bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatric Acquired Immunodeficiency Syndrome: An Unusually High Incidence of Twinning
Authors: THOMAS PAULINE A. , RALSTON STEVEN J. , BERNARD MARIE , WILLIAMS ROSALYN , O'DONNELL RITA
Published: December 2021

Surveillance data on incidence of twins among reported cases of pediatric AIDS in New York City are presented. Most pairs are concordant for HIV infection. Three discordant pairs have been described elsewhere. Possible reasons for the association are discussed, including the most likely explanation that twins show symptoms early and are overrepresented in the early years of surveillance of pediatric AIDS.
Failure of a Nursing Infant to Thrive After the Mother's Gastric Bypass for Morbid Obesity
Authors: MARTENS WILLIAM S. , MARTIN LOUIS F. , BERLIN CHESTON M.
Published: December 2021

A breast-fed 4-month-old infant girl observed since birth had gained only 1230 g (2 lb 11 oz). The mother had three older children with birth weights of 3440 g (7 lb 9 oz), 4000 g (8 lb 13 oz), and 4895 g (10 lb 13 oz). All were exclusively breast-fed and thrived, eventually growing between the 25th and 50th percentiles on the National Center for Health Statistics growth charts. The mother also had five miscarriages during these 7 years. She had gastric bypass surgery for morbid obesity between her third and fourth children. She had lost 49 kg (109 lb) (114 kg to 65 kg) [254 lb to 145 lb]) in the first 12 months after surgery and had been stable at her new weight for 4 months prior to becoming pregnant with this baby.
Celiac Plexus Blockade for a 3-Year-Old Boy With Hepatoblastoma and Refractory Pain
Authors: BERDE CHARLES B. , SETHNA NAVIL F. , KAHN CYNTHIA H. , FISHER DAVID E. , GRIER HOLCOMBE E. , CHANDLER PAUL
Published: December 2021

In the management of pain due to visceral malignancy (especially pancreatic carcinoma) in adults, neurolytic celiac plexus blockade has emerged as an effective pain management procedure1,2; in the management of severe pain due to pancreatic carcinoma, it is regarded by many as the technique of choice.3 In this procedure, a nerve-destructive agent such as ethanol or phenol is injected percutaneously, usually from a posterolateral approach, immediately around the aorta and vena cava at the level of origin of the celiac artery. When performed for pancreatic cancer pain, celiac blockade provides good or excellent pain relief in 85% to 97% of cases, generally for 6 months to 2 years.
Injuries in Day Care
Authors: RIVARA FREDERICK P. , DIGUISEPPI CAROLYN
Published: December 2021

In Reply.—

We appreciate the comments of Gielen et al on our study examining the risk of injuries to children in day care compared with the risks of injuries to children at home. Injury control, a problem ignored for far to long, is finally beginning to attract a sizeable number of investigators and practitioners. Nevertheless, resources are still extremely scarce, and we encourage others involved in this area to use criteria similar to those used at the Harborview Injury Prevention and Research Center in choosing a topic for intervention: the injuries must be frequent, they must be severe, and an effective intervention should exist.
The NICHD Phototherapy Study
Authors: PERLMAN MAX
Published: December 2021

To the Editor.—

After following-up at 6 years of age the subjects enrolled in the National Institute of Child Health and Human Development Randomized, Controlled Trial of Phototherapy for Neonatal Hyperbilirubinemia, Scheidt et al concluded that this treatment "effectively controlled neonatal hyperbilirubinemia without evidence of adverse outcome at 6 years of age and was at least as effective as management with exchange transfusion alone."1 According to the objective of the study stated in the Abstract and the introduction, the latter "effective" refers to "preventing brain injury."
Report of the Subcommittee on Assessment and Methodologic Issues in the Management of Pain in Childhood Cancer
Authors: McGrath P. J. , Beyer J. , Cleeland C. , Eland J. , McGrath P. A. , Portenoy R.
Published: December 2021

Pain is a complex, multidimensional experience that has at least two major components. The first, nociception, is a sensory component directly related to activity in neural pathways responsive to tissue damage. The second is the complex psychologic, physiologic, emotional, and behavioral response to the nociception. This response is determined by many intrinsic and extrinsic factors. In general, children will have less pain when the exacerbating factors, which are outlined in Table 1, are minimized.

Because pain is experienced individually and subjectively, assessment of pain in each individual is essential. Assumptions regarding an individual's pain should not and cannot be inferred from the amount of tissue damage he or she has experienced. Therefore, regarding assessment of pain in children with cancer, the following principles were agreed upon.

1. Systematic assessment of pain should be considered idered a necessary part of the management of cancer. Most children with cancer will be at risk for significant pain at some time during the course of their illness. Such pain can be caused by the disease itself, by invasive diagnostic and monitoring procedures, and by treatment. Therefore, adequate care must include a plan for comprehensive assessment ent and management of all forms of pain in addition to the disease-management protocol.

2. Assessment of pain must be ongoing throughout the course of the illness. Sources of nociception and modifying factors will change through time and must be evaluated continuously.

