bluuebunny/crossref_metadata_2025 huggingface dataset:
Parents' and Children's Adiposity and Eating Style
Authors: Johnson Susan L. , Birch Leann L.
Published: December 2021

Objective. To investigate children's ability to self-regulate energy intake and to determine whether individual differences in the precision of food intake regulation are related to children's anthropometric measures. We collected information pertaining to parental adiposity and dieting practices, as well as mothers' child-feeding practices. Of special interest was the degree of control imposed by mothers over their children's food intake. Our intent was to explore whether these variables might influence children's regulation of energy intake.

Subjects and setting. Seventy-seven 3-5-year-old children who attended a university preschool setting and their parents participated in this experiment.

Measurements and main results. Children completed controlled, two-part meals used to estimate their ability to adjust food intake in response to changes in caloric density of the diet. An eating index, reflecting children's precision in the ability to regulate energy intake, was correlated to children's anthropometric measures. These correlations provided evidence for a relation between children's body fat stores and their responsiveness to caloric density cues: Pearson correlation coefficients revealed that children with greater body fat stores were less able to regulate energy intake accurately. The best predictor of children's ability to regulate energy intake was parental control in the feeding situation: mothers who were more controlling of their children's food intake had children who showed less ability to self-regulate energy intake (r = -.67, P < .0001).

Conclusions. These findings suggest that the optimal environment for children's development of self-control of energy intake is that in which parents provide healthy food choices but allow children to assume control of how much they consume.
Maternal and Child Health Bureau: Roots
Authors: Hutchins Vince L.
Published: December 2021

The Maternal and Child Health Bureau has roots that go back over 80 years to the creation of the United States Children's Bureau on April 9, 1912, when President William Howard Taft approved an Act of Congress that created the Children's Bureau and directed it "to investigate and report on all matters pertaining to the welfare of children and child life among all classes of our people." This was the federal government's first recognition that it has a responsibility to promote the welfare of our nation's children. The Bureau's Chief was to be appointed by the President with the advice and consent of the Senate. Originally placed in the Department of Commerce and Labor, it was transferred to the newly formed Department of Labor in March, 1913.

The Children's Bureau was a logical sequel to several child-oriented social and public health activities of the late 19th century: the establishment of milk stations; concern with the spread of communicable disease after compulsory school attendance laws were passed; the movement to outlaw child labor; and, the opening of Settlement Houses. Lillian Wald, organizer of public health nursing, an ardent fighter against child labor, and the founder of the Henry Street Settlement in New York City, was the person who first suggested a federal Children's Bureau. A bill, with the support of President Theodore Roosevelt, was introduced in both houses of Congress in 1906 and annually during the next 6 years. It met with fierce opposition both from states which felt that the federal government was usurping their responsibility for the welfare of children and from those who feared that it would give federal employees the right to enter and regulate the homes of private citizens.
Classroom Behavior of Very Low Birth Weight Elementary School Children
Authors: Klebanov Pamela Kato , Brooks-Gunn Jeanne , McCormick Marie C.
Published: December 2021

Objective. To examine the effect of birth weight on the classroom behavior of children during elementary school (N = 1120; mean age = 9.16 years).

Design. The study used an inception cohort.

Setting/Participants. Participants were from two previously studied multi-site cohorts: very low birth weight (VLBW) children referred to participating intensive care units and heavier low birth weight (HLBW) children from a stratified random sample of births in geographically defined regions. Teacher reports of children's behavior were obtained for 80% of those eligible. Information was obtained for 137 children who were extremely low birth weight (ELBW, ≤1000 g at birth), 223 who were other very low birth weight (OVLBW, 1001 to 1500 g), 434 who were HLBW (1501 to 2500 g), and 326 who were normal birth weight (NBW, > 2500 g).

Main Outcome Measures. The child's teacher provided reports of language and attention in the classroom, behavior problems, and social competence.

Results. Comparisons were made among the four birth weight groups: ELBW, OVLBW, HLBW, and NBW. The ELBW children had lower attention and language skills, overall social competence, scholastic competence, and athletic ability than all other birth weight groups as measured by classroom teachers, even when controlling for neonatal stay, child's gender and ethnicity, and maternal education. All low birth weight (LBW) children had lower attention and language skills and scholastic competence and higher daydreaming and hyperactivity scores than NBW children. White children and children with more educated mothers generally had greater language and attention and social competence scores and fewer behavior problems; girls had fewer behavior problems than boys. Neonatal health was generally not associated with outcomes, except that healthier children had lower anxiety scores. The classroom behavior of LBW (< 2500 g) children was rated by teachers as poor, even for children who had not failed a grade; LBW children who are on grade level still may be at risk for school problems. Differences between ELBW and NBW children persisted for overall language and attention and social competence scores even when additional controls were added for sociodemographic and familial variables. Of these variables, maternal depression and home environment were significantly associated with social competence scores.
Fluoroscopic Foley Catheter Removal of Esophageal Foreign Bodies in Children: Experience With 415 Episodes
Authors: Schunk Jeff E. , Harrison A. Marc , Corneli Howard M. , Nixon G. William
Published: December 2021

Objective. This study sought to investigate the safety and efficacy of the fluoroscopic Foley catheter technique (FFCT) for removal of esophageal foreign bodies (EFBs) in children, and to identify factors associated with decreased success.

