bluuebunny/crossref_metadata_2025 huggingface dataset:
Access to Ambulatory Care Services for Economically Disadvantaged Children
Authors: Newacheck Paul W. , Halfon Neal
Published: December 2021

Using data from the 1981 Child Health Supplement to the National Health Interview Survey, we examined differences in access to ambulatory services for children of different family incomes. The results indicate that much progress has been made in equalizing access since the War on Poverty was initiated in the mid-1960s. Poor children with superior health status now generally see physicians at the same rates as children in similar health but from higher income families. However, children with substantial health problems from low-income families continue to lag behind their higher income counterparts in similar health. Medicaid was shown to substantially improve access to ambulatory services for economically disadvantaged children in poor health, but less than half of these children are covered by Medicaid. Recent changes in federal and state policies concerning Medicaid are discussed as well as policy options for addressing the needs of children afflicted by both poverty and ill health.
Steroid Therapy as Treatment for Idiopathic Fibrosis of the Retroperitoneum and Mediastinum
Authors: FEILD CHARLES , ARNOLD WATSON , GLOSTER ELIZABETH S. , SHARP GREG , REDMAN JOHN
Published: December 2021

Multifocal idiopathic fibrosis of both mediastinum and retroperitoneum is rare in childhood.1,2 We describe a patient who presented with biopsyproven mediastinal and retroperitoneal fibrosis associated with progressive pulmonary fibrosis, cardiomyopathy, and bilateral ureteropyelocaliectasis; the patient responded to intravenous pulse and oral steroid therapy with relief of his uretenal obstruction and an improvement in pulmonary and cardiac function. Although surgical ureterolysis is generally the management of choice for ureteral obstruction caused by retroperitioneal fibrosis,3,4 steroid pulse therapy and a regimen of oral prednisone may provide an alternative modality of themapy.5-7

CASE REPORT

This 12-year-old black boy was seen in the emergency room with a chief complaint of shortness of breath.
Pediatric Team Physicians
Authors: LUCKSTEAD E. F.
Published: December 2021

Few pediatricians are actively involved in youth sports activities. Although pediatricians are well suited to provide complete health care to young athletes, they have avoided or deferred and referred the sports medical care of large numbers of preadolescent and adolescent youth to others. Is this acceptable? Which physician is most qualified to counsel, guide, and treat the growing child and adolescent? If pediatricians do not accept roles such as the team physician, other doctors and even non-physicians will eagerly step forward. Should athletes and teams be able to participate in sports events when adequate medical support is not available? Do athletes, parents, schools, coaches, and communities understand the actual role of the team physician?
Adolescent Homosexuality: Psychosocial and Medical Implications
Authors: Remafedi Gary
Published: December 2021

Despite a widespread interest in the health of the gay community, the psychosocial and medical problems of gay and bisexual adolescents have not been adequately investigated. In this study, 29 gay and bisexual male teenagers participated in anonymous and confidential interviews regarding the impact of sexuality on family, employment, education, peers, intimate relationships, and physical and mental health. The majority of subjects experienced school problems related to sexuality, substance abuse, and/or emotional difficulties warranting mental health interventions. In addition, nearly half of the subjects reported a history of sexually transmitted diseases, running away from home, or conflict with the law. A minority had been victims of sexual assaults or involved in prostitution. Those less than 18 years of age experienced higher rates of psychiatric hospitalization, substance abuse, high school drop-out, and conflict with the law than did older participants. Various explanations for the prevalence of these problems and their implications for health professionals are discussed.
Intelligence Quotient Scores of 4-Year-Old Children: Social-Environmental Risk Factors
Authors: Sameroff Arnold J. , Seifer Ronald , Barocas Ralph , Zax Melvin , Greenspan Stanley
Published: December 2021

Verbal IQ scores in a socially heterogeneous sample of 215 4-year-old children were highly related to a cumulative environmental risk index composed of maternal, family and cultural variables. Different combinations of equal numbers of risk factors produced similar effects on IQ, providing evidence (1) that no single factor identified here uniquely enhances or limits early intellectual achievement and (2) that cumulative effects from multiple risk factors increase the probability that development will be compromised. The multiple risk index predicted substantially more variance in the outcome measure than did any single risk factor alone, including socioeconomic status. High-risk children were more than 24 times as likely to have IQs below 85 than low-risk children.
Predictors of Intelligence Quotient and Intelligence Quotient Change in Persons Treated for Phenylketonuria Early in Life
Authors: Waisbren Susan E. , Mahon Barbara E. , Schnell Richard R. , Levy Harvey L.
Published: December 2021

Ninety-one individuals with phenylketonuria who were treated early in life were followed for as many as 22 years. Regression analyses were used to determine the best predictors of IQ and IQ change. Among treatment-related variables, good dietary control of the blood phenylalanine level stood out as the best predictor of IQ. Diet discontinuation and the natural (off diet) blood phenylalanine level best predicted IQ loss, suggesting that diet continuation may be important for children with natural blood phenylalanine levels greater than 18 mg/dL.
Measles Spread in Medical Settings: An Important Focus of Disease Transmission?
Authors: Istre Gregory R. , Mckee Phyllis A. , West Gary R. , O’Mara Dennis J. , Rettig Philip J. , Stuemky John , Dwyer Diane M.
Published: December 2021

