bluuebunny/crossref_metadata_2025 huggingface dataset:
Renal and Absorptive Hypercalciuria: A Metabolic Disturbance With Varying and Interchanging Modes of Expression
Authors: Aladjem Mordechay , Barr Joseph , Lahat Eliezer , Bistritzer Tzvy
Published: December 2021

Background. In previous studies, the oral calcium loading and deprivation test has been used to distinguish between children with renal (fasting) hypercalciuria (RH) and absorptive hypercalciuria (AH).

Objective. We evaluated the long-term clinical course of 30 children with idiopathic hypercalciuria and investigated the influence of urinary sodium excretion, as a reflection of its intake, on urinary calcium excretion.

Methods. Thirty normocalcemic, normophosphatemic children (21 boys and 9 girls) with urinary calcium to creatinine ratios greater than 0.57 mmol/L/ mmol/L (> 0.21 mg/dL/mg/dL) on three consecutive examinations participated in this study. They were divided according to their responses to calcium deprivation and loading into AH (16 patients) and RH (14 patients).

Results. When restudied 3 to 7 years later, 6 of the 16 children with AH were normocalciuric and three demonstrated characteristics compatible with RH. The remaining seven patients maintained their initial AH pattern. Of the 14 children with RH, four were normocalciuric and four demonstrated AH. The remaining six children maintained their initial RH pattern. A significant positive correlation was observed between urine sodium and calcium excretion in children with AH or RH. Children who were normocalciuric at the second study had significantly lower values of urine sodium excretion when compared with those in whom hypercalciuria persisted.

Conclusions. We suggest that AH and RH constitute a continuum. The change in characteristics observed during the second study suggests that any attempt to divide these patients into two physiologically distinct subtypes may be artificial. The main factor influencing urinary excretion of calcium in our patients seemed to be sodium intake.
Carbohydrate and Alcohol Content of 200 Oral Liquid Medications for Use in Patients Receiving Ketogenic Diets
Authors: Feldstein Thomas J.
Published: December 2021

Objective. The ketogenic diet is used in patients with intractable seizure disorders. To maintain a ketotic state, patients on this diet must maintain a strict low-carbohydrate intake. Because these patients often require medication, and because many pharmaceutical products (especially liquid formulations) contain significant quantities of carbohydrates, it is important that each drug product be evaluated before proceeding with the ketogenic diet. The purpose of this study was to compile the carbohydrate content of oral liquid products for patients on or considering a ketogenic diet.

Methods. A list of 200 oral liquid drug products and their manufacturers was compiled using the Children's Health Care-Minneapolis pharmacy purchasing database, the Physicians' Desk Reference, and previously published lists of oral liquid medications. Manufacturers were contacted either by telephone or by letter and asked specifically about the sucrose, fructose, sorbitol, glycerin, and alcohol content of these liquid formulations.

Results. The carbohydrate and alcohol content of 200 oral liquid products was determined and shown in an accompanying table.

Conclusions. Many oral liquid medications contain significant amounts of carbohydrate. Tablet and capsule formulations are preferred when possible. To date, it has been difficult to quantify the carbohydrate content of liquid medications because of unavailability of this information. The carbohydrate content of 200 oral liquid medications is provided here to assist health care practitioners, patients, and care givers in designing drug regimens low in carbohydrates for patients on or considering a ketogenic diet.
Prenatal Cocaine and Neonatal Outcome: Evaluation of Dose-Response Relationship
Authors: Delaney-Black Virginia , Covington Chandice , Ostrea Enrique , Romero Al , Baker Dawn , Tagle Maria-Theresa , Nordstrom-Klee Beth , Silvestre Maria A. , Lu Angelilli Mary , Hack Cheryl , Long Jacqueline
Published: December 2021

Objective. The aim of this study was to evaluate the hypothesis that prenatal cocaine exposure would negatively affect newborn behavior.

Methods. A prospective observational study of term infants recruited from the low-risk nursery used a structured, standardized interview to obtain maternal data. Cocaine exposure was determined by radioimmunoassay of the infant's meconium stool. An examiner blinded to the infant's cocaine status administered the Brazelton Neonatal Behavioral Assessment Scales.

Results. The sample was composed of 23 exposed and 29 nonexposed infants. On six of the seven Brazelton Neonatal Behavioral Assessment Scale clusters, cocaine-exposed infants performed less well than control infants, with significant differences observed for autonomic stability. In addition, a dose-response relationship was suggested. Significant negative, within-group relationships were evident in the exposed group, indicating poorer performance with increasing meconium cocaine concentration for orientation (r = -.40) and regulation of state (r = -.40). Regression model testing of the influence of meconium cocaine concentration on neurobehavioral outcomes, after controlling for significant confounders, identified a significant independent, negative effect of meconium cocaine concentration on two clusters—motor and regulation of state.