Design/Setting/Patients. An 11-year retrospective review of all pediatric patients undergoing the FFCT for removal of EFBs at a tertiary-care children's hospital was performed.

Results. Four-hundred and fifteen cases are reported. The median age was 29 months (range, 4 to 193); children ≤ 24 months accounted for 45% (185) of the cases. Of all episodes 86% (355) involved children without known esophageal pathology. Coins comprised 76% (316) of the EFBs.

The FFCT was successful in 91% (378) of the cases. In the 60 episodes involving children with underlying esophageal pathology, the technique had an 83% success rate compared to 92% in children without known pathology (P < .05). There were 290 patients where the duration of impaction was known. The success rate was 96% if the duration was 3 days or less compared to 50% if the duration was longer (P < .0001). Though the overall success in children ≤ 24 months was less than older children (88% vs 94%, P < .05), this effect disappeared when corrected for duration of impaction.

Minor complications occurred in 2% of the episodes, and major complications were noted in 1%.

Conclusions. The FFCT appears to be a safe and effective method for removal of EFBs especially in children without underlying esophageal lesions and a duration of impaction ≤ 3 days. Major complications are rare.
False Allegations of Sexual Touching by Physicians in The Practice of Pediatrics
Authors: Silber Tomas J.
Published: December 2021

It is normal for adolescents to be concerned about their bodies and harbor thoughts and worries about their sexuality.1 This can be manifested as anxiety during the physical examination, especially when the genital examination is performed.2-4 Because of this and the possibility of misinterpreting medical procedures such as breast and pelvic examinations, it has been suggested that male practitioners examine female adolescent patients in the presence of a chaperone. Studies involving chaperones use in office practice show a wide variation of approaches.5-7

Recently there has been an increasing recognition of sexual contact between physicians and their patients, both in the medical,8 psychiatric,9 and the lay literature,10 raising consciousness among the public about possible inappropriate sexual behavior by professionals.
Localized Intestinal Perforation
Authors: The' T. G. , Young M. , Rosser S.
Published: December 2021

We read with pleasure Buchheit's1 article comparing the clinical findings in 21 preterm infants with localized intestinal perforation (LP) versus those of 21 preterm infants with intestinal perforation secondary to necrotizing enterocolitis (NEC). However, we would be grateful if the authors would clarify two points:

1. How are their 21 cases of LP different from the >500 cases of idiopathic gastrointestinal perforation reviewed by Lloyd in 1979?2

2. The authors hypothesized that the placement of midthoracic umbilical artery catheters (UACs) would be a significant factor in the etiology of LP.
Parasite Contamination of Sand and Soil From Day-Care Sandboxes and Play Areas
Authors: Gyorkos Theresa W. , Kokoskin Evelyne , Maclean J. Dick , Soto Julio C.
Published: December 2021

These results document the presence of potentially pathogenic zoonotic helminth parasites in the day-care environment. Evidence from the literature regarding the health risk to children is insufficient and highlights the need for further research assessing the risk of human infection and subsequent morbidity, the viability of these parasites under different environmental conditions, and practical issues related to the management of sand and soil.
Injuries in Child-Care Centers: Rates, Severity, and Etiology
Authors: Alkon Abbey , Kaiser Pamela J. , Tschann Jeanne M. , Boyce W. Thomas , Genevro Janice L. , Chesney Margaret
Published: December 2021

Injuries are the leading cause of mortality among children.1 To develop effective injury prevention programs, more information is needed regarding the incidence, severity, and etiology of injuries sustained by children of different age groups and in different settings.

Childhood injury research has focused primarily on severe injuries and the physical environmental hazards that contribute to those injuries.2-4 Although the incidence of severe injuries is critically important from the perspective of morbidity and mortality, these injuries are relatively rare and consequently difficult to study. Scheidt5 has suggested that it may be useful to determine whether there are reliable markers of risk for severe injuries that are based on more frequently occurring events or easily observable indicators. Minor injuries, the most common type of injury that occurs in child-care settings,6-8 may be a marker of risk for severe injuries; however, previous research has not investigated the relationship between minor and severe injuries.

Childhood injury research has also typically focused on a single category of etiologic factors, generally either environmental factors such as climbing equipment and impact surfaces,2,9 or child factors such as aggression, overactivity, and personal characteristics.10-11 The relative importance of different etiologic factors and the joint contributions of child-related and environmental factors have not been thoroughly examined.