During the period September 1981 to August 1985, we investigated every reported case of measles in Oklahoma to confirm the diagnosis, to determine the source, and to identify contacts to prevent spread of the disease. During this time, 33 serologically and/or epidemiologically confirmed cases were investigated. Nine (27%) persons acquired measles in a medical office or clinic waiting area. Eight of these recalled direct face-to-face contact with a source. An additional six (18%) cases were associated with exposure to these medically acquired cases, for a total of 45% that were the direct or indirect result of exposures in medical waiting rooms. The medical waiting room is a location where a reservoir of susceptible individuals may congregate, allowing for potential exposures to measles and other infectious diseases. Because many persons in these settings are too young to have received routine measles vaccination, other measures to decrease exposures in this setting may be necessary to achieve the goal of measles elimination in the United States.
Caustic Alkali Ingestions by Farm Children
Authors: Edmonson M. Bruce
Published: December 2021

Liquid lye drain cleaners responsible for a childhood epidemic of household ingestions in the early 1970s are now marketed in drastically reduced alkali concentrations and packaged in child-resistant containers. However, farm and industrial caustic agents continue to be sold without poison prevention safeguards, as exemplified by dairy pipeline cleaners (liquid NaOH/KOH concentrations 8% to 25%) used routinely on dairy farms. In this study, the ingestion epidemiology of farm/industrial v household caustic alkali products was compared in a population that included farm children. Forty-three children were admitted from 1973 to 1983 to four rural hospitals for nonintentional caustic alkali ingestion. Farm products constituted 23% of all products and 43% of all drain/pipe cleaners ingested. Dairy pipeline cleaners were the single most common causative substance, injuring ten toddlers (mean age 1.6 years), perforating the esophagus in two. Liquid dairy pipeline cleaners were usually ingested in tiny amounts from nonchild-resistant containers or drinking glasses at evening milking time. In contrast, household drain cleaners were associated with fewer ingestions, with all serious complications related to highly concentrated products not available on the consumer market after 1975. Poison prevention strategies successfully applied in the 1970s to household drain cleaners should be redirected and modified for farm-related caustic alkali agents. Preventive measures are suggested by the highly specific pattern of injury and the small, defined population at risk.
Hypertrichosis and Congenital Anomalies Associated With Maternal Use of Minoxidil
Authors: KALER STEPHEN G. , PATRINOS MARY ELAINE , LAMBERT GEORGE H. , MYERS THOMAS F. , KARLMAN ROBERTA , ANDERSON CRAIG L.
Published: December 2021

Minoxidil is a potent peripheral vasodilating agent used in the treatment of severe hypertension refractory to more conventional therapy. Its use in pregnant women and its effect on pregnancy outcome have not previously received attention in the medical literature.

Hypertrichosis is a well-known side effect of minoxidil.1 It occurs in nearly all patients treated for longer than 4 weeks and is reversible after discontinuation of the drug.2

We recently observed hypertrichosis and multiple congenital anomalies in an infant whose mother was on a regimen of minoxidil, as well as captopril and propranolol, continuously throughout pregnancy As the importance of case reporting in instances of possible teratogenicity has recently been underscored,3 we wish to describe our findings and to encourage additional reports of pregnancy outcome after maternal use of minoxidil.
Child Sexual Abuse, Criminal Justice, and the Pediatrician
Authors: BAUM ELIZABETH , GRODIN MICHAEL A. , ALPERT JOEL J. , GLANTZ LEONARD
Published: December 2021

More children are being recognized as victims of sexual abuse than in the past. Because pediatricians are often the first professionals to see the victim, they are often also the first to assess and to evaluate the child. Increased diagnoses of child sexual abuse may be the result either of an actual increase in the incidence of child sexual abuse or of heightened recognition. Whichever explanation or combination is correct, it is crucial that pediatricians be aware not only of the issue of child sexual abuse but also of the correct procedures in collecting data that may be used as evidence and in preparing to be a witness in a potential criminal prosecution of the alleged offender.
Alcohol Use and Abuse: A Pediatric Concern
Authors:   Committee on Adolescence
Published: December 2021

Since the beginning of recorded history, humans have consumed alcoholic beverages for purposes of religious ceremony, celebration, medicinal therapy, and recreation. Unfortunately, problem drinking also has been recognized and reported for thousands of years.1 There is continuing debate as to whether alcohol is a beverage or a drug and whether its use is always hazardous or is, at times, beneficial to physical and/or psychologic health. There is even greater debate as to whether youth should be restricted from all use of alcohol or encouraged to develop safe and responsible drinking patterns through progressive controlled exposure.

ALCOHOL USE AMONG YOUTH

Alcohol is the drug most often abused by the largest number of children and adolescents. More than 90% have tried alcohol at least once before graduation from high school. In 1984, two thirds of senior high school students admitted to using alcohol at least once a month. Nearly 50% of male high school seniors and 30% of female seniors reported drinking excessively at least once every 2 weeks. One in 20 high school seniors reported drinking daily. Despite efforts to address this problem, there has been no significant change in these statistics for the past decade according to several national surveys. 2,3 Alcohol use by school drop-outs has not been recorded but is suspected to be even greater.

