bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of the Ileal Conduit and Clean Intermittent Catheterization for Myelomeningocele
Authors: Crooks K. Kenney , Enrile Benedicta G.
Published: December 2021

Clean intermittent catheterization has been shown to be a safe and effective means of regular vesical emptying in children with neurogenic bladders secondary to myelomeningocele. The major benefits appear to be the protection of the upper urinary tract, and in many children, improved urinary control. In contrast, the ileal conduit has been shown to produce significant long-term complications; the major one is deterioration of the upper urinary tract. Most children with myelomeningocele begin life with normal kidneys. Our goal of therapy, therefore, is a continent independent child with normal renal function. With proper patient selection, clean intermittent catheterization offers an excellent means of achieving this result in many children; the ileal conduit for permanent urinary diversion in children is outmoded.
Augmented Ventricular Rate Following Verapamil Treatment for Atrial Fibrillation with Wolff-Parkinson-White Syndrome
Authors: Rowland Thomas W.
Published: December 2021

Verapamil has gained increasing acceptance as a first-line drug in the treatment of paroxysmal supraventricular tachycardia in both adults1 and children.2-4 Conversion to sinus rhythm in more than 90% of cases has been reported, an effect related to the drug's prolongation of refractory period and conduction through the atrioventricular node.

The electrophysiologic effects of verapamil on accessory atrioventricular conduction pathways are more variable, and in some patients the drug will cause a decrease in refractory period.5-7 In individuals with reentrant paroxysmal supraventricular tachycardia this action is inconsequential, but in those with ventricular preexcitation accompanied by atrial fibrillation or flutter the effect may be catastrophic.
New Therapy for Severe Cystic Acne
Authors:   Committee on Drugs
Published: December 2021

Isotretinoin, 13-cis-retinoic acid (Accutane, Hoffmann-LaRoche), is brightening the bleak outlook for adolescents and young adults with nodular, cystic, and conglobate acne—a severe, scarring disease—that has resisted treatment with topical or systemic antibiotics, benzoyl peroxide, retinoic acid, and intralesional corticosteroids. Adolescents with less severe forms of acne who learn about the therapeutic triumphs of isotretinoin in severe recalcitrant nodular and cystic acne may assume that the drug also would be beneficial for them. Pediatricians should inform these adolescents that the drug has not been studied in, found effective for, or labeled for the treatment of typical acne.

Patients with multiple, active, deep dermal or subcutaneous cystic and nodular acne lesions are usually given 1 to 2 mg of isotretinoin per kilogram of body weight per day (although dosage as low as 0.05 mg/kg/d has been reported as beneficial), orally, in two divided doses for 15 to 20 weeks or until the cyst count decreases by 70%, if this happens sooner than 15 to 20 weeks. Use of this drug is associated with a reduction in sebaceous gland size and activity (a decrease in sebum excretion by as much as 75% to 90%), with inhibition of sebaceous cell differentiation, and with a reversion to prepubertal skin surface lipid composition. Although isotretinoin is expensive, a course of treatment usually clears the troublesome lesions and a prolonged remission often follows.

Side effects and alterations in patients' laboratory test results do occur; these appear to be lessened by reduction in dosage and to be fully reversible when the drug is discontinued.
Letter to the Editor
Authors: Sinatra Frank R. , Tong Myron J.
Published: December 2021

We appreciate the comments of Sacher et al and share their view that the presence of anti-hepatitis Be in a hepatitis B surface antigen-positive mother does not prevent vertical transmission of either icteric or anicteric hepatitis B. Since publication of our paper1 we have identified two additional infants, born to HBeAg-positive and anti-HBe-positive carrier mothers, in whom evidence of hepatitis B transmission was identified. In one case, transient antigenemia was detected and was subsequently followed by the appearance of anti-HBe.
THE MEDICAL VIEW OF ROLLER SKATING IN 1885
Authors: C. T. E.
Published: December 2021

During the 1880s roller skating had become enormously popular among American children.1 To counteract the widely-held fear that this pastime was detrimental to the health of young children, the following editorial was published in 1885 in one of our best-known nineteenth-century journals.2

THE MEDICAL VIEW OF ROLLER-SKATING

It seems as if America were peculiarly susceptible to epidemic influences of a mental kind. We hear of no other country so violently perturbed by "waves" of temperance crusading, religious revivals, velocipede crazes, pedestrianism, and, finally, roller-skating, upon which latter pastime the thoughts and feelings of three-fourths of the rising generation are at present centered. In intensity and extent, the roller-skating mania has far exceeded all its predecessors, and it must be inferred, either that the psychological contagium is particularly strong, or that the susceptibility of young America to affective epidemic influences is increasing.

Modern scientists of the "Psychical Research" school are putting forward the theory of brain-waves as a possibly potent element in the production of panic fears and epidemic fashions and feelings. The mind acts "exoneurally," we are told, and the vibrating brain-cells of the enthusiastic roller-skater communicate their rhythmical pulsations to the previously insensitive spectator. Whatever the mechanism, there is certainly at present a morbidly exaggerated passion for, and indulgence in, roller-skating. And the question comes home to the physician, whether it is doing any physical or mental harm.

