bluuebunny/crossref_metadata_2025 huggingface dataset:
Bleeding in the Newborn
Authors: Plunket Daniel C.
Published: December 2021

The physician caning for newborns should master four objectives in the assessment and management of bleeding problems in that age group. They are: (1) to recall the neonate's hemostatic peculiarities, (2) to perform a meaningful clinical assessment, (3) to order and interpret appropriate diagnostic tests, and (4) to formulate a treatment plan.

NEONATE'S HEMOSTATIC PECULIARITIES

Table 1 lists the components of the hemostatic mechanism comparing older patient normal values and the neonate's similarities and differences. Certain laboratory tests commonly available are also noted. Several important points should be emphasized. Differences between neonates and older children, in general, are accentuated in direct proportion to the degree of immaturity.

Platelet counts vary little with age. Big platelets (diameter more than one third the size of a red cell's diameter) are young platelets and suggest active thrombocytopoiesis. The blood vessel and platelet function contributions to hemostasis may be suboptimal by older patient standards, but are not of clinical significance unless such dysfunction has been aggravated by drugs or disease.

Most coagulation proteins (procoagulants) are derived from liver and thus are somewhat deficient in amount or function in the neonate whose liver is transiently functionally immature. In general, the more immature the infant the more deficient the procoagulant. This is particularly true of the vitamin K-dependent procoagulants (Factors II, VII, IX, X).
Sleep Problems in Children
Authors: Lozoff Betsy , Zuckerman Barry
Published: December 2021

Sleep problems, such as night waking and bedtime struggles, occur in 20% to 30% of toddlers and preschool-aged children. The management of disturbing sleep behavior is optimized by understanding the physiology of sleep, developmental considerations, and the care-giving environment. Recent research indicates the availability of a variety of effective interventions other than letting children "cry it out." A sleep record is an invaluable tool in designing and implementing an individualized treatment program. Such a program often entails using behavioral techniques in conjunction with understanding normal sleep patterns, parental responses that inadvertently reinforce an undesired sleep behavior, temperamental characteristics of the child, separation and autonomy issues, and parental anxieties. The studies reviewed suggest that effectve intervention is feasible within the constraints of pediatric practice.
Foreign Bodies in the Air and Food Passages
Authors: Kenna Margaret A. , Bluestone Charles D.
Published: December 2021

Foreign bodies of the aerodigestive tract have been recognized for centurles. Before the early 20th century, foreign body aspiration or ingestion often meant prolonged illness and death.1 Prior to the advent of modern endoscopy, bronchotomy was the primary method of laryngotracheo-bronchial foreign body removal, and blunt metallic hooks, wire nooses, esophageal forceps, and pieces of linen attached to a piece of whalebone were used to extract foreign bodies from the esophagus.2

Not surprisingly, Weist, in 1882 (as cited by Clerf2), reported a 27.4% death rate for patients undergoing bronchotomy v a 23.2% mortality for those who were not treated. In 1911, LeRoche (as cited by Clerf2) reported the use of a rigid esophagoscope for removal of sharp foreign objects. It was Chevalier Jackson, however, who developed and refined aerodigestive endoscopy. By 1936, he was able to report a decrease in mortality from foreign bodies from 24% to 2% and a 98% success rate for bronchoscopic removal.1

Although there have been marked changes in anesthesia, equipment, and endoscopic teaching since Jackson's time, his remarkable record of success has not been significantly improved upon. The mortality for all recent series is now well below 1%, mainly due to improved anesthesia, instrumentation, and medical therapy of the suppurative complications.
Children of Parents With Affective Disorder
Authors: Beardslee William R.
Published: December 2021

Depression is a family illness. The pediatrician's involvement is as a physician for the family. Initially, his or her role is as a diagnostician for the family. The presence of depressive symptoms in either a parent or a child requires investigation and may signal distress in other members of the family as well as the individual with symptoms. Often, even for parents, depressive symptoms will be first evident to the pediatrician. This provides a significant responsibility and the opportunity to function as a physician for the family in distress. An ongoing collaborative relationship with a psychiatrist or other mental health professional will aid in the treatment of disorder in the parents. Furthermore, in the absence of acute illness, there is an opportunity to discuss and help the family to understand the illness and to encourage resiliencies within the child or children. There is also the opportunity for continued follow-up, both of the parental distress and of the children's adaptive functioning.
Anemia
Authors: Segel George B.
Published: December 2021

