bluuebunny/crossref_metadata_2025 huggingface dataset:
Total Parenteral Nutrition in Pediatrics: The Borden Award Address
Authors: Winters Robert W.
Published: December 2021

Research in parenteral nutrition in infants has proceeded rapidly over the past few years, thanks in large part to the perfection of safe central venous delivery of hypertonic nutritive infusates.

At present, there are clear definitions of indications and expectations of results for this method of therapy in two well-defined groups of patients-i.e., selected surgical neonates and infants with chronic intractable diarrhea. In addition, we have suggestive evidence of another potentially valuable application in the nutritional management of very low birthweight infants. However, in this group, a controlled study will be necessary before the role of total parenteral nutrition (TPN) in neonatal care of such infants can be determined precisely. Results obtained with TPN in adults with inflammatory bowel disease or acute renal failure suggest that trials of this technique in pediatric patients with these disorders should be carried out.

As a result of the research in TPN carried out thus far, we have learned how to minimize or to treat many of the complications of the technique and we have identified at least the ways by which still others can be prevented. The future holds many new advances not only in the refinement of existing parenteral nutritional solutions but also, and perhaps of even greater importance, in the perfection of individualized total nutritional therapy for specific patients using the enteral route for those discrete components of intake for which digestive and/or absorptive mechanisms are unimpaired and using the parenteral route for the remainder.
The Sodium Pertechnetate Tc 99m Scan: An Aid in the Evaluation of Gastrointestinal Bleeding
Authors: Ho Judith E. , Konieczny Kurt M.
Published: December 2021

Twenty pediatric patients presenting primarily with unexplained gastrointestinal bleeding were evaluated with sodium pertechnetate Tc 99m imaging. Three patients had normal barium enemas and scans consistent with Meckel's diverticulum. These three patients and three additional patients with normal scans underwent surgical exploration. Meckel's diverticula containing gastric mucosa were found in all three patients with positive scans. No diverticula were found in the three patients with normal scans.

Four other patients had scans that were considered abnormal but not felt to represent Meckel's diverticula. In one of these patients a radiographic gastrointestinal study performed after the scan demonstrated a large duodenal ulcer. In another patient, a nonspecific terminal ilial ulcer without gastric mucosa was found at surgery. The two other patients had normal radiographic gastrointestinal studies and no further evaluation was carried out.

The etiology of gastrointestinal bleeding in pediatric patients is frequently unexplained even after thorough evaluation including celiotomy. The sodium pertechnetate Tc 99m scan is a safe, simple, non-invasive procedure that can demonstrate Meckel's diverticula with greater certainty than the barium enema and can suggest suspicious areas that can then be evaluated by more definitive procedures.
Use of intravenously administered lipid in neonates
Authors: Heird William C. , Driscoll John M.
Published: December 2021

In this month's Pediatrics another method for feeding small infants is described. Although the method per se (i.e., intravenous supplementation of tolerated oral feedings) has been used frequently over the past few years, the present application is the first by which intrauterine growth rates with respect to weight, height, and head circumference have been achieved. The unique feature of the current application of the method is inclusion of an intravenously administered fat preparation as part of the nutrient infusate. The impressive growth rates were achieved without the use of central venous catheters with their attendant complications and without the use of indwelling intragastric or intraintestinal tubes.

Several aspects of this interesting paper require comment. First, despite the fact that achievement of intrauterine growth rates postnatally has been the goal of neonatologists for a number of years, such a growth rate has never been shown to be beneficial. In fact, it can be argued that infants who are gaining weight, regardless of how slowly, are receiving adequate nutrients to meet on-going metabolic requirements and are not undergoing a net breakdown of endogenous nutrient stores. Furthermore, a number of changes in body composition (e.g., loss of body water) occur postnatally and these changes make a continued intrauterine growth rate almost impossible out major changes in metabolism and/or metabolic requirements. Moreover, most of the weight increase during the last trimester is fat which, perhaps beneficial before birth, may actually be detrimental when deposited postnatally.

The appropriateness of a continued intrauterme growth rate is particularly pertinent when it is achieved with an agent that has not been evaluated thoroughly in very small infants (i.e., an intravenous soybean oil [Intralipid]).
The Effect of Oral Alanine on Blood Glucose and Glucagon in the Human Newborn Infant
Authors: Fiser R. H. , Williams P. R. , Fisher D. A. , DeLameter P. V. , Sperling M. A. , Oh W.
Published: December 2021

Plasma, glucose, glucagon, and insulin responses to oral feedings of l-alanine were assessed in 44 healthy term infants during the first three days of life. Alanine administration produced significant increases in glucagon and glucose concentrations on day 1, but not on days 2 and 3. These increases occurred within 30 minutes (mean and SEM for glucagon, 127 ± 7 to 219 ± 16 pg/ml, P < 0.001; glucose, 45 ± 3 to 60 ± 7 mg/100 ml, P < 0.01) and persisted at the P < 0.05 level at four hours. Responsiveness to alanine seemed to be related to the baseline blood glucose levels since constant infusions of glucose inhibited the response. These results indicate that the pancreatic islet alpha cell secretion mechanism(s) is functioning in the newborn.
Iodine and Goiter in Children
Authors: Trowbridge Frederick L. , Matovinovic Josip , McLaren Gordon D. , Nichaman Milton Z.
Published: December 2021

