bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatrician Participation in Medicaid: 1978 to 1989
Authors: Yudkowsky Beth K. , Cartland Jenifer D. C. , Flint Samuel S.
Published: December 2021

Optimal pediatrician participation in the Medicaid program is essential if the full benefits of recent eligibility expansions are to be realized. A 1989 national survey of the members of the American Academy of Pediatrics (n = 940), designed as a follow-up to similar studies conducted in 1978 and 1983, was an examination of the factors that influence pediatrician participation. Between 1978 and 1989: (1) basic participation (treating any Medicaid beneficiaries) declined to 77% from 85%; (2) limited participation (seeing only some Medicaid beneficiaries who request care) increased from 26% to 39.4%; and (3) extent of participation (the percentage of a pediatrician's patients who are Medicaid beneficiaries) increased from 15.7% to 19.4%. A dichotomous conceptualization of participation (restricted or unrestricted) was developed. By this definition, only 56% of pediatricians allowed comparable access to their practices for both Medicaid and private patients. Low reimbursement and slow payments discouraged participation. Medicaid reimbursement to pediatricians was approximately equal to their overhead costs. However, a high degree of willingness to care for Medicaid children remains if fees are increased to within 11% to 16% of the private market level. Policy options to enhance participation are discussed.
Ceftriaxone vs Cefotaxime for Treatment of Haemophilus influenzae Meningitis
Authors: MADSON LINDA , GROSE CHARLES
Published: December 2021

To the Editor.—

In a case report, Arditi et al1 d cefuroxime treatment failure in a child with Haemophilus influenzae meningitis. They substituted ceftriaxone for cefuroxime, but they did not mention that ceftniaxone treatment regimens have been associated with two problems. The first is the basis of a case report which described delayed sterilization of H influenzae type B meningitis under management with ceftriaxone.2 The infant had a positive cerebrospinal fluid culture after 3 days (six doses) of ceftriaxone.
Rickets and Metabolic Disorders
Authors: ÖZSOYLU SINASI , BESIM AYTEKIN
Published: December 2021

To the Editor.—

The short report of Morrison and Kerr1 entitled "Growth Plate: Roentgenologic Findings in a Case of Tyrosinosis" deserves some comments.

In addition to phenylketonuria and homocystinuria which were mentioned by the authors, roentgenologic bony changes were shown recently in a 5-month-old boy with mucolipidosis II (I-cell disease).2

Alkaline phosphatase was found to be elevated, and calcium and phosphorus levels were somewhat decreased in most of these cases. With the addition of roentgenologic findings one can be sure that all of these patients had rickets.
Intensive Care Management of Acute Asthma in Children
Authors: KROHN JACQUELINE
Published: December 2021

To the Editor.—

In the article by Stein et al1 it was stated that three deaths occurred. The death of the 17-year-old boy working in the restaurant was reported as due to the acute onset of respiratory distress followed by respiratory arrest. Asthma usually occurs gradually, with prodromal symptoms 24 to 48 hours before an attack. In a few patients, the prodrome can occur less than 6 hours before the respiratory symptoms.2 The time course of the asthma in the 17-year-old boy is more consistent with an acute anaphylactic reaction, most likely from food ingestion.
Parental Presence in the Emergency Department
Authors: CONNOLLY NEVILLE K.
Published: December 2021

To the Editor.—

The article by Baucher et al1 is of interest to me because I have taken care of children in emergency departments where parents were not allowed. In my experience throughout the years the advisability of having a parent in the room when a procedure is being done depends entirely on the character of the parent and the relationship between the parent and the child. In my personal experience, I have had a 2 1/2-year-old child with a severe laceration of the forehead which I sewed up under local anesthesia without restraining the him because the mother, who had a superb rapport with the child, was present.
Epidemiology of Haemophilus influenzae Type b Infections
Authors: Wilfert Catherine M.
Published: December 2021