Exposure to alcohol frequently occurs before or during early adolescence. Of high school students who have used alcohol, 10% had their first drink by grade 6, 30% by grade 8, and 55% by grade 9 according to one national survey.3
Impedance Bridge (Tympanometer) As a Screening Device in Schools
Authors:   Committee on School Health
Published: December 2021

STATEMENT OF PROBLEM

There is confusion in schools about the proper use of the impedance bridge. Some groups recommend its use as a substitute for audiometry and suggest physician referral on the basis of an abnormal tympanogram. In our opinion this is inappropriate.

BACKGROUND

The impedance bridge primarily detects asymptomatic middle ear effusion. This effusion may cause a conductive hearing loss (rarely greater than 20 to 30 dB). There is no consensus as to the advisability of treating this effusion, because it usually remits spontaneously within 2 to 3 months.

RECOMMENDATIONS

The Committee on School Health recommends that (1) the impedance bridge should not be used in mass screening programs for the detection of hearing loss or middle ear effusion; (2) the impedance bridge may be used in the school setting only as an aid in the diagnosis of individual children who are at high risk for, or who are suspected of having, otitis media with effusion; (3) hearing screening by pure-tone audiometry be used as the primary method of detection of hearing loss in school children; (4) the impedance bridge not be used as a replacement for audiometric screening, because it will not detect sensory neural hearing loss and may lead to overreferral of children with asymptomatic middle ear effusion; (5) any persistent abnormality detected by either the impedance bridge or pure-tone audiometry should result in a prompt referral to the child's pediatrician.
Ribavirin Therapy of Respiratory Syncytial Virus
Authors:   Committee on Infectious Diseases
Published: December 2021

Ribavirin is an antiviral drug that has recently been approved by the FDA in an aerosolized form for the therapy of respiratory syncytial virus infections in hospitalized children who do not require assisted ventilation. Ribavirin is different from other antiviral drugs both in its spectrum of activity and in its mode of administration.1,2 The following statement is presented to identify which children should be considered for ribavirin therapy. Questions also have arisen as to the benefits afforded by treatment in comparison to the potential unknown toxicity of the drug and as to whether ribavirin should be administered to infants who require assisted ventilation; the package insert has warned against using the drug in such patients. Whether pregnant women or personnel who care for infants being treated with ribavirin are at risk from exposure to the drug is also of concern. Finally, physicians must be aware that the cost of ribavirin needed for three days of therapy is almost $700.

BACKGROUND

Respiratory Syncytial Virus Disease

Respiratory syncytial virus is the most important cause of lower respiratory tract disease in infants and young children. It usually appears in yearly winter to spring outbreaks and infects essentially all children during their first 3 years of life. The number of infected infants who require hospitalization has been estimated to range in different locations from one in 50 to one in 1,000. Currently, the mortality in hospitalized infants who were previously normal is low, less than 1%.3 In infants with underlying diseases, however, the mortality may be strikingly higher.3-5
Statistics and Sudden Infant Death Syndrome
Authors: OREN JOSEPH , KELLY DOROTHY H. , SHANNON DANIEL C.
Published: December 2021

In Reply.—

Dr Cummins' letter raises two questions regarding the statistical analysis in our report and we forward the following explanations.

First, we agree that the Fisher exact test is superior to the χ2 statistic in analyzing associations between small subgroups. However, as we have already shown, in response to Dr Leblanc's letter (Pediatrics 1986;78:957), the results of the Fisher exact test are in good agreement with the published values using χ2 analysis.

Second, in Figs 1 and 2 the ordinate depicts the 95% confidence interval of the relative risk and not the relative risk per se.
Why I Have Difficulty Being Enthusiastic About Recommending That Children Wear Helmets on Bicycles
Authors: WEISS BARRY D.
Published: December 2021

In Reply.—

Dr Ciastko raises an important point. Serious head injury is not limited to victims of bicycle mishaps. Pedestnians, motor vehicle occupants, playground users, and others are all at risk for serious head injury. Physicians and others involved in preventive health cane certainly should direct their efforts at preventing these other causes of childhood mortality and death.

Nonetheless, the importance of bicycle-related head trauma should not be underestimated. Despite Dr. Ciastko's findings, the literature suggests that bicycle mishaps are an important cause of serious head injuries.
Emergency Medical Services for Children: What Is the Pediatric Surgeon's Role?
Authors: HALLER J. ALEX
Published: December 2021

Comprehensive pediatric emergency care should be integrated into an overall emergency care system and organized regionally to address the special needs of children. Some pediatric voices have suggested that emergency care for children be organized separately in a parallel system with adult emergency systems, but this plan would put children in competition with adults for federal and state funding. Equally important is the natural overlap of many emergency services with obstetric, perinatal, adolescent, and young adult programs, all of which will be strengthened by integration, not by separation. The one non-negotiable principle must be that any emergency medical system that includes children must use the best and most experienced pediatric specialists available in the area.
Bone Scintigraphy in the Evaluation of Children With Obscure Skeletal Pain
Authors: ter Meulen Deborah C. , Majd Massoud
Published: December 2021