Goiter examination was performed on 7,785 children aged 9 to 16 years in four areas of the United States—Michigan, Kentucky, Texas, and Georgia. Urinary iodine and creatinine, thyroxine, protein-bound iodine, and plasma inorganic iodide determinations were made on 377 matched pairs of goitrous and nongoitrous control children. The overall prevalence of goiter was 6.8%. Most children with goiter had palpably but not visibly enlarged thyroids and showed no evidence of clinical or biochemical thyroid abnormality. Mean urinary iodine excretion was 452µg/gm of creatinine, many times the 50µg/gm of creatinine level used to define deficiency. Children with goiter and areas with high goiter prevalence tended to have higher rather than lower iodine excretion. These findings are consistent with other data indicating high iodine intakes in the United States and suggest that goiter in American children cannot be assumed to be related to iodine deficiency. The possible role of high iodine intake in the causation of goiter is discussed.
Basic and Clinical Aspects of the Alpha1-Antitrypsin
Authors: Talamo Richard C.
Published: December 2021

A deficiency of the major serum α1-globulin, the α1-antitrypsin, was first described in five patients by Laurell and Eriksson in Sweden in 1963. It soon became obvious that severe α1-antitrypsin deficiency was familial, and highly associated with chronic lung disease, having its onset in the third or fourth decade of life. Since the early descriptions of this common deficiency state, it has become clearly associated with familial emphysema in some families, familial infantile cirrhosis in others, and occasionally with a combination of childhood lung and liver disease in siblings. For the pediatrician, severe α1-antitrypsin deficiency now enters into the differential diagnosis of both chronic pulmonary disease in childhood and obstructive jaundice in the newborn period. In addition, low levels of α1-anrirtysin in serum are characteristic of respiratory distress syndrome, and elevations of this protein may be found in a variety of clinical situations.

The α1-antitrypsin probably functions as a major control protein against the tissue-damaging effects of both endogenous and exogenous enzymes. This review will cover several basic and clinical features of this protein with respect to its importance in pediatrics.

CHEMISTRY AND METABOLISM

A 50,000 molecular weight glycoprotein, the α1-antitrypsin is synthesized in the parenchymal cells of the liver and is secreted into serum as the major α1-globulin, comprising approximately 4% of the total serum protein level (normal concentrations are approximately 2.2 mg/ml). Alpha1-antitrypsin is present in many body fluids, having been found in microgram per milliliter quantities in nasal secretions, tears, saliva, pulmonary secrelions, duodenal fluid, cerebrospinal fluid, cobstrum, and mother's milk.
FREE WILL, ETHICS, AND HEALTH CARE
Authors: H. R. J.
Published: December 2021

In a recent volume1 Arrow takes the libertarian view that individuals can and should make a free choice of whether and when they want to get medical care, when given all the information.

Pellegrino comments on the limitations of this libertarian view: (1) We are not isolated individuals but social beings whose actions effect others as well as ourselves. (2) Society has now said that it will care for people when sick. But if they are sick because of what they willfully did then should society not provide care? For children it is difficult to argue that they should be punished for their parents' failings. (3) The sick person's ability to deal with "all" the facts is limited, especially so for children. Pellegrino advocates an ethical view of the right to medical care as well as a legal one. " . . . law is the coarse adjustment that guards against the grosser violations of human rights; ethics is the fine adjustment that sets a higher ideal than law can guarantee." It would seem that children should have the right to medical care.
The Peripheral Hemodynamic Effects of Continuous Positive Transpulmonary Pressure Breathing In Neonates Free From Cardiorespiratory Disease
Authors: Powers William F. , Swyer Paul R.
Published: December 2021

We applied continuous pitive transpulmonary pressure (CPTP) by face mask to 22 spontaneously breathing infants who were free from cardiorespiratory disease, and measured resultant changes in peak esophageal pressure (Pes) and peripheral perfusion (Q1). We measured Pes by balloon and transducer, and Q1 by venous occlusion plethysmography with a mercury-in-rubber strain gauge. Application of 7.6 cm H2O CPTP led to a 13% decrease in Q1 (paired t-test = 2.39; P > .02). Thirty-two percent of the applied CPTP was detected as a change in Pes. The biological significance of a 13% decrease in peripheral perfusion is probably minimal.
Errors in Insulin Doses Due to the Design of Insulin Syringes
Authors: Shainfeld Frederick J.
Published: December 2021

Insulins with different durations of activity are mixed in and administered from the same syringe; however, this may lead to errors. Only after a parent of a diabetic child noted the insulin remaining in the tip of the syringe after the plunger had been pushed for complete emptying did the magnitude of the error become apparent. All syringes have space in the tip and in the needle hub. The volume of this dead-space depends upon the style of manufacture (Fig. 1). When mixing most medications, the dead-space is not significant. However, when mixing medications of small volume, the error can be significant. Kochevar and Fry have found the dead-space in four brands of insulin syringes to be 0 to 10 units. We found a similar error in our syringes.
Presentation of the C. Anderson Aldrich Award to Anna Freud
Authors: Solnit Albert J.
Published: December 2021

It is my privilege and pleasure to introduce Anna Freud to you and to read her paper for this most important occasion. Dr. Freud deeply regrets that she is unable to be with you and asked that I represent her at this meeting. May I say how appropriate and fitting it is to honor children throughout the world by conferring the C. Anderson Aldrich Award for 1974 on Dr. Anna Freud. Historically it is impressive that in 1968 and in 1971 this distinguished award was conferred on two of Anna Freud's former students and colleagues. I refer to Dr. Edith B. Jackson and Professor Erik Erikson.