The differential diagnosis of anemia is made easier by classifying RBC morphology as (1) hypochromic and microcytic, (2) normochromic and normocytic, and (3) macrocytic. This limits the number of diagnostic considerations and, hence, limits the laboratory evaluation. There are relatively few considerations if the RBCs are hypochromic and microcytic, including iron deficiency and the thalassemia syndromes. If the RBCs are normochromic, the reticulocyte percentage indicates whether the bone marrow is providing an appropriate response for the degree of anemia. There also are few possibilities if the reticulocyte percentage is low, ie, Diamond-Blackfan syndrome and transient erythroblastopenia of childhood. In the absence of bleeding, a brisk reticulocyte response indicates hemolysis due either to an intrinsic (congenital) or to extrinsic (acquired) RBC defect. The patient's history and physical examination findings may provide additional clues, and RBC features such as irreversibly sickled cells or spherocytes may indicate a specific diagnosis. Finally, the macrocytic anemias are suggested when the MCV exceeds 100 fL per cell and there are macroovalocytes on the blood smear. Such findings warrant further exploration of vitamin B12 and folic acid deficiency syndromes.
The Pediatrician and the Under Toad
Authors: Nazarian Lawrence F.
Published: December 2021

We are introduced to the Under Toad in John Irving's novel. The World According to Garp. A small boy at the beach is warned of the danger of being pulled out to sea by the undertow. He conjures up the image of a malevolent amphibian, lurking unseen and intent on grabbing him. The Under Toad becomes his family's symbol for all the destructive forces waiting to pounce when least expected and disrupt the peace and security of everyday life.

In our work as pediatricians, we feel the presence of the Under Toad. Some days the threat is sensed barely or not at all. At other times we can almost feel the cold breath of something ominous on the backs of our necks.
Acquired Immunodeficiency in Children
Authors: Rubinstein Arye
Published: December 2021

The acquired immunodeficiency syndrome (AIDS) in children is closely linked to infected adult family members, usually the mother. Thus, a brief analysis of the epidemiology of AIDS in adults is necessary for the understanding of future trends in pediatric AIDS.

AIDS was initially reported to occur in homosexual men. Subsequently, it was noted to occur in intravenous (IV) drug-abusing individuals, including women. The infection of women with the human immunodeficiency virus (HIV), the causative agent of AIDS, has, however, not been restricted to IV-drug abusing women. It was soon recognized that a bidirectional heterosexual transmission does occur, with male to female transmission apparently being more efficient than female to male transmission. This form of sexual transmission may occur in more than 40% of regular sexual partners. Nationwide, the percentage of women with AIDS has doubled in 2 years to nearly 7%. Whether the female to male ratio of patients with AIDS will reach 1:1, as in Africa, is yet to be seen. New demographic studies have shown that AIDS in women, especially in those of childbearing age, is increasing dramatically. In New York City the leading cause of death in 1987 for women between the ages of 24 and 35 years was AIDS.
Percutaneous Balloon Valvuloplasty for Congenital Pulmonary Stenosis
Authors: Tingelstad Jon B.
Published: December 2021

Percutaneous balloon valvuloplasty is an effective alternative to open-heart surgery for moderate and severe pulmonary valvular stenosis and is the treatment of choice for the typical form of this congenital heart defect in many medical centers. Standard right and left heart catheterizations with biplane cineangiocardiography to evaluate the anatomy and motion of the pulmonary valve are performed. If the criteria for balloon valvuloplasty are met, a balloon catheter is inserted in the vein and advanced so that the balloon straddles the stenotic pulmonary valve. The balloon is inflated by hand until the constriction caused by the stenosis disappears. The procedure is repeated to confirm the absence of the constriction and the catheter is removed. Balloon valvuloplasty is a safe procedure, and no fatalities or major morbidity have been reported.
Preterm Infant Care After Hospital Discharge
Authors: Bernbaum Judy C. , Friedman Susan , Williamson Marsha Hoffman , D'Agostino JoAnn , Farran Anne
Published: December 2021

The survival of low birth weight infants has been markedly altered by the improvements in neonatal care. Despite these advances, little progress has been made in reducing the incidence of prematurity and low birth weight. Recently available statistics from 1983 indicate that, of all live births, 9.2% were premature (<37 weeks' gestation) and 1.8% were very premature (<32 weeks's gestation). Approximately 6% of infants are born weighing <2,500 g and 1.1% are very low birth weight (<1500 g). Approximately 3.6% of babies born in the United States are both premature and of low birth weight, and 0.8% are VLBW and very premature. Despite these relatively small numbers, this population comprises a disproportionately high percentage of children with medical, neurologic, and developmental problems. It is clear that, as more infants with low birth weights enter the pediatric population, pediatricians must become more expert in managing the medical conditions of these infants, recognizing early signs of neurologic disorders and monitoring their developmental progress. Routine physical examinations are usually not sufficient for such children. More time is generally needed to assess them and to discuss them with their parents than the typical well child. Physicians can play a major role in the identification of problems early in their evolution.
Foster Care
Authors: Schor Edward L.
Published: December 2021

A SYSTEM OVERLOADED: THE FOSTER CARE CRISIS

"The children are now buffeted by countless rejections and severe stress. They often become angry, depressed, and violent. Few of them understand that they are the littlest victims of a system that, by all accounts, has been overwhelmed" (The New York Times, March 15, 1987).

