bluuebunny/crossref_metadata_2025 huggingface dataset:
Inborn Errors of Metabolism of Acute Onset in Infancy
Authors: Ward Jewell C.
Published: December 2021

Pediatricians and neonatologists are frequently presented with ill neonates or older infants whose symptoms have an acute onset and a severe and/or recurrent character. The clinician faced with symptoms that are frequently nonspecific must differentiate among many disorders, usually considering infection, cardiac defects, central nervous system insults, or gastrointestinal problems. Not infrequently, an inborn error of metabolism (IEM) will mimic these more common conditions. Although each individual IEM is rare, throughout the course of a practice the clinician will cumulatively see many patients with such disorders, with various findings. According to a recent estimate, IEM account for as much as 20% of disease among full-term neonates not known to have been at risk.1 The neonatologist and/or pediatrician will be the first to evaluate an acutely ill neonate or infant, and he or she must be alert to the possibility of an IEM. The implications of failing to entertain such a diagnosis may be formidable. An IEM should be considered early and appropriate screening tests obtained concurrently with assessment of the likelihood of more common causes.

The exact incidence with which IEM occur in the neonatal period or with acute symptoms in early to late infancy is not known. Cumulatively, IEM may represent more than 1 in 5000 live births.
The Case of Donnie J
Authors: Burg Fredric D.
Published: December 2021

Mrs J has brought her 4-1/2-year-old son Donnie to your office for a first visit. She and her son have moved recently into your community, and she heard that you were the best pediatrician in town.

At present, Donnie has no complaints. He looks healthy and is comfortable with both his mother and you during the interview. You learn that Donnie has had no medical care since he was 2 years old, when he was hospitalized for a broken arm after he fell out of a tree. His mother has lost his immunization records, but thinks he has had all of his shots. Donnie was the product of a normal full-term pregnancy with no complications at the time of delivery.

His mother reports that she is unmarried and has been a "dead head" (a follower of the musical group "The Grateful Dead") for 14 years. She says that she has had many sexual partners and has used a variety of drugs before, during, and after pregnancy. She is presently living only with Donnie.

In reviewing the patient's history to this point, what points should alert you to potential problems with Donnie?

1. Immunization status.

2. Previous serious accident.

3. Potential prenatal exposure to human immunodeficiency virus.
Caring for the Child with Cancer and the Family: Lessons Learned From Children With Acute Leukemia
Authors: Sahler Olle Jane
Published: December 2021

In a report appearing in 1951, Southam et al1 reported on the natural history of 173 patients with acute leukemia treated supportively at Memorial Center for Cancer and Allied Diseases in New York City from 1926 to 1948. The study population included 65 children less than 10 years of age. The average length of survival of these patients was 19.3 weeks after the onset of symptoms attributable to leukemia. Of the entire sample of patients irrespective of age, only 4 (2.3%) survived 52 weeks or beyond.

In 1948, Memorial Center began treating patients with folic acid or purine antagonists and steroids.
The Pediatrician and Early Intervention for the Developmentally Disabled or Handicapped Child
Authors: Katcher Avrum L. , Haber Julian S.
Published: December 2021

New federal legislation involving infants at risk for handicaps and their families, in the form of Public Law 99-457, will rely on interaction between pediatricians and other professionals to maximize health and social benefits. Involvement in early identification and remediation of infants at risk is a role well suited to the primary care pediatrician.

Early Intervention Programs offer remediation and enhancement of development for children at biologic or environmental risk. Pediatricians should be alert to screen, identify, and assess children who may be helped by Early Intervention Programs. The primary care pediatrician should work with children who have these problems, help coordinate care, and serve as an advocate for the child and family.
Complications of Leukemia
Authors: Berg Stacey L. , Poplack David G.
Published: December 2021

Approximately 2000 children, or 4 per 100 000 younger than 15 years of age, are diagnosed as having leukemia in the United States every year. Three quarters of these children have acute lymphoblastic leukemia; the remainder have acute nonlymphocytic or chronic leukemia. Before the development of modern chemotherapy, virtually all children having any kind of leukemia died within a few months of diagnosis. With the effective forms of therapy now available, however, long-term disease-free survival for children who have acute lymphoblastic leukemia has improved to approximately 60% to 70%. As a result, pediatricians are seeing more children in their practices who either are undergoing antileukemic therapy or are long-term survivors of the disease. To provide optimal care for these children, the pediatrician not only must be familiar with the pathophysiology and treatment of childhood leukemia, but also must be aware of those complications that may occur during and after therapy. This review focuses on common complications of childhood leukemia, particularly those associated with acute lymphoblastic leukemia.