On the whole, we are inclined to take a rather lenient view of the present craze. Considerable inquiry has failed to elicit any facts showing that roller-skating, temperately indulged in, does any harm to growing children; or produces any diseases and injuries peculiar to the sport.
Urinary Potassium Excretion in the Critically III Neonate
Authors: Engle William D. , Arant Billy S.
Published: December 2021

The possibility that negative potassium balance may occur in critically ill preterm neonates is suggested by factors such as the usual provision of minimal potassium intake, increased plasma aldosterone concentrations, increased prostaglandin synthesis, and the frequent use of diuretic agents. In order to assess the relationship between potassium balance and renal prostaglandins, nine infants with respiratory distress syndrome (mean birth weight 1,264 g, mean gestational age 30.6 weeks) were studied sequentially with timed-urine collections during the first four postnatal days and values were compared with those of 18 preterm infants without respiratory distress syndrome. Mean plasma potassium concentrations decreased significantly from 4.87 ± 0.19 mEq/L (mean ± SEM) on day 1 to 3.83 ± 0.18 mEq/L on day 4, (P < 0.05), and cumulative potassium balance was -4.07 ± 0.95 mEq/kg or 10% of estimated total body potassium. Urinary excretion of prostaglandin E, on day 1 in infants with respiratory distress syndrome was significantly greater than in those without respiratory distress syndrome (22.0 ± 4.9 v 8.3 ± 1.6 ng/mg of creatinine) and varied directly with urinary potassium excretion (r = .66, P < .001). These studies suggest that consideration be given to the importance of providing sufficient potassium to prevent hypokalemia in the stressed preterm infant and that pharmacologic agents that alter prostaglandins or potassium excretion should be used with caution.
The Neutral Temperature of Very Low-Birth-Weight Infants
Authors: SAUER PIETER J. J. , VISSER HENK K. A.
Published: December 2021

Recently, guidelines for perinatal care were published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.1 In a chapter on thermoregulation of newborn infants, recommendations for the neutral temperature of newborn infants are given. These recommendations are based on studies done more than 15 years ago.2,3 Although most of the recommendations are still valid, the values given for very low-birth-weight infants during the first week of life might need reconsideration based on more recent studies.

In the original studies, infants were grouped by birth weight and not by gestational age. The group called the "smaller prematures" had a mean birth weight of 1,276 g; all weighed less than 1,500 g.
The Attack on the Tympanic Membrane
Authors: STICKLER GUNNAR B.
Published: December 2021

Fluid in the ear, glue ear, and conductive hearing loss have replaced the "infected, large, or hypertrophied tonsils" and "enlarged adenoids" as a major concern of primary physicians caring for children and the special domain of ear, nose, and throat physicians. Having myringotomy tubes put into the ears has become a favorite topic of discussion for parents marveling at the positive effects. Indeed, these devices must be something of a fashion or status symbol, because it is estimated that tubes of various configurations and materials are placed into the tympanic membrane of at least 1 million children per year in this country.
Feeding of Infants with Cleft Palate
Authors: PARADISE JACK L. , MCWILLIAMS BETTY JANE , ELSTER BARBARA
Published: December 2021

To the Editor.—

We do not agree that the "gravity-flow" nipple described by Martin1 constitutes an advance in the feeding of infants with cleft palate. In our experience, its use has usually proved unsatisfactory. What is needed to compensate for the inability of infants with cleft palate to generate effective oral suction is not a special nipple but rather a compressible feeder. A decade ago, we discussed the basis for feeding difficulties in infants with cleft palate.2
The Uvula and Sudden Infant Death Syndrome
Authors: HARPEY JEAN-PAUL , RENAULT FRANCIS
Published: December 2021

To the Editor.—

Guilleminault et al1 mentioned the case of a child with near-miss sudden infant death syndrome who had an abnormally long uvula and who eventually underwent uvulotomy. When interviewing the Moroccan parents of an infant who died suddenly while asleep at age 2 months, we learned that sudden infant death syndrome had been known for years in Morocco. It was well known, too, that infants who eventually were victims of sudden infant death syndrome had often had hypersialorrhea, snoring, coughing, and regurgitation since the first days of life.
Recognition of Neonates by Facial-Visual Characteristics
Authors: Porter Richard H. , Cernoch Jennifer M. , Balogh Rene D.
Published: December 2021

A series of experiments investigated the salience of newborn infants' facial-visual features for recognition and sex identification. Within 33 hours post-partum, mothers recognized photographs of their own offspring when presented with those of unrelated neonates. Furthermore, adult subjects were able to match photographs of unfamiliar mothers and their infants, and determine the sex of neonates, at a greater than chance level of accuracy. Although recognizable facial features are presumably genetically determined, maternal recognition of offspring probably results from brief exposure and familiarization as well as physical resemblance between the infant and other familiar family members, including the mother herself.
Degenerative Changes in Neutrophils: An Indicator of Bacterial Infection
Authors: Liu Cheng-Hurd , Lehan Carol , Speer Michael E. , Fernbach Donald J. , Rudolph Arnold J.
Published: December 2021