Seemingly on a daily basis, especially in our larger cities, newspapers report the crisis in foster care. State departments of social services are being sued for neglecting children in their care, caseworkers are being accused of malfeasance, and children placed in foster care for their own best interests are reported to have experienced further abuse and some have died. Pediatricians who care for foster children, and who need as well to be their advocates, should understand the foster care system—its origins, mandates, objectives, and how well it has fared.

Although its roots are in the English Elizabethan Poor Law of 1601, foster care as we know it today in the United States grew out of the federal initiative Aid to Dependent Children which was enacted as title IV-A of the Social Security Act of 1935. The objective of this entitlement program was to provide financial assistance to widows and widowers with children to avoid the breakup of families because of economic hardship.
Clumsy Child
Authors: Taft Lawrence T. , Barowsky Ellis I.
Published: December 2021

It has been estimated that 6% to 7% of school-aged children manifest poor coordination.1 Clinicians will rarely identify the presence of this type of disability from their findings during routine physical and neurologic examinations. What is required is careful observation of the child during performance of fine and gross developmental motor tasks.

It is infrequent that parents will express concern to the pediatrician, unless they have clues from nursery school or grade school teachers, coaches, peers, or, occasionally, from the child him- or herself. The child is usually the first one to be aware of motor limitations, especially when he or she is in competition with children of the same age. Unfortunately, the child does not usually verbalize his or her concern but will refrain from participating in competitive motor activities to conceal motor inadequacies.

DEFINITION

The term "clumsy child" refers to a boy or girl who performs fine and/or gross motor tasks in an immature, disorganized, erratic, slow, irregular, or inconsistent fashion. The relevant motor skills are imprecise rather than grossly impaired and the neurologic examination does not reveal significant postural disabilities or involuntary movements.

SIGNIFICANCE

A pediatrician should not minimize the significance of clumsiness. It is frequently associated with other evidence of cerebral dysfunction, such as cognitive and/or perceptual impairments that may result in learning disabilities.
Nephrolithiasis in Children
Authors: Stapleton F. Bruder
Published: December 2021

More than 325 000 Americans are hospitalized each year for the evaluation and treatment of calculi in the urinary tract. It is estimated that an equal number of unfortunate victims of urolithiasis are treated exclusively as outpatients. For years, the problem of urolithiasis was considered to be the scourge of the adult years. Recently, an increasing awareness of the importance of urolithiasis in children has developed. Clearly, urinary stones—or warning signs of future calculi—occur in children, especially in certain geographic regions and in high-risk populations. Recognition of children at greatest risk may allow early detection or prevention of calculus formation based on a laboratory evaluation directed at pathogenetic risk factors known to be important in the formation of nephrolithiasis.

CLINICAL MANIFESTATIONS OF UROLITHIASIS

The classical image of incapacitating flank pain associated with the passage of a urinary calculus is unusual in children. Abdominal or flank pain occurs in approximately 50% of children with urolithiasis; in infants, symptoms of stones may be confused with colic. In older children, abdominal pain may be vague and nonspecific, as well as severe and radiating into the groin. Hematuria, either microscopic or macroscopic, occurs in greater than 90% of children with urolithiasis. Urolithiasis should always be a consideration in children with nonglomerular hematuria especially in geographic regions where nephrolithiasis is common.
"It" Happens
Authors: Menna Vincent J.
Published: December 2021

No matter how hard we try, "it" happens: the mistakes that all humans make, even doctors. Our friends, the lawyers, know this and that is why we are often their prey. During a recent conversation with a lawyer acquaintance, he mentioned that everyone is human and makes mistakes. He related that he almost missed the statute of limitations for one of his clients. Tears streamed down my face.

A pediatric office is ripe for mistakes because it is so busy. Every member of the office—doctors, nurses, receptionists, and secretaries—is anxious to resolve their own particular problems. Doing their jobs frequently entails interrupting a physician.
Observations of a Junior Pediatrician
Authors: Callahan Charles W.
Published: December 2021

A year in the practice of pediatrics puts one a long distance from the omniscience of chief residency. Yet, the comfortable nonchalance of the seasoned practitioner seems still well ahead. Some cherished ideals and notions have been sacrificed long since to efficiency, although several principles have weathered the first year's journey. New principles of practice are observable to the eye and may become essential to the continuing traveler. It is a unique position for observation—finished with the practicing, yet still learning the practice. From this position these observations are made: rules of practice learned from a brief year of practicing.
Pediatrician and School Readiness
Authors: Dworkin Paul H.
Published: December 2021

Editor's note: A reader wrote to ask whether or not the battery of tests for school readiness he uses is appropriate and adequate. We asked Dr Dworkin to respond with the following commentary.

The pediatrician, as the professional concerned with monitoring the growth and development of children during the preschool years, is well suited to contribute to the assessment of children's readiness to begin the task of academic learning, as well as participate in the early identification of children at risk for school dysfunction. Pediatricians view the early identification of children with potential learning disabilities as an important component of primary care.
Nutritional Assessment of the Handicapped Child
Authors: Dietz William H. , Bandini Linda
Published: December 2021

CASE HISTORY

G.R. is a 7-year-old boy with spastic quadriplegia evident since birth and a seizure disorder for which he currently is being treated with phenobarbitol and phenytoin (diphenylhydantoin). His medical history includes a pathologic fracture of his right femur. At the time of his fracture, a radiograph of his femur was described as "markedly osteoporotic." He is currently being treated with 1200 IU of vitamin D.