In summary, H influenzae type b is recognized as the most common cause of bacterial meningitis in the United States. Documentation of the frequency of other associated invasive infections has increased the importance of prevention of infection with this organism. Although all children younger than the age of 5 years are at greatest risk of invasive disease due to this pathogen, the peak occurrence of illness in those infants younger than 1 year of age means that a preventive measure must be effective in children younger than the age of 6 months. There would appear to be increased risk for some specific populations such as native Alaskans, American Indians, blacks, and Hispanics, but environmental and socioeconomic variables may be responsible for this increased risk. Attendance at a day-care center or nursery, the presence of a school-age sibling, and crowding in the home may be factors contributing to primary invasive disease.

An ideal immunogen would be administered to children within the framework of other routinely administered childhood immunizations as early as 6 weeks to 2 months of age. As it is not possible to predict accurately which individual children are at risk, it is important to work toward effective universal immunization of all young infants.
Molecular Epidemiology of Haemophilus influenzae Type b
Authors: van Alphen Loek , Bijlmer Henk A.
Published: December 2021

Ninety-five percent of systemic Haemophilus influenzae infections in childhood are caused by serotype b organisms.1 The high risk for mortality and serious sequelae2 and the increase in antibiotic resistance of H influenzae type b3 are strong arguments for vaccination.

Incidences and age distribution of disease caused by H influenzae type b vary considerably among countries. Compiled data for meningitis (Table 1) show the highest incidences to be among Alaskan Eskimos,4 Navajo5 and White Mountain Indians,6 and aboriginals in Australia.7 High incidences coincide with a peak incidence in a younger age group. This differs from Finland, where 95% of the cases of disease caused by H influenzae type b occur in children older than 7 months of age.8

In general, incidences are low in industrial and high in nonindustrial areas. For example, in Gambia the highest age-specific incidence is at 4 to 5 months after birth (H.A.B., unpublished data, 1988). This implies that a vaccine and regimen similar to that used in Finland would not be as efficacious if used in Gambia because of differences in demographics and incidence.

Vaccines that confer protection at 3 to 4 months of age are, therefore, strongly desired. Outer membrane proteins and lipopolysaccharides of H influenzae type b have been suggested as alternative vaccine candidates in conjugation with the capsular polysaccharide because they apparently can contribute to the virulence of H influenzae type b.15-19 The occurrence and immunogenicity of various outer membrane proteins and lipopolysaccharides among H influenzae type b in industrial and nonindustrial countries and their significance as epidemiologic markers for the spread of disease, the type of disease, the age of acquisition, and their association with antibiotic resistance will be reviewed in this article.
Passive Immunization for Infection With Haemophilus influenzae Type b
Authors: Santosham Mathuram , Reid Ray , Letson G. William , Wolff Mark C. , Siber George
Published: December 2021

Haemophilus influenzae type b is the leading cause of meningitis in children younger than 5 years of age in the United States.1 The incidence of infection with H influenzae type b in certain populations, such as Apache and Navajo Indians and Alaskan Eskimos, is 10 to 20 times higher than in the general US population.2-4 Another important feature of H influenzae type b infections in these populations is that more than 80% of the cases occur during the first year of life, with 35% to 45% occurring during the first 6 months.

One of the currently licensed vaccines that contains the capsular polysaccharide of the H influenzae type b organism is not reliably immunogenic in infants younger than 18 months of age.5,6 A number of new H influenzae type b vaccines prepared by covalently coupling the H influenzae type b capsular polysaccharide with a protein carrier antigen are undergoing clinical evaluation.7-13 One of these conjugate vaccines was shown to be efficacious in preventing disease caused by H influenzae type b in Finnish infants when they were immunized at 3, 4, and 6 months of age.14 Unfortunately, in a recently concluded trial, the same vaccine was not found to be efficacious in preventing such disease in infants younger than 1 year of age among the Alaskan Eskimo population.15