INFECTION

Because children who have acute leukemia are immunocompromised due to both the disease and its treatment, they are at high risk for infection. The pediatrician caring for these children must be aware of common infectious complications and their management.
Use of Growth Hormone in the Treatment of Short Stature: Boon or Abuse?
Authors: Saenger Paul
Published: December 2021

Growth hormone (GH) was isolated approximately 30 years ago. Since then, we have witnessed major advances in understanding the regulation and pattern of GH secretion and its many metabolic actions.1

With the advent of recombinant DNA-generated growth hormone (rhGH) in 1985, the opportunities to treat children who have organic or idiopathic GH deficiencies are now, for the first time, unlimited.

DEFINITION OF GROWTH HORMONE DEFICIENCY

Although a role for GH in the treatment of certain children deficient in GH is established, the definition of GH deficiency remains controversial. The controversy surrounding the diagnosis of GH deficiency was highlighted recently when it was shown that, among the many commercial assay kits available, the same serum sample yielded GH concentrations that differed by as much as 100% for the same sample. Using different GH assay kits, a child who has short stature could be determined to be deficient in GH in the view of one endocrinologist but to have sufficient GH (ie, to be normal) by another endocrinologist.2,3

Despite these obvious limitations, GH testing has an important role in the clinical evaluation of the child who is short. When a child fails a simple screening test (ie, serum GH level of <10 ng/mL following vigorous exercise, such as running for 20 minutes), more definitive GH testing is the next step.
Limb Pain in Childhood
Authors: Sherry David D.
Published: December 2021

Limb pain during childhood is common, and its causes range from the benign, such as joint hypermobility, to the potentially fatal, such as infection or tumor. Clues to the diagnosis are usually evident in the history, which can then give direction to the physical examination and, if necessary, laboratory investigations. Children with limb pain may be either ill or well (Table 1).

ILL CHILDREN WITH LIMB PAIN

Severe Joint Pain

The majority of ill children with severe limb pain experience an acute onset and may have associated symptoms, such as rash, fever, previous infection (especially skin infection, sore throat, or diarrhea), conjunctivitis, dysuria, or weakness (frequently interpreted by the family as tiredness). The severe nature of the pain usually renders the limb immobile or prevents even light weight-bearing. Erythema over the joint is an important sign because it is rare in chronic arthritic conditions (Table 2). The most important possible diagnoses include: infection, neoplasia, gastrointestinal disorders, rheumatic diseases, and cardiopulmonary disease.

Infection: Septic arthritis (with or without osteomyelitis) is the most common cause of severe monarticular pain. The absence of fever does not exclude a bacterial process. This is particularly true of septic sacroilitis and osteomyelitis of the pelvic and vertebral bones. Sudden onset of severe joint pain with marked swelling (and frequently erythema) is characteristic and typically involves the knee, hip, and ankle.
Congenital Dysplasias and Dwarfism
Authors: Clark Robert N.
Published: December 2021

This paper has presented the characteristic features of those types of dwarfism that are manifest at birth. This information has been presented in a fashion that should assist the pediatrician in arriving at an appropriate diagnosis without excessive delay or extensive diagnostic studies. However, variable expressivity may result in subtle presentation and, in those cases, diagnosis may be more challenging.
Toxoplasmosis
Authors: Freij Bishara J. , Sever John L.
Published: December 2021

Toxoplasma gondii is an obligate intracellular parasite capable of infecting humans and a variety of other warm-blooded animals. The organism is distributed widely in nature and may infect as many as 1 of 3 persons worldwide. Most Toxoplasma infections are either asymptomatic or otherwise benign; notable exceptions include the infections of the developing fetus whose mother acquires an acute T gondii infection during gestation and of immunosuppressed patients, such as those with the acquired immunodeficiency syndrome (AIDS), in whom the illness may be severe or even fatal. The cat and other felines (such as the lynx) appear to be the only definitive hosts for this protozoan.

The name Toxoplasma is derived from the Greek word toxon (meaning arc or bow) and is a reference to the shape of the organism. The gondi is a North African desert rodent related to the gerbil in whose splenic and hepatic mononuclear cells the parasite was observed initially.

This article briefly reviews the biology of T gondii and its epidemiology in man and other animals, as well as its pathogenesis, clinical manifestations, methods for accurate diagnosis, and preventive strategies. Information on prenatal diagnosis and treatment modalities is emphasized.

THE ORGANISM

T gondii is a protozoan parasite that exists in three developmental stages: tachyzoite, tissue cyst, and oocyst.
Recombinant Erythropoietin
Authors: Christensen Robert D.
Published: December 2021

Cloning and expression of the human gene encoding erythropoietin has resulted in the availability of recombinant erythropoietin for clinical and laboratory investigation. Results of such investigations are clarifying the mechanisms that regulate production of erythropoietin in health and disease. It seems likely that erythropoietin administration will reduce, if not replace, erythrocyte transfusions for certain pediatric patients. Those with the anemia of end-state renal disease and anemia of prematurity may be most likely to benefit. Clearly, additional well-controlled studies to assess the risks and benefits of erythropoietin administration will be needed prior to widespread usage of erythropoietin for anemic children.
MEDICAL RECORD DOCUMENTATION OF INDIRECT NEONATAL HYPERBILIRUBINEMIA
Authors: Schwartz K.
Published: December 2021

