrome: Recessive Osteopetrosis With Renal Tubular Acidosis and Cerebral Calcification
Authors: Ohlsson Arne , Cumming William A. , Paul Adrien , Sly William S.
Published: December 2021

Four new Saudi Arabian cases of the carbonic anhydrase II deficiency syndrome from two families are described. This autosomal recessive syndrome includes osteopetrosis with renal tubular acidosis and cerebral calcification. Additional features are mental retardation, growth failure, typical facial appearance, and abnormal teeth. Two patients showed evidence of restrictive lung disease, a finding not previously described. One of the patients reported represents the first neonate reported to be affected with this syndrome. Intrauterine growth was normal, but metabolic acidosis was already evident in the neonatal period. Radiographic evidence of osteopetrosis was probably absent at birth but appeared during the late neonatal period. Carbonic anhydrase II deficiency was demonstrated in erythrocyte hemolysates from the older two siblings of this neonate, and a 50% normal level of carbonic anhydrase II was demonstrated in the erythrocyte hemolysate from their father.
Case of Congenital Short Small Intestine: Survival With Use of Long-Term Parenteral Feeding
Authors: Dorney Stuart F. A. , Byrne William J. , Ament Marvin E.
Published: December 2021

Isolated congenital short small intestine is a rare anomaly. Of six (one male, five females) previously reported cases, four died in infancy from intractable diarrhea. We report the case of 7-year-old boy with this syndrome in whom a 2-year period of parenteral feeding at home allowed normal weight gain, growth, and development while intestinal adaptation occurred. Parenteral feeding was discontinued at age 2⅓ years, and for the past 5 years his weight has remained between the tenth and 25th percentiles and his stature between the 25th and 50th percentiles. His development has been normal and he functions at or above grade level at school. Coefficient of fat absorption has increased from 54% to 81%. Vitamin B12 absorption has improved but has not normalized. He remains lactose intolerant. We believe his survival, growth, and development would have been compromised if he had not received a prolonged period of parenteral feeding.
A POSITIVE APPROACH FOR CHILDREN
Authors: Barness Lewis A.
Published: December 2021

Children are the country's future workers and taxpayers, its future leaders, artists, teachers and scientists. Today's children must shoulder tomorrow's national debt, finance its Social Security system and lead this country into the 21st century. Wise investment in children now is sound economic policy in a time of fiscal restraint. Research proves that children's programs that provide services like prenatal cane and immunization save us more money than we spend on them. It costs about ten dollars to provide a baby with a series of immunizations, compared to hundreds of thousands of dollars for a lifetime of care for a child with severe disabilities caused by preventable sickness.
Multicenter Trial of Cryotherapy for Retinopathy of Prematurity
Authors: PALMER EARL A. , PHELPS DALE
Published: December 2021

Retinopathy of prematurity is one of the most discouraging eye diseases seen by pediatric ophthalmologists because the eyes appear so normal during the first month of life, yet by the third month, in severe cases, retinal detachment is either impending or has already occurred. With the improved survival rates of infants most at risk for retinopathy of prematurity, the 1970s have seen an increase in the absolute number of cases of severe retinopathy of prematurity. The search for a way to halt the seemingly inevitable process is a natural outgrowth of this experience. During the past 13 years at least 22 reports have appeared describing transscleral cryotherapy or laser photocoagulation of the peripheral retina of infants with retinopathy of prematurity.
American Academy of Pediatrics and Child Abuse
Authors:   EXECUTIVE COMMITTEE OF THE AMERICAN ACADEMY OF PEDIATRICS
Published: December 2021

The December issue of Pediatrics (1985;76:993-997) carried a commentary by Dr Ray Helfer relating to the 25th Anniversary of the recognition of child abuse as a specific and identifiable entity.

In one paragraph of this article (p 995) one would have to draw the conclusion that the subject of child abuse has been the object of an unfortunate neglect by the American Academy of Pediatrics. For the benefit of our membership and others who have reason to be concerned by this allegation, we feel the necessity to set the record straight.
Myringotomy Tubes—Another Viewpoint
Authors: OLSEN KERRY D.
Published: December 2021

In August 1984, Stickler from the Mayo Clinic wrote a commentary in Pediatrics on myringotomy tubes in which he called for a moratorium on tube placement. At the time, this opinion seemed so isolated and diametrically opposite to my views and those of my colleagues that a reply was not deemed necessary. However, several news agencies have recently used this article to support an argument for stopping the placement of myringotomy tubes and implicating, by inference, the Mayo Clinic as supporters of such a policy.