bluuebunny/crossref_metadata_2025 huggingface dataset:
Anxiety and Life Events in Childhood Migraine
Authors: Cooper Pamela J. , Bawden Harry N. , Camfield Peter R. , Camfield Carol S.
Published: December 2021

The assumption that anxiety and stressful life events are major precipitants of childhood migraine was examined by comparing a group of children referred for evaluation of headaches with their headache-free best friends. Before assessment, 39 children (average age 11 years, 20 girls) and their parents completed standard anxiety, personality, and life events scales. The same scales were administered to the control children and their parents. All subjects met Prensky's criteria for migraine, and all reviewed an audiovisual program on migraine and were given the same instruction about analgesic medications. History of headache averaged 35 months (1 to 132 months). No statistically significant differences were found between patients and controls or between the two groups of parents on any of the anxiety or life events scales. Children's anxiety scores were not related to parents' anxiety scores. Personality profiles of patients were similar to controls. Headache diaries were used to assess headache severity and frequency during a 4-month follow-up period. Although all patients had anxiety scores within the normal range, those with higher self-rated anxiety scores at initial assessment had significantly more frequent and severe headaches during the follow-up period (P < .001). We conclude that children with migraines are not more anxious or stressed than their friends. Normal amounts of stress and anxiety appear to lead to the expression of migraine; however, more anxious children with migraines have more frequent and severe headaches.
THERAPY OF INFECTIOUS DISEASES
Authors: NELSON WALDO E.
Published: December 2021

A word of explanation may be in order in regard to the nature of the program arranged for this panel, since its pattern deviates somewhat from those usually arranged for clinical meetings.

In recent years the introduction of new antimicrobial agents has occurred with such rapidity that emphases have been principally upon which pathogenic organisms were susceptible to the various agents and upon the ranges of effective dosages, the routes of administration and the untoward reactions. Details of acceptable plans of usage of the various therapeutic agents are now common knowledge and are also readily available in the medical literature and in brochures published by the pharmaceutical houses. Other, and as yet unknown, antimicrobial agents will continue to appear and make it necessary for the clinician to be even more discriminating in his selection of therapy than is the case at the moment.

Perhaps of equal importance with the selection of a therapeutic agent is the decision as to whether any artificial assistance is required for the control of a particular infection. If one understood the relationship between the host and a pathogenic parasite at a given moment, he would be in an extremely favorable position to decide whether therapeutic assistance was indicated and even to decide more exactly the nature of that assistance—a clinical utopia.

This program was planned with the idea that those of us whose activities are principally clinical might gain some insight into the thinking and the accomplishments of those who are trying to find out more about the host-parasite relationship and what can be done to help the host control and conquer or live with the pathogenic invader.
THE HANDICAPPED CHILD
Authors: PERLSTEIN M. A.
Published: December 2021

There is a great deal of correlation between the various types of clinical pictures seen in cerebral palsy and the etiologic factors. Thus there are certain noxae which have a predilection for certain portions of the brain. Anoxia tends to attack the extrapyramidal tract system, whereas hemorrhages tend to attack primarily the pyramidal tract.

Thus, one can often prognosticate on the basis of history the clinical pictures which are found. A classification of the various types of cerebral palsy can thus be based either upon an etiologic basis or upon a clinical basis. [see table 1 in source pdf]
DEVELOPMENT OF NEONATAL ELECTROLYTE HOMEOSTASIS
Authors: GRAHAM BRUCE D. , WILSON JAMES L. , TSAO MAKEPEACE U. , BAUMANN MARY L. , BROWN SHIRLEY
Published: December 2021

A study was made of the development of chemical homeostasis in the newborn infant. In a series of 43 essentially healthy, full term, newborn infants, serial determinations during the first day of life of blood pH, plasma CO2, chloride and total base content, and serum protein were made. Comparison with similar data on premature infants and adults is presented.

Most full term infants at birth are in a state of metabolic acidosis with a lowered blood pH and plasma CO2 content, but have essentially normal plasma chlorides and total base values. The majority of these infants within a few hours have a blood pH of adult level but maintain for some time a lowered CO2 content.
INDWELLING POLYETHYLENE NASOGASTRIC TUBE FOR FEEDING PREMATURE INFANTS
Authors: ROYCE STEPHEN , TEPPER CLIFFORD , WATSON WILLIAM , DAY RICHARD
Published: December 2021

Experiences with an indwelling polyethylene nasogastric tube in feeding 30 small premature infants for periods varying from 7 to 49 days have been described. The technic has the following advantages: 1. The interval between feedings may be shortened, if necessary, without any increase in the likelihood of esophageal irritation. 2. Feedings disturb the infant so little as to cause no fatigue. 3. Feeding can be accomplished so easily that less skill is demanded of the nurse.

Two of the 30 infants died, and each had an ulcer in the upper, anterior part of the esophagus. Similar ulcers were noted by Gruenwald and Marsh in 16⅔% of 310 autopsied infants. Two other infants developed a purulent rhinitis on the side of the tube. Each infant suffered from other, seemingly unrelated infections at the time. Thrush was never noted. Occult blood was absent in the 50 stools obtained from 18 infants, as indicated by a negative guaiac test.