A review was made of 195 peripheral blood smears of 157 neonates who required sepsis work-up in the first month of life. Degenerative changes of neutrophils including vacuolization and toxic granulation were observed frequently in infants with culture-proven bacterial sepsis. Of 21 peripheral blood smears from 20 neonates subsequently proven to have bacterial infection, 17 had vacuolization present in the neutrophils for a sensitivity of 81%, a specificity of 93%, and a positive predictive accuracy of 59%. Toxic granulation changes in neutrophils showed similar results. This simple test can be performed easily in all hospitals; it does not require special laboratory facilities. The test appears to provide a valuable adjunct in the early detection of neonatal bacterial infection.
Staphylococcus epidermidis Bacteremia in Neonates: Further Observations and the Occurrence of Focal Infection
Authors: Noel Gary J. , Edelson Paul J.
Published: December 2021

The frequency and clinical significance of Staphylococcus epidermidis isolates from blood cultures of neonates collected during a 17-month period in The New York Hospital neonatal intensive care unit (NICU) were reviewed. Twenty-three episodes of clinically significant S epidermidis bacteremia were detected using the criteria of isolation from 3/3 blood culture bottles from a single culture, or isolation from two or more blood cultures taken at different times, or simultaneous isolation from blood and fluid, pus or vascular catheter. Of these 23 episodes of S epidermidis bacteremia, ten were associated with colonized vascular catheters, and four episodes occurred in infants with necrotizing enterocolitis. Focal S epidermidis infection occurred in ten episodes, and persistent bacteremia occurred frequently in this setting. S epidermidis was the most frequent cause of bacteremia in the Neonatal Intensive Care Unit during the period reviewed. Of the isolates determined to be clinically significant, 74% were resistant to methicillin and cephalothin and 91% were resistant to gentamicin. All isolates were sensitive to vancomycin. In addition to removing vascular catheters suspected of being colonized and searching for potential sites of focal infection, an antibiotic regimen that includes vancomycin should be initiated once significant S epidermidis bacteremia has been recognized in the neonate.
Poison Prevention Education
Authors: Temple Anthony R.
Published: December 2021

Physicians can significantly decrease the frequency and severity of poisoning by educating parents and families in poison prevention. Appropriate strategies for poison prevention education require an examination of epidemiologic characteristics of exposures and potential intervention techniques. Parents should be taught immediate first-aid steps, such as initiating basic life-support measures and irrigation and dilution, that can be taken before seeking medical assistance. Other consumer actions, such as inducing emesis, require medical supervision. The poison control center is the best source for information and advice on treating poisoning. To decrease the frequency of poisoning, parents should be taught to purchase, store, and handle potentially toxic products appropriately. The purchase of household chemicals and drugs in child-resistant safety packaging should be encouraged. To decrease the severity of poisoning, parents should post the phone number of the local poison center, be able to initiate first-aid measures, and keep ipecac syrup on hand. Ideally, a physician should establish a preventive education schedule and discuss poison prevention with parents at regular well-child visits, beginning when the child is very young.
The Face in Otitis Media
Authors: SHARON BRUCE I.
Published: December 2021

To the Editor.—

The distinctive facial features of children who breathe through the mouth as described by Bresolin et al1 may also apply to children with other clinical conditions. Based on gross observation, I have suspected that many children with recurrent otitis media have special craniofacial characteristics that make them more prone to recurrent infections. My suspicion, that these children have comparatively elongated facies, is similar to the findings reported by Bresolin et al in children with chronic nasal obstruction.
Lipids in Milk and the First Steps in Their Digestion
Authors: Hamosh Margit , Bitman Joel , Wood D. Larry , Hamosh P. , Mehta N. R.
Published: December 2021

Human milk contains 3.0% to 4.5% fat. The fat is contained within membrane-enclosed milk fat globules. The core of the globules consists of triglycerides (98% to 99% of total milk fat) whereas the globule membrane (which originates from the mammary secretory cell's Golgi and cell membranes) is composed mainly of phospholipids, cholesterol, and proteins. Milk fat content and composition change during lactation. Whereas the triglyceride level rises, the phospholipid and cholesterol concentrations decrease during the transition from colostrum to mature milk, resulting in an increase in the size of the milk fat globules. Digestion of milk fat depends on the consecutive action of several lipases. The first step is the partial hydrolysis of the milk fat globule core by lingual and gastric lipases in the stomach. Hydrolysis continues in the duodenum, where the bile salt-stimulated lipase of human milk and pancreatic lipase complete the process initiated in the stomach.
Development of Carbohydrate Absorption in the Fetus and Neonate
Authors: Mobassaleh Munir , Montgomery Robert K. , Biller Jeffrey A. , Grand Richard J.
Published: December 2021

Maturation of mechanisms for carbohydrate absorption occurs in a defined sequence during human fetal development. The intestinal enzymes, lactase, sucrase, maltase, isomaltase, and glucoamylase, are at mature levels in the term fetus. Mature levels of pancreatic amylase activity and glucose transport occur postnatally, and levels are low in both the term and preterm neonate. In the preterm infant, sucrase, maltase, and isomaltase are usually fully active, but lactase activity, which increases markedly from 24 to 40 weeks, may be low depending upon fetal age. Despite these developmental patterns, clinical lactose intolerance is uncommon. Postnatal adaptive responses to ingested carbohydrates lead to competent carbohydrate absorption. Inadequately absorbed carbohydrates are salvaged by colonic flora through fermentation of carbohydrates to hydrogen gas and short-chain fatty acids; the latter are readily absorbed by the colon. In this setting, carbohydrate tends to be absent from the stool. Noninvasive reflection of the status of carbohydrate absorption may be obtained from breath hydrogen testing, a technique of particular value in young infants.
Long-Term Effects of Nonorganic Failure to Thrive
Authors: Oates R. Kim , Peacock Anthony , Forrest Douglas
Published: December 2021