Conclusion. In otherwise healthy full-term infants, prenatal cocaine exposure identified by quantitative analysis of cocaine concentration in meconium had a significant, independent negative association with motor and regulation of state that remained after controlling for other significant confounders. A dose-response relationship was evident.
Pediatric Education in Community Settings: Where Do We Go From Here?
Authors: Charney Evan
Published: December 2021

Pediatric education in community settings is an idea whose time has come. The board of the Johnson & Johnson Pediatric Institute recognized this reality, and they deserve great credit for bringing together this impressive group of people for what I believe to be a watershed event. The conference includes, for the first time in my experience, participants from community practice and academic societies such as the Ambulatory Pediatric Association (APA), the American Board of Pediatrics, the Association of Pediatric Program Directors (APPD), and the American Academy of Pediatrics (AAP), including members of its resident section. At least half of residency program directors are here, as are many chairs of pediatric departments in university and community hospitals. Representatives of funding agencies—the Maternal and Child Health Bureau and the Health Resources and Services Administration—are here as well; one of our speakers heads the Center for the Future of Children of the David and Lucile Packard Foundation.

This conference is a pivotal event in medical education. Like those who remember another pivotal event, Woodstock '69, we will look back with nostalgia and pride and say that we were here.

I consider a meeting successful if I leave with one good new idea. At this conference, we have heard many creative and provocative ideas about community-based education, and we will be thinking about them on our way home and during the next several months. One of my favorite quotations, however, is from Alfred North Whitehead: "Ideas won't keep. Something must be done about them.
Editorial One Year's Experience
Authors: H. R. J.
Published: December 2021

This is the last issue of the 1979-1980 PEDIATRICS IN REVIEW. The reason we schedule only ten issues per year (July through April) is to allow two full months from receipt of the April issue until the June Self-Administered Graded Examination (SAGE), or the recertification examination.

What have we learned in this first year? By and large the comments have been very positive. Most readers like the mixture of review articles and abstracts. Some want only new material, some only "cold dope," and others controversies. I believe that by providing a mixture in each issue we can meet more of these individual preferences.
Children and Funerals
Authors: Schowalter John E.
Published: December 2021

Death is the most inevitable and irrevocable problem that we face as physicians and human beings. Although many people seldom think about death, when the death of a close friend or relative does occur, everyone is confronted with a feeling of loss and reminder of his or her own mortality. The emotional reaction triggered by such a loss is called mourning. While in decades past it was debated whether or not children mourned, the consensus now is that they do, but not as completely or satisfactorily as adults. The manner in which children mourn is based on their level of development and on the emotional climate provided them.

Almost without exception in our society, when a person dies, there is a funeral. More often than not parents do not know whether children should attend funerals. Because of this, they often ask pediatricians, but there is little published data that can be used as a guide for an intelligent response. The purpose of this review is to provide practical guidelines and suggestions that can be discussed with parents when this question arises.

FUNERALS IN GENERAL

The funeral is the most ancient rite known. Much of what we know about prehistoric cultures comes from burial customs that favored including everyday objects with the corpse.
Editorial PIR and CME
Authors: H. R. J.
Published: December 2021

In using initials as the title of this editorial, I am not resorting to bureaucratic gobbledygook, but to shorthand. PIR is the name of this journal; CME, as everyone concerned with credits for relicensing knows, is Continuing Medical Education. We hope that readers will be familiar with each.

CME is not new. In 1907, the AMA called on county medical societies to provide systematic review of medical school curriculum to be able, then, to acquaint practitioners with recent advances as being taught in medical schools. Today, the CME effort is much more extensive. But the principle of local implementation of national educational developments seems especially appropriate for the Academy's CME program, and especially for PIR.
Birthmarks: II. Melanocytic and Epidermal Nevi
Authors: Jacobs Alvin H.
Published: December 2021

—Acquired moles—very rare malignancy during childhood

—Congenital moles—10% chance of malignancy

—Café-au-lait spots—associated with neurofibromatosis, Albright's syndrome, tuberous sclerosis, pulmonary hypertension, and temporal lobe dysrhythmias
Focal Epileptic Seizures
Authors: Freeman John M. , Vining Eileen P. G.
Published: December 2021

Focal seizures in children have different etiologies from those in adults and are far less likely to have demonstrated pathology. Appropriate evaluation and vigorous medical therapy will usually result in a normal, well-functioning, and seizure-free adult.
Neural Tube Defects
Authors: Golden Gerald S.
Published: December 2021

The term "neural tube defects" refers to a biologically interrelated series of malformations of the central nervous system and overlying tissues. There is an abnormality in morphogenesis of the brain and/or spinal cord, associated with varying degrees of absence or malformation of the meninges, bone, muscle, and skin. In addition to morphologic similarities, these lesions are related epidemiologically and probably genetically.

The terminology is complex, but the lesions can be placed in a simple framework. The Table outlines the most common defects.

The malformation occurs early in embryonic development, since the gross structure of the central nervous system has been completed by the 26th gestational day. There are numerous theories of pathogenesis and there is a good deal of subprimate teratologic research, but no single etiologic hypothesis is widely accepted or rigorously proven. Despite this, clinical risk factors have been clearly defined and empiric techniques for prenatal diagnosis have been developed.