Anna Freud, who started her professional activities as a teacher of young children, became the founder of child psychoanalysis. Throughout her career she has always had an affinity for working together with pediatricians, teachers, nurses, and all who are concerned with children. To this day she meets at least once a month with a group of distinguished English pediatric colleagues who have been her collaborators for more than 20 years. They share much in their curiosity about and compassion for children. They are devoted to helping children overcome illness and the handicaps of life. These include the burdens, threats, and losses associated with poverty, war, physical illness, genetic handicaps, and the destruction of the child's body and mind that result from adult abuse and deprivation.

In introducing Anna Freud, it is appropriate to call attention to her clinic, the Hampstead Child Therapy Center, and to her gallant colleagues with whom she works so closely on a daily basis.
Lettrt To The Editor
Authors: Gilchrest Barbara , Baden Howard P.
Published: December 2021

The defensive tone of Dr. Van Reken's letter makes one wonder if he suspects himself of misdiagnosing photodistributed viral exanthems. In any case, he is quite correct that (1) Figures 1 and 2 are reversed and (2) the isolation of echovirus 9 from the stool does not alone permit a firm diagnosis of echovirus 9 infection with viremia and exanthem. Our diagnosis was made on clinical grounds and supported by the limited laboratory parameters obtained.
Vietnamese Children
Authors: Carlin Jean E.
Published: December 2021

I am very much concerned about Vietnam and the Vietnamese people, especially because I was there in 1969 and again in 1971 with the Volunteer Physicians for Vietnam. During that time I learned to know and respect many of the Vietnamese including physicians, medical students, and orphans.

Because of my experiences and friendships, I feel I must communicate with the general public and with my country's physicians who will be caring for the imported orphans from Vietnam.
More Criticism of Circumcision
Authors: Carpenter Gary G. , Hervada Arturo R.
Published: December 2021

As natural optimists, we thought medical indications for the tribal, antediluvian custom of routine circumcision of the newborn had been finally terminated by the brief, crisp, and concise statement on circumcision made by the Committee on the Fetus and the Newborn of the American Academy of Pediatrics: "There are no valid medical indications for circumcision in the neonatal period."1

We hoped that foreskin clipping had been arrested as the last surgical procedure done to man without anesthesia or sedation, but we found the paper, "Why Circumcision?" by Burger and Guthrie,2 with unnecessary pessimism again resharpening the brutalized merry-go-round.
Lettrt To The Editor
Authors: Burger Robert
Published: December 2021

We knew that our article would incite and excite some of our colleagues, and it does us good to see the response.

As urologists, we do not usually get called upon to do neonatal circumcisions but instead see the "problem prepuce." We see the paraphimosis, the carcinomatous penis, the verruccous penis, and the infectious processes that start under the prepuce and can eventually destroy penile and scrotal architecture. For this reason, the urologist's view is different from that of the pediatrician or obstetrician and we consider neonatal circumcision to be medical prophylaxis.
The Trisomy 9p Syndrome
Authors: Centerwall Willard R. , Beatty-DeSana Jeanne W.
Published: December 2021

Since the first description of trisomy 9p in 1970, there has been a rapidly increasing recognition and reporting of new cases. The physical and mental features of retarded growth and development, down-turned corners of the mouth, mildly globular nose, slightly wide-set and deepset eyes with anti-Mongoloid slant, and unusual dermatoglyphics are distinctive enough to establish trisomy 9p as a clinical chromosomal entity-one which may prove to be the fourth most common autosomal syndrome (after trisomies 21, 13,and 18).

This paper includes a review and tabulation of features seen in the 20 reported cases and photographs of the faces of ten of these children. A new case included in this survey demonstrates the practical application of four types of chromosome banding identification (C, G, Q, and R). The confirmation of the chromosomal aberration in this syndrome is dependent on the use of one or more of these special laboratory techniques.

Most of the clinical characteristics distinctive of the trisomy 9p syndrome are seen also in other trisomies involving more or less of the number 9 chromosome. From these observations it is determined that the crucial determinants of the classical features of this syndrome lie within the distal half of the number 9 short arm.
Familial Partial Trisomy of the Long Arm of Chromosome 10 (q24-26)
Authors: Moreno-Fuenmayor Humberto , Zackai Elaine H. , Mellman William J. , Aronson Margaret
Published: December 2021

Two fourth cousins with a strikingly similar pattern of malformation and who have an unbalanced translocation (46, XY, —17, +t (17p; lOq) are described. From an analysis of the phenotypes of these patients and others reported with lOq trisomy, we propose that the trisomy 1Oq 24-26 syndrome includes: growth and mental retardation, a characteristic facies (microcephaly, flat face with spacious forehead, small nose, depressed nasal bridge, arched wide-spaced eyebrows, blepharophimosis, microphthamia, low-set ears, bow-shaped mouth with prominent upper lip, micrognathia), palate anomalies (high-arched cleft or agenesis), congenital heart disease, and anomalies of the hands and feet.