MEASUREMENT OF PAIN

Although comprehensive assessment of pain must include more than measurement of intensity or severity, this aspect of pain is important and has been studied the most widely.
Report of the Subcommittee on Disease-Related Pain in Childhood Cancer
Authors: Berde C. , Ablin A. , Glazer J. , Miser A. , Shapiro B. , Weisman S. , Zeltzer P.
Published: December 2021

OVERVIEW: CANCER PAIN SYNDROMES IN CHILDREN

Pain due to cancer may be caused by tumor infiltration or invasion of bone, soft tissues, viscera, and nerves. Disease-related pain is especially common on with metastatic cancer, although there is no predictable relationship between the tumor burden and the intensity of pain. Conversely, exacerbation of pain or dramatic increase in analgesic requirements is often a clue to the occurrence of disease progression.

As with all forms of pain, management of disease-related pain requires a thorough investigation and the establishment of specific diagnoses. There has been detailed study of cancer pain syndromes in adults, and preliminary efforts have been made in this regard in pediatric cancer.10 Specific diagnosis and etiology for the pain are important to document, because more effective systemic or local therapies may be applied. This assessment must be broad-based, and it must take into consideration both disease mechanisms in the narrow sense as well as psychosocial factors which modify the experience of pain.

MANAGEMENT APPROACH FOR DISEASE-RELATED PAIN

In adults, a stepwise approach to the management of the pain associated with cancer using the "analgesic ladder" has been useful. This approach should not be regarded as a " cookbook" to be followed by rote; specific and symptomatic management of pain must be tailored to the needs and wishes of the individual patient.

An algorithm for management of pain is shown in Figure 2.

Effectiveness of Modalities of Cancer Treatment in Pain Relief

A primary means for controlling pain due to cancer lies in specific cancer treatments, especially chemotherapy and radiation.
Youth Health Care in the Netherlands: A Bird's Eye View
Authors: Verbrugge Hans P.
Published: December 2021

In the context of the conference on cross-national comparisons of child health, a short overview is given of youth health care in the Netherlands. After a brief explanation of the financing of the Dutch health care system, trends in child mortality are shown. A short description is presented of obstetrical care, which features independent midwives and 35% home deliveries; the organization of well baby clinics, which provide for 10 visits in the first 15 months and care for 95% of all children; and the school health services, which cover nearly all children.
Unintended Injuries in Children: The French Situation
Authors: Manciaux M. , Tursz A.
Published: December 2021

The French situation with respect to mortality from unintentional injuries in children is far from satisfactory. International comparison is made difficult by statistical bias, but although excess injury mortality is decreasing in France, rates are higher than in most advanced European countries. Many regulations have been enacted during the past 30 years to reduce the economic and social burden of injuries, but political will is insufficient to establish a consolidated national program and enforcement of existing legislation is inadequate. Evaluation of preventive and educational programs is less than optimal; many attempts have not met basic methodologic requirements.

The situation is improving, partly because of growing social concern. New regulations are in preparation, but solution of this major public health problem also demands behavioral change, which is much more difficult to effect than other measures. Greater commitment to research, proper evaluation of sound programs, and enforcement of existing law doubtless would reduce the excess morbidity and mortality resulting from unintended injuries to children.
Postneonatal Mortality in Norway: A Study of Recent Trends and Comparison With Other Mortality Rates in Norwegian Children
Authors: Lie Sverre O.
Published: December 2021

Postneonatal mortality in Norway decreased rapidly from 1956 to 1980 but subsequently remained stable. In recent years the postneonatal death rate appears to be increasing, primarily due to greater numbers of deaths attributed to the Sudden Infant Death Syndrome.

During the same period, mortality among older children has also decreased, with the decline evident in all leading causes. Only among people aged 15 to 19 years have recent trends been less than encouraging, with the number of fatal traffic accidents in particular remaining stable or increasing. Although there is room for continued improvement, the widely held belief that the health status of Norwegian children is good is supported by the trends in mortality.
Annual Summary of Vital Statistics—1989
Authors: Wegman Myron E.
Published: December 2021

US infant mortality continued to decline slowly and the provisional 1989 rate, 9.7 per 1000 live births, was the lowest ever recorded. Final 1988 data showed no change in cause of death distribution or in the wide discrepancy between white and black infant mortality. State rates varied from 6.8 in Vermont to 12.6 in Georgia. Worldwide, the US rate of 10.0 was bettered by 21 other countries, with Japan lowest at 4.8.

Births increased in number and rate, because of a higher fertility rate and more women in the childbearing years. The birth rate to mothers 17 years of age and younger increased again. The proportion of women who had no or inadequate prenatal care was essentially unchanged.

Deaths, crude death rate, and age-adjusted death rate decreased. The excess of births over deaths added almost 1.9 million persons to the US population, the highest rate of natural increase since 1971. The marriage rate was essentially unchanged, whereas the divorce rate decreased slightly, to the lowest level since 1973.