We have evaluated an alternative approach for protecting high-risk infants. A human hyperimmune globulin called bacterial polysaccharide immune globulin (BPIG) was prepared from the pooled plasma of adult blood donors immunized with H influenzae type b, pneumococcal, and meningococcal capsular polysaccharide.16
Home Self-Administration of Intravenous Immunoglobulin Therapy in Children
Authors: Kobayashi Roger H. , Kobayashi AiLan D. , Lee Napoleon , Fischer Susanna , Ochs Hans D.
Published: December 2021

Twelve children with primary immunodeficiency aged 2 to 17 years (mean ± 1 SD = 9.8 ± 5.3), were enrolled in a 9-month study to evaluate the feasibility and safety of home self-infusion of intravenous immunoglobulin (IVIg). An initial 2-month training and supervisory period was followed by a 6-to 7-month period during which the children or their parents infused IVIg in a home setting. Eight children received an average dose of 204 ± 12 mg/kg every 2 weeks, two children received a dose of 400 mg/kg every month, and an additional two children received 240 to 250 mg/kg every 10 days. Peak and trough levels varied from 946 ± 20 mg/dL and 627 ± 16 mg/dL, respectively, in children receiving IVIg every 2 weeks. The peak-trough values for the children receiving IVIg every month were 1105 ± 94 mg/dL and 457 ± 78 mg/dL, while those of children receiving IVIg every 10 days were 840 ± 24 mg/dL and 553 ± 109 mg/dL. A total of 224 infusions were administered, with only two minor reactions occurring (reaction rate of 0.9%). There was no difference in the frequency of infections and antibiotic use during the study compared with the previous phase. The results demonstrate that home self-infusion of IVIg in children is safe and feasible.
Thalamic Hemorrhage With Intraventricular Hemorrhage in the Full-Term Newborn
Authors: Roland Elke H. , Flodmark Olof , Hill Alan
Published: December 2021

Intraventricular hemorrhage is an uncommon problem in the full-term newborn. In a review of 19 full-term infants with intraventricular hemorrhage diagnosed on computed tomography prior to 1 month of age, thalamic hemorrhage associated with the intraventricular hemorrhage was documented in 12 infants. Thus, thalamic hemorrhage appears to be the most common source of intraventricular hemorrhage in this age group, particularly in infants who had uneventful birth histories and in whom clinical abnormalities (signs of increased intracranial pressure, seizures, altered level of consciousness) developed after the first week of life. The majority of these infants had predisposing factors for cerebral venous infarction such as sepsis, cyanotic congenital heart disease, and coagulopathy. The clinical appearance and outcome for infants with thalamic hemorrhage/intraventricular ular hemorrhage were similar to those in infants with intraventricular hemorrhage originating from other sites, except for an increased incidence of cerebral palsy in infants with thalamic hemorrhage/intraventricular hemorrhage. Definitive diagnosis was made on the basis of characteristic radiologic abnormalities.
Effect of Prenatal Alcohol Exposure on Growth and Morphology of Offspring at 8 Months of Age
Authors: Day Nancy L. , Richardson Gale , Robles Nadine , Sambamoorthi Usha , Taylor Paul , Scher Mark , Stoffer David , Jasperse Dorcie , Cornelius Marie
Published: December 2021

In this prospective study of alcohol and other substance use during pregnancy, a cohort of women was interviewed at each trimester of pregnancy and when the offspring were 8 months of age. Data are presented concerning the outcome for 461 infants. A significant relationship was found between alcohol use during pregnancy and the growth and morphology of the offspring at the 8-month follow-up observation. Alcohol use during the second and third trimesters of pregnancy and continuous use of alcohol throughout pregnancy were significantly related to lower weight, length, and head circumference in the exposed infants at the follow-up observation. A significant increase in the risk of minor physical anomalies and fetal alcohol effects was also predicted by prenatal alcohol exposure.
Continuous Hemodiafiltration in Children
Authors: Bishof Nancy A. , Welch Thomas R. , Strife C. Frederic , Ryckman Frederick C.
Published: December 2021