Anomalies common to the cousins, but not described in other patients with trisomy 1Oq, are believed to be expressions of a partial monosomy of 17p.
Hypercortisolism in Childhood: Shortcomings of Conventional Diagnostic Criteria
Authors: Streeten D. H.P. , Faas F. H. , Elders M. J. , Dalakos T. G. , Voorhess M.
Published: December 2021

Two patients are described in whom hypercortisolism occurred prepubertally as a consequence of bilateral adrenocortical hyperplasia. In contrast with the manifestalions of Cushing's syndrome in adults, these children presented with obesity and reduced stature and no other symptoms. Both patients excreted amounts of urinary 17OHCS before and during a conventional suppression test with dexamethasone (0.5 mg every six hours) which were within the usual normal range. However, when urinary 17OHCS excretion was expressed per gram of urinary creatinine or per square meter of surface area, and when the dose of dexamethasone was tailored to body mass (2Oµg/kg/day) the results were clearly abnormal, as were plasma corticoids and (in one patient) cortisol secretion rate. Resumption of linear growth occurred after bilateral adrenalectomy in both patients and was associated, in the one patient so studied, by a return of hypoglycemia-stimulated increases in plasma growth hormone levels from previously suppressed values to the normal range, and by a slight increase in the fasting plasma somatomedin concentration. The observations suggest that pediatric patients with hypercortisolism are likely to be overlooked when conventional criteria for laboratory diagnosis are used, but can be recognized by the simple diagnostic modifications used in these studies.
Suggestions for Improving Multidiscipline Health Care
Authors: James John A.
Published: December 2021

The article by Kanthor et al. illustrates a major problem encountered in all multidiscipline health care programs: How can one achieve adequate communication between team members, between team members and patients, and between the medical center-based team and community resources so that questions of importance do not "fall through the cracks"? As the authors point out, this problem becomes more critical when community physicians are unfamiliar with details of management and possible complications of the child's major disorder; under circumstances the anxiety of the parents increases and they may resort to various subterfuges to achieve what they believe to be the desired action.
Letter to the Editor
Authors: L. J. F.
Published: December 2021

I'm not fond of snowmobiles either!
Exaggerated Natural Measles Following Attenuated Virus Immunization
Authors: St. Geme Joseph W. , George Barbara L. , Bush Bartholomew M.
Published: December 2021

An adolescent girl, devoid of detectable humoral immunity to measles virus despite two inoculations of live, attenuated vaccine, developed an exaggerated atypical rubeola illness following exposure to wild virus. This observation suggests that attenuated virus may be capable of immunologically sensitizing some individuals as has been described with killed virus vaccine.
Cerebellar Hypoplasia in an Infant With Congenital Cytomegalovirus Infection
Authors: Ceballos Ricardo , Ch'ien Lawrence T. , Whitley Richard J. , Brans Y. W.
Published: December 2021

Cerebellar hypoplasia is a prominent feature of fetal brain pathology as produced in experimental animal models with various congenital viral infections.1-3

We have recently studied an infant with classical congenital cytomegalovirus (CMV) syndrome. The pathologic changes noted in the brain of micropolygyria, periventricular calcifications, and chronic inflammation have long been regarded as the hallmarks of chronic CMV infection of the fetal brain.4,5 However, the presence of striking cerebellar hypoplasia, reminiscent of some viral infections of the central nervous system described in the experimental animal models, has prompted this short communication.

CASE REPORT

B.B.P. was born to a 22-year-old mother, gravida 2 para 1, after an uncomplicated pregnancy.
Evidence for Defective Skeletal Mineralization in Low-Birthweight Infants: The Absorption of Calcium and Fat
Authors: Shaw J. C. L.
Published: December 2021

Using serial metabolic balance techniques, the absorption and retention of calcium and the absorption of fat have been measured over the first 30 to 70 days of life in 11 preterm and 2 full-term light-for-dates infants. They were fed either full-cream cow's milk, half-skimmed cow's milk, the proprietary filled milk S.M.A., or breast milk. The values for calcium intake, absorption, and retention were compared with the rate of accumulation of calcium by the fetus in utero, which was calculated from published data on the chemical composition of fetal bodies. Infants fed breast milk had an absolute dietary deficiency of calcium. Those fed other milks ingested sufficient but they did not absorb enough. Though calcium absorption increased with increasing postnatal age, intrauterine rates of calcium retention were never achieved on any of the milks. The average retention of calcium by preterm infants as a percentage of intrauterine accumulation was, for cow's milk 38%, for S.M.A. 27%, and for breast milk 17%. The full-term light-for-dates infants absorbed and retained more calcium than the preterm infants; it was on average 52% of the amount accumulated by the human fetus for an equivalent weight gain. The average absorption of fat by preterm infants was, from the cow's milk preparations 55%, from S.M.A. 61%, and from breast milk 84%. The light-for-dates infants absorbed on average 87% of the breast milk fat. There was no evidence that the amount of calcium absorbed was materially influenced by fat malabsorption. The principal determinants of the amount of calcium absorbed were the length of gestation and postnatal age of the infant.
A Note of Caution
Authors: Zwerdling Robert , Leibel Rudolph L.
Published: December 2021