A retrospective analysis of bone scans of 381 children with unexplained skeletal pain was made. Of these, findings are reported on 358 for whom there were sufficient clinical data. The bone scan results suggested trauma as the cause of pain in 43 patients, inflammatory disease in 73 patients, and neoplasia in ten patients. There was only one false-positive bone scan. Normal findings were obtained from 227 patients, in whom no significant skeletal disease was detected on follow-up, except for juvenile rheumatoid arthritis in 23 patients. Bone scintigraphy is, therefore, an important, noninvasive diagnostic test for evaluating children with obscure bone or joint pain. We recommend that this test be performed early in the evaluation of these children to arrive at the diagnosis expeditiously and with minimal patient discomfort and morbidity.
Qualifications and Utilization of Nursing Personnel Delivering Health Services in Schools
Authors:   COMMITTEE on SCHOOL HEALTH
Published: December 2021

The demands of school nursing services have grown rapidly in recent years. Nursing personnel who work on a day-to-day basis with schoolchildren should have the expertise required to meet these ever-increasing demands.

Today's school nurse should be equipped to assess health problems related to infectious diseases such as immunodeficiency and herpes, pregnancy, drug and alcohol abuse, child abuse (including sexual abuse), chronically disorganized families, mental illness/depression and suicide, eating disorders, physical and learning disabilities, athletic injuries, poor nutrition, and chronic disease. It is important that the school nurse be able to recognize and manage minor illness, offer skilled health counseling and guidance, detect potential health problems, make appropriate medical referrals, and act as the personal physician's extension into the school setting to meet the health needs of the child patient during the school day.

SCHOOLCHILDREN WITH DISABILITIES

The mandates of Public Law 94-142 create an additional need for professional nursing services in schools. Children with varying degrees of disabilities are now in the regular school setting. Many of these students require specialized caretaking procedures such as tracheostomy suctioning, catheterization, ostomy care, nasogastric tube feeding, or maintenance of orthopedic devices. Some children require administration of medications with varying side effects, in varying amounts, and at varying times during the school day. It is often important that a professional school nurse assess the problem, consult with the child's physician or school medical consultant, and administer the physician-prescribed services.

In preschool programs and classrooms for the severely disabled, the professional school nurse working with the child's regular physician, the school medical consultant, or a local health officer should provide in-service instruction regarding prevention of the spread of infectious disease and provide supervision of handwashing, diapering, custodial concerns, and methods of food handling.
Cure of Acute Lymphocytic Leukemia Following Relapse
Authors: RIVERA GASTON K. , MURPHY SHARON B.
Published: December 2021

We read with some interest the article by Musgrave et al (Pediatrics 1986;77:765-769) presenting information on 72 children with acute lymphocytic leukemia (ALL) who have survived disease-free 5 years or longer in their second or subsequent remission. The purpose of this letter is to share our experience at St Jude Children's Research Hospital, an institution that has been engaged in the research and treatment of childhood ALL since 1962. We now have more than 600 children with ALL who are off therapy in remission of their disease.
Phototherapy Effect on the Incidence of Patent Ductus Arteriosus
Authors: WARD KENT E.
Published: December 2021

I just finished reading the article by Rosenfeld et al (Pediatrics 1986;78:10-14). The abstract was quite intriguing and compelled me to read the entire paper. Unfortunately, I found two major flaws in the materials and methods sections that I believe cast serious doubt on the validity of the study.

First, although the findings on physical examination can be helpful in determining the hemodynamic significance of a medium-or large-sized patent ductus, I do not believe the presence or absence of a ductus can be reliably determined in very small premature infants solely on the basis of a physical examination.
In Reply: Phototherapy Effect on the Incidence of Patent Ductus Arteriosus
Authors: ROSENFELD WARREN
Published: December 2021

Dr Ward points to two major problems that we discussed in our paper. At the time this study was begun in our neonatal intensive care unit, only M-mode echocardiography was available. We agree our methods were relatively gross estimations of ductal patency, and we are presently studying the effect of phototherapy using two-dimensional and Doppler echocardiography.

The second flaw of nonblinding was an extremely difficult one to solve in our unit. Those physicians involved in the study spent considerable time in the unit and, even if shields were removed during the scheduled daily examination, it would be difficult to truly blind observers because shields would have been replaced.
PEER INFLUENCE ON PHYSICIAN'S BEHAVIOR
Authors: Student
Published: December 2021

A study of physicians' adoption of innovative practices demonstrated the importance of having a well-informed colleague, or information "gatekeeper" in an institutional setting. These influential physicians are termed "gatekeepers" because they tend to filter and control the flow of information in their institution. Such influence has been shown to be vital in passing along information about new medical technologies.
Psychomotor Adaptation in Children With Severe Chronic Asthma
Authors: Bender Bruce G. , Belleau Louise , Fukuhara Jolene T. , Mrazek David A. , Strunk Robert C.
Published: December 2021