Fourteen children admitted to the hospital at an average age of 12.5 years previously were reviewed in comparison with a group of children matched for age, sex, social class, and ethnic group. The children in the study group were smaller in height and weight, than children in the comparison group. They had lower scores on the verbal intelligence scale of the Wechsler Intelligence Scale for Children—Revised, poorer language development, and less well-developed reading skills. They had lower social maturity and a higher incidence of behavioral disturbances. There were no differences between the study and comparison groups in family size, maternal age, family health, social isolation, and mothers' childhood experiences. The study group mothers had less knowledge about their children's education, were more anxious, and had a tendency toward concrete thinking. To prevent the long-term adverse effects of nonorganic failure to thrive, a more active, practical, and long-term program, begun at the time of presentation, is recommended.
Serious Head Injury in Infants: Accident or Abuse?
Authors: Billmire M. Elaine , Myers Patricia A.
Published: December 2021

The medical records and computed tomography (CT) scans of all children less than 1 year of age admitted to the hospital with head injury over a 2-year period were reviewed. Sixty-four percent of all head injuries, excluding uncomplicated skull fracture, and 95% of serious intracranial injuries were the result of child abuse. The occurrence of intracranial injury in infants, in the absence of a history of significant accidental trauma, such as a motor vehicle accident, constitutes grounds for an official child abuse investigation.
Tissue Damage Caused by the Intramuscular Injection of Long-Acting Penicillin
Authors: Schanzer Harry , Jacobson Julius H.
Published: December 2021

In order to elucidate whether tissue damage produced on occasion by intramuscular injection of longacting penicillin is due to accidental intra-arterial injection or vasospasm, two types of experiments were carried out in rabbits. In the first set of experiments, six New Zealand White rabbits were given intra-arterial injections of 0.4 mL of a mixture containing 300,000 U of penicillin G benzathine and 300,000 units of penicillin procaine per milliliter (Bicillin C-R) into the left femoral artery and 0.4 mL of normal saline into the right femoral artery as autocontrol. In a second set of experiments, 0.4 mL of the same penicillin preparation was injected in the space surrounding the left femoral artery in five New Zealand rabbits, and 0.4 mL of normal saline was injected in a similar fashion around the right femotal artery as control. The legs of the rabbits that received the intra-arterial injection of penicillin invariably developed ischemic manifestations. None of the legs of rabbits given intra-arterial injections of normal saline had pathologic manifestations. None of the rabbits that received the periarterial penicillin preparation or normal saline developed abnormalities. These results strongly suggest that the tissue damage produced by penicillin is secondary to the intra-arterial administration of the drug.
Unconvinced of Value of Antenatal Transfer to Level 3 Intensive Care Units
Authors: PANETH NIGEL , SUSSER MERVYN W. , KIELY JOHN L.
Published: December 2021

In Reply.—

Sepkowitz's arguments are flawed by his use of proportional mortalities instead of actual death rates. The low proportion of neonatal deaths occurring in the first four hours in an Oklahoma community hospital may indeed reflect a favorable first-four-hour death rate. But it might also be due to an unfavorable four-hour to 28 day death rate. Without the actual rates no conclusion can be drawn.

Although it is true (as pointed out in our article) that some of the deaths averted in the first four hours at level 3 units were deferred to later in the neonatal period, a statistically significant and clinically important mortality advantage for low-birth-weight level 3 births was seen in all of our analyses, extending out as far as 3 months of age.1
Early Detection of Bacteremia in an Outpatient Clinic
Authors: Liu Cheng-Hurd , Lehan Carol , Speer Michael E. , Smith E. O'Brian , Gutgesell Margaret E. , Fernbach Donald J. , Rudolph Arnold J.
Published: December 2021

A total of 570 patients, aged less than 24 months, who were seen in the emergency room at Texas Children's Hospital for evaluation of acute febrile illness had a WBC count, differential count, and a blood culture obtained. Bacteremia occurred in 7.7% (n = 44) (22 Haemophilus influenzae; 17 Streptococcus pneumoniae; three Escherichia coli; one group B Streptococcus; one Staphylococcus aureus). The sensitivity, specificity, and positive predictive value of morphologic changes (vacuolization and toxic granulation) of polymorphonuclear neutrophils (segmented neutrophils plus band cells), WBC count ≥15,000/µL and band cells ≥500/µL were examined. Additionally, abnormalities in three of four tests (WBC count ≥15,000/µL, band cells ≥500/µL, segmented neutrophils ≥10,000/µL, and/or total polymor-phonuclear neutrophils ≥10,500/µL) were evaluated. Morphologic changes of polymorphonuclear neutrophils were noted frequently in patients with culture-proven bacteremia (63% and 51% positive predictive value for vacuolization and toxic granulation, respectively) and were more predictive of bacterial infection than traditional tests. If both vacuolization and toxic granulation were present, the positive predictive value increased to 76%. Examination of the peripheral blood smear may provide important adjunctive information for the presence of bacteremia prior to bacteriologic confirmation.
Recurrent Abscess Formation Following DTP Immunizations: Association with Hypersensitivity to Tetanus Toxoid
Authors: CHURCH JOSEPH A. , RICHARDS WARREN
Published: December 2021