December 12, 1990. Nursery Nurse

Dr Schwartz in to do examination and talk with mother. Normal examination. Baby doing well. Formula feeding and routine newborn orders. R. Dunn, RN

December 13, 1990. Nursery Nurse

Baby taking 30 mL of formula every 4 hours. Vigorous with strong cry. One transitional stool this shift; urinated twice. Jaundice noted; total bilirubin 11.8 at 9:00 AM. Dr Schwartz notified; ordered total and direct bilirubin, hematocrit, blood smear, and reticulocyte count for 7:00 PM. R. Dunn, RN

December 13, 1990. Nursery Nurse

Total bilirubin 13.2, with direct of 0.1 at 7:00 PM. Phoned to Dr Schwartz, along with other lab results.
The Limping Child
Authors: MacEwen G. Dean , Dehne Robert
Published: December 2021

Evaluation of a limping child requires careful consideration and a basic knowledge of potential problems affecting the child. The most important point is not to miss or delay diagnosis of the septic hip. This is truly an orthopedic emergency. Complaints of knee pain should not throw the physician off the track of a diagnosis of hip disease.

It is also important to be aware of how the medical history affects the musculoskeletal system. Many causes of limp are best analyzed by repeat examination and stepwise laboratory and radiographic evaluation. One should realize that a painful limp can be caused by something as mundane as a thorn in the heel or as serious as a tumor of the spine: Be suspicious.
Hemophilia
Authors: Lusher Jeanne M. , Warrier Indira
Published: December 2021

Hemophilia is a hereditary bleeding disorder characterized by Factor VIII (F-VIII) or Factor IX (F-IX) deficiency, bleeding into joints and soft tissues, and an X-linked mode of inheritance. Approximately one third of new cases occur as spontaneous mutations, with no family history of hemophilia. The incidence of hemophilia is about one per 20 000 persons, and one per 10 000 males.

DIAGNOSIS

Hemophilia A (characterized by F-VIII deficiency) and hemophilia B (characterized by F-IX deficiency) are clinically indistinguishable. Both affect males almost exclusively; both have the same type of bleeding; and, if the usual coagulation screening tests are performed, both are characterized by a prolonged partial thromboplastin time and normal prothrombin time. The template bleeding time is usually normal; this is expected, because the bleeding time is a reflection of platelet numbers, platelet function, capillary integrity, and von Willebrand factor activity, all of which are normal in the case of hemophilia. Hemophilia A and hemophilia B can be separated by assaying F-VIII and F-IX. Because neither F-VIII nor F-IX crosses the placenta, the diagnosis can be made at birth by obtaining a cord blood sample for assay.

CARRIER DETECTION AND PRENATAL DIAGNOSIS

Carriers of the hemophilia gene may be "obligate" carriers, in the sense that the family pedigree indicates that a particular female must be carrying the gene for F-VIII (or F-IX) deficiency.
Effects of Drugs on the Fetus
Authors: Berlin Cheston M.
Published: December 2021

The tragic consequences for the fetuses of pregnant women using the sedative thalidomide destroyed the theory that the placenta was a type of barrier protecting the fetus from the effects of maternal pharmacology. It now is known that virtually all drugs and chemical compounds cross the placenta. Because such compounds have to cross several lipoprotein barriers in vascular walls to travel from the maternal to fetal circulation, certain physicochemical characteristics of drugs and chemicals favor transport to the fetus: low molecular weight, lipid solubility, and nonionization at a pH of 7.4. Most drugs in current use (prescription and over-the-counter) cross the placenta. Most environmental toxins also cross the placenta and present a special problem; they are very lipid-soluble and may be stored in the woman's body fat, even from childhood until pregnancy occurs. With pregnancy may come mobilization and passage to the fetus. Details of when compounds are transferred across the placenta in pregnancy in humans are not available. Because we are unable to obtain more than the single simultaneous maternal and fetal samples available from the cord blood at delivery, our knowledge of maternal-fetal partitioning and pharmacokinetics remains fragmentary.

Drug exposure can occur at any time from conception through labor and delivery.
INDEX OF SUSPICION
Authors: Smith Summer , Green John L. , Lynch Susan K , Polak Mark J.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 17-year-old boy is admitted to the hospital for evaluation and management of recently diagnosed diabetes mellitus. His mother expresses concern about his acting-out behavior and about frequent difficulties in drinking from a glass due to tremors. On examination he is found to be 68.5 inches tall, and he has a mild scoliosis. Evaluation of sexual development reveals axillary hair at Tanner stage III, pubic hair at stage V, penile length of 8 cm, left testicular volume of 3.0 x 1.8 cm, and an undescended right testicle. No breast tissue is palpable.