Nine of the 10 infants weighing less than 1,000 gm. at birth survived, as did 15 of the 16 who weighed 1,000 to 1,499 gm.

A complete evaluation of esophageal irritation in tube as compared with gavage feeding will require a more extended study.

Results so far with the polyethylene tube lead the authors to believe it to be a better device for feeding premature infants than either the rubber gavage tube repeatedly inserted or the dropper.
ENCEPHALITIS COMPLICATING ATTENUATED RUBEOLA
Authors: ROSENZWEIG JOSEPH L. , KLUGH WALTER G.
Published: December 2021

A case of encephalitis with probable complete recovery following modified rubeola is reported. It is suggested that the occurrence of similar cases be recorded.
Rudimentary Testes Syndrome Revisited
Authors: Acquafredda Angelo , Vassal Jean , Job Jean-Claude
Published: December 2021

Sixteen children who were one day to 9 years of age underwent clinical, anatomic, and hormonal study because of extreme hypoplasia of the phallus and small testes associated with normal 46XY male karyotype. Two of them were first cousins. All patients had Leydig cell deficiency. Among 15 patients who received luteinizing hormone-releasing hormone stimulation during childhood, 11 had an exaggerated response of either one or both gonadotropins. Bilateral biopsy, performed in eight patients, showed a clearly testicular structure with either scant or incompletely differentiated tubules. These characteristics allow clear differentiation from chromosomal abnormalities and malformation syndromes. It is more difficult to differentiate between rudimentary testes and primary gonadotropic deficiencies and may not be possible until the child has reached adolescence. The syndrome of rudimentary testes may be a manifestation of XY primary gonadal dysplasia, along with pure XY gonadal dysgenesis, XY hermaphrodism, XY mixed gonadal dysgenesis, and congenital anorchia, probably resulting from fetal regression of the testes. The observed familial occurrence of the syndrome of rudimentary testes, as well as of XY gonadal dysgenesis, leads to speculation about the possibility of X-linked transmission.
Circumcision Decision: Prominence of Social Concerns
Authors: Brown Mark S. , Brown Cheryl A.
Published: December 2021

Despite policy statements against routine circumcision of newborns by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology more than 10 years ago, there has been virtually no change in circumcision practices in the United States. In addition, controlled trials of programs to educate parents about the lack of medical indications for routine newborn circumcision have shown that parental education has little impact on the circumcision decision. We hypothesized that parents based their circumcision decision predominantly on social concerns rather than on medical ones. We prospectively surveyed parents of 124 newborns soon after they made the circumcision decision to learn their reasons for the decision. The strongest factor associated with the circumcision decision was whether or not the father was circumcised (P.0001). The survey also showed that concerns about the attitudes of peers and their sons' self concept in the future were prominent among parents deciding to circumcise. The circumcision decision in the United States is emerging as a cultural ritual rather than the result of medical misunderstanding among parents. In counseling parents making the circumcision decision, the health care provider should provide a knowledgeable and honest discussion of the medical aspects of circumcision. Until information is available that addresses parents' social concerns about circumcision, it is unreasonable to expect a significant change in circumcision customs in the United States.
Sleep Apnea and Vocal Cord Paralysis Secondary to Type I Chiari Malformation
Authors: Ruff Michael E. , Oakes W. Jerry , Fisher Samuel R. , Spock Alexander
Published: December 2021

A previously healthy 13-year-old boy d boy wimyelo-myelo-dysplasia who had mild scoliosis was seen with complaints of nasal congestion, noisy nighttime breathing, and difficulty sleeping. Flattening of the inspiratory loop on the flow-volume curve was found on pulmonary function testing, suggesting a variable extrathoracic obstruction due to a laryngeal lesion. Bilateral abductor vocal cord paralysis and sleep apnea developed precipitously following general anesthesia. Further workup demonstrated a type-I Chiari malformation with syringomyelia. Brainstem abnormalities such as Chiari malformation with secondary tenth cranial nerve deficits should be considered in previously healthy children and adolescents with signs and symptoms of upper airway obstruction and apnea.
Chronic Nonspecific Inflammatory Bowel Disease of the Cecum and Proximal Colon in Children With Grossly Normal-Appearing Colonic Mucosa: Diagnosis by Colonoscopic Biopsies
Authors: Heyman Melvin B. , Perman Jay A. , Ferrell Linda D. , Thaler M. Michael
Published: December 2021

The diagnosis of inflammatory bowel disease rests on radiologic, endoscopic, and histologic creteria. Five patients, 2 to 17 years of age, sought medical attention because of chronic abdominal pain, diarrhea, and heme-positive stools. Rectal biopsies, visual inspection of colonic mucosa through the colonoscope, and contrast radiographs of the large and small intestine yielded nonspecific results. Serial endoscopic biopsies demonstrated a gradient of inflammatory changes diminishing in severity distally from the ileocecal valve and cecum. The disease process was most evident in specimens from the cecum, whereas biopsies distal to the transverse colon had a normal histologic appearance in all five patients. Biopsies from the proximal colon may provide evidence of inflammatory bowel disease not detectable using standard techniques. The combination of chronic abdominal pain, diarrhea, and heme-positive stools associated with inflammatory changes in biopsy specimens obtained from the proximal colon, but normal findings on radiologic, colonoscopic, and rectal biopsy examinations, may represent an early stage in the evolution of chronic nonspecific inflammatory bowel disease, including ulcerative colitis or regional enteritis (Crohn disease).
Adverse Reactions Reported Following Receipt of Haemophilus influenzae Type b Vaccine: An Analysis After 1 Year of Marketing
Authors: Milstien Julie B. , Gross Thomas P. , Kuritsky Joel N.
Published: December 2021