Acute effects of steroid medications or hypoxic-induced brain damage have been hypothesized to cause neuropsychologic impairment in children with severe asthma. The present investigation included neuromotor, cognitive, psychosocial, and medical evaluations of 67 hospitalized asthmatic children from 9 to 14 years of age, at risk for motor dysfunction. Mean scores from the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) were similar to test norm means and were not indicative of neuromotor impairment. Scores of the BOTMP correlated significantly (P < .01) with measures of child and family psychosocial adaptation but not with measures of cognitive ability, steroid dose at admission, or severity of asthma. Thirteen children had battery composite scores more than 1 SD below age means but did not demonstrate decreased IQ or increased steroid use, respiratory failure, seizures, or abnormal neurologic signs compared with the other 55 children. These results indicate that most severely asthmatic children, including many with histories of hypoxia and high-dose steroid use, do not demonstrate psychomotor impairments indicative of brain damage. It is concluded that neuromotor development in asthmatic children is associated with psychologic characteristics that influence adaptation to illness and activity level.
Natural History of Primary Autoimmune Neutropenia in Infancy
Authors: Conway Lars T. , Clay Mary E. , Kline William E. , Ramsay Norma K. C. , Krivit William , McCullough Jeffrey
Published: December 2021

Five patients with primary autoimmune neutropenia were evaluated during their first 2 years of life. Their illness resolved spontaneously after 6 to 41 months (median 13 months), and the patients were subsequently followed for 13 to 73 months (median 28 months). None required immunosuppressive therapy to induce remission, and routine antibiotic therapy adequately controlled all infectious episodes. An increased rate of infection, particularly otitis media and upper respiratory tract infection, occurred during the neutropenic period. No other noninfectious illnesses, particularly no other autoimmune diseases, were reported in any of these patients at any time. In each case, resolution of neutropenia paralleled the disappearance of neutrophil autoantibodies which were specific for the NA1 antigen. This report describes the clinical and laboratory findings and the long-term history of primary autoimmune neutropenia in these five patients.
Validity of Acoustic Reflectometry in Detecting Middle Ear Effusion
Authors: Schwartz Daniel M. , Schwartz Richard H.
Published: December 2021

Pneumootoscopy, tympanometry, and acoustic reflectometry were performed in 256 middleclass children seen in a surburban pediatric office. The results demonstrated that relectometry, when validated by otoscopic findings, detected middle ear effusion with 88% sensitivity and 83% specificity when a cut-off of 5 linear units was used. Corresponding values for tympanometry were 87% and 77.5%. These results are in keeping with those of earlier studies on acoustic reflectometry and demonstrate the usefulness of this simple technique in detecting chronic and acute otitis media with effusion.
Hand Radiographs in Russell-Silver Syndrome
Authors: Herman Thomas E. , Crawford John D. , Cleveland Robert H. , Kushner David C.
Published: December 2021

Left-hand radiographs were analyzed for bone age of 15 patients with Russell-Silver syndrome. No single finding was pathognomonic. However, in children between 2 and 10 years of age, the concordance of significantly delayed maturation, clinodactyly, fifth middle or distal phalangeal hypoplasia, ivory epiphyses, and a second metacarpal pseudoepiphysis is suggestive and should prompt a search for the well-recognized clinical features of this condition.
Nipple (Papilla) Development in Puberty: Longitudinal Observations in Girls
Authors: Rohn Reuben D.
Published: December 2021

The purpose of this study was to determine the manner of breast nipple (papilla) development occurring during puberty in girls on a longitudinal basis and to compare this development to the established criteria of sexual maturation. Forty-six girls (19 white and 27 black) were followed for periods of 2 to 5 years (mean 2.67 years). In each, the nipple diameter was measured and the Tanner stage assessed. Minimal nipple development occurred from stages PH1 to PH3 (3.24 to 4.44 mm) and B1 to B3 (3.00 to 4.72 mm) or more than 1 year prior to menarche (3.75 mm). Significant growth occurred beyond stages PH3 (PH4 6.54 mm, PH5 8.98 mm) and B3 (B4 7.25 mm, B5 9.41 mm) and from less than 1 year prior to menarche to more than 1 year after menarche (5.92 mm for girls less than 1 year premenarche, 7.88 mm for girls in their first year after menarche, and 9.05 mm for girls more than 1 year beyond menarche). A more objective definition for breast stages B4 and B5, based upon nipple diameter, is now feasible. Thus, these data enhance the precision with which physiologic events occurring toward the close of puberty in girls can be studied.
Computational Model for Insensible Water Loss From the Newborn
Authors: Ultman James S.
Published: December 2021