Case 2 Presentation

A 16-year-old girl is seen at your office with a history of prolonged fatigue and weakness. She has missed school frequently over the past 4 to 5 months, having had many vague complaints of "no energy," headaches, sore throats, aching knees, and the feeling that she will almost "pass out" if she does gymnastics or physical exertion of any kind.
Child Sexual Abuse
Authors: Berkowitz Carol D.
Published: December 2021

Child sexual abuse has been recognized with increasing frequency since the early 1980s, a trend attributable to a number of factors. Increased public awareness has led to programs, particularly in schools, facilitating disclosure by children about abuse. Likewise, parents are more likely now than previously to believe allegations children make about being abused by trusted extrafamilial friends and advisors. Additionally, the medical community is more knowledgeable about both the behaviors that may indicate abuse and the possible physical changes in the anogenital area of sexually abused children.

Definition

Child sexual abuse is the involvement of children and adolescents in sexual activity that they do not understand and to which they cannot give consent by virtue of their developmental level. There is chronological and developmental asymmetry between the individuals, and the activity is for the sexual gratification of the older individual. Incest involves sexual activities between individuals in whom such activity is prohibited by virtue of societal taboos. These restrictions involve individuals related by blood or by marriage.

Sometimes physical abuse may result in injuries in the genital area. Such injuries are not sexual in intent.

Epidemiology

More than 2 million cases of child abuse are reported annually. Approximately 40% of these cases involve sexual abuse.
Menstrual Disorders in the Adolescent: Amenorrhea
Authors: Polaneczky Margaret M. , Slap Gail B.
Published: December 2021

The menstrual history is an integral part of the evaluation of the adolescent femaie. Abnormal menstrual flow or timing may be the first sign of systemic illness or sexually transmitted disease. Amenorrhea may signal an endocrine or genetic disorder or may suggest structural abnormalities of the genital tract. Most importantly, any abnormality in menstruation should alert the clinician to the possibility of pregnancy.

Normal Menstrual Cycle

The average age of menarche in the United States is 12.8 years and ranges from 9 to 16 years. Menarche usually occurs 2 to 2.5 years after breast budding and 1 year after the growth spurt. Consequently, the absence of menarche at 15 years of age may be normal in an adolescent who just passed her growth spurt but abnormal in an adolescent who completed puberty 2 years earlier. Most early menstrual cycles are anovulatory. As a result, menses in the young adolescent often are irregular and may be prolonged or heavy. Dysmenorrhea and premenstrual symptoms tend to accompany ovulatory cycles and, therefore, are more common in the older adolescent.

Regular ovulatory cycles usually are established within 1 to 2 years of menarche. Although normal cycle length ranges from 21 to 45 days, the length for a given individual is fairly constant.
Malformations of the Gut
Authors: Duffy Lynn F.
Published: December 2021

Although there are many different malformations of the intestine, clinically they can present similarly. In addition, even conditions that are not congenital may be difficult to differentiate. An approach that employs a detailed history, physical examination, and use of appropriate radiologic studies is important. Some malformations can have life-threatening consequences if diagnosis is delayed; therefore, expediency is imperative.
Consultation with the Specialist
Authors: Pakula Lawrence C.
Published: December 2021

Among the most frequent questions pediatricians must address are those related to sibling rivalry, which is important regarding both behavior and development.1 The parents' concerns often begin before the next child is born and may be the result of their own personal experience or family situation. They need guidelines for managing this situation. Parents often find it difficult to understand the concept of innate competition between siblings and to accept some conflict as common in healthy families regardless of how loving, clever, persistent, and available adults may be. The pediatrician is in a unique position to intervene because of the frequent contacts with the family.

Many potential situations should alert both parents and physicians to a potential problem, including: the sibling reaching significant milestones (eg, walking); change in status (eg, no longer being the oldest, only, or youngest child); change in health status of sibling (eg, injury, malignant illness, identification of disabilities); and change involving a significant adult (eg, illness, death, divorce, job loss, change in caregiver).

History taking is essential and can be therapeutic as well as diagnostic. It should include inquiry about who is involved (both children and adults) and their perceived roles; the reporter and most frequent observer; time, situation, and place of occurrence; significance attached to the problem by each of the parents; other occurrences in the entire household regarding relationships; why this problem is receiving attention now and not earlier; and any long-term concerns.
Menstrual Disorders in the Adolescent: Dysmenorrhea and Dysfunctional Uterine Bleeding
Authors: Polaneczky Margaret M. , Slap Gail B.
Published: December 2021

Dysmenorrhea

Dysmenorrhea, or painful menstruation, is the most common gynecologic problem that occurs during adolescence. It is estimated that 75% of menstruating women experience dysmenorrhea, making it the leading cause of school and work absenteeism among young women.

Primary dysmenorrhea is defined as painful menses with no identifiable pelvic pathology. Secondary dysmenorrhea refers to painful menses resulting from a pelvic abnormality, such as endometriosis or fibroids. This is an important distinction because treatment is based on the cause of the dysmenorrhea.