FREQUENCY AND EPIDEMIOLOGY

Neural tube defects represent one of the most common groups of major congenital malformations. Each year approximately 6,000 to 8,000 infants are born with these conditions in the United States. Incidence rates vary among different groups from 0.6 to 4.1/1,000 total births for anencephaly. The risk is not uniformly spread over the entire population; a number of factors are related to initial occurrence and recurrence.
Food Fads: Safe Feeding of Children
Authors: Forbes Gilbert B.
Published: December 2021

... in some important aspects, our rational scientific approach fails to fulfill the desperate needs of suffering people, and it is to these needs that quacks and cultists address themselves.

Strong emotions have a profound effect fect on one's well-being ... if they are aroused in a setting of massive human and supernatural encouragement, and in a context of hopefulness, they can be healing ....A cult gains its power from its culturally determined symbolic meaning.1

When it comes to food, variety is literally the spice of life. It is the large variety of foods available, taken together with our efficient transportation and storage facilities, and food fortification techniques that render the average American diet so nutritious. Young infants will thrive if they are provided with sufficient milk, and dietary deficiencies are rare in children whose diets include the "basic four" food groups: (1) meat, fish, poultry, and eggs; (2) milk, cheese, and milk products; (3) fruits and vegetables; (4) cereal grains, potatoes, and rice.

Dietary surveys have shown that the vast majority of Americans have a varied diet and are free of overt nutritional deficiencies, with the possible exception of iron deficiency anemia. Americans consume large quantities of meat, milk, and eggs.

Set in the midst of this sea of abundance are growing numbers of citizens who have chosen to deviate from modern dietary norms by adopting so-called "fad diets."
Day Care
Authors: Loda Frank A.
Published: December 2021

The fundamental and noncontroversial fact about day care is that increasing numbers of children will be in some form of day care during the next decade as their mothers join the work force. Only a major unforeseen economic or social upheaval will prevent this trend from continuing. More than 37% of women who have children under the age of 6 years—more than 5 million—now work. One third of mothers of children under 2 years of age are in the work force.

REASONS WOMEN WORK

Most women work because of economic need.1 For some women, such as those in single parent families, economic need means providing the basic necessities. For other women, the economic need is to maintain a middle class living standard or to finance educational programs for their children. Other considerations are important. Many women feel the need to escape the constant responsibility of child care. Many find the work-related social contacts and achievements fulfilling. The latter are particularly important to middle and upper class women who possess the job skills appropriate to achievement of professional or managerial status. Most women who lack specific job skills are limited to low-paying and low-status positions. Women also join the work force because of the growing belief in our society that homemaking and child care are not a worthwhile, full-time task.
Eating Disorders in Adolescents
Authors: Comerci George D.
Published: December 2021

Anorexia nervosa and bulimia nervosa must be understood and appreciated to be chronic disorders. Too often pediatricians and other health care providers expect that the patient with an eating disorder will be quickly cured. We anticipate and readily accept patient relapses in other chronic conditions such as diabetes, cystic fibrosis, or rheumatoid arthritis, but we do not expect, nor do we tolerate, relapses in patients with eating disorders! Rather, we perceive the relapse as a treatment failure, often blaming ourselves and our lack of knowledge and skills, our treatment team, and, of course, the patient and his or her family.

During medical school and residency training there are few good role models for the care of chronically ill patients. We have not learned to enjoy caring for people who do not rapidly improve and recover, especially when the illness is their "personal choice." Little wonder that so many pediatricians reject the responsibility to care for patients with an eating disorder and elect to refer them to others.
Foreign Body Aspiration: Potential Cause of Coughing and Wheezing
Authors: Holroyd H. James
Published: December 2021

As many as half of routine ill-patient visits in pediatrics practice involve respiratory symptoms. It is not surprising that we see so much coughing and wheezing when we consider that children are still developing immunologically and are, therefore, more susceptible to infection. In early life, most of these infectious diseases occur in the respiratory and gastrointestinal tracts. In addition, the gradual exposure of the constitutionally allergic child to environmental allergens pre-disposes to the development of respiratory symptoms. Childhood is also a time for congenital defects of the cardiopulmonary system to become apparent.

A sometimes overlooked cause of respiratory symptoms in infants and young children—and one that can become rapidly and severely complicated if misdiagnosed—is the aspiration of foreign bodies. Aspiration or ingestion of foreign bodies remains a significant cause of morbidity and mortality in the pediatric population. Children between 8 months and 4 years of age are at highest risk. Not all cases of aspiration are of the acute, obstructive variety, and pediatricians should consider a foreign body as a possible cause of coughing and wheezing even when no definite history of aspiration is obtained.