A mathematical model for predicting insensible water loss from the newborn infant has been developed, and its adjustable parameters have been evaluated using existing data for respiratory and transepidermal water loss components. Subsequently, the model was verified by using an independent set of available data on total insensible loss from naked infants who were not mechanically ventilated and who did not sweat. Under these conditions, the model was capable of correctly predicting the influence of ambient humidity, gestational age, and postnatal age, and in general, the predictions had a precision of ± 14%, but they tended to underestimate insensible water loss by –16%. The straightforward algebraic form of the model makes it suitable for computerized calculations, which can be readily available at the bedside and quickly updated to account for changes in infant or environmental variables. The model is useful both for anticipating the abnormally large insensible water loss of the premature infant early in life and for computing expected changes in insensible water loss as a result of intentional manipulation of environmental factors, such as incubator temperature or supplemental humidification.
Genital Findings in Sexually Abused, Symptomatic and Asymptomatic, Girls
Authors: Emans S. Jean , Woods Elizabeth R. , Flagg Nancy T. , Freeman Amanda
Published: December 2021

Although evaluation of the vulva of sexually abused girls using magnification with a colposcope or pediatric otoscope has become increasingly popular, the incidence of various genital findings in sexually abused and asymptomatic children has not been reported. A prospective study was carried out in which 20 genital findings from three groups of girls (mean age 4.8 ± 2.6 years) were analyzed. The three groups were (1) sexually abused girls (n = 119), (2) normal girls with no genital complaints (n = 127), and (3) girls with other genital complaints (n = 59). Group 1 was more likely than group 2 to have scars on the hymen or posterior forchette (9% v 1%, P = .002), increased friability of the posterior forchette (10% v 1%, P = .001), attenuated hymen (18% v 4%, P = .0003), and synechiae from the hymenal ring to the vagina (8% v 0%, P = .0009). Groups 1 and 3 were remarkably similar with the exception of erythema which was more common in group 3 (34% v 68%, P = .0001). Hymenal diameter was slightly greater in group 1 than 2 but not 3. Although genital findings distinguish some sexually abused girls from asymptomatic girls, many findings also occur in girls with other genital complaints, which suggests that many of these girls have also been molested or that vulvar inflammation may lead to some of these findings.
Chronic Illness, Disability, and Mental and Social Well-Being: Findings of the Ontario Child Health Study
Authors: Cadman David , Boyle Michael , Szatmari Peter , Offord David R.
Published: December 2021

Chronic childhood illness, disability, and psychosocial problems are receiving major attention in current pediatric care. Much of the evidence associating chronic physical problems and mental health and adjustment problems has come from clinic-based studies and is often inconsistent in its conclusions. This paper reports the findings of the Ontario Child Health Study, an epidemiologic survey of 3,294 children 4 to 16 years of age in the general community, concerning the relationship of psychiatric disorders and social adjustment problems among children with chronic illness, medical conditions, and long-term disability in contrast to children free of chronic physical health problems. Age- and sex-adjusted risks for psychiatric disorders and social problems, compared with those for healthy peers, were calculated: children with both chronic illness and associated disability were at greater than threefold risk for psychiatric disorders and considerable risk for social adjustment problems. Children with chronic medical conditions, but no disability, were at considerably less risk: about a twofold increase in psychiatric disorders but little increased risk for social adjustment problems was observed. A relative underuse of specialized mental health services by children who might benefit supports the opinion that all physicians in the community who care for children with chronic health problems should become skilled in the recognition of existing or incipient mental health and social problems and familiar with preventive and treatment approaches that may lessen the excessive burden of psychosocial problems among those with chronic ill-health.
Evaluation of Interpersonal Skills and Ethics After Pediatric Training
Authors: MONTGOMERY WILLIAM C.
Published: December 2021

In this issue of Pediatrics (pp 829-833) there is a statement by the Medical Ethics Subcommittee of the American Board of Pediatrics entitled "Teaching and Evaluation of Interpersonal Skills and Ethical Decision Making in Pediatrics." The American Academy of Pediatrics agrees with and supports the thoughts and plans expressed in this statement and agrees that candidates should be examined on these issues as part of the Board's certifying process.

In 1978, the Academy published a report entitled The Future of Pediatric Education, the authorship of which was a joint effort of representatives from ten medical organizations concerned with educating pediatricians. That report clearly stated the need for formal education in medical ethics and interpersonal skills in the pediatric residency curricula in order that the biosocial needs of infants, children, and adolescents be satisfactorily addressed.
Generic Prescribing, Generic Substitution, and Therapeutic Substitution
Authors:   Committee on Drugs
Published: December 2021

This Clinical Report was reaffirmed May 2005, October 2008, October 2012, and September 2019.

Pressures generated by a constellation of professional consumer, legislative, and health care provider vider groups in this era of increasing health care costs have led to enactment of generic substitution laws in 50 states. The general acceptance of this concept, despite conflicting evidence that it has reduced the cost of prescription items to the consumer, has led to the concept of therapeutic substitution. Considerable confusion exists among health care professionals regarding the precise meaning of these concepts.

Generic prescribing is the prescribing of a drug by a physician using the generic name. This leaves the choice of brand to the dispensing pharmacist. Generic substitution is a pharmacist-initiated act by which a different brand or an unbranded drug product is dispensed instead of a drug brand that was prescribed by the physician. This means substituting the same chemical entity in the same dosage form for one marketed by a different company. Therapeutic substitution is a pharmacist-initiated act by which a pharmaceutical or therapeutic alternate for the physician-prescribed drug is dispensed without consulting the physician. This denotes replacement of the prescribed drug with a chemically different drug within the same therapeutic category, eg, hydrochlorothiazide for furosemide; ranitidine for cimetidine; chloramphenicol for erythromycin.