The use of indwelling radial artery lines in the intensive blood gas monitoring of certain sick neonates may well represent a significant technical advance.1 However, new clinical techniques tend to lose some of their glitter as the expectations born of novelty are tempered by experience. The rugged road to the current restricted use of umbilical artery lines is strewn with the kidneys, spinal cords, and limb parts of many infants. The fastest drivers have the most spectacular accidents.
Where's the hyperactive child going?
Authors: Myers Gary J. , Pless I. Barry
Published: December 2021

Hyperactivity in childhood, and its correlates of behavior problems and learning disorders, is a problem that pediatricians are facing with increasing frequency. Newspapers, magazines, scientific journals, and other media have popularized this topic and consequently parents, teachers, psychologists, and just friends are looking at children in a new light. As a result, physicians are frequently being asked how a child's learning abilities can be improved or maximized, what will happen when he grows up, if medication is indicated, and a variety of related questions. In this issue of Pediatrics Huessy and Cohen present data on hyperkinetic children followed over a seven-year period.
Oxygen Toxicity in the Newborn Lung: Reversal of Inhibition of DNA Synthesis in the Mouse
Authors: Northway William H. , Rezeau Laurel , Petriceks Rita , Bensch Klaus G.
Published: December 2021

Continuous exposure to 100% oxygen at atmospheric pressure for two weeks causes significant alterations in the growth of the lung and the body of newborn mice. These changes can be divided into three phases. The initial phase, which lasts 96 hours, is characterized by inhibition of lung DNA synthesis, diminished total lung DNA, and a decrease in the ratio of lung DNA to body weight. The intermediate phase from 96 to 144 hours is characterized by a sharp increase in mortality, a plateau in body weight, and a minimal lung DNA/body weight ratio. During this period, however, surviving animals show a reversal of the inhibition of DNA synthesis and thus an increase in total lung DNA. The third phase, occurring after 144 hours, is characterized by a continued increase in DNA synthesis and total lung DNA, a gain in body weight, a return of the lung DNA/body weight ratio to control levels, and a sharp decline in mortality. The survival rate of 54% in newborn mice over two weeks contrasts with the near total mortality reported for adult experimental animals similarly exposed. The reversal of the inhibition of lung DNA synthesis in surviving mice suggests either that some newborn animals are inherently resistant to pulmonary oxygen toxicity or that they develop, during a critical exposure period, an adaptive process necessary for their survival.
Longitudinal Observations of the Relationship Between Free Erythrocyte Porphyrins and Whole Blood Lead
Authors: Reigart J. Routt , Whitlock Norris H.
Published: December 2021

Short- and long-term comparison of the variations with time of whole blood lead and free erythrocyte porphyrins (FEP) suggests that changes in FEP are slow and predictable whereas blood lead changes are quite unpredictable. However, when FEP suggests a different clinical category from blood lead, the blood lead is likely to change in the direction predicted by the FEP. Comparison of FEP to blood lead at first contact in 349 children with mild elevation of blood lead reliably predicted which children would still have elevated blood lead six weeks later and which would fall or be normal. The observation of long-term follow-up in four groups of children with various combinations of FEP and blood lead indicated that the follow-up blood lead could be predicted to change in the direction indicated by the FEP measurement. The implications for screening for lead poisoning are discussed.
Compliance of Chronic Asthmatics With Oral Administration of Theophylline as Measured by Serum and Salivary Levels
Authors: Eney R. Donald , Goldstein Eugene O.
Published: December 2021

A group of ambulatory asthmatic children was studied with serum and salivary theophylline levels following a prescribed dose of a hydroalcoholic solution of theophylline to determine compliance. The gas chromatographic procedure used was both selective and sensitive for theophylline without the necessity of withholding coffee, tea, chocolate, or cocoa. In the first group of patients, only 11% achieved therapeutic levels, 65% had less than therapeutic levels, and 23% had no measurable drug in saliva. With more directive and supervised drug administration in a second group of patients, 42% achieved therapeutic levels, 51% were below therapeutic levels, and only 6% had no measurable drug.