Continuous arteriovenous hemofiltration is a form of renal replacement therapy whereby small molecular weight solutes and water are removed from the blood via convection, alleviating fluid overload and, to a degree, azotemia. It has been used in many adults and several children. However, in patients with multisystem organ dysfunction and acute renal failure, continuous arteriovenous hemofiltration alone may not be sufficient for control of azotemia; intermittent hemodialysis or peritoneal dialysis may be undesirable in such unstable patients. Recently, the technique of continuous arteriovenous hemodiafiltration has been used in many severely ill adults. We have used continuous arteriovenous hemodiafiltration in four patients at Children's Hospital Medical Center.

Patient 1 suffered perinatal asphyxia and oliguria while on extracorporeal membrane oxygenation. Patients 2 and 4 both had Burkitt lymphoma and tumor lysis syndrome. Patient 3 had septic shock several months after a bone marrow transplant. All had acute renal failure and contraindications to hemodialysis or peritoneal dialysis. A blood pump was used in three of the four patients, while spontaneous arterial flow was adequate in one. Continuous arteriovenous hemodiafiltration was performed for varying lengths of time, from 11 hours to 7 days. No patient had worsening of cardiovascular status or required increased pressor support during continuous arteriovenous hemodiafiltration. The two survivors (patients 2 and 4) eventually recovered normal renal function.

Continuous arteriovenous hemodiafiltration is a safe and effective means of renal replacement therapy in the critically ill child. It may be ideal for control of the metabolic and electrolyte abnormalities of the tumor lysis syndrome.
Evaluation of Children With Possible Appendicitis Using Technetium 99m Leukcyte Scan
Authors: Henneman Philip L. , Marcus Carol S. , Inkelis Stanley H. , Butler John A. , Baumgartner Fritz J.
Published: December 2021

We evaluated the use of technetium 99m albumin colloid white blood cell (TAC-WBC) scan in 33 children with possible appendicitis. Ten children had appendicitis, four of whom had perforated their appendix at the time of surgery. Children with appendicitis differed from children without appendicitis in the incidence of right lower quadrant rebound tenderness (60% vs 17.4%), and white blood cell count (x103/mm3) (14.0 + 1.9 vs 10.7 ± 1.0). TAC-WBC scans were interpreted as either positive, negative, or indeterminate for appendiceal pathology. Twenty-five children had positive or negative scans for appendiceal pathology. There were 7 true positives, 2 false positives, 16 true negatives, and 0 false negatives. This resulted in a sensitivity of 100%, a specificity of 89%, an accuracy of 92%, a positive predictive value of 78%, and a negative predictive value of 100%. The TAC-WBC scan was indeterminate (abnormal but nondiagnostic for appendicitis) in eight children (24%), three of whom had appendicitis. The main values of TAC-WBC scan in our study of children with possible appendicitis were that it could be used emergently, it was abnormal in 100% of children with appendicitis, and it had a high negative predictive value (100%). The main limitation of TAC-WBC scan in our study was that it was indeterminate for appendiceal pathology in 24% of children. We recommend that TAC-WBC scan be used in children with possible appendicitis because it may allow outpatient management of up to 48%.
Urethral Catheter Knots
Authors: ANDERSON MARY H.
Published: December 2021

Balloon bladder catheters smaller than 8F are available in the United States on a limited basis; therefore, 3F and 5F feeding tubes are commonly used as bladder catheters in neonates and small infants. Knotting of these catheters in the bladder lumen has been reported in the urobogic1-4 but not the pediatric literature. It has been suggested that knots occur when improper technique is used to insert and secure feeding tubes used to drain the bladder3. Because pediatricians and pediatric nurses commonly use feeding tubes as bladder catheters, they should be aware that knotting is a possible complication. We present an infant in whom a 5F feeding tube knotted in the bladder.
Sterilization of Women Who Are Mentally Handicapped
Authors:   Committee on Bioethics
Published: December 2021

The recent statement of the American College of Obstetricians and Gynecologists on the sterilization of mentally handicapped women (REF) is comprehensive and is endorsed in principle and substance by this Committee. As pediatricians, we reinforce and reiterate the following:

1. With rare exception, there is no indication for sterilization of a child before menarche. An example is when sterilization is not intended, but is an unavoidable consequence of other surgery, such as surgery for a malignancy.