His diet as presented is balanced with respect to nutrients. Although spillage is not substantial, eating requires great effort, and each meal lasts approximately 1 hour. He is fed breakfast and supper at home by his mother and lunch in school. There is no history of pain with food intake, no vomiting, and no diarrhea.

He weighs 14 kg (far below the 5th percentile), and his length is 112 (at the 5th percentile). His weight for height is far less than the 5th percentile. His mother is 157.5 cm (5 ft 2 in) tall and his father is 167.5 cm (5 ft 6 in) tall. His midarm circumference is 154 mm (less than the 5th percentile), his triceps skinfold is 5 mm (5th percentile), and his midarm muscle circumference is 138 mm (less than the 5th percentile).
Precocious Puberty
Authors: Pescovitz Ora Hirsch
Published: December 2021

The child with premature sexual development requires a thorough history, physical, and appropriate laboratory evaluation. The physician and other medical staff should remain sensitive to the family's concerns and the child's emotional adaptation. Counseling and open discussion of the psychosocial and sexual issues may greatly assist both the child and family. Making the correct diagnosis is critical to the selection of the appropriate form of therapy. Fortunately, in most cases in which therapy is warranted, it is extremely effective. In the remaining conditions, promising new forms of therapy are being investigated.
Point-Counterpoint
Authors: Shonkoff Jack P.
Published: December 2021

In an article concerning the "Clumsy Child" (Pediatr Rev. 1989; 10:247-253), Taft and Barowsky provide an overview of mild motor dysfunction and emphasize the potential impact of clumsiness on a child's later learning abilities and emerging sense of personal competence, peer acceptance, and self-esteem. One of our readers expressed concern about some of the global predictions included in this article, cautioned about the dangers of overidentification of pathology in young children, and noted that family and social context variables have been demonstrated to be better predictors of school difficulties than early motor inefficiencies. Calling for more careful assessment of a child's life situation as well as his or her motor abilities, the reader warned about the iatrogenic consequences of overzealous identification of deviation in the preschool period.
Cholelithiasis in Infants, Children, and Adolescents
Authors: Holcomb George W. , Holcomb George W.
Published: December 2021

During the past two decades, cholelithiasis has been recognized in increasing numbers of pediatric patients. This diagnosis should be considered in the event of upper abdominal complaints, particularly when one or more risk factors are evident. The etiology may be unknown or may be related to risk factors, including hemolytic conditions. In recent years, it has become evident that approximately 80% of gallstones in children are not due to hemolytic disease and that the remaining 20% are related to recurring hemolysis. The diagnosis of gallstones is best confirmed with ultrasonography. Routine ultrasonographic evaluation should be performed at intervals for all children who received TPA for more than 4 weeks, particularly those who have had ileal resection or have had chronic enteritis (Crohn disease).

Cholecystectomy is the procedure of choice for symptomatic children with cholelithiasis, regardless of age. Cholecystectomy is recommended for the asymptomatic child younger than 3 years of age when echogenic shadows have been present for at least 12 months following resumption of oral feedings or when the gallstones are radiopaque. Also, cholecystectomy is advised for asymptomatic children who are older than 3 years of age if ultrasonographic studies confirm that echogenic foci with shadowing are true stones and not echogenic sludge. Complications of common bile duct obstruction, pancreatitis, perforation with bile peritonitis, and life-threatening sepsis may thus be prevented. Morbidity and mortality following cholecystectomy are expected to be relatively low in the pediatric age group.
The Pediatrician and the Care of Children With Malignancy
Authors: H. R. J.
Published: December 2021

Most of us, as general pediatricians, know little about the technical aspects of modern care for the child with neoplasia. As Dr Pizzo points out in the commentary which follows, this is one of the disease groups for which this technical care is best given at a tertiary care center. However, the general pediatrician must make the diagnosis promptly, refer the patient to the appropriate site, maintain contact with the child and family, deal with intercurrent illnesses, and keep up-to-date with modern advances regarding the diagnosis and treatment of these disorders to be able to interpret them to the family.
Follow-up on "The Case of Donnie J"
Authors: H. R. J.
Published: December 2021

Few review articles published in Pediatrics in Review have elicited such strong disagreements with the recommendations of the author as "The Case of Donnie J," published in our July 1990 issue. The disagreements were in three areas: (1) the extensiveness of the workup and large number of immunizations recommended by Dr Burg at the first visit; (2) the pejorative nature of descriptions of the mother, such as that she was a "dead head"; and (3) the practicality of treating such a patient in private practice. Dr Burg was asked to comment on these letters.

