bluuebunny/crossref_metadata_2025 huggingface dataset:
Is Ear Pulling Associated With Ear Infection?
Authors: BAKER ROBERT B.
Published: December 2021

To the Editor.—

I have been impressed over the years by the number of children who were brought to the office by their parents because of a sole complaint of ear pulling. These children had no other symptoms, and their parents were clearly concerned about the possibility of otitis media. I decided to perform a small study within my practice of those children brought in with a chief complaint of ear pulling and to evaluate them for other signs of illness as well as otitis media.
Lack of Money—Barrier to Immunization
Authors: ZIMMERMAN RICHARD K. , GIEBINK G. SCOTT , STREET HEIDI B.
Published: December 2021

To the Editor.—

Schulte et al1 reported in 1991 that 73% of participating Dallas County, Texas, primary care physicians referred some children to immunization clinics in 1988. As a pilot project, we interviewed 31 of 37 (84%) eligible board-certified primary care physicians in urban/suburban areas across Minnesota. Participants rated the likelihood of referring children with various types of insurance coverage to public clinics for immunization. More physicians (52%) were likely to refer children from economically disadvantaged homes without insurance than either children who had Medicaid coverage (10%, P < .001) or private insurance (0%, P < .001).
α-Fetoprotein and Hypothyroidism in Infants
Authors: MIZEJEWSKI G. J. , PASS K. A.
Published: December 2021

To the Editor.—

We recently have documented a relationship between serum α-fetoprotein (AFP) and congenital hypothyroidism (CH) in the newborn period. Previous studies in our laboratory and others had reported a relationship between elevated serum AFP and elevated thyroid-stimulating hormone (TSH)/low thyroxine T4 in newborns and infants in the first few months of life.1-4 The New York State Newborn Screening Program for CH routinely screens more than 300 000 specimens per year diagnosing 120 to 140 confirmed cases of CH annually.
Is the Denver II Developmental Test Worthwhile?
Authors: GLASCOE FRANCES PAGE , BYRNE KAREN E.
Published: December 2021

In Reply.—

We thank Dr Adesman for his timely and insightful comments regarding our research on the Denver II and Dr Dworkin for his accompanying commentary. Our findings, and Dr Adesman's comments, illustrate why it is important for authors to validate their measures prior to publication, whether their instruments are developmental checklists or screening tests. Validation is proof that instruments assess important rather than insignificant aspects of development. Validation enables authors to remove items which fail to concur with diagnostic measures and add items which best predict performance criteria (eg, successful demonstration of kindergarten readiness skills).
Fever Phobia: The Pediatrician's Contribution
Authors: May Ariane , Bauchner Howard
Published: December 2021

Fever phobia, the exaggerated fear of fever, is found among parents of all socioeconomic classes. Pediatricians may inadvertently contribute to fever phobia if their practice and educational message are incongruent. To determine how pediatricians treat fever in their practice, the authors sent a self-administered questionnaire to a sample of members of the American Academy of Pediatrics who lived in Massachusetts. Pediatricians were asked (1) how dangerous they believed fever to be, (2) how they treated fever in their practice, and (3) what types of educational information they gave families regarding fever. One-hundred seventy-two of the 234 (74%) eligible pediatricians returned the survey; 151 were completed. Sixty percent of the respondents were male, and 75% practiced some form of primary or episodic care. Ninety-eight (65%) believed that fever itself could be dangerous to a child, with 58 (60%) of the original 98 citing that a temperature of 104°F or greater could lead to complications such as seizures, brain damage, or death. In practice, 108 (72%) always or often recommended treatment to reduce fever and 96 (89%) of the 108 did so at temperatures between 101° and 102°F. One hundred thirty-one (88%) respondents agreed that a sleeping child with fever should be left undisturbed. One hundred twenty-one (80%) pediatricians always or often tried to educate families about fever during sick-child visits, yet only 38% addressed the dangers of fever. It is concluded that (1) many pediatricians believe that fever (with no underlying treatable cause) greater than 104°F could lead to serious complications and (2) most pediatricians educate families about fever predominately during sickchild visits. Pediatricians may be contributing to fever phobia by presenting mixed messages to parents about fever—for example, by prescribing antipyretics for children with temperatures between 101° and 102°F while recommending that a sleeping child with fever be left undisturbed and by failing to address parental concerns about fever during all types of pediatric visits.
Improving Influenza Vaccination Rates in Children With Asthma: A Test of a Computerized Reminder System and an Analysis of Factors Predicting Vaccination Compliance
Authors: Szilagyi Peter G. , Rodewald Lance E. , Savageau Judy , Yoos Lorrie , Doane Cynthia
Published: December 2021