With the exception of human immunodeficiency virus infection, homicide, and pulmonary malignancies, rates for most causes of death declined from 1988 to 1989. In comparison with 1940, most declines were substantial, led by pneumonia, down about 80%, and perinatal conditions, down about 75%. The only large-scale increases among major causes in the half century were in two diseases related to cigarette smoking: chronic obstructive pulmonary disease, up eightfold, and respiratory cancer, up almost sixfold. Death rates from all other cancers, as a group, decreased by some 20% and from cardiovascular diseases by some 60%.
Clinical Role of Respiratory Virus Infection in Acute Otitis Media
Authors: Arola Mikko , Ruuskanen Olli , Ziegler Thedi , Mertsola Jussi , Näntö-Salonen Kirsti , Putto-Laurila Anne , Viljanen Matti K. , Halonen Pekka
Published: December 2021

The clinical characteristics of acute otitis media in relation to coexisting respiratory virus infection were studied in a 1-year prospective study of 363 children with acute otitis media. Respiratory viruses were detected using virus isolation and virus antigen detection in nasopharyngeal specimens of 42% of the patients at the time of diagnosis. Rhinovirus (24%) and respiratory syncytical virus (13%) were the two most common viruses detected. Adenovirus, parainfluenza viruses, and coronavirus OC43 were found less frequently. The mean duration of preceding symptoms was 5.9 days before the diagnosis of acute otitis media. Ninety-four percent of the children had symptoms of upper respiratory tract infection. Fever was reported in 55% and earache in 47% of cases. Patients with respiratory syncytial virus infection had fever, cough, and vomiting significantly more often than patients with rhinovirus infection or virus-negative patients. No significant differences were found in the appearance of the tympanic membrane and outcome of illness between virus-negative and virus-positive patients with acute otitis. Most patients respond well to antimicrobial therapy despite the coexisting viral infection. If the symptoms of infection persist, they can be due to the underlying viral infection, and viral diagnostics preferably with rapid methods may be clinically useful in these patients.
Arthropathy of Down Syndrome
Authors: Olson Judyann C. , Bender Joan C. , Levinson Joseph E. , Oestreich Alan , Lovell Daniel J.
Published: December 2021

A juvenile rheumatoid arthritis-like arthropathy has previously been documented in 12 patients with Down syndrome. An additional 9 patients are described and the literature is reviewed. It is unknown whether these patients have juvenile rheumatoid arthritis or a unique arthropathy in light of the genetic and immunologic abnormalities associated with Down syndrome. Most of the patients had a progressive course with polyarticular disease complicated by subluxations and a long lag time to diagnosis. The purpose of reporting these children is to increase awareness of this association and facilitate more appropriate and timely diagnosis of arthritis in Down syndrome patients.
Surfactant Treatment of Full-Term Newborns With Respiratory Failure
Authors: Auten Richard L. , Notter Robert H. , Kendig James W. , Davis Jonathan M. , Shapiro Donald L.
Published: December 2021

Surfactant inactivation has been shown to be a significant factor in animal models of lung injury and may also be important in some forms of respiratory failure in full-term newborns. Fourteen full-term newborns with respiratory failure associated with pneumonia (7 patients) and meconium aspiration syndrome (7 patients) were treated with 90 mg/kg of a calf lung surfactant extract, given intratracheally up to every 6 hours for a maximum of four doses. The group mean fraction of inspired oxygen (Fi02) before treatment was 0.99 ± 0.01 SEM, and the mean airway pressure (MAP) was 14.6 ± 1.0 cm H2O. Patients showed significant improvement in oxygenation after initial surfactant treatment, with the arterial-alveolar oxygenation ratio (a/A ratio) rising from 0.09 ± 0.01 before surfactant treatment to 0.22 ± 0.05 by 15 minutes (P = .03) and remaining improved for 6 hours. The oxygenation index, incorporating MAP as well as oxygen variables, also improved significantly from 26.2 ± 3.1 to 11.2 ± 1.7 at 15 minutes (P < .001), with improvement sustained for more than 6 hours. Chest radiographs were blindly scored from 0 (normal) to 5 (severe opacification), and these improved with marginal significance after initial surfactant treatment (from 2.9 ± 0.2 to 2.5 ± 0.2, P = .05). Eight patients subsequently met retreatment criteria (Fi02 ≥ 0.5 and MAP ≥ 7 cm H2O) and received a second surfactant dose, with a/A ratio rising from 0.124 ± 0.02 before treatment to 0.26 ± 0.07 after 45 minutes (P = .03) and remaining improved for more than 4 hours; the oxygenation index was also significantly improved over similar times by the second surfactant dose. Six patients received a third surfactant dose, with no increase in a/A ratio and a less prominent improvement in oxygenation index. There were no significant improvements in oxygenation in the three patients who received a fourth surfactant dose. Of the 14 patients treated, none died, required extracorporeal membrane oxygenation, had tension pneumothorax after study entry, required oxygen supplementation for more than 14 days, or required oxygen supplementation at discharge. These findings suggest that surfactant supplementation may provide therapeutic benefits for newborns with respiratory failure due to pneumonia or meconium aspiration and that expanded controlled trials of this therapy are indicated.
Does Nasogastric Tube Cause Pulmonary Aspiration in Children?
Authors: BAR-MAOR JEHUDA ADONIRAM , LAM MENACHEM
Published: December 2021

Aspiration pneumonia due to gastroesophageal reflux is a serious and frequently encountered problem in pediatrics and pediatric surgery.1-3 Occasionally aspiration may be silent and minimal, yet chronic unexplained respiratory symptoms may appear.4

A number of authors have reported another cause of aspiration in children, namely aspiration of gastric juice while the child is receiving mechanical ventilation by means of a respirator, especially if an uncuffed endotracheal tube is used.5-7