Adverse local reactions to vaccines containing diphtheria and tetanus toxoids and pertussis antigen (DTP) are common, but generally benign. Most often, these reactions are manifested by erythema, induration, and tenderness occurring at the injection site 12 to 24 hours following immunization.1-3 Less frequently, abscess formation may complicate intramuscular injections and these may be staphylococcal, clostridial, or sterile in etiology.4

Tetanus toxoid has been associated with a reaction incidence of 3% to 13%,5,6 and adverse reactions appear to be related to the number of prior immunizations and the height of preexisting antibody responses.3,6 However, recurrent abscess formation associated with hypersensitivity to one or more of the components of the DTP vaccine has not been reported previously.
Polaroid Confirmation of the `Difficult-to-Demonstrate' Inguinal Hernia
Authors: KRASNA IRWIN H.
Published: December 2021

Pediatric surgeons are often confronted with a child referred for an inguinal hernia, in which the hernia cannot be elicited or demonstrated at physical examination. The mother usually gives an excellent history, but in spite of pushing and prodding of the baby, and making the baby cry, the hernia does not appear. This report will demonstrate how a clever mother confirmed the presence of a bulge in spite of the surgeon's inability to demonstrate it on three visits.

CASE REPORT

A 15-month-old male infant was seen because the mother had noticed a left inguinal bulge. On physical examination, in spite of every maneuver attempted, no bulge was demonstrated.
Misleading Editorial
Authors: LILDHOLDT TORBEN
Published: December 2021

To the Editor.—

The commentary, "The Attack on the Tympanic Membrane,"1 "calls for some comments as the author referred to a preliminary report of my study.2

Stickler1 suggests that we "demand prospective studies of untested surgical procedures before our patients are subjected to them," and nobody can disagree with that. However, the aim of such investigations is to arrive at a scientific analysis that is based on a weighing of the pros and cons. This process is going on concerning the use of ventilation tubes in secretory otitis media and, if a status has to be made, both types of information should be evaluated.
Chest Pain in Children
Authors: Selbst Steven M.
Published: December 2021

In a retrospective study of chest pain, 267 children were identified. This gave an occurrence rate (per patient visit) of 0.249%. Male patients were identified as often as female patients, and teenagers as often as children less than age 12 years. Chest pain was found to be present for more than 1 month in 8.6% and for more than 1 year in 7.8%. Idiopathic chest pain was the most common diagnosis made, followed by functional pain (anxiety related) and musculoskeletal pain. Laboratory tests were not helpful in establishing the etiology of chest pain.
Ipecac Use in the Home
Authors: RUMACK BARRY H.
Published: December 2021

The two articles concerning syrup of ipecac in the home (appearing in this issue of Pediatrics) raise and partially answer some questions of importance to pediatricians and poison centers. As is constant in the medical literature, additional questions are raised which provide grist for other studies. It seems unlikely that we will ever run out of questions and completely "solve" the quandries of pediatrics or poisoning.

Both studies rely on the telephone management and follow-up of patients. This admittedly results in secondhand data and can never be as good as that which an individual researcher observes. It is, however, "real" in that poison centers and pediatricians operate in this way much of the time.
Preventing Sexual Abuse of Children in Day Care: Whose Problem Is It Anyway?
Authors: KRUGMAN RICHARD D.
Published: December 2021

In his 1977 C. Anderson Aldrich Award address, Henry Kempe highlighted child sexual abuse as "another hidden problem." It is no longer hidden. Public and professional awareness of the issue is rapidly increasing (reported cases have increased more than 600% in the last 7 years). The disclosure of multiple child victims in day care centers in California, Nevada, New York, and elsewhere has led to demands that "something be done."

Legislators have responded by passing packages of laws that increase penalties for perpetrators, mandate long sentences for repeat offenders, and/ or require fingerprinting and FBI (Federal Bureau of Investigation) background checks on day care center employees.
Questions on the Vitamin E Study
Authors: SPEER MICHAEL E. , RUDOLPH ARNOLD J. , HITTNER HELEN M.
Published: December 2021

In Reply.—

Regarding the efficacy of a few early intramuscular injections of vitamin E to decrease the incidence and severity of intraventricular hemorrhage reported by Speer et al,1 Jansen adds his concerns to those already expressed in the commentary by Phelps.2

The intraventricular hemorrhage data were a retrospective study, the inborn and outborn infants were not randomly separated into control and treatment groups, and the small numbers resulted in some nonsignificant differences between control infants and treated infants.
Chronic Nonspecific Diarrhea: The Value of a Preliminary Observation Period to Assess Diet Therapy
Authors: Boyne Linda J. , Kerzner Benny , McClung H. Juhling
Published: December 2021

Eighteen children with chronic, nonspecific diarrhea were evaluated prospectively to determine "basal" fat consumption and the response of their diarrhea to diets containing either 25% or 50% of total calories as fat. In the observation period, prior to initiating any alteration in dietary fat content, diarrhea subsided. Only five of the 18 patients had a low fat intake (less than 27% of total calories) at the outset of the study, and spontaneous resolution of the diarrhea precluded an assessment of the effect of altering fat intake on stool frequency. We are, therefore, impressed that a preliminary observation period, in which details of the diarrhea are documented, is essential to evaluate any treatment modality for this poorly defined condition.
Subdural Hemorrhage in Utero
Authors: GUNN TANIA R. , MOK PUI M. , BECROFT DAVID M. O.
Published: December 2021

Acute subdural hemorrhage following the trauma of a difficult birth is a recognized cause of an increase in head circumference and anemia soon after birth.1 Although major subdural hemorrhages occurring in the fetus before the onset of labor are relatively rare, in most reported cases these also have been traumatic, the result of motor vehicle accidents or assaults.2-7 With few exceptions, there have been associated uteroplacental or other fetal injuries.