Fewer than 10% of children with moderate or severe asthma receive an annual influenza vaccination despite their heightened susceptibility to severe infections and recommendations by the American Academy of Pediatrics and the Immunization Practices Advisory Committee that all such children be vaccinated annually. Patient, provider, and system factors leading to this poor vaccination rate are not well understood. This study tested the effectiveness of a computerized reminder system in improving influenza vaccination rates in children with asthma and examined patient barriers to vaccination at one pediatric clinic in an urban teaching hospital. A computer database identified 124 children with moderate or severe asthma. Patients were randomly assigned either to a study group (n = 63), who were sent a personalized letter reminder about the need for an influenza vaccination, or to a control group (n = 61), who received no reminder. Study group mothers were interviewed 2 months after the letter was sent to assess factors associated with receipt of vaccination, including demographic features, parental worry about asthma and vaccine side effects, the four dimensions of the Health Belief Model, and health locus of control beliefs. Nineteen study group patients (30%) received an influenza vaccination, compared with only 4 control patients (7%) (P < .01). Forty-three mothers of children in the study group were interviewed; 14 (33%) of these children had received the vaccination. Of the characteristics investigated, two significantly correlated with vaccination compliance: high levels of parental worry about asthma (positively correlated: odds ratio = 23.3,P < .01) and high levels of parental worry about vaccine side effects (negatively correlated: odds ratio = 0.087, P = .025). It is concluded that (1) the computerized reminder system helped to increase influenza vaccination rates; (2) the majority of patients still did not respond to the reminder system; and (3) parental worry was an important intervening variable affecting compliance with influenza vaccination.
Pediatric Residency Training: Ten Years After the Task Force Report
Authors: Wender Esther H. , Bijur Polly E. , Boyce W. Thomas
Published: December 2021

A sample of 3000 pediatricians who had completed their residency training in 1978 or later were surveyed regarding the perception of the adequacy of their residency training in specific aspects of pediatric practice and in a number of subspecialty areas. The survey was almost identical with the one that formed the basis for the American Academy of Pediatrics Task Force on Pediatric Education report in 1978. The results revealed relatively little change in the high rates of perceived "insufficient training" in all the areas of pediatrics described as "underemphasized" in the Task Force report. However, those residents who received their training during the second half of the 10 years since the Task Force survey reported significant improvement in the previously underemphasized areas of developmental and behavioral pediatrics and adolescent medicine. Results also revealed a significant increase in the number of pediatricians who identify either a subspecialty interest or subspecialty practice in developmental or behavioral pediatrics. The increase in pediatric subspecialists and the improved training experience since 1984 indicate that the Task Force report may have had a positive impact on residency training in developmental and behavioral pediatrics.
Excess Morbidity Associated With Interhospital Transport
Authors: Kanter Robert K. , Boeing Nancy M. , Hannan William P. , Kanter Deborah L.
Published: December 2021

A prospective study was performed to determine whether excess morbidity occurred in critically ill and injured pediatric patients during interhospital transport compared with morbidity in a control group. Control observations were made during the first 2 hours of pediatric intensive care unit (PICU) care of patients emergently admitted from within the same institution and not requiring interhospital transport. The first 2 PICU hours of control patients corresponded to the interval of transport in those who required interhospital transfer. Transport care was provided by nonspecialized teams from referring hospitals. Morbidity occurred in 20.9% of 177 transported patients, exceeding the morbidity rate of 11.3% in 195 control patients (P < .05). The difference in morbidity was due to intensive care-related adverse events (eg, plugged or dislodged endotracheal tubes, loss of intravenous access) in 15.3% and 3.6% of transported and control patients, respectively (P < .05). Physiologic deterioration occurred at similar rates of 7.9% and 8.7% in transported and control patients, respectively (P > .05). Slightly greater pre-ICU severity of illness in transported than control patients (median Pediatric Risk of Mortality Score = 10 and 7, respectively, P < .05) and greater pre-ICU therapy relative to severity (P < .05) in control patients are potential confounding sources of the morbidity differences. If patients are stratified into subgroups of similar pre-ICU severity, an excess of intensive care-related adverse events in transported patients remains evident in the severe subgroup (P < .05). Further investigation is warranted to determine whether specialized transport teams can reduce the excess morbidity associated with interhospital transport of critically ill and injured pediatric patients.
Outlook for the Child With a Cephalocele
Authors: Brown Mark S. , Sheridan-Pereira Margaret
Published: December 2021

Specific information on the outcome for a child with a cephalocele can be difficult to find and interpret. To update outcome information for the child with a cephalocele, the investigators compared outcome of 34 infants from their institution with that of those in previously published series. For the infants from the investigators' institution, overall mortality was 29% and was confined to infants with posterior defects, which was consistent with other published series. Additional major congenital abnormalities were present in nearly half the infants, and these were an important factor in contributing to a poorer prognosis as well as whether the defect could be operatively reduced. Seizures and hydrocephalus were often secondary problems in those infants who did worse. In addressing outlook for the infant with the cephalocele, primary factors to be considered are operability and the presence of additional major abnormalities, both intracranial and extracranial.
Diagnostic Outcome in Children With Multiple Café au Lait Spots
Authors: Korf Bruce R.
Published: December 2021