Nasogastric tubes are frequently used in pediatrics and pediatric surgery. It was found that the incidence of postoperative pneumonia in adults was 10 times higher in patients in whom nasogastric tubes were used.8
Safe Transportation of Premature Infants
Authors:   Committee on Injury and Poison Prevention and Committee on Fetus and Newborn
Published: December 2021

Increasing survival rates and earlier hospital discharge of premature infants have resulted in babies weighing less than 2500 g being transported frequently in the family car. Provision for safe motor vehicle transportation of this vulnerable population of infants is a major concern of parents and health professionals. The American Academy of Pediatrics Committee on Injury and Poison Prevention and the Committee on Fetus and Newborn believe that specific guidelines should be followed to ensure proper selection and use of car seats and other occupant restraint devices for low-weight infants.

Currently, Federal Motor Vehicle Safety Standard 213, which established design and dynamic performance requirements for child restraint systems, applies to children weighing up to 50 lb, but no minimum weight limit is established in the standard. Most safety restrains on the market are designed for infants weighing more than 7 lb (3.1 kg), and only recently have studies been done which allow some prediction of the protective capabilities of restraint devices for infants weighing less than 7 lb.1,2 Initial research has indicated that some infants, particularly premature, low-weight infants, may be subject to oxygen desaturation when placed in an upright position in car safety seats.3,4 Both rate of growth and neurologic maturation may influence potential risk of respiratory compromise in these and other seating devices. Further investigations will be necessary to precisely define the population at risk and the variety of situations in which risk occurs.

Proper positioning of small infants in car seats is important to minimize the risk of respiratory compromise while providing protection for the infant in the event of a crash or sudden stop.
Bismuth Subsalicylate in the Treatment of Acute Diarrhea in Children: A Clinical Study
Authors: Soriano-Brücher Humberto , Avendano Pablo , O'Ryan Miguel , Soriano Humberto A. , Braun Steven D. , Manhart Michael D. , Balm Timothy K.
Published: December 2021

Bismuth subsalicylate (BSS) and placebo were evaluated in a double-blind, placebo-controlled study as adjunct to rehydration therapy in 123 children, aged 4 to 28 months, hospitalized with acute diarrhea. The dosing regimen was 20 mg/kg five times daily for 5 days. Significant benefits were noted in the BSS group compared with placebo as manifested by decreases in stool frequency and stool weights and an improvement in stool consistency, significant improvement in clinical well-being, and shortening of the disease duration. Patients treated with BSS had a significant reduction in duration of hospital stay (6.9 days) compared with placebo-treated patients (8.5 days). Also, intravenous fluid requirements decreased significantly more rapidly and to a greater degree in the BSS-treated group. Bismuth subsalicylate was associated with clearance of pathogenic Escherichia coli from the stools in 100% of cases but was not different from placebo in rotavirus elimination. Bismuth subsalicylate was well tolerated with no reported adverse effects. Blood bismuth and serum salicylate levels were well below levels considered toxic. In this study, BSS provided effective adjunctive therapy for acute diarrhea, allowing children to get well sooner with less demand on the nursing and hospital staff.
Use and Misuse of Oral Therapy for Diarrhea: Comparison of US Practices With American Academy of Pediatrics Recommendations
Authors: Snyder John D.
Published: December 2021

To determine how closely US pediatricians follow the 1985 American Academy of Pediatrics Committee on Nutrition's recommendations on oral therapy for acute diarrhea, a questionnaire was administered to four groups: New England private practitioners, pediatricians from 27 states attending a postgraduate course, representatives of departments of pediatrics at US schools of medicine, and housestaff at Boston Children's and Massachusetts General hospitals. The responses from departments of pediatrics and housestaff were not significantly different from those of community practitioners in most categories. The reported rate of use of glucose-electrolyte solutions recommended by the American Academy of Pediatrics was not different from the use of nonphysiologic, high-osmolar, low-salt solutions such as sodas and juices. The usage rate for glucose-electrolyte solutions meeting the American Academy of Pediatrics-recommended carbohydrate-to-sodium ratio of less than 2:1 was less than 30%. Other findings included the general lack of agreement on the use of a single type of therapy and the common use of oral therapy only for mild or no dehydration. Although the American Academy of Pediatrics recommends that feeding be reintroduced in the first 24 hours of a diarrheal episode, the majority of respondents withhold feeding until the second day or later. These findings indicate that educational programs on oral therapy during acute diarrhea are needed in the United States.
Infrared Thermometry of Newborn Infants
Authors: Johnson Karen J. , Bhatia Priya , Bell Edward F.
Published: December 2021

An infrared thermometer, the FirstTemp, was tested among newborn infants by comparing tympanic membrane temperature measurements in three operating modes, "Cal-tympanic," "Cal-surface," and "Cor-tympanic," with nearly simultaneous tympanic membrane, rectal, and axillary temperature measurements using other standard methods. The FirstTemp underestimated other measurements of body temperature in the "Cal-tympanic" mode and overestimated them in the "Cor-tympanic" mode. In the "Cal-surface" mode, the First-Temp readings were significantly lower than tympanic membrane temperatures measured with a thermistor probe and electronic thermometer (mean difference 0.2°C) but not significantly different from rectal or axillary temperatures. According to these results, the FirstTemp can be used reliably in the "Cal-surface" mode but not in the "Cal-tympanic" or "Cor-tympanic" mode. Its speed and ease of operation offer significant advantages over traditional clinical methods of temperature measurement.
A New System for Location of Endotracheal Tube in Preterm and Term Neonates
Authors: Blayney Marc , Costello Simon , Perlman Max , Lui Kel , Frank John
Published: December 2021