Research on childhood injuries indicates that a small subgroup of children, usually 15% to 20% of a sample, sustain the majority of injuries in any given setting.6,8,10,12 This phenomenon may be the result of chance or characteristics of the subgroup that may differ from those of other children.
Health in Child Day Care: The Physician—Child-Care-Provider Relationship
Authors: Taras Howard L.
Published: December 2021

Health promotion and disease prevention strategies for child day-care have not kept pace with the needs of children. One example is the inconsistent interaction between community physicians and child-cane providers. Although there isn't yet data documenting benefits of increased communication between health practitioners and child-care professionals, there is speculation by many that these sorts of physician-community liaisons will help to close serious gaps in current health-care practices.1-3 This paper reviews how increased physician involvement could improve the health situation in child day care and explores ways physicians can become more involved.

THE HEALTH NEEDS

Need for Consultants

There are basic and predictable health issues that arise from grouping young children together. They are topics for research and discussion among epidemiologists, medical investigators, and other health professionals. The issues include exclusion criteria for attendance in day care, spread of respiratory and gastrointestinal infections,4 the potential for childhood viruses to affect unborn children of pregnant care givers,5 medication policies,6 and the pros and cons of "sick-care" centers.7 Other health issues such as child development and emotional, behavioral, and nutritional health of children are also under study.8 This body of literature has served to define most health consultation needs of child day-care programs. Few day-care centers on family day-care homes actually use a health consultant.9 It is hoped that publication of the American Public Health Association's and American Academy of Pediatrics' (APHA/AAP's) National Health and Safety Performance Standards10 and its distribution to health professionals and child-care providers will help to change that. Its success depends partly on whether health professionals will be available, willing, and trained to serve as health consultants.
Economic Issues in Child-Care Policy
Authors: Bergmann Barbara R.
Published: December 2021

There are four important, interrelated issues in child-care policy, on which economists can make contributions. One is the adequacy of the supply of "affordable" child care. A second is the proper role of government, if any, in providing or paying for child care. A third is whether the public could afford to have the government provide child care, assuming that such provision was deemed appropriate and desirable. A fourth is the standards of quality that should be mandated by the government for federal or private-sector child-care facilities. The standard literature tends to be scant on all of these topics.1,2

Economists are seldom unanimous in their opinions, and they certainly do not agree on child-care issues. The now-sizeable school of economists led by Milton Friedman, whose members have staffed the administrations of the last two US presidents, believe that, with very few exceptions, government interventions into the economic functioning of the citizens and their businesses are pernicious.

Economists faithful to this tradition argue that parents should buy child care out of their own incomes from nongovernmental providers and that those providers should be regulated minimally if at all.

An opposing point of view is that child care is different in important ways from such commodities as shoes and strawberries. Children are the direct consumers of child care, and government intervention in protection of their interests is justified because they lack abilities that can be assumed to reside in the usual participants in the economy. Further, child care provided by or subsidized by government is an indispensable ingredient of any program aimed at bringing about the rescue of the 20% of American children who are officially designated as poor, who are living in conditions that should not be tolerated by a rich and civilized country.1
An International Perspective on Child Day-Care Health
Authors: MD, PhD Patrick Olin , Tandon B. N. , Meme Julius S. , Ford-Jones E. Lee , Belsey Mark , Chang Albert
Published: December 2021

If we are committed to the health and development of children, we need to recognize that the vast majority of the world's women are working women. In Africa, 80% of the women are actively engaged in economic activities outside the home. The "economic miracle" in Southeast Asia was made possible by the nimble fingers of thousands of women working in textile and electronics factories.

There is need for pre-day-care advocacy for infants, through promotion of breast feeding and maternity leave. When the mother returns to work, the standard of the International Labor Organization should be applied, namely "...the care of children while the parents are working cannot be ignored because it forms a focal point on which three main concerns of development policy—work, health, and education—converge." Several principles emerged from the presentations in the international panel:

1. Child-care programs must be community based, using the resources of the families and the community organizations themselves.

2. Programs require the active involvement of the communities, women's groups, and other partners.

3. Programs are modified by innovations created by community organizations, universities, and other groups.

4. Programs require the mobilization of trained young men and women into the field of early childhood education and development.

This international panel provided an overall uniting theme, that throughout the world the hope for the survival and better life for children unites parents of every country and every creed. This is one of the most powerful and strongest motivational resources in the world. We need to recognize the power of this hope and address that hope, providing with a certain degree of humility that there exist no single model, and no single country has all the answers. By respecting the ideas of the many innovations and different approaches of women, parents, and families, we can find the answers. There is a clear need for national networks as well as for international networks, exchanges of information, sharing of experience, and mobilization of the social resources in advocating early childhood education and development for the world's children.
Translating Science Into Practice in Child Day-Care Settings
Authors: Roper William L. , Thacker Stephen B. , Teutsch Steven M.
Published: December 2021

We trust our children, indeed our world's future, to care givers in day-care settings for as much as 8 to 10 hours each day. Through hard work and good science, the US and other countries have established rigorous health standards for day care, but we must do more. We must give others—the institutions and the individuals who care for our children—the tools to foster a healthful environment and promote healthy behaviors. The vision of the Centers for Disease Control and Prevention (CDC) is "healthy people in a healthy world to achieve a quality life." We must work together to make that vision a reality for our children in day care.