Children of course are curious and their natural tendency is to reach out and explore new objects. Bringing objects to their mouths to taste and to test textures is common.
General Pediatrician's Role in High-Risk Deliveries
Authors: Keener Patricia A.
Published: December 2021

Fortunately, most infants make the transition to extrauterine existence well, even when a number of highrisk factors are present. In those few instances in which the pediatrician and his or her team are called upon to use knowledge, experience, and skill to respond to a delivery room emergency, the need is great. It is the responsibility of pediatricians who attend high-risk deliveries to maintain their skills at the highest level and to promote the education and preparedness of the other team members. The pediatrician must work to assure that every delivery room, regardless of the size of the hospital or the level of care in the nurseries, offers resuscitative and stabilization skills of the highest possible caliber.
Stimulation of Preterm Infants
Authors: Field Tiffany
Published: December 2021

Preterm neonates are deprived of their final weeks in utero and may also be deprived of appropriate extrauterine stimulation. The environment of the incubator features bright light and continuous noise, and the neonates are handled infrequently and only briefly. Although the effects of this environment are virtually unknown, some have suggested that the neonatal intensive care nursery may constitute a source of sensory deprivation. Others have suggested that preterm neonates may be overstimulated or, at the very least, may experience inappropriate patterns, rather than inadequate amounts, of stimulation. Despite the limited data regarding the effects of routine stimulation in the intensive care nursery environment, a number of clinicians and researchers have provided stimulation experiences for preterm neonates and have investigated the effects of these.

STIMULATION STUDIES

The types of interventions provided for preterm neonates have included those that are thought to mimic the environment of the womb or the outside world. Some have viewed the preterm neonate as an extrauterine fetus, whereas others consider that the preterm neonate differs from the fetus insofar as sensory systems undergo physiologic changes at birth. Different forms of stimulation may be necessary for extrauterine development than for intrauterine maturation regardless of gestational age.

Stimulation is usually begun as soon as possible after birth and continues until the infant approximates term gestational age, regains birth weight, or is discharged.
Cystitis and Urethritis
Authors: Parrott Thomas S.
Published: December 2021

CLASSIFICATION

Although the terms cystitis, urethritis, and pyelonephritis are useful to the clinician for describing different clinically encountered varieties of urinary tract infection, one must not be limited only to site of localization when classifying urinary infections. Two other helpful schemes of classification (Table 1) have evolved based on pathogenesis1 and management.2

FREQUENCY OF OCCURRENCE

Children and adolescents with cystitis or urethritis have urinary symptoms suggestive of urinary tract infection. In fact, not all symptomatic patients have true bacteriuria. Of all patients less than 15 years of age with urinary symptoms, only 9% were bacteriuric, and only 18% with dysuria had positive cultures for a pathogen.3 The incidence of true urinary tract infection from these data is 1.7 per 1,000 boys and 3.1 per 1,000 girls per year. The incidence of apparent first symptomatic urinary tract infection declines with increasing age, the decline being more rapid in boys (Figure).

Patients with nonsymptomatic infections often feel more comfortable after treatment or more commonly may report loss of characteristic odor after appropriate therapy has been initiated for the positive culture results obtained for surveillance purposes. Data from large screening surveys of so-called healthy populations demonstrate a prevalence of unrecognized bacteriuria in 0.5% to 1.6% of school-aged girls.
Undescended Testis and Orchiopexy: Recent Observations
Authors: Hawtrey Charles E.
Published: December 2021

Within the past two decades, observations from a number of sources have expanded our understanding of undescended testes in children. As neonatology has grown, the observations of infants with low birth weight and knowledge of the implications of this condition for undescended testes have also increased. Information obtained from biopsy, including that from studies using electron microscopy, has suggested decreased spermatogonia in children with abdominal testes with age, indicating a need for medical or surgical intervention soon after 1 year of age. The effects of orchiopexy and hormonal manipulations to assure fertility in adulthood have been clarified to the extent that an algorithm for patient management can be constructed.

ANATOMY

An undescended testis has been identified in 0.8% of male infants at 1 year of age1 and in about 0.2% of adult male military recruits. The incidence rises to 21% in premature neonates weighing less than 2,500 g. Even more striking, nearly 100% of profoundly low-birth-weight neonates (weighing approximately 900 g) exhibit bilateral undescended testes. With weight gain and age, the testes of infants who weighed 900 g at birth proceed toward descent and at 1 year of age have the same incidence as their peers.

Many authors in Europe and the United States have noted that scrotal descent of the testis by 3 years of age preserves spermatogonia, implying a beneficial effect on adult fertility.
Cures in Childhood Cancer
Authors: Chauvenet Allen R. , Wofford Marcia M.
Published: December 2021

Dramatic advances have been made in the treatment and potential cure of childhood cancer in the past two decades. In the case of the most common childhood malignancy, acute lymphoblastic leukemia, Mauer wrote in 1969 that he did "not think that the attempt to encourage parents by discussion of the possibility of a cure being found is any real help to the parents in facing the inevitable consequences of this disease." By 1973, Pochedley, while noting that the great majority of patients would die from disease, commented that "remissions can last five or more years and in a few patients they seem to be permanent." In 1989, Poplack stated that "about 60% of children with this disease achieve prolonged disease-free survival (over 5 years from diagnosis) and most of these patients are considered to be cured."