An analysis of adverse reactions occurring after receipt of Haemophilus influenzae type b vaccine and reported to the Food and Drug Administration during the first year of marketing of the product was performed. During the period April 1985 to May 1986, adverse reaction reports on 152 patients, excluding those of vaccine failure and concurrent infection, were received. Several adverse reactions not previously recognized, including convulsions, allergic reactions such as anaphylactoid-like and serum sickness-like reactions, and vomiting were received. The vast majority of adverse reactions were benign. Because there are many biases that result in the reporting of or failure to report an adverse reaction, it is not possible to derive a rate of reactions from these data. Furthermore, causality cannot be inferred from any single report. The data, however, indicate that, in light of widespread use of the vaccine, its use appears to be safe.
Immunogenicity of Haemophilus influenzae Type b Polysaccharide-Neisseria meningitidis Outer Membrane Protein Conjugate Vaccine in 2- to 6-Month-Old Infants
Authors: Lenoir Allen A. , Granoff Paul D. , Granoff Dan M.
Published: December 2021

Fifty infants, 2 to 6 months of age, were vaccinated with Haemophilus influenzae type b capsular polysaccharide covalently linked to an outer membrane protein from Neisseria meningitidis group B. Subjects were given two injections and were randomly assigned to receive the injections separated by 1 or 2 months. Each dose contained 15 µg of polysaccharide and 51 µg of protein, or approximately twice the amount of polysaccharide as used in our previous trial (Lancet 1986;2:299). Fevers of 38.0° to 38.8°C developed in three infants (6%) within 24 hours after vaccination, but there were no other notable reactions. Following one injection, the geometric mean antibody concentration increased from 0.13 µg/mL in preimmune serum to 1.50 µg/mL in serum obtained 1 to 2 months later (P < .001). After a second injection, there was a further increase in serum antibody (geometric mean = 3.11 µg/mL, P < .007). The geometric mean antibody concentration of the group reimmunized 2 months after the first injection was higher than that in the group reimmunized after 1 month (3.95 v 2.32 µg/mL, P = .05, by analysis of covariance with age as the covariant). These data confirm our previous preliminary observations on the safety and immunogenicity of this new conjugate vaccine in infants 2 to 6 months of age. The data suggest that a 2-month interval between the first and second injections results in higher levels of serum antibody than a 1-month interval.
Breast-Feeding and Jaundice
Authors: MAISELS M. JEFFREY
Published: December 2021

In Reply.—

I have no doubt that Drs Fleiss and Jelliffe are correct in their assertion that certain hospital practices interfere with breast-feeding, but whether these practices contributed to our findings is difficult to determine. The vast majority of our breast-feeding mothers roomed-in with their infants (continuously if they so desired), were unmedicated, and were given both verbal and written instructions about breast-feeding techniques. No routine supplements of any kind were provided and the data on the 1,260 breast-fed infants referred to fully breast-fed, unsupplemented babies.
Acute Illnesses in the 2 Weeks After Hospitalization for Bacterial Meningitis
Authors: Powell Keith R. , Hendley J. Owen , Gadomski Anne , Mendes Tarina , Lohr Jacob A.
Published: December 2021

The hospital records of 118 2-month-old to 3-year-old children who had been treated for bacterial meningitis were reviewed. Within 2 weeks after hospitalization, one fourth of the patients sought medical attention for an acute illness, but only one was treated for the possible relapse or recurrence of meningitis. Because only five of the 113 patients with available follow-up information required a diagnostic lumbar puncture procedure, it is not recommended that a lumbar puncture be performed following treatment of bacterial meningitis to provide end-of-treatment baseline information.
Immunogenicity of Haemophilus influenzae Type b Capsular Polysaccharide Vaccines in 18-Month-Old Infants
Authors: Hendley J. O. , Wenzel J. G. , Ashe K. M. , Samuelson J. S.
Published: December 2021