APPROPRIATENESS OF A COMPLETE WORKUP OF DONNIE J AT THE FIRST VISIT
Diagnosis of Osteomyelitis
Authors: Gold Ronald
Published: December 2021

The early diagnosis of acute hematogenous osteomyelitis depends on a high index of suspicion whenever the physician is confronted with a child experiencing acute onset of bone pain or limited motion of an extremity, regardless of the presence or absence of signs of infection such as fever, local tenderness, redness, swelling, or heat (Table 4). Early diagnosis is aided greatly by the use of plain radiography to exclude other conditions and radionuclide bone scans to detect evidence of inflammation at the site of bone pain. "High-tech" procedures such as CAT and MRI should be reserved for situations in which the diagnosis cannot be made by the simpler methods, such as osteomyelitis of the spine or pelvis, or when the anatomic detail provided by MRI is required for planning of surgery. It is very unlikely that CAT or MRI will every be required in the majority of cases of uncomplicated osteomyelitis in children.
Granulocyte Transfusions in Neonates
Authors: Hill Harry R.
Published: December 2021

Human neonates, especially those born prematurely, are prone to developing overwhelming infections in response to bacterial pathogens. It is estimated that 1 to 8 per 1000 live births are complicated by such infections. Moreover, almost 30% of neonatal mortality and morbidity can be attributed to neonatal infection. Thus, in spite of all of the support measures offered in neonatal intensive care units and the use of new, potent antimicrobial agents, we continue to lose far too many infants to overwhelming infections. It is likely that we have come as far as we can with these accepted regimens for treating bacterial infection in the neonate. This has led many investigators to explore the possibility of using various forms of immunotherapy in neonates who have infections, because the neonatal host defense system is compromised significantly.

Most neonates who develop infection lack opsonic antibody to the infecting strain of bacteria. In addition, the infant complement system is compromised significantly with the concentration of most components being only approximately 50% of that of adults. Deficiency of antibody and complement lead to defective opsonization of most bacteria by neonatal serum. Additional consistent abnormalities in the neonatal host defense system are present in the cells that act as the first line of defense against bacterial invasion, polymorphonuclear leukocytes (PMNs), PMNs must arrive at the site of bacterial invasion within a very critical 2- to 4-hour period if infection is to be contained so that systemic spread does not occur.
Osteosarcoma
Authors: Jaffe Norman
Published: December 2021

Osteosarcoma is principally a disease of the pre-teenager and teenage individual. Pain and swelling of an extremity are the usual initial symptoms. A number of neoplastic and nonneoplastic conditions must be considered in the differential diagnosis. Good quality radiographs complement pathologic material in establishing the diagnosis. Major advances as a consequence of chemotherapy have been achieved during the past decade. Disease-free survival following surgical ablation of the primary tumor and postoperative adjuvant chemotherapy is approximately 60%. The majority of patients undergoing modern forms of treatment are also candidates for limb salvage.
To Test or Not to Test in Pediatric Practice?
Authors: Barness Lewis A.
Published: December 2021

Decreasing atherosclerosis and atherosclerotic events is highly desirable, and the prevention of atherosclerosis and cardiovascular disease may be possible even from early ages. Attention has been focused by some on decreasing serum cholesterol levels. Serum cholesterol has been termed a "risk factor" for cardiovascular disease. This is a misnomer because, even in extensive epidemiologic studies in which elevated serum cholesterol levels have been associated with increased incidence of cardiovascular disease, no causal relationship has been established. A more accurate term, with present knowledge, is that an elevated level of serum cholesterol (or specific lipoprotein or apoproteins) is a "marker" for increased cardiovascular risk events.
Breast Milk Jaundice
Authors: Powers Nancy G. , Rosenthal Philip , Sinatra Frank R.
Published: December 2021

A reader writes about the article on "Jaundice in Infancy" published in the September 1989 issue of Pediatrics in Review:

My first concern is that the authors do not distinguish "breast feeding jaundice" from "breast milk jaundice." This is an important distinction, and it is nicely outlined in a recent publication.1 Secondly, the issue of breast milk jaundice is covered only very superficially, and there is an unequivocal therapeutic suggestion to "interrupt breast feeding" in Table 2 on page 80. The third concern is that fatty acids are suggested as a possible mechanism for breast milk jaundice, when in fact there are several other current theories.1
Muscle Disease in Children: A Practical Approach
Authors: Patterson Marc C. , Gomez Manuel R.
Published: December 2021

This paper has given an overview of the complexity of childhood muscle disease. Fortunately, astute history-taking and physical examination, combined with readily available tests, will usually enable the clinician to formulate a diagnosis and plan of management.
Steroids: Breakfast of Champions
Authors: Dyment Paul G.
Published: December 2021

Anabolic steroids (called "steroids" hereafter) have been used to enhance performance by athletes for almost three decades. Initially, they were used because of their ability to increase muscle size ("bulk-up") and were popular with football players who needed to increase their size and weight to compete successfully for line positions on a football team. Despite early scientific reports that steroids increased neither strength nor athletic performance, their use became widespread among nationally competitive athletes. Competition fosters all sorts of practices designed to enhance athletic performance. Many of them are valueless, including the widespread practice of taking amino acid supplements to build muscle size and strength. At least, however, amino acid supplements are harmless; the side effects of steroids can be fatal.