Forty-one children, ranging in age from 1 month to 14 years, had six or more café au lait spots at their initial visit and were examined annually. Signs of neurofibromatosis type 1 eventually developed in 24. The most common feature to appear to confirm the diagnosis was skin-fold freckling, which occurred in 18 subjects. Diagnosis was based on the appearance of Lisch nodules in 5, and on neurofibromas in 3. In most instances, diagnosis was established within 3 years of initial evaluation, usually before 5 years of age. Six children had a segmental distribution of café au lait spots, suggesting segmental neurofibromatosis. In 3, diagnoses other than neurofibromatosis type 1 were established (Bannayan-Riley-Rulvalcaba syndrome, multiple lentigines syndrome, and fibrous dysplasia). In 8 subjects only multiple café au lait spots are present, and no definite diagnosis has been established. It is concluded that with regular follow-up, including physical and ophthalmological examinations, a definite diagnosis, most commonly neurofibromatosis type 1, can be established for most children having multiple café au lait spots.
Epidemiology of Juvenile Chronic Arthritis in Southwestern Sweden: A 5-Year Prospective Population Study
Authors: Gäre Boel Andersson , Fasth Anders
Published: December 2021

Previous epidemiological studies of juvenile chronic arthritis (JCA) report divergent results owing to differences in diagnostic criteria, patient retrieval, and study designs. To investigate incidence and prevalence of JCA in a total population, this prospective survey was performed in southwestern Sweden between 1984 and 1988. Cases were identified using the European League Against Rheumatism criteria for JCA and were reported annually from eight pediatric departments and local pediatricians in the studied area. During the 5 years, 213 new cases of JCA were found, corresponding to an incidence of 54.6 per 100 000 children younger than 16 years of age. The average annual incidence was 10.9 per 100 000. The peak incidence rate, 18.3 per 100 000 was found in girls 0 through 3 years old. The lowest incidence rate, 6.4 per 100 000, was found among boys 12 through 15 years old. In December 1988, 334 cases of JCA were recorded, giving a prevalence of 86.3 per 100 000. When patients in remission were omitted the prevalence was 64.1 per 100 000. The monoarticular + pauciarticular onset type constituted 68.3% of the prevalence cases, while 21.9 were polyarticular and 6.6% had systemic onset. To avoid underestimation of incidence and prevalence, and to get a correct picture of disease patterns, epidemiological surveys of JCA should be population-based rather than referral center-based. Further descriptive studies of JCA in different well-defined geographic areas are important to make valid comparisons. Such comparisons could give clues to etiological factors, both genetic and environmental.
Database Use in Neonatal Intensive Care Units: Success or Failure
Authors: Slagle Terri A. , Gould Jeffrey B.
Published: December 2021

The purpose of this national survey was to define the extent and features of database use by 445 tertiary level neonatal intensive care nurseries in the United States. Of the 305 centers responding to our survey, 78% had a database in use in 1989 and 15% planned to develop one in the future. Nurseries varied remarkably in the volume of data collected, the amount of time devoted to completing data collection forms, and the personnel involved in data collection. Although data were used primarily for statistical reports (93% of nurseries), quality assurance (73%) and research activities (61%) were also enhanced by database information. Neonatal databases were used to generate reports for the permanent medical record in 38% of centers. Satisfaction with the database was dependent on how useful the database information was to centers which collected and actually used a large volume of information. Overall, nurseries expressed a high degree of confidence in the data they collected, and 65% felt their neonatal database information could be used directly in publication of research. It was disturbing that accuracy of data was not monitored formally by the majority of nurseries. Only 27% of centers followed a routine schedule of data quality assurance, and only 53% had built in error messages for data entry. We caution all who receive database information in the form of morbidity and mortality statistics, clinical reports on patients cared for in neonatal units, and published manuscripts to be attentive to the quality of the data they consume. We feel that future database design efforts need to better address data quality control. Our findings stress the importance and need for immediate efforts to better address database quality control.
Overtreatment of Neonates? A Personal Retrospective
Authors: Silverman William A.
Published: December 2021

Man's power over Nature is really the power of some men over other men, with Nature as their instrument.

—C. S. Lewis

The question of overtreatment of seriously compromised neonates with life-prolonging hardware is, in the end, a weighing of values—a moral judgment. The most pressing issues of our time, it has been said, are not matters of engineering, but of human values. And, didactic opinion to the contrary notwithstanding, I am prepared to argue that moral judgment is not monolithic. A system of values is not the same everywhere and for everyone. Nor is it an unchanging construct over time—even throughout one's own lifetime.

Piaget,1 Kohlberg,2 and Rest3 have all made a strong case for the view that differences among people, in the way they evaluate moral problems, are determined, largely, by their concepts of fairness. A sense of right grows more discerning with age and is influenced by the amount and the complexity of social experience.