Evaluation of the adolescent who has dysmenorrhea begins with questioning about the timing, character, and location of the pain as well as the presence of associated systemic symptoms. A history of pelvic infection, menorrhagia, or intermenstrual bleeding suggests that the dysmenorrhea is secondary to pelvic pathology. Pelvic pain at times other than menstruation (eg, mid-cycle, during intercourse, with defecation) may indicate endometriosis. The onset of dysmenorrhea soon after menarche with rapid worsening over several cycles suggests an outlet obstruction, which may result from a partially imperforate hymen or uterine malformation.

A pelvic examination should be performed before initiating treatment for dysmenorrhea. Abnormal uterine size, position, or shape suggest uterine malformation rather than fibroids, which are uncommon during adolescence. Cervical cultures for gonorrhea and chlamydia should be performed because chronic pelvic inflammatory disease (PID) may appear as dysmenorrhea.
Bleeding Disorders in Neonates
Authors: Pramanik Arun K.
Published: December 2021

The newborn infant is particularly susceptible to bleeding complications for a variety of reasons: physiologic deficiencies of coagulation factors (both quantitative and qualitative), influences of maternal disease or drugs, immaturity of blood vessels, vulnerability to birth trauma, and other conditions associated with bleeding, such as sepsis and asphyxia.1-5

Physicians caring for newborn infants frequently must manage sick neonates who have either obvious or occult bleeding, the latter often masquerading as unexplained anemia or hypotension.1-4 It is crucial to identify the underlying disease(s) in such cases because these infants require vigorous support with blood products as well as aggressive therapy for the underlying disorders. Clinicians often care for well neonates who have abnormalities in coagulation without obvious bleeding; such abnormalities usually represent primary coagulation defects that are either hereditary or immune-mediated.1-5 In these cases, therapy is designed to correct the specific coagulation defect.

Thrombotic complications, which may be either congenital (in the form of homozygous protein-C deficiency or antithrombin III deficiency) or acquired (via catheters, infection, or renal-vein thrombosis), also may present with bleeding in the neonate. Their diagnosis and management is discussed elsewhere.1,3-5

Physiology of Neonatal Coagulation and Hemostasis

The initial defense mechanism against bleeding is the vascular endothelium, which is developed inadequately in the neonate.
INDEX OF SUSPICION
Authors: Green John L. , Shannon Michael , Lovejoy Frederick H. , DeAngelis Catherine
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 12-y-old boy is seen several hours after the onset of rather severe scrotal discomfort. The pain began shortly after the gym class in which an errant basketball pass struck him squarely in the scrotal area. He is in obvious pain, complains of nausea, and vomited on the car ride to your office. On examination, there is swelling and erythema of the left hemiscrotum and any movement or palpation of the left testis causes great pain; gentle elevation of the testis brings no pain relief. The testis is of firm consistency and quite tense. A cremasteric reflex cannot be elicited on the left side.

Case 2 Presentation

A 12-y-old boy is brought to the office with a 3- to 4-d history of intermittent headache and lethargy.
Depression and Suicide in Children and Adolescents
Authors: Brent David A.
Published: December 2021

Depression, suicide, and suicidal behavior in the pediatric population are serious public health problems. Pediatricians in collaboration with psychiatrists and other mental health professionals can make an important contribution to the mental health of children and adolescents through the identification, referral, and management of depressed and suicidal youth.
Children Who Have Attentional Disorders: Diagnosis and Evaluation
Authors: Reiff Michael I. , Banez Gerard A. , Culbert Timothy P.
Published: December 2021

Attentional disorders (ADs) are among the most common chronic biobehavioral problems encountered during childhood and adolescence. Children who have attention problems represent a very diverse, heterogeneous population who exhibit a broad spectrum of symptom severity and a wide range of associated diagnoses. ADs are approximately six times more frequent in boys than in girls. Symptoms persist into adulthood in 40% to 60% of individuals who were hyperactive as children. The prevalence of these disorders is estimated at 3% to 5% of the school-age population. In spite of this, ADs remain some of the least understood and most commonly reconceptualized constructs in pediatric practice. Labels for these problems have included minimal brain dysfunction (MBD), hyperkinesis, hyperactivity, attention deficit disorder (ADD), attention deficit disorder with hyperactivity (ADDH), and presently, attention deficit hyperactivity disorder (ADHD). In this review, AD often will be used as a generic term for these entities.