In this review, data are presented in support of the conclusion that cures can be found for oven half of the children in this country in whom the diagnosis of cancer is made. The focus is not on clinical presentations but on staging systems, treatment principles, and outcomes for the most common pediatric malignancies.

DATA ANALYSIS AND POTENTIAL BIAS IN DATA

In the United States, the great majority of children with cancer are treated by pediatric hematologists/oncologists who are members of a cooperative study group (the Pediatric Oncology Group and the Children's Cancer Study Group); major reports of treatment results are based on data concerning children participating in groupwide, multi-institution studies, in single large institutions (usually with affiliates), or in intergroup studies.
Pediatrician—The Rodney Dangerfield of Medicine
Authors: Menna Vincent J.
Published: December 2021

As an intern in the distant past, I remember a gynecologist who regularly made rounds at 2 PM. Approximately 1 hour before his appearance on the floor, the nurses began to scramble and prepare. At 2 PM, they were "standing tall." General Patton and certainly Waldo Nelson would not have precipitated such activity. As pediatricians, do we need or desire that kind of sycophantic behavior? Of course not, but I believe that we deserve more respect than we are currently receiving.

At the risk of being superfluous, I note that we are on the low end of the pay scale. Those of you who have perspired over the 2-week-old infant with fever or the apneic newborn wonder why.
Recent Advances in the Management of the Infant, Child, and Adolescent With Chronic Renal Failure
Authors: Fine Richard N.
Published: December 2021

The prognosis of the infant, child, or adolescent with chronic renal failure, defined as an irreversible reduction in glomerular filtration rate, has improved during the past quarter century because of the use of dialysis and renal transplantation. These have prolonged lives in previously fatal situations. Because the potential not only to sustain life but also to effect full rehabilitation exists with the introduction of these treatments, it is now imperative that the multisystem consequences of uremia be either minimized or totally avoided in the pediatric patient with chronic renal failure.

The role of the pediatrician in managing the infant, child, or adolescent with chronic renal failure should be directed toward minimizing the potentially devastating consequences of uremia so that the patient is in optimal clinical condition when end stage renal disease occurs.

INCIDENCE

It is difficult to know the incidence and prevalence of chronic renal failure and end stage renal disease in children. Surveys in Europe and North America have been conducted to obtain precise information regarding these issues; not only have the definitions included in these surveys differed, but the upper and lower age limits defining pediatric patients have not been uniform.

The available data suggest a prevalence of chronic renal failure of 18.5 per 1 million child population and an incidence of end stage renal disease of from 3 to 6 children per 1 million total population.
Alopecia in Children: The Most Common Causes
Authors: Atton Andrew V. , Tunnessen Walter W.
Published: December 2021

The differential diagnosis of alopecia in the pediatric age group is simplified by the fact that 90% to 95% of the cases are caused by four major entities: alopecia areata, telogen effluvium, tinea capitis, and trichotillomania. Careful examination of the scalp, hair, and historical pattern of the loss will usually be rewarded by the correct diagnosis.
Perinatal Blood Loss
Authors: Molteni Richard A.
Published: December 2021

In recent years a great deal of attention has been paid to the evaluation and treatment of conditions characterized by red blood cell excess (polycythemia). The debatable practice of routine newborn hematocrit screening was initiated and perpetuated by the still uncertain short-term and long-term complications of polycythemia and its commonly associated state of hyperviscosity. Previously unsuspected anemia is often identified during this same screening process. Unless profound (leading to hypovolemic shock) or associated with more visible signs of hemolysis (jaundice), the etiology of this state of diminished red blood cell mass is often ignored or evaluated incompletely. This review focuses on the effects of anemia in the fetus and neonate, discusses mechanisms of fetal red blood cell production, and provides a basic diagnostic approach for the clinician when anemia is recognized in the neonatal period.

PHYSIOLOGIC EFFECTS OF RED CELL REDUCTION

Tissue Oxygen Delivery

Maintenance of adequate red blood cell numbers can be even more critical during fetal life than during the postnatal period. The fetus, dependent upon maternal oxygen sources, cannot raise tissue oxygen delivery acutely by increasing placental oxygen transfer, even when its red blood cell numbers are decreased. Total oxygen content (sum of oxygen dissolved in plasma and bound to hemoglobin) of the blood is dependent upon both the partial pressure of oxygen (Pao2) and the quantity of hemoglobin available.
Health Supervision for the High-Risk Preschooler
Authors: Rivara Frederick P. , Kemper Kathi J.
Published: December 2021

Guidelines for the well child care of the high-risk preschooler differ from those for the average middle class patient. Such a child can be defined as one who by virtue of medical, family, or social history is at increased risk of health problems during the preschool years. Two particular, special types of high-risk children are specified in the educational objectives: the child who is a recent immigrant to the United States and the child who has repeated injuries. The focus of this article is on assessment of growth and development; immunization; screening for tuberculosis, parasitic infections, and anemia; injury prevention; and general counseling issues.