Let me explain what I am getting at, by relating the growth of my own social experience as a rescuer of extremely small neonates. It began 47 years ago, when I was on the housestaff at The Babies Hospital in New York City. On January 27, 1945, a premature neonate was born in a small hospital in the Bronx, at 5½ months of gestation; birth weight was 600 g. The obstetrician was astounded that this extremely small girl breathed spontaneously and he was even more amazed to find her still alive the following day.
Malignant Vasovagally Mediated Hypotension and Bradycardia: A Possible Cause of Sudden Death in Young Patients with Asthma
Authors: GRUBB BLAIR P. , WOLFE DOUGLAS A. , NELSON LOIS ANNE , HENNESSY JAMES R.
Published: December 2021

Asthma is a common chronic disorder affecting roughly 3% of the population of the United States and producing considerable morbidity.1 However, despite increasing knowledge concerning the pathophysiology of this disease and an expanded therapeutic armamentarium, mortality rates from asthma have increased, particularly in younger patients.2 Although some of the increase can be accounted for by under-treatment, inadequate access to care, and delays in appropriate management,3 a number of episodes of unexpected sudden death have occurred in young patients with asthma without adequate explanation.4

Recent literature provides evidence that severe episodes of vasovagally (autonomic) mediated hypotension and bradycardia (the malignant vasovagal syndrome) may mimic or cause sudden death episodes in young people.5
Pyogenic Granulomas of Infancy Masquerading as Strawberry Hemangiomas
Authors: FRIEDEN ILONA J. , ESTERLY NANCY B.
Published: December 2021

Pyogenic granuloma (lobular capillary hemangioma) is a neovascular proliferation which is relatively common in children. The development of pyogenic granuloma may follow minor trauma or may occur on undamaged skin. We present five cases of pyogenic granulomas in young infants which were confused with strawberry hemangiomas, and we discuss the differences between these two vascular growths and implications for therapy during early infancy.

CASE REPORTS

Patient 1

A 5-month-old male infant was seen in the Pediatric Dermatology Clinic of the Children's Hospital of Wisconsin for an expanding lesion on the left cheek. The lesion had developed shortly after birth and had enlarged rapidly during the 2 to 3 months before the visit that resulted in a diagnosis of hemangioma of infancy.
Relationship Between Epidemiologic Risk Factors and Clinicopathologic Findings in the Sudden Infant Death Syndrome
Authors: Haas Joel E. , Taylor James A. , Bergman Abraham B. , van Belle Gerald , Felgenhauer Judy L. , Siebert Joseph R. , Benjamin Denis R.
Published: December 2021

The risk of sudden infant death syndrome (SIDS) is said to be enhanced by factors such as prematurity, low birth weight, and perinatal distress. The significance of risk factors for SIDS research was questioned because the majority of SIDS victims seem to lack them. Therefore, postmortem records of 1144 infants who died suddenly and unexpectedly in King County, Washington, over a 25-year period were studied. Deaths were classified as "explained" if a cause was apparent, "classic" SIDS if the history and autopsy were unrevealing or, where the diagnosis of SIDS was doubtful, as "probable" or "possible" SIDS. The infants' birth certificates were compared with those of 3647 infants born during a similar period. Seventy-nine deaths (7%) were explained. The 1065 previously certified as SIDS were reclassified classic SIDS (82%), probable SIDS (13%), and possible SIDS (5%). Low birth weight, small size for gestational age, prematurity, and low 5-minute Apgar scores each form a "continuum"; the possible-SIDS group had the highest proportion of such infants, followed by the probable- and classic-SIDS groups, which exhibit extensive overlap with the control population. A 5-minute Apgar score of less than 7 and delayed postnatal growth rate are not risk factors for classic SIDS. Risk factors are more prevalent in SIDS infants where the diagnosis may be doubtful. The great majority of SIDS victims possess fewer risk factors. To avoid the bias of confounding variables, SIDS research should focus on as "pure" a SIDS population as is possible.
Bronchial Hyperresponsiveness in Children With Atopic Dermatitis
Authors: Salob Stacy P. , Laverty Aidan , Atherton David J.
Published: December 2021

Using histamine provocation tests, bronchial responsiveness was measured in 43 children with atopic dermatitis, aged 7 to 15 years, who had attended pediatric dermatology clinics within the past 5 years. The children were divided into two groups, one group of 21 children in whom asthma had been previously diagnosed and in whom symptoms of asthma had occurred in the preceding year, and the other comprising 22 children who denied any such symptoms. Bronchial hyperresponsiveness (as defined by a 20% fall in forced expiratory volume in 1 second at a provoking dose of histamine of 7.8 µmol or less [PD20]) was demonstrated in all but 1 of the children with atopic dermatitis and asthma, in 18 of the 22 children with atopic dermatitis alone, but in only 3 of a control group of 18 children without atopic dermatitis or asthma. The asthmatic subjects (median PD20 = 0.22 µmol) had more severe bronchial hyperresponsiveness than the nonasthmatic subjects (median PD20 = 2.10 µmol). This study confirms the strong association between atopic dermatitis and bronchial hyperresponsiveness, even in the absence of overt asthmatic symptoms.
Inadvertent Administration of Positive End-Distending Pressure During Nasal Cannula Flow
Authors: Locke Robert G. , Wolfson Marla R. , Shaffer Thomas H. , Rubenstein S. David , Greenspan Jay S.
Published: December 2021