The initial reports indicating that steroids were not performance-enhancing were controlled studies using average athletes in whom continuing weight-training during the period of study caused an increase in strength regardless of whether or not steroids were being taken.1 These studies were then repeated on elite athletes, who were already at their peak strength and in whom further weight-training merely kept their strength performance stable; these athletes did increase their muscle strength in response to steroids.2 There is no evidence that steroids increase aerobic capacity or endurance, however.
Guides for Record Review
Authors: Alden Errol R.
Published: December 2021

With this issue of Pediatrics in Review, we are pleased to launch one of the first new components of the Pediatrics Review and Education Program (PREP). As part of a special arrangement with the American Board of Pediatrics, the Academy will be distributing several Guides for Record Review like the one on Acute Pharyngitis that accompanies this issue. Our current plans include distribution of twelve of these Guides, which were developed by the American Board of Pediatrics, during the next 4 years. They will be mailed as supplements to Pediatrics in Review to all subscribers and participants in the PREP program.
Childhood Hodgkin and Non-Hodgkin Lymphomas
Authors: Leventhal Brigid G. , Kato Gregory J.
Published: December 2021

Lymphomas were recognized originally by Virchow as swellings of lymph nodes that were unrelated to tuberculosis or to other recognized pathology in the drainage area of the lymph node group. Lymphomas were not recognized initially as malignancies; proof of this came only in this century. Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL), which together account for approximately 12% of childhood cancer, have become among the most curable of pediatric malignancies. Today, the projected cure rates for children in certain categories are as high as 90%. Recent advances in molecular biology have permitted immense strides in understanding the pathogenesis and biology of these two diseases.

FACTORS PREDISPOSING TO LYMPHOMAS

Of individuals with immune deficiency or defects of DNA repair function, 1% to 35% develop lymphomas. NHLs are highly associated with Wiskott-Aldrich syndrome, common variable immunodeficiency, severe combined immune deficiency syndrome, X-linked lymphoproliferative syndrome, and Bloom syndrome, and they are found in patients receiving immunosuppressive therapy following organ or bone marrow transplant. Both HLs and NHLs are seen with increased incidence in patients with ataxia-telangiectasia and acquired immunodeficiency syndrome.

Epstein-Barr virus, first strongly implicated epidemiologically in African Burkitt lymphoma, appears to have a role in the pathogenesis of at least 20% of B-cell lymphomas.
Whole Cow Milk Feeding Between 6 and 12 Months of Age? Go Back to 1976
Authors: Oski Frank A.
Published: December 2021

In 1976, the Committee on Nutrition of the American Academy of Pediatrics recommended that the non-breast-fed infant receive an iron-fortified proprietary formula during the entire first year of life.1 In 1983, the Committee on Nutrition reversed the previous recommendation and concluded, "If breast-feeding has been completely discontinued and infants are consuming one third of their calories as supplemental foods consisting of a balanced mixture of cereal, vegetables, fruits, and other foods, whole cow milk may be introduced."2 The Committee, in their report, acknowledged the fact that "there are many unanswered questions concerning the use of whole cow milk in the second half year of life." I believe that we now have answers to some of these questions and that we should return to the original recommendation discouraging the use of whole cow milk (WCM) until infants have reached their first birthday.

Studies performed since the 1983 report have demonstrated that the introduction of WCM prior to the first birthday is associated with an increased risk of occult gastrointestinal bleeding3 and an increased incidence of iron deficiency anemia.4,5 In addition, iron deficiency anemia in infants less than 1 year of age has been shown to be associated with cognitive and psychomotor impairment6-8; such impairment may not be correctable with iron therapy.7-9
Conduct Disorders in Children and Adolescents
Authors: Gottlieb Susan E. , Friedman Stanford B.
Published: December 2021

Conduct disorder is the most prevalent psychopathologic condition of childhood. It is characterized by a persistent and repetitive pattern of aggressive, noncompliant, intrusive, and poorly self-controlled behaviors that violate either the rights of others or age-appropriate societal norms.1 These behaviors have a significant impact on the daily functioning of the child or adolescent and on the ability of parents and other adults to manage them.

The specific behavioral criteria for the diagnosis of conduct disorder can be conceptualized as either aggressive or nonaggressive in type (Table 1). Examples of aggressive behaviors are physical fighting and bullying, assault, vandalism, purse snatching, physical cruelty to persons or animals, breaking and entering, and arson. More serious aggressive behaviors are armed robbery, rape, and extortion.

Nonaggressive behaviors of conduct disorder include substance abuse, persistent truancy, running away from home overnight, frequent lying in a variety of social settings, theft not involving a confrontation with a victim, and chronic violation of rules or the basic rights of others.