Haemophilus influenzae vaccine containing polyribosyl ribitol phosphate (PRP) or PRP covalently linked to diphtheria toxoid (PRP-D) was given to 94 healthy infants 17 to 22 months of age at the same time, but not at the same site, as a diphtheria-tetanus-pertussis booster. Systemic reactions were similar in the two vaccine groups and resembled those expected with the diphtheria-tetanus-pertussis injection alone. Six (13%) and seven (14%) of the PRP and PRP-D recipients, respectively, had minor local reactions to the Haemophilus vaccine. Among the 77 children who were not already naturally immune (ie, anti-PRP antibody concentration of ≤0.15 µg of protein per milliliter) before vaccination, PRP-D was significantly more effective than PRP in inducing protective levels of antibody. Only 15 (43%) of the 35 nonimmune PRP recipients achieved a concentration of ≥0.15 µg/mL and only seven (20%) reached a concentration ≥1.0 µg/mL following vaccination. In contrast, 34 (81%) of the 42 nonimmune recipients of PRP-D had a concentration of ≥0.15 µg/mL following vaccine and 32 (62%) had a concentration of ≥1.0 µg/mL (P ≤ .001). These results suggest that more than one-half of nonimmune 18-month-old infants will not respond to PRP with protective levels of antibody. In light of the current data, recommendation for revaccination at 24 months of age for those immunized at any younger age is appropriate.
Ipecac-Induced Emesis and Reduction of Plasma Concentrations of Drugs Following Accidental Overdose in Children
Authors: Amitai Yona , Mitchell Allen A. , McGuigan Michael A. , Lovejoy Frederick H.
Published: December 2021

Syrup of ipecac is widely used following accidental drug overdosage in children. Proof of its efficacy, however, in reducing the risk of poisoning is limited. We prospectively studied the effect of early v late induction of emesis by ipecac in 50 children younger than 5 years of age with accidental acetaminophen poisoning. The mean estimated ingested dose was 165 mg/kg, and all patients vomited within 15 to 255 (mean 78) minutes postingestion. Although the predicted four-hour plasma acetaminophen concentration was 97 ± 4 µg/mL (mean ± SEM, calculated on the basis of the estimated ingested dose), the measured four-hour plasma acetaminophen concentration was 34 ± 5 µg/mL (P < .01). To assess the efficacy of early v late ipecac-induced emesis, we used the ratio of measured to predicted four-hour acetaminophen plasma concentration. The ratio of the measured to predicted four-hour level increased as the delay in time to vomiting increased (r = .60, P < .001). Ipecac syrup was administered more promptly when available in the home than when obtained from a pharmacy or a medical facility (26 ± 8 v 83 ± 13 minutes postingestion, respectively; P < .001) and vomiting occurred earlier (49 ± 9 v 103 ± 12 minutes postingestion; P < .01). Although the mean estimated doses ingested were greater in patients who received ipecac syrup at home, their four-hour plasma acetaminophen concentrations were lower. These data suggest that prompt administration of ipecac syrup results in a greater reduction in plasma acetaminophen concentrations in potentially toxic overdosages in children. Further availability of ipecac syrup at home facilitates its prompt use.
Successful Direct Extubation of Very Low Birth Weight Infants From Low Intermittent Mandatory Ventilation Rate
Authors: Kim Eun H. , Boutwell Walter C.
Published: December 2021

It is common practice to use endotracheal continuous positive airway pressure for various time periods up to 24 hours before attempting extubation in infants who are mechanically ventilated. A few studies in newborns have indicated that airway resistance is increased through small endotracheal tubes. This increases the work of breathing and the likelihood of subsequent ventilatory failure. In this study, 27 very low birth weight infants who were ½ to 28 days old at the time of extubation were randomly divided into two groups. One group of 13 study infants were extubated directly from intermittent mandatory ventilation rates of six to ten per minute, and the other 14 control infants were placed on continuous positive airway pressure through endotracheal tubes for six hours prior to an attempt to extubate. There was no difference between the two groups in gestational age, postnatal age, weight, or severity of lung disease at the time of extubation. All 13 study infants were successfully extubated without significant apnea or respiratory acidosis. Of the 14 control infants, only seven were successfully extubated; six infants had significant apnea and in one infant respiratory acidosis with pH 7.13 and Pco2 65 developed while receiving continuous positive airway pressure (13/13 v 7/14, P < .005). The seven infants who failed the preextubation trial of continuous positive airway pressure were later extubated from low intermittent mandatory ventilation rates without significant pnea or respiratory acidosis. Furthermore, slight CO2 retention developed in the very low birth weight infants after six hours of continuous positive airway pressure but not after direct extubation (mean change Pco2 ± SD: 4.43 ± 3.87 v -0.23 ± 3.79 mm Hg, P < .01). This study demonstrates that the recommended preextubation trial of continuous positive airway pressure through an endotracheal tube is not only unnecessary but detrimental to very low birth weight infants, in whom more apnea and slight CO2 retention develop probably because of increased airway resistance through small endotracheal tubes.
Cow's Milk Protein Intolerance
Authors: LECKS HAROLD I.
Published: December 2021

In Reply.—

The literature has been replete with discussions of cow's milk protein hypersensitivity relevant to its diagnosis as well as clinical patterns of presentation since the entity was initially described by M. Rubin 40 years ago. Drs Gilbertson and Bentley now suggest a comparatively simple diagnostic procedure for detecting cow's milk protein intolerance (hypersensitivity) by merely inspecting the rectal mucosa of the infant at risk. My criticism of their observations relates initially to the specificity of rectal mucosal vascularity changes, as well as to the pragmatic aspects of this diagnostic procedure.
Sustained Release and Standard Methylphenidate Effects on Cognitive and Social Behavior in Children With Attention Deficit Disorder
Authors: Pelham William E. , Sturges James , Hoza JoAnn , Schmidt Casey , Bijlsma Jan Jaap , Milich Richard , Moorer Sam
Published: December 2021