In the clinical setting, nasal cannulas are frequently used to deliver supplemental oxygen to neonates and are not believed to affect the general respiratory status. In contrast, it was hypothesized that clinical changes associated with nasal cannula gas flow may be related in part to the generation of positive end-distending pressure. To test this hypothesis, alterations in esophageal pressure were quantified as an indication of end-distending pressure and thoracoabdominal motion was quantified as an indication of breathing patterns in 13 preterm infants at gas flow levels of 0.5, 1, and 2 L/min delivered by nasal cannula with an outer diameter of either 0.2 or 0.3 cm. Changes in esophageal pressure were assessed by esophageal balloon manometry. Ventilatory patterns were assessed from thoracoabdominal motion by using respiratory inductive plethysmography. Thoracoabdominal motion was quantitated as a phase angle (Θ); larger values represent greater asynchrony. The 0.2-cm nasal cannula did not deliver pressure or alter thoracoabdominal motion at any flow. In contrast, the 0.3-cm nasal cannula delivered positive end-distending pressure as a function of increasing levels of gas flow (r = .92) and reduced thoracoabdominal motion asynchrony. The mean pressure generated at 2 L/min was 9.8 cm H2O. These data demonstrate that nasal cannula gas flow can deliver positive end-distending pressure to infants and significantly alter their breathing strategy. This finding raises important concerns about the indiscriminate therapeutic use, size selection, and safety of nasal cannulas for the routine delivery of oxygen in preterm infants.
Questions about Bilirubin
Authors: VAN DE BOR MARGOT , ENS-DOKKUM MARTINA , SCHREUDER ANNEKE M. , VEEN SYLVIA , VERLOOVE-VANHORICK S. PAULINE , BRAND RONALD
Published: December 2021

In Reply.—

We agree with Dr Stein that there is ample discussion as to the potential neurotoxicity of bilirubin in relation to the etiology of hyperbilirubinemia. Unfortunately, no data were collected regarding the etiology of hyperbilirubinemia in our study population other than blood group incompatibility. Only two children suffered from blood group incompatibility. The maximal serum total bilirubin concentrations of these two children were between 151 to 200 µmol/L (8.8 to 11.6 mg/dL) and 201 to 250 µmol (11.7 to 14.6 mg/dL), respectively.
New Recommendations Not Very Different from Current Practice
Authors: AHLFORS CHARLES E.
Published: December 2021

To the Editor.—

After reading the article by Newman and Maisels1 regarding evaluation and treatment of the jaundiced term newborn, I fail to see why their recommendations are substantially different from current practice. They merely point out what everyone has known (and not known) for a long time:

1. The magnitude of blood bilirubin concentration is not a particularly good predictor of bilirubin toxicity except in specific clinical settings such as hemolysis; ie, the total bilirubin concentration is neither a sensitive or specific indicator of the likelihood of bilirubin toxicity in the well, term jaundiced newborn.
Overtreatment of Neonates
Authors: FLEISCHMAN ALAN R.
Published: December 2021

To the Editor.—

Dr William Silverman's recent article entitled "Overtreatment of Neonates? A Personal Retrospective"1 is a thoughtful and provocative addition to the debate on the method to decide how much treatment is appropriate for critically ill and tiny babies. He basically believes that parents should be the decision makers and that the appropriate decision is the withholding of aggressive treatments from infants at the threshold of viability. He adds his voice to others who would criticize the paternalistic physicians who ignore the values of families and merely fulfill their own "rescue fantasies (New York Times.
Overtreatment of Neonates
Authors: WEIL WILLIAM B.
Published: December 2021

To the Editor.—

Silverman makes a cogent argument for the role of parents in making decisions regarding the treatment of severely ill newborns. His presentation of his position, both at the APS/SPR meeting on May 4, 1992, and in the accompanying article, is thoughtfully developed, carefully crafted, and elegantly prepared (and delivered).

I would agree wholeheartedly with Dr Silverman's plea for more information, gathered carefully, about the long-term outcomes for the children and their families of decisions made to treat intensively or to forego such intensity in the care of seriously imperiled neonates.
Overtreatment of Neonates
Authors: LANTOS JOHN
Published: December 2021

To the Editor.—

At a recent meeting of the Society for Pediatric Research, Tyson et al presented an algorithm that correctly predicted outcome or could correctly predict outcome for 78% to 85% of infants.1 A subset of infants could be correctly assigned a mortality rate of >90%. I asked a number of neonatologists who read the poster about the implications. For most, a prediction of >90% mortality rate would not justify a decision to withhold or withdraw treatment.
Overtreatment of Neonates
Authors: SILVERMAN WILLIAM A.
Published: December 2021

In Reply.—

I am delighted to see that your respondents have voiced some disagreement with my inflammatory comments. May I remind your readers about the advice of Reverend Robert Hall (1764-1831):

The evils of controversy are transitory, while its benefits are permanent.
Day Care for the Child Born Prematurely
Authors: Gross Ruth T.
Published: December 2021

The Infant Health and Development Program (IHDP) has contributed to our knowledge of the role of high-quality, educational day care in the lives of children with special needs.

The IHDP was a randomized clinical trial to evaluate the efficacy of a comprehensive early intervention program in improving the health and developmental outcomes of low birth weight (LBW), premature infants. One component of this program was the provision of special day-care centers for the children receiving this intervention.