Three subtypes of conduct disorder are identified in the Diagnostic and Statistical Manual of Mental Disorders, revised 3rd edition.1 These are descriptions of the functional contexts in which the particular behavior problems occur. The group type involves problematic behaviors that occur as part of an activity with peers.
The Interaction of Pubertal and Psychosocial Development During Adolescence
Authors: Litt Iris F.
Published: December 2021

During the second decade of life, the physical changes of puberty interact with those of psychosocial and cognitive development to forge the young adult, who often bears little resemblance to the same individual as a child. This article reviews those elements of the developmental process that have an impact on the physician's ability to understand and care for the adolescent patient.

PUBERTY

Endocrine Changes

Release of inhibition on the hypothalamus unleashes an outpouring of releasing hormones, which stimulate the secretion of gonadotropins and growth hormone by the pituitary. These are produced in a sleep-augmented, pulsatile fashion that characterizes the onset of pubertal development. As a result, within the few years between the onset and completion of puberty, levels of estradiol increase eightfold in females, and levels of testosterone increase 18-fold in males. These hormonal changes stimulate the growth spurt and development of secondary sex characteristics.

Development of Secondary Sex Characteristics

Breast Development. In females, one of the earliest signs of puberty is development of the breast bud. The subsequent progression of breast development is orderly and predictable, thus forming one of the bases for the categorization in females of the stages of puberty, often referred to as Tanner stages or SMRs (sex maturity ratings).
Infancy Problem Behaviors
Authors: Algranati Paula S. , Dworkin Paul H.
Published: December 2021

The goal of pediatric health supervision is to promote the optimal growth and development of children. Parent-infant interaction and parental attitudes toward their infant are important determinants of child development. Anticipatory guidance during child health supervision enables the pediatric provider to discuss developmental stages and demystify common stage-related behaviors, such as fussing, night-waking, repetitive movements, and clinging. Anticipating the emergence of such behaviors and issues may lessen parental anxiety and concern. When behavioral problems such as colic or sleep difficulties do arise, a consideration of developmental stage is helpful in suggesting specific management strategies. The successful implementation of developmentally-oriented approaches has benefits for the family and pediatric provider, including increased parental self-confidence, enhanced family functioning, and increased parental confidence in the pediatrician. Furthermore, by encouraging developmentally-oriented approaches, parents will be less inclined to adopt inappropriate or ineffectual behavioral management strategies.
Left Upper Quadrant Masses in Children
Authors: Vane Dennis W.
Published: December 2021

The discovery of an abdominal mass in a child alarms and concerns both parents and the physician. The diagnosis and treatment of these lesions have undergone significant changes during the past few years, and the physician understandably may have some doubts about an appropriate diagnostic evaluation.

An improved outcome can be expected with early detection and prompt treatment. As is the case in evaluating all abdominal problems, a careful physical examination is critical and may obviate the need for further investigations. An accurate history is also important, but this often is clouded by information from parents or other historians who may not have all the data at their disposal. The child may be too young, may not remember the exact chronology and occurrence of events, or may be afraid to relate them. This is particularly true if the incident involved trauma related to an act forbidden by the parents.

It is critical that the child be calm and relaxed to make the examination effective, often a nearly impossible feat. This occasionally can be accomplished with a few words from the examiner and the assurance that no pain will result from simple palpation. Patience often is rewarded with a good examination; however, should this approach fail, the physician may resort to sedation.
POINT-COUNTERPOINT
Authors: Sinkin Robert A. , Davis Jonathan M.
Published: December 2021

Because of the continued concern expressed by one of the readers regarding our article "Cardiopulmonary Resuscitation of the Newborn" (PIR. 12:5(Nov 1990):136-141), we have drafted the following statement.

The goal of our article was to provide the pediatrician with appropriate guidelines for this crucial and lifesaving intervention for newborn infants. However, possible confusion on the relationship of Apgar scores and resuscitation needs to be resolved. Apgar scores should not be used to make decisions regarding the course of initial resuscitation, and this is clearly stated in our article. Instead, decisions should be based primarily upon evaluation of an infant's respirations, heart rate, and color.
Amblyopia: Etiology, Detection, and Treatment
Authors: Magramm Irene
Published: December 2021

Amblyopia is a preventable cause of visual loss in children that may be permanent unless it is detected and treated early. It may be caused by strabismus, refractive errors, or cataracts. Primary strabismus may lead to loss of vision from amblyopia and the loss of binocularity. Secondary strabismus may be a sign of primary visual loss in one or both eyes. The most serious disorder that may present as secondary strabismus is retinoblastoma. It is imperative to detect retinoblastoma early because of its morbidity and mortality.

Amblyopia is detected by assessing the visual acuity of each eye. Strabismus is detected by using the corneal light reflex test and the cover test. Focusing problems are detected by assessing the visual acuity and the red reflex. Cataracts and retinoblastoma may be detected by examining the red reflex of the eye.

Treatment of amblyopia consists of correcting the amblyogenic factor with appropriate glasses and surgery. The preferred eye is patched with an adhesive patch to stimulate visual development in the amblyopie eye.