Two studies were conducted to investigate the relative effects of sustained release methylphenidate (Ritalin [SR-20]) and standard methylphenidate (Ritalin, 10 mg, administered twice daily). In the first study, 13 boys with attention deficit disorder participating in a summer treatment program went through a double-blind, within-subject trial of each form of methylphenidate and placebo. Measures of social and cognitive behavior were gathered in classroom and play settings. Although group analyses of the data showed that both drugs were effective and there were few differences between them, standard methylphenidate was superior to SR-20 on several important measures of disruptive behavior. Furthermore, analyses of individual responsivity showed clearly that most boys responded more positively to standard methylphenidate than to SR-20. The second study involved a partially overlapping group of nine boys with attention deficit disorder participating in the same summer treatment program. Also double-blind, within-subject, and placebo controlled, this study tracked the time courses of the two forms of methylphenidate. Both were shown to have similar time courses on the Abbreviated Conners Rating Scale and other measures, but SR-20 had a slower onset than did the standard drug form on a continuous performance task. Effects of SR-20 were still evident eight hours after ingestion.
Taurine Improves the Absorption of a Fat Meal in Patients With Cystic Fibrosis
Authors: Belli Dominique C. , Levy Emile , Darling Pauline , Leroy Claudie , Lepage Guy , Giguère Robert , Roy Claude C.
Published: December 2021

The effect of taurine supplementation on the absorption of a fat meal was evaluated in patients with cystic fibrosis. In a cross-over design study, five patients with cystic fibrosis (12.1 ± 2.6 years of age) and three control subjects received either placebo or taurine (30 mg/kg/d) for two 1-week periods, a month apart, followed by a fat meal test. Blood samples were drawn 0, 1, 2, 3, 5, 8 hours after the meal. Four patients with cystic fibrosis and severe steatorrhea despite appropriate enzyme therapy showed a significant (P < .05) improvement in the absorption of triglycerides, total fatty acids, and linoleic acid while receiving taurine supplements. Three control subjects and one child with cystic fibrosis and mild steatorrhea receiving enzyme therapy did not experience such an effect. The difference in triglyceride absorption, when calculated as the area under the curve, receiving and not receiving taurine was significantly (P < .05) correlated with the degree of steatorrhea. Furthermore, in contrast to control subjects, the fatty acid composition of chylomicrons in these four study patients showed important discrepancies with that of the fat meal and was corrected, in part, by taurine supplementation. These results suggest that taurine supplementation could be a useful adjunct in the management of patients with cystic fibrosis with ongoing fat malabsorption and essential fatty acid deficiency.
Perilymph Fistula: An Important Cause of Deafness and Dizziness in Children
Authors: Parnes Lorne S. , McCabe Brian F.
Published: December 2021

This study underscores the importance of considering a perilymph fistula, an abnormal communication between the inner and middle ear, in any child with a progressive sensorineural hearing loss. A concomitant complaint of intermittent dizziness or observed spells of imbalance (56%) is another indication of the disease. Six of 16 patients (37.5%) with proven fistulas were less than 2 years of age at the onset of symptoms. Unless the fistula is identified and repaired by grafting, the ear may become totally deaf. This would be disastrous in the presence of bilateral fistulas, which occur commonly in children (56% of patients had symptoms of bilateral disease). Our experience in recognizing and treating fistulas and thereby saving and restoring hearing is described.
Primary Hemochromatosis in Childhood
Authors: Escobar Gabriel J. , Heyman Melvin B. , Smith W. Byron , Thaler M. Michael
Published: December 2021

Primary hemochromatosis is a genetic disorder rarely recognized in childhood; its long-term consequences include cirrhosis and liver cancer. We report a family with primary hemochromatosis affecting three generations, including a 7-year-old child and a 29-month-old child; these are the youngest children with primary hemochromatosis yet reported. The pathophysiology, genetics, and clinical findings of this disorder are reviewed. Serum ferritin and transferrin saturation are useful screening tests; definitive diagnosis, however, depends on determination of hepatic iron content. A plan for evaluating and treating affected patients is proposed. Physicians caring for children must learn to recognize this potentially treatable disorder.
Native American Postneonatal Mortality
Authors: Honigfeld Lisa S. , Kaplan David W.
Published: December 2021

Although dramatic gains have been realized in lowering the incidence of neonatal deaths among native American infants to a level lower than the white race, postneonatal death rates for this population remain twice as high as in the white race. The limited data available reveal that excessive postneonatal deaths among native American infants largely result from preventable accidents and treatable acute medical conditions, such as pneumonia and gastroenteritis. This suggests that native American infants leave the hospital healthy but go to unsafe environments, which decrease their chances of survival past 1 year. In particular, the poorer socioeconomic conditions that native American families experience and the related problems of alcoholism, unemployment, and family disorganization contribute to the high rate of postneonatal mortality. Intervention programs to lower native American postneonatal mortality should focus on promoting prompt recognition of and health seeking for treatable medical conditions and prevention of accidents and other postneonatal health problems. The roots of the problem of native American postneonatal mortality lie in the socioeconomic conditions of many Indian communities and cannot be addressed without recognition of how these factors combine with the health care delivery system to diminish life expectancy for native American infants.
Diagonal Fontanel Measurements
Authors: SKOGLUND R. R.
Published: December 2021