Our paper addresses translating scientific knowledge into practice and making prevention a practical reality. We outline the concepts underlying the assessment of the effectiveness of prevention activities and illustrate its use in three case studies from child day care. We close with a description of the prevention effectiveness program recently initiated at CDC.

PREVENTION EFFECTIVENESS

It is important to assess the effectiveness of prevention practices to ensure that public health programs are built on scientifically sound strategies for improving the quality of life and reducing unnecessary morbidity and premature mortality.1 There are three basic approaches to prevention: clinical, behavioral, and environmental. Clinical prevention strategies rely on the one-on-one, provider-to-patient interaction, which underlie immunization and screening programs. These interactions usually occur within our regular health-care delivery system.

Behavioral techniques use a broad array of strategies to encourage lifestyle changes, such as exercise and healthful diets.
Developmental and Service Needs of School-Age Children With Human Immunodeficiency Virus Infection: A Descriptive Study
Authors: Papola Pamela , Alvarez Mayra , Cohen Herbert J.
Published: December 2021

Objective. To describe the developmental functioning and service needs of a group of school-age children with human immunodeficiency virus (HIV) infection.

Design. Retrospective data were collected through chart reviews and follow-up telephone calls to primary care givers.

Setting. A multidisciplinary team provided care at a developmental diagnostic and treatment center.

Patients. Cases were 90 school-age children (ages 5 to 14 years) with presumed perinatally acquired HIV infection.

Results. Forty-four percent of the 86 children on whom there were diagnoses were functioning in the low average to average range of intelligence, whereas 56% were functioning in the borderline range or lower. Fifty percent of the children demonstrated significant language impairments, with 28% also demonstrating an articulation disorder. Thirty-six of the children (42%) were formally diagnosed as having emotional/behavioral disorders. Eighty-six of the children were in school-based programs and of that group, 74% were in special education classes and receiving related services.

Conclusions. Most of the children in this study demonstrated deficits in the cognitive and learning areas, although they are clearly functioning better than earlier studies of children with HIV infection would have predicted. Their service needs include alternative living arrangements, remedial education, and psychotherapeutic interventions. The children's increasing longevity will place strains on the respective service systems.
Reducing the Risk of Human Immunodeficiency Virus Infection Associated With Illicit Drug Use
Authors:   Provisional Committee on Pediatric AIDS
Published: December 2021

Injection and other illicit drug use plays a major role in the transmission of infection with human immunodeficiency virus (HIV), including cases among infants, children, and adolescents.1,2 Transmission to adolescents and adults occurs either directly from contaminated drug paraphernalia, including needles and syringes, or through sexual contact with an infected partner. Transmission to infants occurs transplacentally or perinatally from mothers who are most often either drug users themselves, or who have become infected from sexual partners who are injection drug users. It is therefore clear that a reduction in the transmission of HIV infection secondary to illicit drug use and the use of contaminated injection equipment is a pediatric concern and should be part of any prevention program.

The adverse consequences of illicit drug use are multiple and certainly not limited to the potential acquisition and transmission of HIV infection. Ideally, treatment and prevention programs should seek to reduce drug use itself, not solely HIV infection. However, many users of injection drugs do not enter drug treatment, remain in treatment, or maintain complete abstinence while in treatment. Therefore, promoting safer injection practices can provide an important public health benefit in lowering the risk of HIV transmission, while simultaneous efforts continue to reduce and eliminate drug use.

Initiatives with the singular objective of increasing access to sterile equipment are understandably controversial, as they do not directly address the causes and broader consequences of illicit drug use. In addition, there are continuing concerns that any program increasing access to sterile needles and syringes might actually increase injection drug use by creating the impression of relative safety and tacit community approval for such behavior.
Letter To the Editor
Authors: Stewart Dan L. , Davis-Freeman Stacia
Published: December 2021

The commentary by Bess and Paradise1 addresses the recommendation that was made in a National Institutes of Health (NIH) Consensus Statement2 that hearing screening be performed within the first 3 months of life, preferably before discharge from the hospital newborn nursery. They state that further studies related to many issues of newborn hearing screening are crucial and that, in fact, no rational decision on undertaking universal screening for infant hearing loss is possible until studies are conducted and their results tabulated.
Type of Day-Care Setting and Risk of Repeated Infections
Authors: Collet J.-P. , Burtin P. , Bossard N. , Ducruet T. , Kramer M. S. , Floret D.
Published: December 2021