Clinically, children who have AD exhibit core symptoms of inattention, impulsivity, and overactivity that are inappropriate for their developmental level and interfere with their optimal functioning. Difficulty with adhering to rules and instructions and excessive day-to-day variability in performing tasks or following directions also are thought by some investigators to be primary deficits in these disorders.
Consultation with the Specialist
Authors: Spinelli Henry M.
Published: December 2021

External ear deformities by themselves do not require emergent treatment, but associated abnormalities need to be defined to enable long-term planning. The pediatrician can orchestrate the specialists and keep parents and patient informed maximally.
Sudden Infant Death Syndrome
Authors: Carroll John L. , Loughlin Gerald M.
Published: December 2021

The causes of SIDS are unknown, and there are no tests that predict which infants will die of SIDS. Home monitoring, while it may prevent death in some high-risk infant populations, has not altered the overall incidence of SIDS. Studies have identified several important risk factors, such as prematurity, low birth-weight, inadequate prenatal care, maternal smoking, maternal anemia, and poor socioeconomic conditions. Other recent studies have raised important questions about child care practices, such as infant sleeping position. Still others raise equally important questions about the role of neglect or intentional injury, which now must become the subject of proper scientific investigation. The possibility that underlying metabolic defects may account for a substantial proportion of cases has been raised but requires verification. A common thread is evident: There are risk factors, such as maternal smoking and infant sleeping position, that could be subject to preventive intervention strategies.

Approximately 200 new articles are published on the topic of SIDS every year. The pediatrician must have the necessary perspective to incorporate these into the "big picture." Because the main role of the pediatrician involves support, advice, and counseling of parents of present SIDS victims and future siblings, a strong knowledge base is essential. The pediatrician also can serve as an advocate for future children by insisting

[See table in the PDF file]

on the full and proper investigation of every SIDS case. Although we will never eliminate sudden unexplained death during childhood, we can at least hope, through better diagnosis of treatable conditions and improved preventive intervention strategies, to whittle away this diagnosis of exclusion to its minimum possible incidence.
INDEX OF SUSPICION
Authors: Rivera Juan A. , Taubman Bruce , Walsh-Kelly Christine M.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 12-year-old girl is brought to you by her grandmother with a variety of complaints. The child has been overweight all of her life, and she tends to be constipated. She describes recurrent, colicky mid-abdominal pain after eating fatty meals and has had recurrent bouts of vomiting associated with cough and hiccups dating back to her infancy. There is no recent history of fever, asthma, or jaundice.

On examination, the girl is obese, weighing 105 kg (231 lb). Chest and abdominal examinations are normal, with no masses or organomegaly. No focal tenderness is demonstrated. Formed soft stool is noted on rectal examination; the stool is hemocultnegative. Urinalysis is normal; urine culture is negative. The results of screening blood chemistry tests are normal except for a cholesterol level of 267 mg/dL and triglycerides of 280 mg/dL.
Adult Respiratory Distress Syndrome
Authors: Fiser Debra H.
Published: December 2021

Definition

The adult respiratory distress syndrome (ARDS) was first defined by Ashbaugh et al in 1967. It is a syndrome of acute parenchymal lung dysfunction characterized by the following clinical presentation: 1) a major antecedent precipitating event, 2) the sudden onset of tachypnea and hypoxemia refractory to high concentrations of inspired oxygen, 3) the presence of diffuse patchy infiltrates on the chest radiograph, 4) a decrease in static lung compliance, and 5) the exclusion of cardiogenic pulmonary edema and chronic pulmonary disease as the sole causes of pulmonary dysfunction.

Etiology

A wide variety of major antecedent events may precipitate ARDS. Common triggering events include trauma, sepsis, shock, pulmonary aspiration of gastric contents, near-drowning, diffuse intravascular coagulation, pulmonary contusion, severe pneumonia, massive transfusion of blood products, fat embolism, burns, and cardiopulmonary bypass surgery. Despite the diversity of these predisposing conditions, the similarity in pulmonary pathology and physiology among patients who have ARDS implicates a final common pathway for alveolar injury.

Pathogenesis

ARDS is characterized histologically by diffuse alveolar epithelial and endothelial damage. Subsequently, water, solutes, protein, cellular elements, and collagen may be deposited in the interstitium and air spaces, resulting in decreased compliance and hypoxemia.

Large gaps remain in our knowledge of the pathophysiologic alterations at the cellular and molecular levels, and many mediators have been suspected of playing a role in causing ARDS.
Sexually Transmitted Diseases in Adolescents
Authors: Gittes Elissa B. , Irwin Charles E.
Published: December 2021

Introduction

Sexually transmitted diseases (STDs) are the most common reported infectious diseases among sexually active adolescents. The acquisition of an STD by the adolescent may result in significant morbidity, including eventual death from human immunodeficiency virus (HIV) infection. Serious medical sequelae for the adolescent female include pelvic inflammatory disease (PID), tubo-ovarian abscess, ectopic pregnancy, infertility, anogenital cancer, acquired immunodeficiency syndrome (AIDS), and morbidity and mortality of her off-spring. For the adolescent male, serious sequelae include epididymitis, proctitis, anogenital cancer, impaired fertility, and AIDS. The adolescent often begins his or her sexual career while under the care of a pediatrician, who, therefore, plays a crucial role in the evaluation and treatment of STDs in the adolescent patient. Of paramount importance is the clinician's role in education about and prevention of STDs in both the abstinent and the sexually active adolescent.