To the Editor.—

Duc and Largo1 assert that assessment of the size of the anterior fontanel is a part of the routine examination of the infant. The reality is that the measurement is not used routinely and indeed is rarely noted in neonatal reports or records because it has not proved to be clinically reproducible.2 This hypothesis was tested and reported using landmarks and standards described by Popich and Smith3 and Davis and Anari.4 Two physicians independently examined 50 healthy term infants with normal head circumferences by the Nellhaus graph.
Heart Transplantation
Authors: FRICKER F. JAY , GOLD LARRY M.
Published: December 2021

In Reply.—

The authors would like to thank Mr. Lantos for his comments. The political, economic, and ethical issues raised are important ones but obviously not the focus of our paper. We will, however, provide additional information in an attempt to answer some of Mr Lantos' questions. The question about what encouraged us to start is easy to answer. An 8-year-old child languishing in our intensive care unit on IV inotropic support with no hope of survival was the first orthotopic heart transplantation performed at Children's Hospital of Pittsburgh.
Streptococcal Perianal Disease in Children
Authors: Kokx Nicholas P. , Comstock Jody A. , Facklam Richard R.
Published: December 2021

From October 1985 through June 1986, 31 children in a single pediatric practice were treated for perianal signs and symptoms associated with growth of group A β-hemolytic streptococci from perianal cultures. Signs and symptoms included perianal dermatitis (90%), perianal itching (78%), rectal pain (52%), and blood-streaked stools (35%). Ages ranged from 7 months to 8 years (mean 4.25 ± 1.8 years). There were 24 boys (77%) and seven girls (23%). The 31 cases occurred in 19 families. Intrafamily spread was only to siblings and occurred in 50% of the possible situations. Direct perianal antigen studies had a sensitivity of 89% for predicting positive cultures. Four different T types of group A streptococci were isolated from these cases, but the T type within each family outbreak was identical except in one case. When group A streptococci were found in the pharynx (64% of patients), the T type of the pharyngeal and perianal isolates were identical. Treatment was usually with oral penicillin. Relapses occurred in 39%. Signs of cellulitis were absent in all 31 cases and, therefore, we suggest that the nomenclature for this entity be changed from streptococcal perianal cellulitis to streptococcal perianal disease.
Parenteral Nutrition Effect on Serum Insulin in the Preterm Infant
Authors: Andronikou S. , Hanning I.
Published: December 2021

Blood glucose and serum insulin levels were measured in two groups of preterm infants that had been matched for gestational age. Both groups were fed parenterally during the first 72 hours of life and were mechanically ventilated because of respiratory distress syndrome. Group A infants (n = 11) received 10% glucose (infusion rate 5 mg/kg/min) and group B infants (n = 12) received amino acid solution (1.2 g/kg/d) in addition to 10% glucose at the same rate as those in group A. Infants in both groups received 90 mL/kg of fluid per day. There was no difference in blood glucose or serum insulin levels between the two groups 24 hours after beginning the infusion; however, at 48 hours there was a significantly (P < .01) higher insulin level in infants receiving amino acid and glucose infusion compared with those receiving only glucose. Blood glucose level remained stable in both groups. We conclude that, in the stable preterm infant, the higher insulin level associated with continuous amino acid infusion does not result in hypoglycemia.
Are Venous Circulatory Abnormalities Important in the Pathogenesis of Hemorrhagic and/or Ischemic Cerebral Injury?
Authors: Perlman Jeffrey M. , Volpe Joseph J.
Published: December 2021

The venous circulatory changes in 12 intubated premature infants with fluctuations or elevations in arterial BP were studied. The objectives of the study were to determine whether important alterations in venous pressure occur in infants with fluctuations in arterial BP or with elevations in arterial BP associated with suctioning. Venous and arterial catheters were present in all infants. Perfusion pressure was derived from the difference between mean arterial BP and venous pressure. At rest, minimal change in arterial BP, venous pressure, and perfusion pressure was observed. Elevations in arterial BP were accompanied by pronounced changes in venous pressure. However, because the magnitude and the direction of the changes in venous pressure were not consistent, pronounced changes in perfusion pressure resulted. Fluctuations in arterial BP were associated with fluctuations in venous pressure, which also resulted in pronounced and continuous alterations in perfusion pressure. Induced muscle paralysis in two infants obliterated the changes in arterial BP, venous pressure, and perfusion pressure associated with suctioning. These data demonstrate that marked venous circulatory changes accompany common arterial circulatory abnormalities; such alterations on the venous side of the circulation may be important in the pathogenesis of neonatal hemorrhagic and/or ischemic injury.
Haemophilus influenzae Type b Vaccine: Use in the Pediatric Population
Authors: Gururaj Vymutt J. , Patrick Jenny K. , Rogers Patricia Fields
Published: December 2021