As a direct result of demographic and sociologic changes, increasing numbers of children are attending day care in all industrialized countries. Unfortunately, the close physical contact among children in day care favors the transmission of infectious diseases. Previous studies have focused mainly on the risk of upper respiratory tract infection (URTI) and otitis media, which are reported to occur two to three times more frequently in children attending day care centers than in those cared for at home.1-7 Similarly day-care attendance has been found to be associated with an increased risk of lower respiratory tract infections (LRTI),8 gastroenteritis,9 as well as with the dissemination of infections caused by hepatitis A,10 cytomegalovirus,11 and H. influenzae type b.12

Despite convincing evidence for a higher risk of infection in day-care centers, most parents do not have an acceptable alternative to day care. It may be more useful, therefore, to identify the types of day-care structures associated with lower infectious risks. Family day care, in which several children are cared for in another family setting, offers a viable alternative to group day care, but previous studies have provided conflicting information on the risk of respiratory infections and otitis media in this setting. In four studies, the risks observed in family day care were very close to those of children who remained at home3-5,8; in two, they were intermediate between the risks at home and those in formal day-care centers6,7; while in two others, they were very close to those in day-care centers.13 These conflicting results can be explained by several factors including the lack of strict definitions for the different types of day-care settings and failure to control for the potentially important confounding differences in the number of children attending each type, the age range (from 2 to 60 months), and the time per week spent in the setting.
The American Pediatric Society
Authors: Pearson Howard A.
Published: December 2021

Pediatrics as a defined area in medicine did not emerge on the American scene until well into the 19th century. With few definitive therapies and little understanding of the pathogenesis of diseases, the "proto-pediatrics" of the first half of the nineteenth century in the United States was largely descriptive and empiric, but the problems of children were monumental. Deadly infectious diseases, including diphtheria, measles, and cholera infantum (infectious diarrhea), killed tens of thousands of American children annually. Deficiency diseases, especially scurvy and rickets, were rampant. Because children were considered chattel, abuse in the home and work place was prevalent. The Society for Prevention of Cruelty to Animals founded in 1866 conducted the first organized effort to prevent abuse and protect children.
Joint Committee on Infant Hearing 1994 Position Statement
Authors:   Joint Committee on Infant Hearing
Published: December 2021

This 1994 Position Statement was developed by the Joint Committee on Infant Hearing. Joint committee member organizations that approved this statement and their respective representatives who prepared this statement include the American Speech-Language-Hearing Association (Allan O. Diefendorf, PhD, Chair; Deborah Hayes, PhD; and Evelyn Cherow, MA, ex officio); the American Academy of Otolaryngology—Head and Neck Surgery (Patrick E. Brookhouser, MD, and Stephen Epstein, MD); the American Academy of Audiology (Terese Finitzo, PhD, and Jerry Northern, PhD); the American Academy of Pediatrics (Allen Erenberg, MD, and Nancy Roizen, MD); and the Directors of Speech and Hearing Programs in State Health and Welfare Agencies (Thomas Mahoney, PhD, and Kathie J. Mense, MS).

The Joint Committee on Infant Hearing endorses the goal of universal detection of infants with hearing loss as early as possible. All infants with hearing loss should be identified before 3 months of age, and receive intervention by 6 months of age.

I. BACKGROUND

In 1982, the Joint Committee on Infant Hearing recommended identification of infants at risk for hearing loss in terms of specific risk factors and suggested a follow-up audiologic evaluation until an accurate assessment of hearing could be made (Joint Committee on Infant Hearing, 1982; American Academy of Pediatrics, 1982). In 1990, the Position Statement was modified to expand the list of risk factors and recommend a specific hearing screening protocol.

In concert with the national initiative Healthy People 2000 (US Department of Health and Human Services, Public Health Service, 1990), which promotes early identification of children with hearing loss, this 1994 Position Statement addresses the need to identify all infants with hearing loss.
Universal Versus Selective Screening for Lead in Children
Authors: Kawatu David , Weinberger Howard L. , Blatt Steven D.
Published: December 2021

In his commentary in the February 1994 issue of Pediatrics, Dr Harvey recommends selective screening for lead in children based on the lack of evidence that a blood lead (BPb) level <20 µg/dL leads to important consequences if not remediated and that the prevalence of BPb > 10 µg is too low to justify universal screening.1 We agree that all screening programs should be continually evaluated so that timely refinements can be made. Such evaluations should be based on a fair representation of all available evidence.
Letters to the Editor
Authors: Harvey Birt
Published: December 2021

Kawatu et al state that effects of lead on cognitive and neurobehavioral development in children may be seen at the 10 to 15 µg/dL blood lead (BPb) level, and they note that I did not cite many articles supporting a dose-dependent adverse effect of lead. Since I granted in my commentary that there may be an effect at BPb levels even below 10 µg/dL, I felt it unnecessary to cite many articles supporting this premise. The question is, at low BPb levels, are there important consequences for the individual child?
The Newborn's Spo2: A Routine Vital Sign Whose Time Has Come?
Authors: Katzman Gerald H.
Published: December 2021