The rationale for the IHDP was based, on the one hand, on documented need. Low birth weight children are known to be at risk for a variety of medical complications in the first year of life.1-3 Thereafter, the major area of risk is delayed cognitive development, which often leads to difficulties in learning and school achievement.4-6 An increased risk for behavior problems might exacerbate these school-related difficulties.7-9 The outcomes of LBW infants have been the subject of several recent reviews.2,10-12

On the other hand, there was some evidence of effectiveness of early interventions for LBW infants, although these tended to be reports of early outcomes at single sites.13,14 More compelling was the evidence of longer-range improvement in cognitive development resulting from comprehensive early interventions for disadvantaged children of normal birth weight14,15

Given the increasing survival of premature infants, including those of very low birth weight, it was considered important to test the efficacy of such an intervention for this at-risk population in a randomized trial. The models for the IHDP were two longitudinal comprehensive programs, Abecedarian and Project CARE,16 which combined home visits, parent support, and a comprehensive educational curriculum within special day-care centers.
Continuity of Supervised Care for School-Age Children
Authors: Seligson Michelle , Allenson Michael
Published: December 2021

Inappropriate assumptions about schoolchildren's lives can lead us to patently false conclusions. Some of us assume that mothers wait patiently at home for their children to return each day from school, or we assume that, if mothers cannot be home to greet their children, someone else will be there. Otherwise, we assume, the school probably offers some kind of supervised playground.

As authoritative a source as the Bureau of Labor Statistics subscribes to such conventional illogic, positing the notion that 5 hours of school obviates a child's need for any further daily attention. "Once a child reaches age 6," states a Bureau of Labor Statistics economist, "child care arrangements are less necessary, as most children attend school at this age."1

These assumptions do not accurately reflect a grasp of contemporary American realities. The proportion of all American children younger than age 18 with mothers in the labor force rose from 39% in 1970 to 62% in 1990; in the same 20-year period, the proportion of those mothers employed full-time rose from 26% to 46%.2 Despite recessionary pressures on the labor force, these numbers evidence a drastic decline in mothers' accessibility to their children during working hours. While extended-family members—aunts, uncles, grandparents—once reliably provided care and supervision for school-age children, in contemporary America these relatives also work, or they live too great a distance from the children's primary residence to be available, or perhaps they are simply not "into it."

More and more often, American children are left to fend for themselves before and after school.
Employers and Child Care
Authors: Galinsky Ellen , Morris Anne
Published: December 2021

The issue of employers and child care evokes mixed feelings in the public at large. While some herald corporate involvement in child care as the shot in the arm that will bring about genuine quality improvements, others see it as little more than a public relations ploy aimed at selling the image or product of the company rather than at the well-being of children. While some maintain that corporate involvement is widespread, others are more skeptical, believing that the "noise in the system" has been caused by the efforts of a few highly publicized companies and that this so-called trend is not widespread at all. While some see corporate involvement as a lasting commitment, others suspect that it will be short-lived, a fad doomed to extinction at the first business downturn. Likewise, the effect of corporate involvement is disputed. While some see the effect as radiating out, affecting the total child care delivery system, others suspect that only the employees' children in involved companies truly benefit. Such critics may be, in fact, grateful for a limited impact because they believe that much of corporate action would probably result in quick fixes undertaken without a true appreciation for the complexities of the child care system.

One of the main reasons that the issue of employers and child care arouses such divergent reactions is that there have been few data to use in assessing its prevalence, its predictors, its effect, and its future prognosis. Thus, the public debate has revolved more around rhetoric than fact, on "guesstimates" rather than true estimates.
Transmission of Human Genital Papillomavirus Disease: Comparison of Data From Adults and Children
Authors: Gutman Laura T. , Herman-Giddens Marcia E. , Phelps William C.
Published: December 2021

A substantial body of evidence has demonstrated that the primary means of transmission of genital warts in sexually active adults is through sexual contact. However, the epidemiology and social significance of anal-genital warts in prepubertal children is controversial. Debate continues regarding the frequency with which these lesions have resulted from sexual abuse or transmission by other means. An accurate understanding of the dominant means of transmission of anal-genital warts in children is of particular importance because that understanding influences the extent to which child protective services may become involved following a diagnosis. This paper reviews the evolution of the data on the means of transmission of human papilloma virus disease of the genital tract of adults and compares those data with the information available concerning the transmission of anal-genital human papillomavirus-related disease in children. Methods for the diagnosis of child sexual abuse that have developed in the past decade form one of the bases for the evaluation of studies of the transmission of anal-genital human papillomavirus-related diseases to children.
Comparison of Maternal Sera, Cord Blood, and Neonatal Sera for Detecting Presumptive Congenital Syphilis: Relationship With Maternal Treatment
Authors: Chhabra Rakesh S. , Brion Luc P. , Castro Martha , Freundlich Lawrence , Glaser Joy H.
Published: December 2021