CHILDREN FROM OTHER COUNTRIES

A 3-year-old Laotian girl is brought into the clinic for her first health supervision visit. Her mother speaks little English, but indicates that she is being treated with isoniazid; her physician has recommended she bring the child to a pediatrician for a complete checkup. She says that her physician was concerned about the child's short stature and limited speech. The mother doesn't know which "shots" or tests the child has had in the past, but the child has always seemed healthy to her.

Children immigrating from other countries may have important unmet medical problems (eg, growth delay, nutritional anemia, parasitic and other infectious diseases) at the same time they are confronting the psychological upheavals of moving, learning a new language, meeting new cultural expectations and behaviors, and recovering from the horrors they left behind in their country of origin.
"1-800:Please Admit"
Authors: Menna Vincent J.
Published: December 2021

During my internship on medicine rotation I made daily rounds with an internist. One of his female patients had a different pain daily that radiated to all parts of her body. I was impressed at how patiently he listened to her symptoms and was amazed that he was taking notes. One day I looked over his shoulder to discover that while she was complaining, he was making a list of his inpatients.

That patient along with others who were in the hospital for a "rest" justifiably would have a great deal of difficulty being admitted in 1990. However, I feel that the pendulum has swung too far in the opposite direction from the days of the lady with total body pain.
Clinical Disorders of Neutropenia
Authors: Roskos Rudolph R. , Boxer Laurence A.
Published: December 2021

Not uncommonly, during the course of a workup for fever, the pediatrician will find that a patient has neutropenia. Neutropenia is defined as an absolute decrease in the number of circulating neutrophils in the blood. The lower limit for normal neutrophil counts is 1000/mm3 in infants between 2 weeks and 1 year of age; after infancy the corresponding value is 1500/mm3. Blacks have lower neutrophil counts, and the lower limit is 100 to 200/mm3 less than those cited for whites. These lower counts probably reflect a relative decrease in the storage pool of the bone marrow.

CLASSIFICATION OF NEUTROPENIA

Neutropenia can be classified as mild (neutrophil counts of 1000 to 1500/mm3), moderate (neutrophil counts of 500 to 1000/mm3), or severe (neutrophil counts less than 200/mm3). This stratification is useful in predicting risk of infection, but it provides no etiologic information. On the other hand, it is useful to classify patients as having an abnormality either in production or in destruction of neutrophils, because each of these processes is now frequently amenable to distinct therapies if needed.

Susceptibility to bacterial infection, even in the face of severe neutropenia, is variable. Most patients with chronic neutropenia do not experience as many serious infections as those patients receiving cancer chemotherapy or those infected with human immunodeficiency virus who develop comparable degrees of neutropenia.
Pickles, Pizza, and PREP
Authors: Sahler O. J.
Published: December 2021

The Department of Education of the American Academy of Pediatrics has provided residency training program directors with a complimentary copy of CompuPREP, the computerized version of the PREP Self-Assessment, each year since the computer version became available. Formatted for IBM and Macintosh personal computers, CompuPREP was developed in response to numerous requests from Academy members for computerized educational materials. Currently, it is sent to more than 3,000 subscribers annually. Although the questions, critiques, and references are identical to those contained in the printed version (which is distributed to all pediatric residents through a grant from Ross Laboratories), the computer version has several features that make it a particularly good learning tool: access to immediate feedback about answers without moving from booklet to booklet; an option to review questions by subject area to enhance concentrated learning; and an automatic scoring system that produces a personal performance chart.
INDEX OF SUSPICION
Authors: DeAngelis Catherine , Robertson William O. , Chapman Daniel D.
Published: December 2021

Clinicians often form a diagnostic impression at the time of a patient's first presentation. Usually the initial impression is correct because commonly encountered illnesses come to mind and are, of course, most likely to be responsible. Sometimes, however, a less familiar disorder is responsible and will not be detected or will be diagnosed after a prolonged delay unless the physician maintains a suspicion of the unusual.

This section reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to put in writing possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations with discussions.

Case 1 Presentation

A 4-year-old black boy known to have sickle cell disease is brought to your office by his mother, who is concerned because he has become listless and weak during the past 12 hours. He has been complaining of abdominal pain and is breathing "harder and faster" than usual. On examination, a greatly enlarged, tender spleen is palpated.
Fetal Environmental Toxins
Authors: Holmes Lewis B.
Published: December 2021

The pediatrician often is asked by concerned parents whether their child's medical problems could be due to some type of exposure during pregnancy. Unfortunately, there seems to be an endless number of new and disturbing possibilities, such as video display terminals and electromagnetic fields, which are suggested regularly in newspaper articles, magazines, and the television news to be harmful. Experience has shown that many of these possibilities are false alarms, but much work is required before reassuring evidence becomes available. This review will summarize the current knowledge of "fetal environmental toxins" or human teratogens—terms that encompass an exposure during pregnancy that has a harmful effect on the developing fetus.