In 1976, the AAP Committee on Drugs published a commentary in Pediatrics (1976;57:275-277) on generic prescribing and concluded that "the lack of data on bioavailability and bioequivalence in children precludes blanket support of generic prescribing for infants and children." The Committee recently reviewed this issue and concluded that the situation has changed little during the past decade.
Neonatal Personpower
Authors:   For the AAP Committee on Fetus and Newborn, MERENSTEIN GERALD B.
Published: December 2021

In Reply.—

We appreciate Dr Katzman's interest in this complex issue. His position is similar to that previously suggested by Auld1 and would certainly suggest an increased need for more neonatologists.

The current number of neonatologists has already had a significant impact on regionalization and upon the practicing pediatrician.2 Katzman suggests that neonatal-perinatal medical care skills include resuscitation of as-phyxiated newborns, identification and treatment of high-risk newborns, management of respiratory failure, and evacuation of pneumothorax.
Smokeless Tobacco and Hypertension in an Adolescent
Authors: ADELMAN RAYMOND D.
Published: December 2021

To the Editor.—

Concern has been expressed recently about the health hazards of the widespread use of smokeless tobacco by

[See figure in the PDF file]

children. Some surveys have reported regular use by as many as 12% to 33% of male high school students.1,2 Complications of smokeless tobacco include oral cancer, periodontal disease, and dependence. Hypertension may also occur due to the sodium and nicotine content of smokeless tobacco1 and glycyrrhizinic acid. This extract of Glycyrrhiza glabra root, present in many chewing tobaccos and natural licorice, has potent mineralocorticoid activity and may produce hypertension and, in some patients, hypokalemia, alkalosis, sodium and water retention, and suppressed plasma renin activity.3-5
Benzyl Alcohol in Neuromuscular Blocking Agents
Authors: VAN DER HAL ANDRE L. , MACDONALD HUGH M. , SHAW LAURENCE , SREEPATHI SUKSHMA , BEASLEY SCOTT A.
Published: December 2021

To the Editor.—

Recent letters to the Editors1,2 suggested discontinuation of clinical trials with doxapram for apnea of prematurity, because the preparation contains the preservative benzyl alcohol, implicated as the cause for the gasping syndrome at doses of 94 to 245 mg/kg/d.3 After we reexamined our standard arsenal of drugs used in the neonatal intensive care unit, we found an additional class of drugs containing benzyl alcohol: neuromuscular blocking agents. Pancuronium bromide (Pavulon, [Organon]) is prepared in 1-mg/mL vials containing 1% (10 mg/mL) benzyl alcohol.
Passage of the First Stool in Very Low Birth Weight Infants
Authors: Jhaveri Meenakshi K. , Kumar Savitri P.
Published: December 2021

Times of first stool passage were studied in 171 infants who weighed less than 1,500 g at birth. Delayed passage (greater than 48 hours) was noted in 20.4% of this group. Significant differences were noted between the delayed and nondelayed groups for gestational age, presence of severe respiratory distress syndrome, and the time of the first enteral feeding. In very low birth weight infants, delay in the passage of the first stool is a common occurrence. This delay is probably due to physiologic immaturity of the motor mechanisms of the gut, lack of triggering effect of enteral feeds on gut hormones, and the presence of severe respiratory distress syndrome, which may singly or in concert adversely affect gastrointestinal motility.
Pimozide Treatment of Tic and Tourette Disorders
Authors: Shapiro Arthur K. , Shapiro Elaine , Fulop George
Published: December 2021

Tourette disorder is a chronic multiple tic condition that begins in childhood and may require lifelong treatment. Neuroleptics are the most effective and frequently used drugs for the treatment of both Tourette and tic disorders. Haloperidol was the first neuroleptic drug approved by the Food and Drug Administration (FDA) for the treatment of adult patients with Tourette disorder in 1969 and for children in 1978. Its effectiveness in the treatment of tics is well documented.1,2 However, adverse effects limit its usefulness and new drugs that have fewer adverse effects and greater efficacy are needed.2-5

The need for new medications is critical because of the epidemic increase in the number of patients with the diagnosis. We now know that Tourette disorder was underdiagnosed because of the erroneous belief that the etiology was psychologic and that the diagnosis required the presence of coprolalia, echolalia, and intellectual and psychologic deterioration. Following the development of accurate diagnostic criteria, early detection and diagnosis was facilitated. This in turn led to a dramatic increase in the number of physicians diagnosing and treating tic disorders and the establishment of Tourette disorder clinics throughout the country. The lifetime prevalence in the United States is now estimated as 0.5% for Tourette disorder and 1.6% for both Tourette and chronic motor tic disorders.6,7

However, a new neuroleptic drug, pimozide, was recently approved by the FDA for use in patients with Tourette disorder in 1984. Our studies on the effectiveness of pimozide, begun in 1977, were largely responsible for appoval of pimozide.
Brain Death?
Authors: MORRAY JEFFREY P. , KRANE ELLIOT J. , LYNN ANNE M. , TYLER DONALD C.
Published: December 2021