In 1977, MacDonald et al8 believed they were making the first case report of an infant born with hydrocephalus and anemia due to bilateral subdural hematomas in which there was no history of maternal trauma.
Behavioral and Cognitive Effects of Anticonvulsant Therapy
Authors:   Committee on Drugs
Published: December 2021

Behavioral disturbances associated with the use of anticonvulsant therapy may be readily apparent and easily diagnosed. They are most commonly reported with the use of barbiturates and usually include hyperactivity, disturbed sleep, irritability, and emotional lability. But, subtle behavioral disturbances may also adversely affect performance and learning. Behavioral changes resulting from therapy with barbiturates and benzodiazepines tend to be idiosyncratic as opposed to the dose-related affects seen with phenytoin and valproate therapy. Carbamazepine and valproate can affect mood and behavior negatively, but, generally, this occurs less frequently than when several other anticonvulsants are used; this is especially true in patients without CNS damage.

The suspicion that there may be a causal relationship between anticonvulsant therapy and impairment of cognitive skills in nonintoxicated patients is gaining increasing support. Neuropsychologic studies in acutely exposed normal volunteers, studies in epileptic patients receiving monotherapy, and crossover studies between drugs have incriminated barbiturates and hydantoin drugs. Memory/cognitive dysfunction, although affected to a greater extent with higher drug dosages, has been reported with levels within the therapeutic range. Thus, serum drug levels cannot be considered good predictors of which patients will have subtle side effects. Carbamazepine and valproate seem to be relatively free of many adverse neuropsychologic effects, although additional studies need to be performed.

The complete separation of seizure effects from drug effects remains on ongoing goal. Similarly, in comparative studies to date, the issues of whether the differences between the drugs are due to negative effects of one or positive psychotropic effects of the other, or both, are not adequately addressed. In addition, because current physician office procedures do not detect subtle mental impairments, more sensitive techniques are needed to assess potential cognitive and behavioral side effects of medications.
Postpartum (Neonatal) Sibling Visitation
Authors:   Committee on Fetus and Newborn
Published: December 2021

A fundamental goal of maternal newborn care is to foster parent-newborn-family relationships; therefore, the concept of family-centered care should be integrated into every aspect of perinatal services.1

Sibling visitation is consistent with the concept of family-centered perinatal care. Parents respond very favorably to the opportunity for sibling visits.2 Children who visit their mothers after the birth of a sibling have been reported to be more responsive to their mothers and siblings than nonvisiting children.3 In two studies of sibling visits to neonatal intensive care units, there were no adverse effects noted.4,5

Umphenour6 and Wranesh7 have both demonstrated no effect of bacterial colonization of neonates with the institution of sibling visitation to normal neonates. In a controlled study of sibling visitation to a neonatal intensive care unit, Maloney and associates4 demonstrated no increase in infectious disease rates in those infants who were visited.

Due to differences in hospital facilities and personnel, it is essential that each hospital develop its own set policies for sibling visitation. Guidelines should be developed with input from nursing, pediatric, obstetric, and infectious disease personnel.

The following guidelines can be used for institution of antipartum visitation by children:

1. Siblings should not have been exposed to known communicable diseases (eg, chickenpox).

2. Siblings should not have fever or symptoms of acute illness such as upper respiratory tract infection or gastroenteritis.

3. Children should be prepared in advance for their visit.

4. Children should be supervised by parents or a responsible adult during the entire hospital visit.

Because limited data are available, there is a need for continued evaluation and reporting of the risks and benefits of sibling visitation.
Pancuronium Risks
Authors: KILCHEVSKY EITAN S. , WUNG JEN T.
Published: December 2021

To the Editor.—

We would like to congratulate Cabal et al1 on their article and their suggestion that the benefits of pancuronium in ventilated neonates might be outweighed by its possible risks.

We have been bothered by the many reports in the literature that recommend such use of pancuronium. The finding of Cabal et al that pancuronium did not increase the TcPo2 is in contrast to prior reports2 and should be emphasized, because the improvement in Po2 is cited as the criteria for the success of the drug.3
Pulsed Doppler Determinations of Cardiac Output in Neonates: Normal Standards for Clinical Use
Authors: Walther Frans J. , Siassi Bijan , Ramadan Naglaa A. , Ananda Ananda K. , Wu Paul Y. K.
Published: December 2021