Many different types of fetal environmental toxins have been identified (Table), including:

• drugs taken by the pregnant woman,

• infections during pregnancy,

• maternal diseases,

• hypoxia,

• heat, and

• heavy metals.

The pediatrician evaluating the child who is reported to have had a harmful exposure in utero should be aware of the variety of potential effects of these exposures, including:

• spontaneous abortion;

• growth retardation, before and/or after birth;

• microcephaly;

• distinctive patterns of major and minor malformations;

• isolated major malformations;

• metabolic dysfunction, such as the diabetes mellitus that occurs in 30% of adults who had congenital rubella syndrome1;

• cognitive dysfunction;

• mental retardation;
Herpes Simplex Virus Infections: The Genital Tract and the Newborn
Authors: Arvin Ann M. , Prober Charles G.
Published: December 2021

There are six recognized members of the human herpes group of viruses. These include type 1 and type 2 herpes simplex viruses (HSV-1 and HSV-2), cytomegalovirus (CMV), Epstein-Barr virus (EBV), varicellazoster virus (VZV), and human herpes virus type 6 (HHV-6). These ubiquitous double-stranded DNA viruses are relatively large and lipid-enveloped. The capacity to induce a state of latency in the infected host has been proved for all of the herpes viruses. That is, after primary infection, the viruses remain forever with the host with the possibility for subsequent reactivations. The mechanisms of these reactivations are not understood completely. Both primary infections and recurrences may be associated with clinical illness or may be asymptomatic. To a large extent, the status of the host immune system determines the severity of the infection and the likelihood of recurrences. In general, infections are more severe and recurrences are more frequent in the most compromised hosts. This review focuses on HSV-1 and HSV-2, with emphasis on neonatal infections and maternal genital infections as a source of infection in the newborn.

The clinical illnesses caused by HSV-1 and HSV-2 are usually quite distinct. HSV-1 is the predominant cause of oral, ocular, and central nervous system infections occurring after the neonatal period, and HSV-2 is the predominant cause of genital and neonatal infections.
Cutaneous Fungus Infections in Children
Authors: Rasmussen James E.
Published: December 2021

Cutaneous fungus infection in children may be either superficial or deep. The most common superficial infections include tinea versicolor, tinea capitis, tinea corporis, tinea cruris, tinea pedis, and candidiasis. "Ringworm" is a common term used to describe these infections, stemming from the fact that "tinea" is Latin for "worm" or "moth." The only deep fungal infection discussed in this review is sporotrichosis.

Diagnostic Methods

All forms of superficial fungal infection can be diagnosed easily with a variety of quick, simple, and inexpensive diagnostic methods. Once mastered, the tests need not be used on patients with obvious diagnoses; nevertheless, confirmation of one's clinical impression is personally satisfying and often important.

POTASSIUM HYDROXIDE

Superficial fungal infections of the skin involve the outer portion of the epidermis, including the hair and nails. Hyphae and spores are visible easily with low-to-moderate microscopic magnification. With the exception of mucous membranes or eroded surfaces (as often found in the case of candidiasis), skin and hair for sampling should be moistened with a drop of water or an alcohol swab. The skin should be abraded gently with the round belly of a 15 blade at the active margin of tinea corporis or, in the case of tinea capitis, any place where alopecia is visible.
Viral Hepatitis: A, B, C, D and E—Infection
Authors: Krugman Saul
Published: December 2021

Viral hepatitis is caused by at least five etiologically and immunologically distinct viruses: hepatitis A (HAV), hepatitis B (HBV), hepatitis C (HCV), hepatitis D (HDV), and hepatitis E (HEV). The clinical, epidemiologic, and immunologic features of these five forms of viral hepatitis may be similar or different. Hepatitis also may occur during the course of disease caused by cytomegalovirus, Epstein-Barr virus, herpes simplex virus, varicella-zoster virus, adenoviruses, enteroviruses, rubella virus, arboviruses, and other agents.

Hepatitis A is synonymous with "infectious hepatitis," an ancient disease described by Hippocrates and formerly known as epidemic jaundice, acute catarrhal jaundice, and other designations. The fulminant form of the disease was called acute yellow atrophy of the liver.

Hepatitis B is synonymous with "serum hepatitis," a disease with a more recent history. The first known outbreak occurred during 1883 among a group of shipyard workers who were vaccinated against smallpox with glycerinated lymph of human origin. Later, an increased incidence of the disease was observed among patients attending venereal disease clinics, diabetes clinics, and other facilities where multiple injections were given with inadequately sterilized syringes and needles contaminated with the blood of a viral carrier. The most extensive outbreak occured in 1942, when yellow fever vaccine containing human serum caused 28 585 cases of hepatitis B infection with jaundice among United Stated military personnel.
Decision Making and the Child with Febrile Seizures
Authors: Freeman John M. , Vining Eileen P. G.
Published: December 2021

Seizures, both febrile and nonfebrile, are the most common neurologic problem seen in children. Most seizure problems can, and should, be managed by the pediatrician. This article, along with the following one, represents a dialogue—one we often have with pediatricians about the evaluation and management of seizures in children.