Presently, it is recommended that temperature, heart and respiratory rates, skin color, adequacy of peripheral circulation, type of respiration, level of consciousness, tone, and activity be monitored every 30 minutes until the newborn's condition has remained stable for 2 hours.1 Skin color, as the single suggested screen for level of oxygenation, is probably not an adequate indicator of the status of oxygenation. Indeed, the concept of "subcyanotic anoxia"2 is not new. Cyanosis may not be obvious when desaturation is mild.
Letters to the Editor
Authors: Poets Christian F. , Southall David P.
Published: December 2021

Dr Katzman raises an important issue: the unreliability of clinical signs in detecting hypoxemia. In our recent review,1 we omitted emphasizing the dangers involved in relying on cyanosis as an indicator of hypoxemia. Cyanosis occurs if there is >50 g/L of reduced hemoglobin. This implies that cyanosis will occur at, for example, an oxygen saturation (Sao2) of 75% in an infant with a total hemoglobin content of 200 g/L, but only at a Sao2 of 50% in an infant who is mildly anemic (Hb 100 g/L).
Surfactant Therapy In Neonates With Respiratory Deterioration Due to Pulmonary Hemorrhage
Authors: Pandit Paresh B. , Dunn Michael S. , Colucci Enza A.
Published: December 2021

Objective. To study the effect of exogenous bovine surfactant on oxygen and ventilatory requirements in neonates with respiratory deterioration due to pulmonary hemorrhage.

Design. Retrospective case series.

Setting. Three regional neonatal intensive care units.

Methods. Infants who received surfactant following a clinically significant pulmonary hemorrhage during the time period July 1991 to December 1993 were identified from a database. Infants were excluded if any other cause was found to explain their deterioration. The primary outcome was change in respiratory status following surfactant therapy, as reflected by oxygenation index (OI) and arterial/Alveolar oxygen ratio. Data points were taken as averages of 3 through 6 hours and 0 through 3 hours for the 6 hours before and after surfactant. Differences were analyzed using analysis of variance for repeated measures, with treatment and time as co-variates.

Results. Fifteen patients fulfilled inclusion criteria. Median values (range): birth weight, 960 g (595 to 4045); age at pulmonary hemorrhage, 24.4 hours (0.3 to 62); and interval between pulmonary hemorrhage and surfactant therapy, 10 hours (3.7 to 46.5). Mean OI improved from 24.6, at 0 to 3 hours presurfactant, to 8.6 at 3 to 6 hours postsurfactant (P .001). No patient deteriorated following surfactant therapy. The primary respiratory diagnosis was respiratory distress syndrome (RDS) in 8, meconium aspiration syndrome in 3, and isolated pulmonary hemorrhage in 4. All those with RDS had also received surfactant before their pulmonary hemorrhage.

Conclusions. Exogenous surfactant appears to be useful adjunctive therapy in neonates with a clinically significant pulmonary hemorrhage. Its use for this indication should be further investigated by a randomized controlled trial.
Is Continuity of Care Preserved in Children Who Utilize the Pediatric Emergency Department?
Authors: Vivier Patrick M. , Lewander William J. , Block Stanley H. , Simon Peter R. , Alario Anthony J. , Linakis James G.
Published: December 2021

Objective. Inner city families often use multiple sites for nonemergent medical care, including the pediatric emergency department. This practice raises concerns about continuity of care. The present study examined one aspect of continuity of care: Do children who receive care in a pediatric emergency department return to their primary care site so that appropriate follow up may be obtained?

Methods. Over a 4-week period two groups of neighborhood health center children were studied: Those who sought care at the pediatric emergency department and those who were "walk-ins" at the health centers. All visits during the 4-week study period which resulted in a recommendation for the child to be seen within 6 weeks at the health centers were included in the analysis.

Results. During the study period there were 87 patient visits to the pediatric emergency department with a documented physician instruction to be seen at their health center within 6 weeks. In 66 (76%) of the cases, the patient was seen at one of the health centers during the 6 weeks following the pediatric emergency department visit. There were 146 "walk-in" visits to the health centers with a documented physician instruction to be seen again at the health centers during the 6 weeks following the walk-in visit. In 111 (76%) of the cases, the patient was seen during the 6-week period.

Conclusion. Our study shows that revisit rates were comparable for the two groups. We conclude that the rate of compliance with follow-up recommendations is similar for those who utilized the pediatric emergency department versus those who used the primary care site.
LIFETIME COSTS OF BIRTH DEFECTS CALCULATED
Authors: L. J. F.
Published: December 2021

Coinvestigators at the University of Utah and the University of California, Davis and Berkeley, estimated the indirect mortality and morbidity costs, as well as the direct costs of medical care, developmental services, and special education over the entire lifespan of those born with each birth defect in California in 1988. They found that net per capita medical costs in 1988 dollars are largest for spina bifida ($99 000); heart defects such as truncus arteriosus ($209 000), tetralogy of Fallot ($109 000), and single ventricle ($99 000); and cerebral palsy ($142 000). Long-term care costs for those with cerebral palsy and Down syndrome are high, largely reflecting expenditures for State developmental services. Total special education costs in California are substantial, exceeding 20% of total medical costs for many conditions. They are particularly high for those with Down syndrome ($37.1 million), cerebral palsy ($28.6 million), and spina bifida (5.3 million).