A randomized, controlled trial was conducted to evaluate a new noninvasive system for placement of the endotracheal tube, based on a magnetic field interference-sensing technique. Seventy-two neonates treated by the standard technique were compared with 70 treated by the new system (TRACH MATE), with radiographic localization as the standard. As judged by the author(s) on the morning after the intubation, correct initial placement was achieved in 69 (78%) of 88 intubations using the new system, compared with 71 (66%) of 107 using the standard technique (Fisher's Test, one-tailed, P = .044). Repositioning was actually done in 23 (26%) of 88 TRACH MATE intubations, compared with 42 (39%) of 107 standard intubations (Fisher's test, one-tailed; P = .037). Intubation of the right main bronchus occurred in 7 standard intubations, but in none of the TRACH MATE intubations (Fisher's test, one-tailed; P = .014). Endotracheal tube position (high, low, or appropriate) was correctly determined by TRACH MATE in 77 (90%) of 85 intubations; the position was not recorded on three occasions. No differences in the number of complications (eg, unplanned extubations, distal displacement, subglottic stenosis) were found between the two groups. It is concluded that the TRACH MATE technique is superior to the standard clinical method in initial placement of the endotracheal tube.
Risk of Respiratory Illness Associated with Day-care Attendance: A Nationwide Study
Authors: Hurwitz Eugene S. , Gunn Walter J. , Pinsky Paul F. , Schonberger Lawrence B.
Published: December 2021

The risk of respiratory and other illnesses in children (age groups: 6 weeks through 17 months, 18 through 35 months, and 36 through 59 months) in various types of day-care facilities was studied. Children considered exposed to day care were those who were enrolled in day care with at least one unrelated child for at least 10 hours per week in each of the 4 weeks before the interview; unexposed children were not enrolled in any regular child care with unrelated children and did not have siblings younger than 5 years of age receiving regular care with unrelated children. Although an increased risk of respiratory illness was associated with attending day care for children in all three age groups, this risk was statistically significant only for children 6 weeks through 17 months of age (odds ratio = 1.6; 95% confidence interval = 1.1 to 2.4) and children 18 through 35 months of age who had no older siblings (odds ratio = 3.4; 95% confidence interval = 2.0 to 6.0). In contrast, day-care attendance was not associated with an increased risk of respiratory illness in children 18 through 35 months of age with older siblings (odds ratio = 1.0). For children aged 6 weeks through 17 months, the exposure to older siblings was associated with an increased risk of respiratory illness; however, for children aged 36 through 59 months, older siblings were protective against respiratory illness. In addition, for the children in each age group currently in day care, increased duration of past exposure to day care was associated with a decreased risk of respiratory illness. It is estimated that during the period of the study approximately 10% of respiratory illnesses in the United States in children younger than 5 years of age were attributable to day-care attendance.
Unsupervised Children in Vehicles: A Risk for Pediatric Trauma
Authors: Agran Phyllis , Winn Diane , Castillo Dawn
Published: December 2021

In this study, a series of instances of children injured by a motor vehicle set in motion by an unsupervised child are reviewed. During a 24-month period, nine such children were identified through a multihospital and coroner's office monitoring system in a single urban county. Injuries ranged from multiple abrasions and contusions to serious leg and head injuries. Three children died. The typical circumstance involved a child releasing the brake or placing the vehicle in gear in a private driveway which resulted in the vehicle striking or rolling over the victim. In four of the nine cases, the child who set the vehicle in motion fell or jumped from the vehicle and then became the injured victim. The extent of these unusual motor vehicle-related injuries is unknown because they are unlikely to be reported in official police statistics. According to the study findings, there is a need to educate the public and health professionals about the risks associated with leaving a child unattended in a motor vehicle and the hazardous environment of the private driveway. Preventive measures would include not leaving a child unattended in a vehicle, locking unattended vehicles to prevent access, and redesigning of private driveways.
Daddy MD
Authors: Avner Jeffrey R.
Published: December 2021

It's been almost two years since the weekend my daughter couldn't breathe.

It started Thursday evening with a runny nose and low-grade fever, not unlike the times she's had colds before. Even when she developed the barking cough, which heralded the onset of the croup, we weren't concerned. We had seen this many times with other children and knew that it was uncommon for a child with croup to be seen in the emergency room. Still, before we went to bed that night we turned on the intercom in Arly's room; it was the first time we'd used it in a year.