Noninvasive monitoring of cardiac output can greatly facilitate the clinical assessment and management of neonates with cardiovascular compromise. To assess normal values of cardiac output in neonates, mean blood flow velocity was measured in the ascending aorta from a suprasternal approach using a range-gated, pulsed Doppler velocity meter, and aortic root diameter was determined from an M-mode echocardiogram. These techniques were combined, and cardiac output was evaluated in 59 healthy premature and 62 term newborn infants during the first week of life. Birth weights ranged from 780 g to 4,740 g and gestational age from 27 to 42 weeks. Cardiac output values increased linearly with advancing birth weight (r = +.94, P < .001) and gestational age (r = +.95, P < .001). Mean cardiac output values (±SD) per kilogram of body weight were 249 ± 34 mL/mm/kg and decreased with advancing birth weight: <1,500 g = 265 ± 32 mL/min/kg; 1,500 to 2,500 g = 253 ± 34 mL/min/kg; and >2,500 g = 241 ± 33 mL/min/kg. For clinical use, 325 mL/min/kg and 200 mL/min/kg can be used as upper and lower limits of normal, respectively. Doppler cardiac output estimates compared favorably with studies using invasive techniques.
Are Granulocyte Transfusions of Value in Septic Neonates Without Neutrophil Storage Pool Depletion?
Authors: NEWMAN RICHARD S. , OCARIZ JOSE A.
Published: December 2021

To the Editor.—

A recent report by Cairo et al1 suggests the possible value of granulocyte transfusions in septic neonates who do not have bone marrow neutrophil pool (NSP) depletion. In this study, three of seven neonates who had documented sepsis and who did not receive granulocyte transfusions did not survive, and only one of seven of these neonates had neutrophil storage pool depletion at the time of entry into the study. Because approximately one half of the neonates who had documented sepsis and did not receive granulocyte transfusions survived, one must conclude that a significant number of neonates in the study of Cairo et al probably received granulocyte transfusions unnecessarily.
T Lymphocyte Subpopulations in High-Risk Infants: Influence of Age and Blood Transfusions
Authors: Pahwa Savita , Sia Concepcion , Harper Rita , Pahwa Rajendra
Published: December 2021

Methodology was established to analyze T lymphocytes and T cell subsets with monoclonal antibodies on microsamples of blood obtained by heel puncture in infants. Results in 39 high-risk infants indicated that during the early neonatal period they had a higher percentage of T4-bearing cells and a lower percentage of T8 antigen-positive cells as compared with adults. These values progressively approached adult values, and at 3 to 7 months the T cell subsets and the T4/T8 ratios were within the adult range. A significant inverse relationship was noted between the number of blood transfusions given to the infants between 2 and 12 weeks of age and the corresponding T4/T8 ratio. These findings suggest that interpretation of T cell subsets in frequently transfused infants should take into consideration not only the age of the infant but also the possible influence of transfusions per se on the distribution of T cell subsets in the peripheral blood.
Attention Deficit Disorder With Hyperactivity: Differential Effects of Methylphenidate on Impulsivity
Authors: Rapport Mark D. , DuPaul George J. , Stoner Gary , Birmingham Bruce K. , Masse Glenn
Published: December 2021

The impulsivity component of attention deficit disorder with hyperactivity requires regulation because its effects interfere with children's school performance and persist into adulthood. The present investigation examined the effects of low to intermediate doses of methylphenidate on impulsivity (measured by the Matching Familiar Figures test, a primary index of cognitive tempo) in 14 children with attention deficit disorder with hyperactivity. The mean percentile error score in the highest dose (15 mg) group was significantly lower than those in placebo (P < .01), 5-mg (P < .01), and 10-mg (P < .01) groups. Trend analysis revealed a linear relationship between dose and error score with total errors decreasing as dose increased. Changes in children's error scores were examined using both fixed-dose and milligram per kilogram data-plotting methods. This work demonstrates the need to consider specific task and child characteristics while assessing the child's responsivity to psychostimulants across a range of safe doses and a variety of behavioral domains.
Proteus Syndrome: Report of Two Cases With Pelvic Lipomatosis
Authors: COSTA TERESA , FITCH NAOMI , AZOUZ E. MICHAEL
Published: December 2021

Localized growth disturbances are characteristic of a group of congenital hamartomatous disorders, the most common of which is neurofibromatosis. The literature contains many reports of individual cases that have been difficult to place into well-delineated syndromes, although a few had been recognized as new entities. Some of these1-6 were clearly established as a new syndrome when wiedmann and colleagues7 described four patients with an unusual constellation of findings, including partial gigantism of the hands and/or feet, asymmetry, cutaneous abnormalities, macrocrania, and osseous protuberances of the skull. They called this the Proteus syndrome. Eleven possible cases were recently reviewed.8,9 We report two other patients with the Proteus syndrome who, in addition, were found to have abdominal and pelvic lipomatosis.
Drinking Patterns and Social Consequences: A Study of Middle-Class Adolescents in Two Private Pediatric Practices
Authors: Schwartz Richard H. , Hayden Gregory F. , Getson Pamela R. , DiPaola Anthony
Published: December 2021

One hundred sixty-two adolescents who were seen at two suburban private pediatric practices completed an anonymous, written questionnaire about drinking and drug habits. The respondents' ages ranged from 14 to 17 years; all were white and from middle- or upper middle-class families. The adolescents reported high self-esteem, good general health, and few psychologic problems. The majority (63%) reported having drunk alcohol at some time, and the proportion who professed never to drink alcohol became progressively smaller with age, to only 15% at age 17 years. Overall, one fifth claimed that they had to drink more than six beers before they "got a buzz," and this proportion increased to 43% by age 17 years. Among the 17-year-old respondents, 40% replied that their good friends had used alcohol more than 50 times. Twenty-four percent of respondents said that a good friend had received a citation for driving while intoxicated. Almost one fifth of respondents stated that someone in their family drinks alcohol every day, and that someone close to them has a drinking problem. Social acceptance of drinking, peer pressure, and the ready availability of alcohol have led to an epidemic of alcohol use among teenagers and to social, academic, and health problems in many frequent users. Pediatricians should play a more active role in the identification and management of alcohol abuse by their adolescent patients.
Dynamics of Nasopharyngeal Colonization With Haemophilus influenzae b During Antibiotic Therapy
Authors: GILSDORF JANET R.
Published: December 2021