Athrough birth defects are the leading cause of infant death in the United States, most children with birth defects do not die in infancy, note the researchers. They conclude that, based on their estimates of societal costs, additional research on the etiology and epidemiology of birth defects could lead to new strategies and, thus, have a net economic benefit.

For more information, see "Estimates of the Economic Costs of Birth Defects," by Norman J. Waitzman, PhD, Patrick S. Romano, MPH, and Richard M. Scheffler, PhD, in the Summer 1994 issue of Inquiry 31, pp. 188-204.

Research Activities, A.H.C.P.R., October/November 1994
Pregnancy Experience after Delivery of a Child with a Major Birth Defect: A Population Study
Authors: Davis Margarett K. , Khoury Muin J. , Erickson J. David
Published: December 2021

Objective. Data from a large population-based, case-control study were analyzed to determine whether women giving birth to children with major birth defects have different subsequent pregnancy patterns than those giving birth to live-born babies without defects. Other studies examining this phenomenon have been smaller, have not been population-based, or have not addressed the different effects that a wide range of major defects might have on mothers' subsequent pregnancy rates.

Methods. Mothers of 4918 infants with major birth defects born from 1968 through 1980 in metropolitan Atlanta were compared with mothers of 3029 control infants, frequency-matched on birth year, birth hospital, and race.

Results. The pregnancy rate in the first 3 years after the index birth was higher among case mothers (36%) than among control mothers (30%, P < .0001). This excess was seen for mothers of stillborn case infants (64%) and mothers of case infants who died in infancy (58%), but not for mothers of case infants who survived the first year of life (31%). Pregnancy rates varied by birth defect type. Maternal and infant factors varied among case and control subjects and influenced subsequent pregnancy rates.

Conclusion. The reproductive behavior observed in this study supports the theory that mothers of nonsurviving children with birth defects compensate by acting to "replace" the lost child. Reproductive behavior was also strongly associated with having completed a previous pregnancy and by the type of birth defect.
The Treatment of Attention-Deficit Hyperactivity Disorder in Tourette's Syndrome: A Double-Blind Placebo-Controlled Study With Clonidine and Desipramine
Authors: Singer Harvey S. , Brown Janice , Quaskey Shirley , Rosenberg Leon A. , Mellits E. David , Denckla Martha B.
Published: December 2021

Objectives. Because psychostimulants can exacerbate preexisting motor/phonic tics in individuals with Tourette's syndrome (TS), a clinical trial was performed to examine the ability of clonidine and desipramine to modify attention-deficit hyperactivity disorder (ADHD) behaviors in children with TS + ADHD.

Methods. A double-blind, placebo-controlled protocol was used in which each subject served as his or her own control and received, in a randomly assigned fashion, 6-week medication cycles with clonidine (0.05 mg four times daily), desipramine (25 mg four times daily), and placebo.

Results. Thirty-seven children with TS + ADHD between the ages 7 to 13 years and of normal intellect were recruited, and 34 (31 males, 3 females) completed the entire protocol. Outcome measures for ADHD included Parent and Teacher Child Behavior Checklists (CBCL), continuous performance tests, and neuropsychologic tests of executive function. Several markers for ADHD were shown to improve significantly (P < .05) after treatment with desipramine (parent linear analogue rating, parent CBCL "hyperactivity" subscale, and teacher CBCL subscales "nervous/overactive," "anxious," and "unpopular"). Improvement with desipramine was always superior to that noted with clonidine. Clinical improvement did not correlate with drug blood levels. On measures of tic severity, neither drug made tics worse. Desipramine showed a statistically significant improvement on a global linear analogue scale, but not on the Hopkins Motor/Vocal Tic Severity Scale, the Tourette Syndrome Severity Scale, or the Yale Global Tic Severity Scale. Clonidine did not significantly alter tic severity on any measure.

Conclusion. The results of this study suggest that desipramine may be a useful alternative for the treatment of symptoms of ADHD in children with TS.
Cranial Ultrasound Prediction of Disabling and Nondisabling Cerebral Palsy at Age Two in a Low Birth Weight Population
Authors: Pinto-Martin Jennifer A. , Riolo Stephanie , Cnaan Avital , Holzman Claudia , Susser Mervyn W. , Paneth Nigel
Published: December 2021

Objective. To employ multivariate analytic techniques to assess the association between neonatal cranial ultrasound (US) abnormalities and subsequent cerebral palsy (CP), defined as disabling CP (DCP) or nondisabling CP (NDCP) depending on the level of motor dysfunction.

Design. Prospective cohort study.