Monitoring patients with salivary theophylline levels proved an effective way of improving compliance and also alerted physicians to noncompliance as a possible explanation of "treatment failure." Salivary specimens are readily obtained and noninvasive so that the technique is readily adaptable for use in the office of clinic setting.
Echocardiography: Its Role in the Severely Ill Infant
Authors: Solinger Robert , Elbl Francisco , Minhas Kareem
Published: December 2021

Echocardiography is a noninvasive diagnostic tool which has the capacity to provide reliable information on cardiac anatomy and function without risk or discomfort to the patient. The quality and quantity of information obtained in any given study is highly dependent upon the skill of the examiner. The anatomic and physiologic data obtained through its use in the severely ill infant allows immediate separation of infants with serious anatomic cardiovascular defects from those with conditions simulating heart disease. In some cardiac defects the echographic findings are specific enough to allow an accurate diagnosis.
Dr. Kearsley et al. Reply
Authors: Kearsley Richard B. , Zelazo Philip R. , Kagan Jerome , Hartmann Rebecca
Published: December 2021

Dr. Palmeri acknowledges that the day-care experience described its our article was "qualitatively comparable" and "a good surrogate" for that of the home-reared child. He agrees that infant day care "...did not interfere with the maturation and emergence of that important developmental landmark, separation anxiety and protest." He recognizes, as do we, that thought and feeling are interwoven. He expresses concern that the comments offered in our paper "may induce pediatricians to take infant day care lightly...."
Commentson Breast-Feeding and Immunity
Authors: Du Busc James V.
Published: December 2021

Dr. Gerrard's recent review, "Breast-Feeding: Second Thoughts"1 concluded that breast-feeding offered a measure of immunological protection during the first six months of extrauterine life. Before this conclusion is accepted, further examination of the surveys cited in the article is warranted.

Gerrard states that Grulee et al.'s 1934 survey2 is "the most convincing evidence on the subject." The author's review fails to mention the design or controls employed in Grulee et al.'s "study." In fact, Grulee et al. merely compiled statistics on all those infants (20,061 from 1924 to 1929) who had been observed periodically during the first nine months of life, not including those who died.
Comment on Comments About Reading
Authors: Cavanaugh James J. A.
Published: December 2021

The recent article by Silver1 that provoked Dr. Snyder's reflections2 on the importance of reading skills in our school children cited some of the many sides of this phenomenon of learning disability in youngsters of school age. Dr. Snyder's persuasions that the troubled reader should explore alternative modes of communication have been advanced previously3 and demand response.

The printed word may not be the best form of communication but in a literate society it is the best we have.
Use of Limulus Lysate for Detecting Gram-Negative Neonatal Meningitis
Authors: Dyson Donald , Cassady George
Published: December 2021

The Limulus, lysate test was evaluated as a method for rapid detection of neonatal gram-negative bacterial meningitis. A total of 208 CSF samples were collected from 145 newborn infants suspected of having meningitis. Initial samples from all six babies with culture-proven gram-negative bacterial meningitis had positive Limulus tests within 30 minutes of incubation. Samples from 14 infants with gram-negative organisms isolated only in blood and/or urine, as well as from four neonates with gram-positive organisms in CSF cultures and from 13 with gram-positive organisms in blood cultures all yielded negative Limulus tests.

Thus, of 37 newborn infants with bacteria demonstrated in systemic cultures, only those six with gram-negative organisms in CSF had positive CSF Limulus tests. The CSF Limulus test was shown to be a rapid, reliable, and specific test for the detection of neonatal gram-negative bacterial meningitis.
Measurement of Human Chorionic Gonadotropin (HCG) Concentrations in Paired Maternal and Cord Sera Using an Assay Specific for the Beta Subunit of HCG
Authors: Penny Robert , Olambiwonnu N. Olatunji , Frasier S. Douglas
Published: December 2021

Human chorionic gonadotropin (HCG) concentrations were determined in paired maternal and cord sera using an essay specific for the beta subunit of HCG. The sera of 46 mothers and 46 infants, 24 female and 22 male, were studied. Results were compared to those obtained using a radioimmunoassay for luteinizing-hormone (LH) which cross-reacted with HCG.

With either assay system, mean maternal HCG concentrations were lower when the sex of the fetus was male than when the sex of the fetus was female. Mean cord HCG concentrations of male (0.09 ± 0.02 IU/ml) and female (0.09 ± 0.04 IU/ml) infants were not different as determined by the beta HCG assay. In contrast, the mean cord serum concentration of HCG was significantly greater (P < .005) in male infants (0.29 ± 0.05 IU/ml) than in female infants (0.23 ± 0.09 IU/ml) as determined by the cross-reacting assay. HCG concentrations were lower in both maternal and cord sera when assayed in the specific HCG system than when assayed in the cross-reacting system. There was a significant correlation (r = < .9; P.005) between the results obtained with the two assays in both maternal and cord blood. Regardless of the assay system employed, the cord serum concentration of HCG was markedly less than the corresponding maternal serum concentration. There was no correlation between maternal and cord serum HCG concentrations with either assay.