The pediatrician plays a crucial role in the early detection of amblyopia, strabismus, and cataracts. The key to successful visual outcome is early recognition by the pediatrician, referral to the pediatric opthalmologist, and prompt treatment.
"Lethargic" and Other Adjectives
Authors: Menna Vincent J.
Published: December 2021

An anathema for the general pediatrician is the task of ascertaining the significance of a child's symptoms relayed over the telephone by a parent. The use (or misuse) of certain words by a parent may determine whether a child is examined. Many other factors also are involved, including an anxious parent, the "vulnerable child" syndrome, a visiting grandparent, and a tired doctor.

"Lethargic" is the most common malapropism. We often have heard the history that a child has a fever and is lethargic. Is it meningitis, septicemia, or just a viremia? Being unsure, one certainly must see the patient. Usually, at the time of the office visit, it requires a receptionist and two nurses to restrain the patient.
Consultation with the Specialist
Authors: Strong William B.
Published: December 2021

What is the likely pathophysiology of this event? What are the more common complications of hypoxemia in the older infant and young child? This clinical scenario is uncommon, but it represents one of the two feared central nervous system complications of cyanotic congenital heart disease, (ie, cerebrovascular accident and brain abscess).

A uniform response to hypoxemia of cardiac etiology is the production of erythropoietin to produce more red blood cells. This is a compensatory mechanism to maintain oxygen delivery to the peripheral tissues. Normally, hemoglobin is about 96% saturated with oxygen. Therefore, the oxygen-carrying capacity of blood with a normal hemoglobin concentration of 15 g/dL is approximately 20.3 mL of oxygen per 100 mL of blood (ie, 15 g of hemoglobin x 1.35 mL of O2 per g of hemoglobin = 20.3). The oxygen content of blood equals the oxygen-carrying capacity multiplied by the oxygen saturation. At a normal oxygen saturation of 96%, the O2 content of arterial blood (Hgb 15 g/dL) equals 19.5 mL/dL (96% x 20.3 mm3/dL) or 195 mL per liter of cardiac output.

The arterial O2 content of this child, assuming an average arterial saturation of 85%, will be 11.1 mL/dL. Therefore, every liter (10 dL) of cardiac output will carry 111 mL of O2 or 84 mL of O2 less than the child with a 15 g/dL hemoglobin level.
Depressant Substances in Adolescent Medicine
Authors: DuPont Robert L. , Saylor Keith E.
Published: December 2021

The benzodiazepines have replaced widespread use of barbiturates and other sedatives. They are effective, safe medicines used to treat a variety of disorders associated with excessive CNS excitability. Although many physicians avoid prescribing benzodiazepines to adolescents, there is little evidence to support this practice. Unless an adolescent has a history of substance abuse/dependence and suicidal ideation, the benzodiazepines are safe. Benzodiazepine toxicity rarely occurs unless another CNS depressant, especially alcohol, is used concurrently.
Failure to Thrive/Growth Deficiency
Authors: Bithoney William G. , Dubowitz Howard , Egan Harwood
Published: December 2021

Definition

CLASSIFICATION AND TYPOLOGY

Although the diagnosis of "failure to thrive" (FTT) is made frequently, both the meaning of the term and its value as a diagnosis remain debatable. Because any serious disease can cause growth failure, the term FTT has little diagnostic usefulness. Classically, the etiology of FTT has been divided into organic and nonorganic types, with nonorganic FTT defined as growth deficiency without a diagnosable medical etiology and organic FTT defined as growth failure caused by a specific medical illness. A number of authors have questioned the adequacy of this dichotomous view, suggesting the need for a third category: "mixed" etiology. In this group of children, chronic, mild problems, such as recurrent otitis media in concert with behavioral problems, result in aberrant behaviors, such as difficult temperament, sleep disorders, and altered eating behavior, which together impair growth. Even in cases in which the growth deficiency is primarily due to organic or nonorganic causes, the problems seen in the children are often multiple (eg, infants who have cardiac failure also have feeding disorders). Given the multiple contributory factors to FTT and the lack of diagnostic specificity of the term, we recommend that it be abandoned in favor of the term "growth deficiency," which describes the presentation of this entity: An underweight, often stunted, undernourished child.
Update on Thalassemia
Authors: Giardina P. J. , Hilgartner M. W.
Published: December 2021

Many advances in the understanding and management of the thalassmia syndromes have been made during the past several years. Our knowledge of normal globin gene function and of the consequences of specific mutations has been advanced by identification of the genetic defects causing thalassemia. Prenatal diagnosis is now possible with molecular biology technology.

Standards have been established for transfusion, splenectomy, prevention of postsplenectomy infection, and effective iron chelation therapy. Bone marrow transplantation is now available for those with a compatible familial donor. Research efforts currently are directed toward safer blood products, oral iron chelators, and improved understanding of the developmental regulation of globin gene expression for effective gene transfer.