Subjects and methods. The Neonatal Brain Hemorrhage Study enrolled a geographically representative sample of 1105 newborns 501 to 2000 g and obtained follow-up data on 777 (86%) of the 901 survivors at age two. One hundred thirteen children (14.6%) had motor findings severe enough to classify them as having CP. The 61 (7.9%) of these children who were disabled by their motor impairment we classified as having DCP. The remaining 52 (6.7%) who had definite neurologic findings (usually mild spastic diplegia) but without evidence of interference with daily living, we classified as having NDCP.

Results. In a multivariate logistic regression model of perinatal and postnatal variables, the following factors were found to be significant risk factors for DCP: parenchymal echodensities/lucencies or ventricular enlargement (PEL/VE) on cranial US (OR = 15.4; 7.6, 31.1), germinal matrix/intraventricular hemorrhage (GM/IVH) (OR = 3.5; 1.7, 6.9) and mechanical ventilation (OR = 2.9; 1.2, 7.1). Fully 93.4% of infants were correctly classified as to presence or absence of DCP on the basis of this model. Birth weight, gestational age, length of hospital stay, gender, race, plurality, presence of labor and Apgar score were not significant independent predictors of DCP. For NDCP, the only risk factor significant in the multivariate model was PEL/VE (OR = 5.3; 2.2, 12.6).

Conclusions. Among perinatal and postnatal factors, cranial US abnormalities are by far the most powerful predictors of disabling CP in low birth weight infants. Although PEL/VE was the strongest predictor, GM/IVH also appeared to independently contribute to the risk of DCP. NDCP in low birth weight infants appears to have a different risk profile than DCP. In particular, it is less closely related to US evidence of perinatal brain injury.
The Education of Pediatricians for Primary Care: The Score After Two Score Years
Authors: Charney Evan
Published: December 2021

In a 1973 monograph on the education of physicians for primary care, Joel Alpert and I wrote, "There are two interrelated and serious problems in our present educational structure—not enough physicians enter primary care and those who do so are not adequately prepared for the job."1 Twenty years and many task forces and exhortatory editorials later, much the same could be said. But that conclusion would not be entirely fair: changes have indeed occurred in the subsequent two score years.

There is now clear consensus that a strong primary care system should be the linchpin of our nation's health care system, with 50 to 60% of physicians as generalists, 2,3 and the medical profession has at least professed to agree with that strategy.4
Ribavirin. Red Book Committee Recommendations Questioned
Authors: Mitchell Ian , Joffe Ari , Newth C. J.L.
Published: December 2021

We wrote this letter to comment on the recently published guidelines on the use of ribavirin for respiratory syncytial virus (RSV) infection,1 and to commend the commentary provided by Drs Wald and Dashefsky questioning these recommendations.2 In addition we point out the recent advertising campaign by ICN Canada where it is claimed that the Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) studies3,4 show "widespread underutilization" of ribavirin for RSV bronchiolitis,5 a conclusion not supported by detailed review of the literature.
Efficacy of Albuterol in the Management of Bronchiolitis
Authors: Serwint Janet
Published: December 2021

I read with interest the article by Gadomski et al entitled Efficacy of Albuterol in the Management of Bronchiolitis.1 It is a thoughtful study regarding an important question with careful attention to the inclusion and exclusion criteria. However, I have the following three concerns.

First of all, I am curious as to why the authors chose to measure outcomes at 30 and 60 minutes. The peak impact of nebulized albuterol is 1 to 2 hours after treatment while that of oral albuterol is 2 to 3 hours after the dose.
The Diagnostic Utility of Bronchoalveolar Lavage in Immunocompetent Children With Unexplained Infiltrates on Chest Radiograph
Authors: Rock Michael J.
Published: December 2021

Objective. To assess the diagnostic utility of bronchoalveolar lavage (BAL) in a heterogeneous group of immunocompetent children with unexplained infiltrates on chest radiograph.

Design. This was a retrospective case series.

Setting. The setting was a tertiary care referral center in an urban children's hospital.

Patients. Twenty-five consecutive children, median age 4 years 6 months, had flexible bronchoscopy with BAL. Preprocedure diagnoses were right middle-lobe syndrome (3 patients), granulomatous lung disease (3 patients), adult respiratory distress syndrome (3 patients), and persistent infiltrate on chest x-ray (16 patients). The majority of patients were receiving parenteral antibiotics before bronchoscopy. BAL fluid was sent for bacterial, viral, fungal, and, if indicated, mycobacterial cultures.

Results. Twenty-seven procedures were performed in 25 patients. A specific diagnosis was made in eight (30%) of the procedures. Four patients had viral infections, two had fungal infections, one had a bacterial infection, and one had a mixed fungal and bacterial infection.

Conclusion. Submitting BAL fluid for bacterial, viral, and fungal culture can be helpful in diagnosing infection in immunocompetent children. Empiric antibiotic therapy remains the standard treatment for pneumonia in children. Bronchoalveolar lavage may yield a diagnosis in patients unresponsive to empiric antibiotics. Careful selection of patients, a bronchoscopist skilled in the procedure, and the risk/benefit ratio all must be considered.