The incidence of congenital syphilis has increased rapidly over the past few years. Most infected mothers and their newborns are asymptomatic at birth and diagnosis depends on serologic testing during pregnancy and at delivery. This study was initiated to compare maternal sera, cord blood, and neonatal sera for detecting presumptive congenital syphilis and to assess the role of maternal treatment (administration of penicillin to the mother at least 1 month before delivery) on the serologic results at the time of delivery. The serologic results from all live deliveries complicated by a positive maternal and/or neonatal test for syphilis during a 12-month period were compared using χ2 analysis and multiple comparisons for proportions. Of 3306 livebirths, 73 (2.2%) were complicated by a positive maternal or neonatal serology. At delivery, the serologic test was positive in 68 (94%) of 72 maternal sera, 30 (50%) of 60 cord sera, and 43 (63%) of 68 neonatal sera. In the absence of maternal treatment, 95% of the maternal sera, 66% of the cord blood samples, and 86% of the neonatal sera were positive. If the mother had been treated, 94% of maternal sera, 36% of cord sera, and 39% of neonatal sera were positive. Cord blood and neonatal sera appear to be inferior to maternal sera for detecting prenatal exposure to syphilis. Cord serology is also inferior to neonatal serology at 2 to 3 days of age. The most effective way to identify newborns at risk for congenital syphilis is to obtain a maternal serologic diagnosis during pregnancy and to test maternal and neonatal sera at delivery.
Home Phototherapy: Use and Attitudes Among Community Pediatricians
Authors: Meropol Sharon B. , Luberti Anthony A. , De Jong Allan R. , Weiss Jeffrey C.
Published: December 2021

Rather than using home phototherapy (HP), many pediatricians admit neonates to the hospital for the treatment of unconjugated hyperbilirubinemia. This study investigates the concerns and experiences of pediatricians related to HP use. A questionnaire was sent to 150 pediatricians in the Philadelphia, PA, area and 94 returned questionnaires. Of the responders, 30 of 94 had used HP. Twenty-nine users and 62 of 64 nonusers answered detailed questions regarding HP. Few practitioners follow American Academy of Pediatrics guidelines in selection of HP candidates. Among 29 pediatricians, prematurity (7), Rh incompatibility (13), positive direct Coombs (21), and ABO incompatibility (22) were not considered contraindications, although the American Academy of Pediatrics recommends all as contraindications. Almost all (29/30) HP users identified at least one problem with home treatment. The most commonly reported problems were parental anxiety, blood testing difficulties, and reimbursement issues. Nonusers (62) were asked their reasons for not using HP. The most common replies related to concerns about noncompliance (25), medical-legal issues (23), and administrative difficulties (22), none of which were cited as problems by HP users.
Extent of Duplication in Lower-Limb Malformations Suggests the Time of the Teratogenic Insult
Authors: Packard David S. , Levinsohn E. Mark , Hootnick David R.
Published: December 2021

Investigations of vertebrate limb development have suggested that a process called "specification" instructs the cells of the future limb as to which tissues they should form. This process proceeds in a wave-like manner, starting at the most proximal levels of the future limb and ending at its distal tip. Human limb specification probably occurs during the fourth and fifth weeks of development. It is proposed that human limb duplications result from errors of specification and, furthermore, that the more distal the duplication, the later the occurrence of the teratogenic event during the specification process. Therefore, among human lower limbs with duplications, one may be able to estimate the relative time of the teratogenic event by comparing the levels at which the duplications occur.
Scope of Health Care Benefits for Infants, Children, and Adolescents Through Age 21 Years
Authors:   Committee on Child Health Financing
Published: December 2021

All infants, children, and adolescent patients through age 21 years must have access to comprehensive health care benefits that will ensure their optimal health and well-being. The following services should be included in the health benefit plans offered by all private and public insurers. These services should be performed in a cost-effective manner that does not compromise the highest quality of care in a variety of appropriate settings. As these services are physician directed and medically necessary, they should not be limited and should include all of the following:

1. Medical care, including (a) health supervision with its preventive care and immunizations according to the "Recommendations for Preventive Pediatric Health Care"1 of the American Academy of Pediatrics, and, (b) diagnosis and treatment of acute and chronic illness, developmental disabilities, learning disorders, and behavioral problems.

2. Surgical care.

3. Mental health services including those appropriate for treatment of substance abuse and other psychosocial problems, as directed or prescribed by a physician.

4. Emergency and trauma care services.

5. Inpatient hospital services.

6. Specialty and pediatric subspecialty consultations occurring either in the inpatient or outpatient setting.

7. Family planning services.

8. Pregnancy services including: (a) genetic counseling and related services as needed; (b) prenatal care; (c) prenatal consultation with a pediatrician; (d) care of all complications; (e) counseling on all pregnancy options; (f) elective termination of pregnancy; (g) care for the pregnancy of a single dependent of the policy holder.