To assess the use of the Haemophilus influenzae type b vaccine and the attitudes of health professionals regarding its use in the pediatric population, we conducted a study of community clinics, health department clinics, university-based teaching clinics, and private practice groups in the state of Texas. Whereas 59.6% of the private practice groups and 57.1% of the university-based teaching clinics administered the vaccine to more than 75% of their eligible children, 72.7% of community clinics and 81.7% of health department clinics never administered the vaccine to their eligible children. Likewise, whereas 100% of the university-based teaching clinics and 95.7% of the private practice groups had the vaccine available to their patients, only 22.7% of the community clinics and 15.5% of the health department clinics did so. The two most common reasons given by health professionals concerning the nonuse of the vaccine were nonavailability and high cost of the vaccine. Our findings suggest that a large segment of eligible children do not have access to this important vaccine and that children who depend on community and health department clinics for their routine health care are particularly affected in this regard. Strategies identified to increase the use of the vaccine include providing vaccine free of charge, increasing patient awareness of the vaccine benefits, and passing mandatory state laws requiring vaccine administration before day-care enrollment.
Personal and Family History of Seizures and Measles Immunization
Authors:   Committee on Infectious Diseases
Published: December 2021

A recent analysis of reports of reactions following measles immunization has revealed that children who had seizures following measles vaccine were more likely to have a personal history of seizures or a history of seizures in siblings or parents than vaccinees who had nonneurologic reactions associated with immunization.1 These seizures usually are associated with fever and occur five to 11 days postimmunization when febrile reactions to live measles virus are most common; approximately 5% to 15% of vaccinees have elevated temperatures during this time. The seizures resemble typical febrile seizures which are common at this age and are rarely associated with any sequelae. In one study, the vast majority of children who had seizures following live measles vaccination had temperature elevations and about half were associated with intercurrent infections.2

The Committee strongly recommends that children who have a personal or family history of seizures should receive live measles vaccination. Seizures are unpleasant experiences but the risk of measles to unimmunized children is far more significant. Outbreaks in schools with as few as 5% of the children seronegative have been reported.3 Thus, live measles vaccine should not be denied these children.

The parents of children who have either a personal or a family history of seizures should be advised of the risk and told in advance of immunization what they should do if the child does indeed have a seizure. Because the period of risk is approximately 1 week, it is difficult to recommend an effective method of decreasing the chances of seizure occurring.
Family History of Convulsions in Candidates for Immunization With Pertussis-Containing Vaccines (Diphtheria, Tetanus, Pertussis)
Authors:   Committee on Infectious Diseases
Published: December 2021

Family history of convulsions is not presently a contraindication to the use of pertussis vaccine.1,2 It was suggested in a recent report that there might be an increased risk of seizures following diphtheria, tetanus, pertussis (DTP) vaccination in individuals who have a "family history of convulsions." Unfortunately, the degree of relatedness was not specified in the questionnaire from which these results were derived.3 A subsequent questionnaire specifying relatedness only to siblings and parents also indicated an increased risk. A family history of convulsions was obtained in 17.3% and 16.7% of children who had febrile and nonfebrile convulsions, respectively, following DTP vaccine as compared with 4.8% in vaccinees who had nonneurologic complications following DTP vaccination (Centers for Disease Control, unpublished data, 1987).

The risk of seizures following DTP vaccination is approximately one in 1,750 doses. These are usually febrile seizures.4,5 Follow-up of these patients had indicated that they rarely, if ever, have sequelae.5 Convulsions of this type (DTP vaccination induced) are differentiated from encephalopathy which occurs once in about 1:140,000 doses, one third of which result in permanent sequelae.6 Recent studies have demonstrated that the administration of acetaminophen, 15 mg/kg per dose, at the time of immunization with DTP and four and eight hours later, reduces febrile reactions.7 Although this study was too small to allow determination of the effect on seizures following DTP, it is reasonable to expect that reduction in fever also would decrease the likelihood of febrile seizures following DTP.

Local pertussis epidemics in the United States occur in unpredictable fashion.
Newborn Screening for Congenital Hypothyroidism: Recommended Guidelines
Authors:   American Academy of Pediatrics,   American Thyroid Association
Published: December 2021

During the past decade newborn screening for congenital hypothyroidism has become an important health activity in most developed countries. These screening programs have not only benefited patients and their families but also have produced new information about the epidemiology, pathophysiology, diagnosis, and treatment of thyroid disease in infancy and childhood. During this period of implementation and growth of the screening programs, a variety of issues and questions arose. Some of these have been resolved, and some have not. The point has now been reached where collation of the combined experiences of the North American programs can address these issues. The reader should understand that what follows reflects current opinion and may require changes when the results of the next decade of screening are reviewed.

SCREENING METHOD

Thyroxine (T4) and Thyroid-Stimulating Hormone (TSH)

Most North American programs use a two-tiered laboratory approach. An initial T4 measurement is followed by measurement of TSH in specimens with low T4 values. In addition to detecting infants with primary hypothyroidism (low or low normal T4 level with elevated TSH value; prevalence 1:3,500 to 4,500 newborns), this approach can also identify infants with thyroxine-binding globulin deficiency and some with hypothalamic-pituitary hypothyroidism (low or low normal T4 level with normal TSH value; prevalence 1:5,000 to 10,000 and 1:50,000 to 150,000 newborns, respectively). Programs that quantify T4 values also have the option of identifying newborns with hyperthyroxinemia (1:20,000 to 40,000 newborns).