Haemophilus influenzae type b, a major cause of serious infections in infants and young children, may colonize the nasopharynges of healthy, asymptomatic carriers as well as patients with invasive H influenzae type b disease. Person to person spread of this organism is suspected to be by infected respiratory tract secretions. Recently, clusters of epidemiologically related cases have been recognized among young household and day-care contacts of children with H influenzae type b disease,1 demonstrating the contagious potential of H influenzae type b infections.

Serious nosocomial infections with H influenzae type b have been described in pediatric patients in acute and chronic care hospitals.2-4
Neonatal Intracranial Hemorrhage and Phenobarbital
Authors: Kuban Karl C. K. , Leviton Alan , Krishnamoorthy Kalpathy S. , Brown Elizabeth R. , Teele Rita Littlewood , Baglivo Jenny A. , Sullivan Kathleen F. , Huff Kenneth R. , White Susan , Cleveland Robert H. , Allred Elizabeth N. , Spritzer Karen L. , Skouteli Helen N. , Cayea Paul , Epstein Michael F.
Published: December 2021

We enrolled 280 intubated babies with birth weights of less than 1,751 g in a double-blind randomized prospective clinical trial to evaluate whether phenobarbital influences the likelihood of developing subependymal-intraventricular-intraparenchymal hemorrhage. Phenobarbital was associated with an increased risk of developing any subependymal-intraventricular-intraparenchymal hemorrhage and was not associated with a diminished risk of either severe hemorrhage or germinal matrix hemorrhage. This increased risk was apparent even after we considered the influence of phenobarbital levels, timing of phenobarbital administrations, institutional differences, quality of ultrasound scans, gestational age- and birth weight-specific effects, ascertainment bias, and other possible confounders of phenobarbital administration.
Sudden Infant Death Syndrome in Infants Evaluated by Apnea Programs in California
Authors: Ward Sally L. Davidson , Keens Thomas G. , Chan Linda S. , Chipps Bradley E. , Carson Stephen H. , Deming Douglas D. , Krishna Vijaya , MacDonald Hugh M. , Martin Gilbert I. , Meredith Keith S. , Merritt T. Allen , Nickerson Bruce G. , Stoddard Ronald A. , van der Hal Andre L.
Published: December 2021

Home apnea/bradycardia monitoring is frequently used in the management of infants at increased risk for sudden infant death syndrome (SIDS). However, some infants have died despite evaluation by infant apnea programs, and the benefits of home monitoring remain unproven. To determine the SIDS rate and risk factors of infants evaluated by infant apnea programs, 31 apnea programs and ten home monitor vendors in California were surveyed. Eleven (35%) of the apnea programs and four (40%) of the vendors responded. Information was obtained on 26 infants who died. Thirteen (50%) deaths were due to SIDS. Abnormal sleep studies did not predict death. Fifteen infants died despite a recommendation for home monitoring. Seven deaths occurred in association with technical errors or noncompliance with monitoring. Four deaths were due to nonaccidental trauma. The apnea programs evaluated 3,406 infants during a 5-year period; 1,841 had monitoring recommended. Term infants with apnea, subsequent siblings of SIDS victims, and infants evaluated at referral centers were more likely to have monitoring recommended than premature infants with apnea or infants evaluated at nonreferral centers (P < .0001). Infants who had monitoring recommended were at equal risk of dying of SIDS as those who did not.
Outcome in Infants Born to Mothers With Unexplained Elevations of Maternal Serum α-Fetoprotein
Authors: Burton Barbara K. , Dillard Robert G.
Published: December 2021

The outcome in infants without fetal neural tube defect born to mothers with elevated maternal serum α-fetoprotein was studied. Elevated maternal serum α-fetoprotein with normal amniotic fluid α-fetoprotein was found to be associated with an increased incidence of intrauterine growth retardation and nonneural tube congenital anomalies. There was no increased incidence of developmental disabilities in infants born to mothers with elevated maternal serum α-fetoprotein. It is speculated that adverse events occurring early in gestation may simultaneously result in congenital anomalies and subsequently elevated maternal serum α-fetoprotein, perhaps through disruption of the normal placental barrier between the fetal and maternal circulations.
Chest Pain
Authors: ROGERS WILLIAM B.
Published: December 2021

To the Editor.—

I was interested in the article by Dr Selbst on chest pain (Pediatrics 1985;75:1068-1070). I was interested not only because of the numerous cases of chest pain I have seen in 40 years, but also because I, as an adolescent, experienced recurrent episodes of severe thoracic pain too.

Unlike Dr Selbst, who reported the most common etiologies were idiopathic or muscular skeletal, I have found the majority to be a distinct clinical entity called "benign pleuralgia," or "catch in the chest."