Prevalence

During the past 2 decades, the age of onset of heterosexual intercourse has been decreasing, with a resultant increase in the prevalence of STDs. Data from the 1988 national survey on adolescent sexual debut indicate that by age 15 years, 25% of black and white females and white males and 69% of black males have initiated coitus. By age 19 years, 76% of white females, 85% of white males and black females, and 96% of black males report having had sexual intercourse at least once.1
Consultation with the Specialist
Authors: Poland Ronald L. , Watterberg Kristi L.
Published: December 2021

Recognizing neonatal bacterial sepsis early is one of the most difficult problems that pediatricians encounter. Only 1 in 500 to 1 in 1600 newborns have proven bacterial sepsis. Prematurely born and stressed infants exhibit sepsis more frequently than do unstressed term infants. Therefore, the general pediatrician confronts proven neonatal sepsis uncommonly and needs to be alert to the early signs of sepsis because of the great danger of this potentially treatable condition. Prior to the introduction of antibiotics, mortality from neonatal bacterial sepsis was greater than 90%. Antibiotics and supportive therapy have reduced this mortality to 13% to 50%. There remains much room for improvement. Good outcomes depend on early diagnosis, appropriate treatment, and host factors that still are being explored.

Neonatal sepsis tends to appear as either "early onset" or "late onset" syndromes, but some cases are difficult to classify. Early onset disease is seen in the first few days of life, tends to be fulminant, and is associated more often with maternal or perinatal risk factors, such as maternal fever, prolonged rupture of the membranes, and fetal distress. On the other hand, late onset disease usually occurs after 1 week of age, tends to develop more gradually, and is less likely to be associated with the previously mentioned risk factors.
Nicotine Dependence: Diagnosis, Chemistry, and Pharmacologic Treatments
Authors: Miller Norman S. , Cocores James A.
Published: December 2021

Columbus brought tobacco to the Old World, and in the following centuries, tobacco smoking spread throughout the world, despite vigorous opposition. The tobacco plant was named Nicotiana tabacum after Jean Nicot, who promoted his belief that the plant had medicinal value.

Nicotine, the basic addicting drug contained in cigarettes, may be the deadliest drug known to humans in terms of overall morbidity and mortality. The morbidity and mortality from nicotine addiction is greater than that from World Wars I and II, the Vietnam War, AIDS (Acquired Immune Deficiency Syndrome), and heroin and cocaine addiction combined. Tobacco use is linked to more than 390 000 deaths per year in the United States alone. The powerful lobbying forces of the tobacco industry have managed to keep supplies of nicotine available to the public despite efforts from medical and legal bodies to reduce advertising and educate the public about the adverse consequences of nicotine use.

The addictive potential of cigarettes and the extent to which nicotine is the active ingredient in generating and sustaining addiction has been debated. The reasons for the resistance to considering whether nicotine is addictive have origins in attitudes toward addiction. Free will and personal choice have prevailed as explanations for why a 20-cigarette per day smoker will receive more then 70 000 boluses of nicotine per year despite the high rate of morbidity and mortality associated with this drug.
The Yellow Flag is Still Up
Authors: Krugman Richard
Published: December 2021

Several years ago, I wrote an editorial entitled "It's Time to Wave the Yellow Flag."1 The metaphor was to automobile racing, where a yellow flag is waved following a crash. Drivers are "cautioned," hold their places, but keep moving. The impetus for that editorial was the increasing criticism the child protection system was coming under for both failing to protect children who were being "killed" with "open cases" and for being too intrusive and violating family rights on the basis of "false reports."

I was reminded of that editorial recently, when Pediatrics in Review published the Carol Berkowitz review on "Child Sexual Abuse."2
Consultation with the Specialist
Authors: Harris J. Peter
Published: December 2021

Introduction

As many as 90% of children will have an audible heart murmur at some point in time. However, the prevalence of nontrivial heart disease in this age group is less than 4 per 1000. The practitioner's task is to distinguish the ubiquitous innocent or normal murmur from the murmur indicating heart disease. Normal murmurs include vibratory and pulmonary flow murmurs, venous hums, carotid bruits, and the murmur of physiologic branch pulmonary artery stenosis. Mislabeling of a normal murmur as pathologic may have adverse psychological effects on the family and the child, including unwarranted exercise restrictions and problems later with insurability and employment. Alternatively, failure to identify a pathologic murmur may delay appropriate intervention, especially in early infancy. Recent well-publicized sudden cardiac deaths of professional athletes have augmented the anxiety caused by the specter of heart disease in the young.