By three in the morning we were awakened by Arly's harsh breathing, which seemed to vibrate the entire apartment. We went to her room. She was only half asleep because she was working so hard to breathe. My wife, Rhonda, carried Arly into the bathroom and turned on the hot water in the shower. During my pediatric residency I had given many of my clinic patients' parents the same advice. Arly got only a little better. We didn't take her to the emergency room that night, even though if she had been someone else's child I would have admitted her. Perhaps I was afraid her condition would improve after the car drive to the emergency room and my fellow residents would think I was overreacting. You would think doctors would be more attuned to the dangers of their children's illnesses, yet, all too often, we wait too long.
Upper Respiratory Tract Infections in Young Children: Duration of and Frequency of Complications
Authors: Wald Ellen R. , Guerra Nancy , Byers Carol
Published: December 2021

This study was performed to determine the usual duration of community-acquired viral upper respiratory tract infections and the incidence of complications (otitis media/sinusitis) of these respiratory tract infections in infancy and early childhood. Children in various forms of child-care arrangements (home care, group care, and day care) were enrolled at birth and observed for 3 years. Families were telephoned every 2 weeks to record on a standardized form the type and severity of illnesses experienced during the previous interval. Only children remaining in their original child-care group for the entire study period were compared. The mean duration of an upper respiratory tract infection varied between 6.6 days (for 1- to 2-year-old children in home care) and 8.9 days (for children younger than 1 year in day care). The percentage of apparently simple upper respiratory tract infections that lasted more than 15 days ranged from 6.5% (for 1- to 3-year-old children in home care) to 13.1% (for 2- to 3-year-old children in day care). Children in day care were more likely than children in home care to have protracted respiratory symptoms. Of 2741 respiratory tract infections recorded for the 3-year period, 801 (29.2%) were complicated by otitis media. During the first 2 years of life, children in any type of day care were more likely than children in home care to have otitis media as a complication of upper respiratory tract infection. In year 3, the risk of otitis media was similar in all types of child care.
Professional Liability in a Pediatric Emergency Department
Authors: Reynolds Sally L. , Jaffe David , Glynn William
Published: December 2021

The risk of professional liability resulting from care given in the pediatric emergency department is a growing concern. This retrospective study examined the patients, diagnoses, and outcome of all threatened and actual claims that originated in the emergency department of a pediatric teaching hospital from 1977 through 1988. Twenty-five cases were identified by the hospital risk manager from approximately 320 000 visits (8.0 cases/100 000 visits); 22 charts were available for review. Ages of the patients ranged from 2 weeks to 13 years (mean 2.9 years, median 3.0 years). The patients' payment status was private insurance (n = 10), state public aid (n = 5), and no third-party payment source was listed for 7 children. Ten patients (46%) visited the emergency department between midnight and 8:00 AM, when an attending physician was not present. Return visits within 2 weeks for the same complaint occurred in 10 cases. The majority of the patients were discharged home (n = 18), and all of them had appropriate, adequately documented discharge instructions. The final diagnoses fell into four general categories: minor trauma/abuse (n = 7), neoplasms/chronic illnesses (n = 7), infectious diseases (n = 6), and appendicitis (n = 2). Review of the charts before knowledge of the legal outcome raised quality-of-care issues in 41% of the cases (n = 9). The legal claims were categorized as failure to diagnose (n = 16) and inappropriate treatment (n = 6). No claims went to trial, 12 were dropped by the family, 5 patients received some payment, 3 claims were unfounded, and 2 cases remain open. Legal fees incurred in 16 cases over the 10-year period totaled $191 677, and the total payment to families was $43 850. Conclusions: (1) malpractice claims were uncommon in the emergency department studied; (2) a disproportionate number of claims occurred when an attending physician was not in the emergency department; (3) no one specific diagnosis was overrepresented in the majority of claims; (4) visiting the emergency department more than once for the same complaint increased the risk of professional liability; and (5) the cost of the associated legal fees was more than four times the money paid to families.
Diagnostic Utility of Lower Extremity Radiographs of Young Children With Gait Disturbance
Authors: Blatt Steven D. , Rosenthal Bruce M. , Barnhart Douglas C.
Published: December 2021

The diagnostic utility of lower extremity radiographs was evaluated using 84 outpatients 1 to 5 years of age with gait disturbance whose lower extremities appeared physically normal. Chief complaints included limp (65 children [77%]), refusal to walk or stand (37 children [44%]), and frequent falling (6 children [7%]). A total of 43 children (51%) had more than one complaint. The mean age of patients was 26 months and the median duration of symptoms was 1 day. Trauma was reported in 43 (51%) cases and fever in 14 (17%). Results of radiographical studies appeared normal in 81 children (96%), demonstrated soft tissue swelling in 2 children, and revealed a bony island in 1 child. In 1 patient admitted to the hospital for failure to thrive and irritability, and whose radiographic results appeared normal, findings consistent with osteomyelitis later developed. Of the remaining children, 68 (81%) were available for follow-up observation 4 to 28 months after the initial visit and all reported spontaneous resolution of the initial complaint. It was concluded that in a well-appearing child with an otherwise normal physical examination results, an acute gait disturbance is likely to be a self-limiting condition and radiographs are unlikely to contribute to the diagnosis.
Infant Botulism: A Review of 12 Years' Experience at The Children's Hospital of Philadelphia
Authors: Schreiner Mark S. , Field Emily , Ruddy Richard
Published: December 2021