These data are in agreement with the results of previous studies employing less specific methodology which indicated that maternal serum HCG concentrations were less when the fetus was male than when it was female. They are also consistent with a placental barrier effect with regard to HCG transfer to the fetus. The difference in results obtained in cord blood with the two assay systems suggests that the newborn male infant secretes more LH and/or alpha LH subunits than the newborn female infant.
The Dauphin of Munchausen: Factitious Passage of Renal Stones in a Child
Authors: Sneed R. C. , Bell Roy F.
Published: December 2021

The urinary tract appears to play an infrequent role in adult malingering and in Munchausen syndrome, an elaborate, highly organized form of malingering.1-3 We have found only a small number of reports of factitious hematuria4-6 and only two cases of genuine renal stones factitiously passed.7.8 Herring reported in a series of 10,000 analyzed urinary calculi that only 85 were artificial in nature, the commonest being pebbles."9 Only a small number of these "stones" were felt to be innocent errors. We know of no reports of these symptoms in children on the basis of conscious malingering. We have treated a child with a clinical picture of renal colic complete with hematuria and "passed stones" which proved to be factitious.
Survival Following Brain Metastases in Wilms' Tumor
Authors: Morgan Samuel K. , Buse Maria G.
Published: December 2021

The brain is apparently a very rare site for metastases in Wilms' tumor and survival of a patient with such metastases with a prolonged disease-free interval following therapy has not been previously reported to our knowledge.1-4 The purpose of this paper is to report a child with Wilms' tumor who first developed bilateral pulmonary metastases, and later cerebral metastases to two sites and who recovered, and has been presumably disease-free for four years and off therapy for two years. The currently employed combination of therapeutic modalities for Wilms' tumor were utilized. The importance of an aggressive approach to this common childhood malignancy is reemphasized.
Was the Patient Nonatopic?
Authors: Hamburger Robert N.
Published: December 2021

In the article "Diazepam-Associated Asthma"1 the authors present evidence that the patient was at least capable of an IgE-mediated allergic response to diazepam. The authors then go on to state, "The serum IgE concentration was 200 IU/ml. On the basis of a nonallergic family history, personal history, negative skin tests, and a normal IgE level we concluded that E. B. was a nonatopic individual."

Our data2-3 as well as that from other laboratories4-6 would suggest that, in the absence of helminthiasis, a normal serum IgE concentration for a nonatopic 9-year-old boy would be 60 IU/ml.
The Drs. Bergner Reply
Authors: Bergner Arthur , Bergner Renee K.
Published: December 2021

Since the presentation and publication of our report numerous verbal reports have been received of persons with apparent hypersensitivity to pancreatin powder. The condition is evidently not rare and should be suspected in patients with cystic fibrosis as well as relatives exposed to these enzymes.

Dr. Abernathy's letter raises the issue of the value and limitations of scratch and intradermal testing as an aid for identifying a causative allergen.

Our reluctance to rely on a skin test in the diagnosis of pancreatin hypersensitivity in our patient was not limited to concern about anaphylaxis.
The Management of Cerebral Edema in Pediatric Practice
Authors: Batzdorf Ulrich
Published: December 2021

Cerebral edema is one of the most dreaded complications associated with many central nervous system (CNS) disorders. The condition adds significantly to the morbidity from such diverse conditions as neonatal hypoxia and hypernatremia, water intoxication, meningitis, encephalitis, birth trauma, lead poisoning, and radiation therapy of the brain, as well as brain tumors and abscesses. Cerebral edema increases the volume of the intracranial contents and, thus, may precipitate the intracranial translocation syndromes of uncal and tonsillar herniation which often result in death. Indeed, the mass effect due to edema of the CNS tissue (brain, cord) is often more harmful than is that of the underlying blood clot, tumor, or other pathologic process (Fig. 1). Diffuse and widespread cerebral edema can produce massive increases in intracranial pressure. The successful treatment of cerebral edema, therefore, remains a matter of paramount importance and may have a critical effect upon the patient's prognosis. Two types of therapeutic measures must be considered: (1) those that diminish the volume of intracranial contents in a nonspecific manner, and (2) those that reduce cerebral edema per se. An understanding of their correct use is essential.1,2

Prevention of cerebral edema is, of course, preferable to treating it. In infants and children undergoing neurosurgical operations, preoperative prophylactic measures can be instituted to reduce the magnitude of postoperative cerebral edema. In most situations, however, therapy cannot be initiated before the edema-producing insult occurs. Nevertheless, steps to minimize the development of cerebral edema often may be taken, and these will be discussed.

Cerebral edema has been defined as the abnormal accumulation of fluid in cerebral tissue.
Bradycardia in Preterm Infants: Indications and Hazards of Atropine Therapy
Authors: Kattwinkel John , Fanaroff Avroy A. , Klaus Marshall H.
Published: December 2021

Eight preterm infants are presented to demonstrate the indications and hazards of using atropine for treatment of bradycardia in the high-risk premature nursery. Three infants developed bradycardia following initiation of nipple feedings, one following gavage feedings, three following surgical manipulation of visceral structures, and one associated with presence of chronic pulmonary disease. It is suggested that the first seven cases represent "reflexic bradycardia," probably vagally mediated and thus amenable to atropine therapy, whereas the eighth is an example of "hypoxic bradycardia" where administration of atropine may be detrimental. Polygraphic monitoring, arterial blood gases, and the clinical status are helpful in distinguishing reflexic from hypoxic bradycardia. These parameters should be evaluated prior to institution of atropine therapy.
Evaluation of the Porta-Warm Mattress as a Source of Heat for Neonatal Transport
Authors: Nielsen Heber C. , Jung August L. , Atherton Stephen O.
Published: December 2021