Because less than 5% of heart murmurs in children denote cardiac pathology and because each practitioner is likely to see no more than five patients per year who have important heart disease, distinguishing normal from organic murmurs is not always simple. Nevertheless, given the high prevalence of murmurs in the young and because nearly 50% of the patients who have murmurs referred to pediatric cardiologists do have underlying heart disease of variable severity, most clinicians can recognize normal murmurs.
Migraine Headaches in Children
Authors: Singer Harvey S.
Published: December 2021

Headache, especially migraine, is a common medical complaint that has confounded physicians since ancient times. Hippocrates, about 500 BC, is credited with describing symptoms we now associate with migraine. Galen, a Greek physician in the second century AD, recognized the unilateral feature of these headaches and coined the term "hemicrania." Migraine is a French word that was derived from the Latin term for hemicrania.

In the US it is estimated that 8.7 million females and 2.6 million males suffer from disabling migraine. The occurrence of migraine is greatest in adulthood, but this disorder is one of the most common causes of headache in children as well. In a 14-year longitudinal study of more than 9000 school children, Billie reported that 5% had had migraine attacks by 15 years of age. A recent population-based study in Olmsted County, Minnesota, suggests an even greater incidence in this age range. For example, the highest incidence of newly diagnosed migraine headaches appearing in males, 246 per 100 000 person-years, occurred in those aged 10 to 14 years.

This review is directed toward the identification, classification, pathophysiology, and management of migraine in children and adolescents. Readers are referred to several recent articles for more general discussions of chronic recurrent headaches in childhood (see Suggested Reading).
Insulin-dependent Diabetes Mellitus
Authors: Plotnick Leslie
Published: December 2021

Insulin-dependent diabetes mellitus (IDDM) is a chronic, serious disease in children and adolescents. Its diagnosis is straightforward and rarely subtle. The major challenges of this disease for the child, family, and health-care team involve long-term management of medical and metabolic factors as well as psychological and behavioral concerns. While developments in the past 10 to 15 years have made metabolic control technically possible, psychological stresses and behavioral problems often interfere with metabolic goals. There are few, if any, other diseases that require such intensive and extensive self-care skills.

Definitions

Diabetes generally is classified in two types. Type I, or IDDM, is seen mostly in younger people (children and adolescents). It previously was called juvenile onset or ketosisprone. Insulin deficiency characterizes IDDM, and patients need exogenous insulin for survival. Type II, or non-IDDM (NIDDM), previously called adult or maturity onset, is the type seen most commonly in older people and in obesity and is not discussed in this review.

To make a diagnosis of diabetes, a child must have either classic symptoms with a random plasma glucose above 200 mg/dL or specific plasma glucose levels before and after a standard glucose load if asymptomatic. The diagnosis of IDDM usually is clear-cut.
PERIPHERAL BRAIN
Authors: Mandl Kenneth D. , Lovejoy Frederick H.
Published: December 2021

This new section of Pediatrics in Review is designed to be clipped or duplicated and filed in a handy place in the office, clinic, or emergency department, providing a convenient and concise reference. The table below, "Specifics of Therapy, "explains the abbreviations used in the sections that deal with particular poisons. The final table lists clinical and laboratory findings and reminds the reader of those agents that should be considered. These tables are meant as a guide for the physician treating the pediatric poisoning victim. The lists of drugs, effects, and therapies are by no means exhaustive or complete. (Additional useful tables can be found in last November's issue on Poisoning, PIR 1993;14:411-422.) Consultation with a poison control system is highly recommended in the treatment of overdoses.
Consultation with the Specialist
Authors: Seidel James
Published: December 2021

Achieving vascular access in infants and children is often a challenge for emergency medical technicians, nurses, and physicians. It is a vital intervention in the critically ill or injured child and is necessary for infusing medications and fluids and obtaining blood samples for laboratory analysis. It often takes more than 10 minutes to achieve venous access during pediatric resuscitation. The presence of subcutaneous fat, the small size of peripheral vessels, vasoconstriction, and the behavior of anxious and frightened infants and children often are barriers to successful intravenous line placement. Other factors that may affect success include: 1) the skill of the person performing the procedure, 2) immobilization of the patient and/or extremity, 3) the availability of small over-the-needle catheters, 4) the availability of all materials necessary to secure the line, and 5) the site of catheter placement.

Critically ill or injured pediatric patients need rapid vascular access. Health-care providers, therefore, must understand the priorities for obtaining access to a vein. Peripheral venous access is a satisfactory route for infusions, but no more than 1 to 2 minutes should be spent attempting to establish peripheral intravenous access in ill or injured patients. A reasonable approach to vascular access in these patients is as follows: 1) Attempt peripheral access for 1 to 2 minutes
The Roar Behind the Door
Authors: Sayre James W.
Published: December 2021

In a pediatric office there is always some background noise to which we've grown accustomed: phones, children crying from shots, or infants balking at being weighed. But sometimes an unaccustomed commotion, a noise that sounds different, comes from an examination room. If I happen to be nearby or perhaps standing outside the door looking over the family's chart, I like to go close to the scene and cock my ear for a minute just outside the closed door to get a few snatches of the sounds. "Stop that!" " No, don't do that!" "Get out of there!" Then, perhaps, a wail, a brief cry, or a thump or two.