Fifty-seven patients with infant botulism were cared for at The Children's Hospital of Philadelphia between 1976 and 1987. The ages of the children ranged from 18 days to slightly more than 7 months. The average duration of hospitalization was 44 ± 34 days, with the average intensive care unit stay lasting 29 ± 25 days (54 of 57 patients). The majority (77%) of the patients were ultimately intubated and mechanicaily ventilated (68%). The principal indication for intubation was loss of protective airway reflexes and not hypercarbia or hypoxemia. In those patients who required mechanical ventilation the average duration was 23 ± 22 days, with the 10 most severely affected patients (≥28 days of mechanical ventilation) averaging 53 ± 25 days. Excluding patients ventilated for more than a month, those who underwent tracheostomy were hospitalized nearly twice as long as those who were managed by nasotracheal intubation only (33.5 days vs 63.2 days). The use of continuous nasogastric feedings has supplied most infants with sufficient enteral feedings to avoid weight loss and the need for central intravenous alimentation.
Sudden Infant Death Syndrome and Small Airway Occlusion: Facts and a Hypothesis
Authors: Martinez Fernando D.
Published: December 2021

Respiratory failure is almost certainly the cause of death in the majority of cases of sudden infant death syndrome (SIDS), but the mechanisms leading to it have not been elucidated. SIDS shares many environmental and socioeconomic risk factors with severe forms of bronchiolitis, and the age distribution of incident cases is similar. Present knowledge of lung and airway development during infancy, determinants of peripheral airway patency, changes in lung surface activity in infants with SIDS, and fluid film dynamics in small airways are reviewed. It is hypothesized that many cases of SIDS may be due to a final episode of progressive peripheral bronchial occlusion in infants with preceding critically diminished conductance of the smaller airways.
Ehrlichiosis in Children
Authors: Harkess John R. , Ewing S. A. , Brumit Timothy , Mettry Charles R.
Published: December 2021

Tick-borne rickettsiae of the genus Ehrlichia have recently been recognized as a cause of human illness in the United States. In the years 1986-1988, 10 cases of ehrlichiosis were diagnosed in children in Oklahoma. Fever and headache were universal; myalgias, nausea, vomiting, and anorexia were also common. Rash was observed in six patients but was a prominent finding in only one. Leukopenia, lymphopenia, and thrombocytopenia were common laboratory abnormalities. Six patients were treated with tetracycline, three with chloramphenicol, and one was not treated with antibiotics; all recovered. The onset of illness in spring and early summer for most cases paralleled the time when Amblyomma americanum and Dermacentor variabilis are most active, suggesting that one or both ticks may be vectors of human ehrlichiosis in Oklahoma.
Risks of Alternate-Day Prednisone in Patients With Cystic Fibrosis
Authors: Rosenstein Beryl J. , Eigen Howard
Published: December 2021

In recent years an immune-mediated inflammatory process has been implicated in the genesis of the pulmonary damage seen in patients with cystic fibrosis.1,2 A 4-year double-blind, placebo-controlled trial of alternate-day prednisone (2 mg/kg) was conducted in 45 cystic fibrosis patients with mild-to-moderate pulmonary disease to assess the effect of this drug on the pulmonary inflammatory process.3 The patients in the prednisone group showed better growth and pulmonary function and less morbidity compared with those in the placebo group. No complications were reported among the prednisone-treated patients. To extend these observations, the United States Cystic Fibrosis Foundation sponsored a multicenter double-blind, placebo-controlled trial of alternate-day prednisone. Since March 1986, 283 patients with cystic fibrosis, followed up at 15 centers in the United States and Canada, have been enrolled in this trial. Patients 5 through 14 years of age with mild-to-moderate pulmonary disease were randomly assigned to receive prednisone 2 mg/kg (high-dose) every other day, prednisone 1 mg/kg (low-dose) every other day, or placebo. On entry into the study, patients in the three groups were closely matched by a variety of clinical and laboratory parameters (Table 1).

Patients are closely monitored at 3-month intervals for both efficacy and side effects. An interim analysis is carried out every 6 months and the results are reviewed by an unblinded study ombudsman. Initially, 95 patients were randomly assigned to the high-dose group, 94 to the low-dose group, and 94 to the placebo group. At the time of the most recent interim analysis, mean duration in the study was 33.9 months for the high-dose group, 35.3 months for the low-dose group, and 36.8 months for the placebo group.
Fetal Hemoglobin in Neonatal Anemia
Authors: KOELLER DAVID M.
Published: December 2021

To the Editor.—

A recent paper in Pediatrics by Bard and Prosmanne1 described an elevation of fetal hemoglobin (Hb-F) production in infants with bronchopulmonary dysplasia (BPD) and oxygen dependency. The authors described a novel approach to the evaluation of occult hypoxemia in infants, with potential application in a wide range of disorders. However, in their paper the etiology of the elevation of Hb-F production in BPD patients may have been due to factors other than pulmonary disease.
Fetal Hemoglobin in Neonatal Anemia
Authors: BARD HARRY
Published: December 2021

In Reply.—

The hypothesis being tested was that increased HbF synthesis which is an erythropoietic response to hypoxemia could occur in infants with BPD. Hypoxemia as a result of anemia should result in the same phenomena. Dr Koeller is correct in noting that newborn infants requiring intensive care have frequent blood sampling; however, because intensive care also includes maintaining physiological blood volume and hematocrit, anemia was not a factor for the increased production of HbF reported in this study.
Encopresis Caused by Mother's Stoma
Authors: PILAPIL VIRGILIO R.
Published: December 2021