On the other hand, this approach will miss infants who have normal T4 values but elevated TSH values. Such infants are relatively commonplace in European programs where initial screening is done by measurement of TSH.
Care of Uncircumcised Penis
Authors: WATSON STAN J.
Published: December 2021

To the Editor.—

The controversy regarding circumcision and urinary tract infections following the article by Dra Wiswell and Roscelli has not addressed one important factor—what kind of care is appropriate for the uncircumcised boy. After 40 years of pediatric practice, I am firmly convinced that the best hygiene is to keep hands off and leave the prepuce alone. I have had many infants with problems fro inadequate and poorly done circumcisions; similarly, I have had many uncircumcised infants who got into trouble when a "helpful" nurse, doctor, or grandmother forcibly retracted and cleaned a tight prepuce.
Dr Glueck and Co-Authors' Letter of Withdrawal
Authors: GLUECK CHARLES J. , LASKARZEWSKI PETER , MELLIES MARGOT J. , PERRY TAMMY
Published: December 2021

To the Editor.—

Our paper (Pediatrics 1986; 78:338) was seriously flawed by unintentional errors, which we profoundly regret. The committee that reviewed the patient charts found errors and inconsistencies in our use of some of the lipid data but not the height and weight data. When we corrected the errors, they were found to be nonsystematic and random. The clarified data led to the same conclusion as the original paper: long-term therapy with cholesterol-lowering diet and/or bile acid-binding resin did not affect normal growth and development in children.
Design and Participation
Authors: Webber Larry S. , Frank Gail C. , Smoak Carey G. , Freedman David S. , Berenson Gerald S.
Published: December 2021

Cardiovascular risk factor variables were examined in a cohort of 440 infants from birth through 7 years of age. Anthropometric measures, BP, serum lipid and lipoprotein values, and dietary intake data were obtained according to detailed protocols. Various quality controls to ensure the collection of valid and reliable data were instituted. Participation remained high throughout the study with 80% of the children examined at 6 months and 60% at 7 years of age. Rates were slightly higher for black than for white children. Children born in the private hospital were more likely to continue in the study than children born in the charity hospital. Children of parents examined when the child was 2 years of age were more likely to be examined during the preschool phases, but parental examination was not related to child examination when the child was 7 years of age. As in studies of school-aged children, measurement errors were lowest for height, weight, and serum total cholesterol. Measurement errors for BP were highest at the younger ages, particularly for diastolic BP. Examination of a newborn cohort throughout time affords the opportunity to study early development of relationships and tracking of cardiovascular risk factors.
Serum Lipids and Lipoproteins
Authors: Freedman David S. , Srinivasan Sathanur R. , Cresanta James L. , Webber Larry S. , Berenson Gerald S.
Published: December 2021

Serum lipids and lipoprotein cholesterol fractions were examined in a newborn cohort that was followed from birth to 7 years of age. Although white and female infants had higher cord blood levels of high-density lipoprotein cholesterol (HDL-C) than did black and male infants, respectively, these differences did not persist throughout early childhood. Mean levels of all serum lipids and lipoproteins increased greatly in the first 6 months of life, and by 2 years of age, levels approached those seen in adolescents. Infants consuming cow's milk had higher 6-month levels of serum total cholesterol and low-density lipoprotein cholesterol than did formula-fed infants. However, milk source in infancy did not significantly influence total cholesterol or low-density lipoprotein cholesterol levels at age 7 years. Serum lipid and lipoprotein levels at age 7 years were associated with previously measured levels as early as 6 months of age, and infants with unfavorable levels were likely to have similar adverse levels at 7 years of age. In addition, increases in obesity between 6 months and 7 years of age were positively associated with increases in levels of serum triglycerides. These results suggest that certain persons at increased risk for cardiovascular disease can be identified in infancy.
Annual Summary of Vital Statistics—1986
Authors: Wegman Myron E.
Published: December 2021

Data from this article, as in previous reports,1 are drawn principally from Monthly Vital Statistics Report, published by the National Center for Health Statistics (NCHS).2-6 The international data come from the Demographic Yearbook7 and the quarterly Population and Vital Statistics Report,8 both published by the Statistical Office of the United Nations, which has also been kind enough to provide directly more recent data. Except for mortality data by cause and age, which are based on a 10% sample, all the US data for 1986 are estimates by place of occurrence, based upon a count of certificates received in state offices between two dates, 1 month apart, regardless of when the event occurred. Experience has shown that for the country as a whole the estimates, with few exceptions, are close to the subsequent final figures. There are considerable variations in some states, however, particularly in comparing provisional figures by place of occurrence and final data by place of residence. State information should be interpreted cautiously.

Careful attention should be paid to the denominator when studying rates presented in this article. For overall rates, like the birth rate or death rate, the standard denominator is 1,000 total population. In instances where more refined analysis is possible, the denominator may be 100,000 and the character of the population specified. The particular denominator is indicated in the table or in the context.