9. Care of all newborns and infants including: (a) Attendance and management at high-risk deliveries; (b) health supervision; (c) treatment of congenital anomalies and other illnesses on injuries.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: WHITE PAUL F.
Published: December 2021

To the Editor.—

As a new Chair, I found this article extremely helpful.
Effect of Maternal Race on Outcome of Preterm Infants in the Military
Authors: Greenberg David N. , Yoder Bradley A. , Clark Reese H. , Butzin Clifford A. , Null Donald M.
Published: December 2021

Previous studies suggest that low birth weight black infants have less morbidity and birth-weight-specific mortality during the perinatal period than low birth weight white infants. We studied the effect of maternal race on outcome in preterm infants born at a military hospital that offers free access to obstetric and neonatal care. Between January 1, 1986, and December 31, 1991, data were prospectively collected on all 667 infants delivered at Wilford Hall USAF Medical Center with an estimated gestational age of less than 35 weeks. Three hundred ninety-two white infants and 165 black infants were included in the data analysis. The mean (±SD) birth weight was 1701 ± 65 g for white infants and 1462 ± 66 g for black infants. The mean estimated gestational age was 31.0 ± 3.2 weeks for white infants and 29.9 ± 3.8 weeks for black infants. Preeclampsia was more frequent in black mothers than in white mothers for the entire study population (21% vs 14%), but the birth weight differential between races remained after correction for preeclampsia. There were no significant differences between races in stillbirths, gender, maternal age, maternal transfer status, number of prenatal visits, or percentages of mothers with small-for-gestational-age infants, multiple-gestation infants, prolonged rupture of membranes, or initial prenatal visit during the first trimester. Intraventricular hemorrhage was more frequent in white infants at 27 through 29 weeks estimated gestational age (50% vs 13%). There were no significant differences between the two groups in survival or in the occurrence of severe infraventricular hemorrhage or bronchopulmonary dysplasia. It is concluded that preterm black infants are smaller than preterm white infants when matched for gestational age despite essentially equal utilization of prenatal care. However, maternal race has little direct effect on the survival of liveborn preterm infants in this population.
Is Combination Therapy for Encopresis Nutritionally Safe?
Authors: McClung H. Juhling , Boyne Linda J. , Linsheid Thomas , Heitlinger Leo A. , Murray Robert D. , Fyda John , Li B U.K.
Published: December 2021

Chronic constipation accounts for 3% to 5% of pediatric primary care outpatient visits. The most severely affected of this group develop a flaccid colon insensitive to distention, and encopresis. Laxatives and lubricants have been the standard therapeutic agents during the bowel decompression phase of encopretic therapy. Fiber has been the cornerstone of maintenance programs. Each of these agents is accompanied by considerable anxiety in the lay literature. This study evaluates the safety of combined high-fiber, laxative, and lubricant therapy on bowel movement frequency, fecal soiling, and nutritional status over a 6-month period. Blood chemistry values, dietary fiber intake, defecation pattern, and a psychological profile were evaluated before and after the 6-month study. Biochemical and anthropometric indicators of nutritional status were not adversely affected by the therapy. Seventy-five percent of the children were able to remain free of soiling and the remaining 4 of 16 had soiling episodes reduced to a frequency of less than once a week. This study confirms that children with encopresis can respond to a combined program of increased fiber intake, laxatives, and mineral oil following a complete bowel cleanout, without experiencing deleterious effects.
Recurrent Hemolytic Uremic Syndrome Secondary to Escherichia coli 0157:H7 Infection
Authors: SIEGLER RICHARD L. , GRIFFIN PATRICIA M. , BARRETT TIMOTHY J. , STROCKBINE NANCY A.
Published: December 2021

Recurrence of the hemolytic uremic syndrome (HUS) is unusual; most recurrent cases are atypical,1 that is, not preceded by the customary diarrheal prodrome. We report a case in which results of serologic tests and stool culture provided evidence that both the initial episode and the recurrence followed diarrhea caused by Escherichia coli 0157:H7. This child was previously described because of severe ocular involvement that followed the initial HUS episode.2)

CASE REPORT

A 16-month-old white boy from rural Idaho was in good health until about 1 week before admission, when a respiratory tract infection complicated by otitis media developed. He was treated with amoxicillin.
Familial Vesicoureteral Reflux
Authors: ROSCELLI JOHN D.
Published: December 2021

To the Editor.—

I read with interest a recent article in Pediatrics concerning screening for familial vesicoureteral reflux (VUR).1 The authors found a 46% incidence of VUR in the siblings of index cases. These index cases had VUR diagnosed by voiding cystourethrograms (VCUGs) which were performed because the patients had experienced a urinary tract infection (UTI). This was an interesting and well-done study. It suffers, however, from the same problem as other studies on this subject,2,3 ie, the lack of a control population to define the underlying incidence of VUR in "normal" individuals from "normal" families.
Button Battery Recommendations Questioned
Authors: MARCUS STEVEN M. , HONCHARUK LOIS , RUCK BRUCE , JENNIS THELMA , DENNIS SUSANA
Published: December 2021

To the Editor.—

We are writing to comment on the article "Ingestion of Cylindrical and Button Batteries, an Analysis of 2382 Cases" and the accompanying commentary on the article that appeared in the April 1992 issue of Pediatrics.1,2

We are concerned with the commentary statement that "the study provides clear and unambiguous data and a well-considered management protocol that should be followed as the standard of care." We have difficulty with an editorial comment that establishes a standard of care because this opens the arena to litigation.