One risk of transport of newborns to referral centers is hypothermia. Modern transport incubators have limitations in their ability to keep infants euthermic. As tested in the laboratory and during actual transport the Porta-Warm mattress extends the capability of the transport incubator to keep neonates euthermic by (1) reducing the time required to warm the incubator and (2) warming the incubator in cooler environments. The mattress is an effective adjunct to the transport incubator for keeping newborns warm during transport.
A Pediatric Screening Examination for Psychosocial Problems
Authors: Metz J. Richard , Allen Constance M. , Barr George , Shinefield Henry
Published: December 2021

In an effort to avert the cumulative effects of unresolved emotional problems on children's social and school adjustment, a psychosocial phase was added to a pediatric multiphasic examination. Based upon a cumulative stress concept, the screening procedures included child behavior and family stress questionnaires for parents, and abbreviated standard psychological tests for children, administered by specially trained aides. Computerized results were reported to the child's pediatrician. Follow-up by mental health counselors attached to the pediatric clinic was provided for patients identified as being at high risk of serious psychosocial problems.

Evidence of validity of the screen, factors affecting the scores, and effectiveness of clinical follow-up of high-risk patients are discussed. Valid semicomputerized screening of school-age children for serious psychosocial problems can be carried out routinely and at relatively low cost by paraprofessional personnel in a pediatric setting. Impediments to effective use of the screening results on the part of both health care provider and patient are discussed.
Dr. Hoekelman Replies
Authors: Hoekelman Robert A.
Published: December 2021

The issues raised by Dr. Stein and Dr. Weinberger are quite important and, in fact, prompted the determination of correlation coefficients for the actual number of well-baby visits made and the maternal competence, satisfaction, and compliance scores between and within settings by provider groups and, overall, between settings. These were all less than .25 as reported in the text of the article.

It must be remembered that the visit figures presented in Table XIV to which both writers refer are means for the entire sample.
Concern About Theophylline
Authors: Brady Raymond E.
Published: December 2021

The introduction of a new therapeutic modality, in this case the use of theophylline in the treatment of "apnea of prematurity," needs careful evaluation before its acceptance as a routine therapeutic measure. The studies by Shannon et al.1 and Uauy et al.,2 and Lucey's commentary3 attest to the success of theophylline. However, I feel a few comments are needed.

Therapeutic effects of theophylline (besides bronchodilatation) include diuresis and natriuresis4; lowering of peripheral resistance, right atrial pressure, and mean pulmonary artery pressure; and an increase in cardiac output.5
Rapid Onset of Essential Fatty Acid Deficiency in the Newborn
Authors: Friedman Zvi , Danon Abraham , Stahlman Mildred T. , Oates John A.
Published: December 2021

To study the effect of fat-free alimentation on essential fatty acids (EFA), their levels in plasma phospholipids, cholesterol esters, triglycerides, and free fatty acids were measured in five sick newborns. Four patients were under 32 weeks of gestation; three were small for gestational age and one was an infant of a diabetic mother. All developed biochemical evidence of EFA deficiency during the first week of life—the smallest infant did so by the second day. Biochemical evidence of EFA deficiency included a decrease in plasma lipid arachidonic and linoleic acids, an increase in 5,8,11-eicosatrienoic acid, palmitoleic, and oleic acids and a trienoic/tetraenoic ratio of more than 0.4. Oral feeding with EFA reversed these changes. The two infants showing the most severe biochemical evidence of EFA deficiency died. Neither exchange transfusion nor multiple blood transfusions prevented or corrected the development of EFA deficiency. An alternative method for efficient and safe delivery of EFA to such infants is required.
A Useful Radiologic Sign for the Diagnosis of Turner's Syndrome
Authors: Bercu Barry B. , Kramer Sandra S. , Henning Hans
Published: December 2021

A new X-ray sign of gonadal dysgenesis is described. In this series nine out of ten patients with Turner's syndrome have a coarse, reticular pattern of the carpal bones. A comparison with other previously described roentgenographic characteristics on hand and wrist films of these children leads to the conclusion that the new sign is more reliable and specific.
Fetal Hemoglobin in the Diagnosis of Neonatal Subarachnoid Hemorrhage
Authors: Chaplin Edward R. , Schlueter Murren A. , Phibbs Roreric H. , Kitterman Joseph A. , Tooley William H.
Published: December 2021

Intracranial hemorrhage is a leading cause of mortality and morbidity in newborn infants, particularly those born prematurely.1-8 Major intracranial hemorrhage in the preterm infant is usually intraventricular.3-6 Although intraventricular hemorrhage is a common autopsy finding, it may be difficult to diagnose before death because its early signs are also often associated with cardiopulmonary disease.3-7 Thus, particularly in prematurely born infants with severe hyaline membrane disease, there may be no pathognomonic sign of intracranial bleeding and often only a presumptive clinical diagnosis can be made. Laboratory diagnosis based on bloody spinal fluid may also be misleading, since the blood in the spinal fluid could be the result of either a traumatic lumbar puncture or preexisting subarachnoid blood.