To the Editor.—

Because we are now able to provide long-term cardio-pulmonary support, the determination of cerebral death in children is a critical issue, both to provide an unambiguous diagnosis of death and, when appropriate, to allow recovery of organs for transplantation. Perhaps this latter issue provided the impetus for Drake et al1 to evaluate their recent experience at Loma Linda and to present a protocol for the determination of brain death in children.
Adult Heart Disease Prevention in Childhood: A National Survey of Pediatricians' Practices and Attitudes
Authors: Nader Philip R. , Taras Howard L. , Sallis James F , Patterson Thomas L.
Published: December 2021

There is controversy about the role of pediatric care givers in reducing presumed risk factors for cardiovascular diseases in children. A national mail survey of 2,000 pediatricians was designed to determine the attitudes, current practices, and knowledge among primary care pediatricians regarding these risks. The response rate was 60% (779 primary care pediatricians). Responses indicated that a majority of pediatricians take a family history of cardiovascular diseases, assess BP, recommend exercise to school-aged children, and advise patients and parents against smoking. Few pediatricians felt confident in their ability to affect change in patient life-styles. There was a relatively low level of provision of dietary advice, and most pediatricians do not measure serum cholesterol levels, except in high-risk older children. A substantial minority do not discuss smoking, even with adolescents. Practices and attitudes varied with the age of the patient. Obesity was the topic most frequently chosen for continuing medical education. Older pediatricians were most likely to advocate and practice risk reduction in children. Attitudes and reported practices also varied by gender and geographic location of the pediatrician as well as the ethnic composition of the practice. Implications for continuing medical education are discussed.
Developmental Outcome in Children Exposed to Chloride-Deficient Formula
Authors: Willoughby Anne , Moss Howard A. , Hubbard Van S. , Bercu Barry B. , Graubard Barry I. , Vietze Peter M. , Chang Charles C. , Berendes Heinz W.
Published: December 2021

The developmental outcome of 2- and 4-year-old children who had been exposed as infants to chloride-deficient formula was studied. A negative dose-response relationship was demonstrated between use of the formula without additional nutritional supplementation and cognitive outcome as measured by the Bayley Scales of Infant Development (Pearson r = –.55, P = .01) at 2 years of age. A similar negative relationship was demonstrated between this exclusive use of the defective formula and perceptual (Pearson r = –.51, P < .05), motor (Pearson r = –.52, P < .05), and fine motor (Pearson r = –.75, P < .002) ability as measured by the McCarthy Scales of Children's Abilities at 4 years of age. When other known predictors of developmental outcome were taken into account by means of multiple linear regression analyses, exclusive formula use emerged as an important predictor of the children's cognitive functioning at 2 years (model R2 = .59, P < .005) and of quantitative (model R2 = .58, P < .006), perceptual (model R2 = .63, P < .009), and fine motor ability (model R2 = .74, P < .003) at 4 years of age. These data raise concern about the developmental outcome of the children exposed to chloride-deficient formula.
Neuroblastoma: The Case for Screening Infants in North America
Authors: Woods William G. , Tuchman Mendel
Published: December 2021

Neuroblastoma is a disease in which easily measured tumor markers are excreted. It is curable when diagnosed in an early stage and at an early age, and it has a high incidence relative to other serious childhood diseases. Recent advances in screening infants for neuroblastoma by detection of urinary homovanillic acid and vanillylmandelic acid, the most useful markers of neuroblastoma, are described. Based on results from Japan's mass-screening program and on the authors' observations, it is estimated that mass screening for neuroblastoma could save 260 lives annually in the United States.
Mental and Motor Development Correlates in Patients With End-Stage Biliary Atresia Awaiting Liver Transplantation
Authors: Stewart Sunita M. , Uauy Ricardo , Waller David A. , Kennard Betsy D. , Andrews Walter S.
Published: December 2021

We measured mental and motor development in 27 infants and 14 children with end-stage biliary atresia who were awaiting liver transplantation, and we measured disease-related variables (physical growth, liver function, and severity and duration of disease) that may relate to development. We then determined the relationship between development and the disease-related vanables. Infants were assessed with the Bayley scales, and children were assessed with the Stanford-Binet scales of intelligence and the Minnesota Child Development Inventory. The mean ± SD mental and motor scores for infants were 79.5 ± 19.6 and 69.7 ± 17.6, respectively. The mean ± SD IQ and motor development scores for children were 76.1 ± 16.6 and 56.9 ± 18.1, respectively. For infants, mental and motor development were related significantly to height and weight (r values ranged from .42 to .72). Mental development in infants was also related significantly to serum vitamin E levels (P = .03). Multiple regression analyses combining growth and disease-related indices predicted 70% of the variance in mental and motor development in infants (P = .001). For children, development was related to measures of liver function (ie, to serum bilirubin, r = –.51, P = .08, and to serum albumin, r = .54, P = .06) but not to growth. Careful nutritional support during infancy and aggressive management of liver disease prior to transplantation may be important in optimizing the development of children with biliary atresia who subsequently undergo liver transplantation.