A seizure is defined as a paroxysmal electrical discharge of neurons in the brain resulting in alteration of function or behavior. A febrile seizure is defined as a seizure caused by fever. The diagnosis of a febrile seizure is one of exclusion. Before the diagnosis is made definite, it must be established that there was not another cause for the seizure.

Factors Important in the Diagnosis of Febrile Seizures

AGE

Febrile seizures are most common between the ages of 6 mo and 5 y. Beyond this range, seizures are more likely to have another etiology. However, this does not mean that every child outside of this age range needs a brain scan and an extensive initial evaluation.

TEMPERATURE

The height of the fever at the time of the seizure is helpful to know. Anyone can have a seizure if his or her temperature is sufficiently high. Therefore, in the absence of other demonstrable causes, the higher the fever, the more likely that an initial seizure, occurring in the typical age range, was precipitated by the fever.
Allergic Rhinitis
Authors: Virant Frank S.
Published: December 2021

Epidemiology

Allergic rhinitis affects as many as 8% to 10% of children in the United States. Many of these children suffer significant morbidity, leading to millions of lost school days annually. Morbidity is amplified when these children concurrently suffer from complications of allergic rhinitis, such as recurrent otitis media or chronic sinus disease.

Typically, children who have allergic rhinitis have a family history of atopic disorders. Upper airway allergy may become manifest at any age, but the appearance of symptoms is most common during childhood or young adulthood. Clinical signs of rhinitis may be perennial, seasonal, or episodic, and the primary focus of complaints may relate to secondary problems, including ear, sinus, or lung disease.

Pathophysiology

In the allergic patient, disease is mediated by the production of antigenspecific IgE by the patient's B lymphocytes. Current research suggests that the primary defect may be the excessive production of interleukin 4 (IL-4) or a deficient level of gamma interferon (γ-INF) when a T-cell is presented with an antigen. This constellation of immunomodulators directs the B-cell to produce IgE rather than the IgG response of the non-allergic patient.

Clinical disease occurs when an allergen reacts with antigen-specific IgE on the patient's nasal mast cells. When these factors combine, the mast cell is activated to release a variety of preformed and newly produced mediators, including histamine, leukotrienes, and prostaglandins (Fig 1).
School Readiness: An Overview for Pediatricians
Authors: Casey Patrick H. , Evans Larry D.
Published: December 2021

Pediatricians historically have played a role in determining whether a child is prepared for school entry by performing preschool physical examinations. Recent trends, including a tendency among some middle-class families and school districts to delay entry of typical kindergarten-age children until the next school year, the increased use of school readiness tests in schools, and the emphasis of federal legislation to identify preschool (P.L. 99-457) and school-age (P.L. 94-142) handicapped children, have placed a greater burden on pediatricians to assess the "school readiness" of their patients.

Much controversy exists among educators about how to define school readiness, measure it, and manage children who may not be ready for school. Some of these controversies will be presented in this article. In light of these issues, a cautious role for pediatricians in assessing and making recommendations for school readiness, commensurate with the pediatricians' developmental perspective and awareness of the child's family and environment, will be described.

What is School Readiness?

All schools arbitrarily set a date by which children must reach their fifth birthday to enter kindergarten, and this date has moved ahead considerably during the past decades to the current typical September 1 to October 1 cutoff. Although this age approach may be the most equitable method of allowing access to public education, the earlier age of entry results in a younger group of children who are potentially less ready to participate in school.
Foot and Leg Problems
Authors: Craig Clifford L. , Goldberg Michael J.
Published: December 2021

Metatarsus Adductus

Forefoot adduction, a common deformity in infants, can present a spectrum of severity. Unfortunately, the terminology used in the literature is confusing. Congenital metatarsus adductus is an intrauterine postural deformity of the forefoot. Congenital metatarsus varus is an intrauterine subluxation of the tarsometatarsal joint, with adduction of the metatarsals. The distinction is important because metatarsus adductus usually corrects spontaneously, whereas metatarsus varus will progress without active intervention.

INCIDENCE AND ETIOLOGY

Metatarsus varus occurs in about 1 per 1000 live births. There is no definable inheritance pattern. The risk of a second occurrence within a family is about 1 in 20. Pathogenesis has been studied by dissecting the feet of stillborn infants. This supports the concept of medial subluxation of the tarsometatarsal joints occurring while the foot is dorsiflexed. Adaptive changes of the bone and soft tissues occur secondarily. The incidence of congenital metatarsus adductus is unknown but is far more frequent than 1 per 1000 live births. The etiology is presumed to be a "packaging problem," with the forefoot compressed into adduction. Greater utilization and expertise with fetal ultrasound will help resolve these issues.

DIAGNOSIS

In congenital metatarsus adductus, the forefoot easily can be corrected passively to line up parallel to the heel and frequently can be overcorrected into abduction.