In Reply.—

I appreciate the opportunity to comment on the case report "Encopresis Caused by Mother's Stoma" by de Vos et al. The situation that led to constipation and encopresis in their case, although differing from that of mine,1 nevertheless created the same effect of producing severe anxiety in the child when she needed to assume her bowel function in the usual manner and setting. I have no doubt that there could be many other parallel situations in which bowel function is impaired by fearful thoughts and anxiety as a consequence of a viewed or imagined situation that may relate to bowel function or use of the toilet.
Spatially Localized Magnetic Resonance Spectroscopy of the Brains of Normal and Asphyxiated Newborns
Authors: Moorcraft J. , Bolas N. M. , Ives N. K. , Sutton P. , Blackledge M. J. , Rajagopalan B. , Hope P. L. , Radda G. K.
Published: December 2021

Phase-modulated rotating frame imaging is a modification of magnetic resonance spectroscopy, which uses a linear radiofrequency field gradient to obtain spatially localized biochemical information. Phase-modulated rotating frame imaging was used to study regional cerebral energy metabolism in the brains of 9 normal newborns and 25 newborns after birth asphyxia. Relative concentrations of phosphorus-containing metabolites and intracellular pH were determined for brain tissue at three specified depths below the brain surface for all neonates. Wide variations in metabolite ratios were seen among normal neonates, and considerable metabolic heterogeneity was demonstrated in individual neonates by depth-resolved spectroscopy. Asphyxiated neonates with severe hypoxic-ischemic encephalopathy and a poor neurodevelopmental outcome showed the expected rise in inorganic orthophosphate and fall in phosphocreatine concentrations in both global and spatially localized spectra. Phase-modulated rotating frame imaging showed that metabolic derangement was less in superficial than in deeper brain tissue. The inorganic orthophosphateadenosine triphosphate ratio from 1 to 2 cm below the brain surface was more accurate than any global metabolite ratio for the identification of neonates with a poor short-term outcome. These data are consistent with the known vulnerability of subcortical brain tissue to hypoxic-ischemic injury in the full-term neonate.
Hypoxanthine Levels in Vitreous Humor: Evidence of Hypoxia in Most Infants Who Died of Sudden Infant Death Syndrome
Authors: Rognum Torleiv O. , Saugstad Ola D.
Published: December 2021

Postmortem changes of the hypoxanthine in vitreous humor in humans were investigated. Hypoxanthine is formed from hypoxic degradation of adenosine monophosphate. Repeated sampling was performed in 13 deceased adults. Keeping the bodies at +6°C, the increase of the hypoxanthine levels was estimated to 3.5 µmol/L per hour when sampling was started more than 12 hours after death (range 2.8 to 5.6 µmol/L per hour). Results of hypoxanthine measurements from vitreous humor in 73 infants with sudden infant death syndrome, 17 infants and children who died sudden violent deaths, and 6 neonates who died suddenly without hypoxemia prior to death were corrected according to the expected postmortem hypoxanthine increase. The time between death and autopsy was similar in the three groups studied. The corrected median hypoxanthine level in the group with sudden infant death syndrome was 227 µmol/L, which is significantly higher than in the other groups; 22 µmol/L in the group who had violent deaths (P < .01), and 0 µmol/L in the neonate group (P < .01). The findings seem to confirm that sudden infant death is preceded by a relatively long period of tissue hypoxia in most cases.
Location of Port-Wine Stains and the Likelihood of Ophthalmic and/or Central Nervous System Complications
Authors: Tallman B. , Tan O. T. , Trainor Shawn , Morelli J. G. , Weston W. L. , Piepenbrink J. , Stafford T. J.
Published: December 2021

Of 310 patients with port-wine stains, 68% had more than one dermatome involved; 85% had unilateral and 15% had a bilateral distribution of their port-wine stain. At the time of examination, 8% of all patients with trigeminal port-wine stains had evidence of eye and/or central nervous system (CNS) involvement. Extensive involvement, with port-wine stain over the trunk and extremities as well as the head and neck, was observed in 12%. Patients who did not have port-wine stains on the areas served by branches V1 and V2 of the trigeminal nerve had no signs or symptoms of eye and/or CNS involvement. Port-wine stains of the eyelids, bilateral distribution of the birthmark, and unilateral port-wine stains involving all three branches of the trigeminal nerve were associated with a significantly higher likelihood of having eye and/or CNS complications. Twenty-four percent of those with bilateral trigeminal nerve port-wine stains had eye and/or CNS involvement compared with 6% of those with unilateral lesions. All those who had eye and/or CNS complications had port-wine stain involvement of the eyelids; in 91% both upper and lower eyelids were involved, whereas in 9% only the lower eyelid was involved. None of those with upper eyelid port-wine stains alone had eye and/or CNS complications. In addition, 3 (75%) of the 4 subjects with seizures alone had bilateral port-wine stain involvement. A third group, those with unilateral V1, V2, and V3, port-wine stains, had eye and/or CNS complications in 3 (19%) of 16 subjects. Therefore, persons who have port-wine stains of the eyelids, unilateral V1, V2, V3, port-wine stains, or bilateral lesions should be screened for glaucoma and have appropriate testing for CNS involvement.