2. The primary or contributing indications for sterilization (particularly surgical sterilization) based on presumed or anticipated hardships to others must be viewed with great reservation and in light of acceptable alternate care arrangements which might be made for the mentally retarded individual. The judgment of "hardship" is extremely subjective and must not be simply a matter of inconvenience or a preference for the easier of two alternatives.

3. When sterilization or pharmacological control of menses is chosen after the appropriate informed deliberations and attempts at obtaining consent, the pediatrician should always advocate the least permanent and intrusive methodology consistent with lowest risk for the patient. Present and future research and clinical trials may very well make newer forms of chemical contraception or pharmacologic amenorrhea preferable to surgical sterilization.

4. Even if satisfactory informed consent cannot be provided by the patient, all efforts must be made to communicate the procedure and intent of the planned intervention to the patient; estimations of the patient's ability to comprehend and participate in the decision-making process should be done by personnel who are familiar with the individual patient and who are experienced in communication with persons with diminished mental capacity.
Summary of Annual Meeting of Section on Pediatric Urology
Authors: Kramer Stephen A.
Published: December 2021

The Section on Urology of the American Academy of Pediatrics met for 2½ days in conjunction with the 58th Annual Meeting of the Academy in Chicago, IL, October 21 to October 23, 1989. The papers presented at this meeting that were thought to be of interest to the practicing pediatrician are summarized here according to topic. The recipient of this year's Pediatric Urology Medal is Jack Lapides. Dr Lapides is recognized for his numerous academic achievements and his excellence in teaching as Professor and Chairman of the Department of Urology at the University of Michigan. His introduction and popularization of intermittent self-catheterization has revolutionized the treatment of neurogenic bladder dysfunction and is clearly one of the most significant contributions to urology during the past few decades.

GENITOURINARY TUMORS

Those of us involved in the care of patients with Wilms tumor continue to search for prognostic indicators which will allow identification of patients at low risk or high risk for the development of metastatic disease. The accumulated data from National Wilms' Tumor Studies II and III showed that decreasing amounts of chemotherapy can be administered to patients with favorable prognostic factors, whereas patients with poor prognostic factors require more aggressive chemotherapy and radiation therapy. While favorable histology and the absence of nodal metastatic disease have clearly been shown to be associated with enhanced survival, Gearhart and coworkers have used nuclear morphometry to predict response to treatment in patients with Wilms tumor. In a retrospective analysis of 29 patients with Wilms tumor, morphometric nuclear analysis (using several shape descriptors) was very useful in identifying responders vs nonresponders to chemotherapy.
Pediatric Emergencies
Authors:   American Medical Association Commission on Emergency Medical Services
Published: December 2021

PREAMBLE

The purpose of these guidelines for the classification of pediatric emergency services is (a) to allow any given community to identify the level of care available for the critically injured or ill pediatric patient, and (b) provide guidance to hospitals and EMS systems as to the resources necessary to provide optimal care to these children. This is a necessary step in the development of EMS systems that meet the needs of the pediatric patient.

These systems require (1) patient and parent recognition of when to access the system and knowledge of how to access the system; (2) prehospital care providers with appropriate expertise in the assessment and treatment of infants, children, and adolescents; (3) regional networking of hospitals at varying levels of pediatric sophistication with transport systems to ensure that the critically ill or injured child is promptly identified, stabilized, and brought to the tertiary pediatric center; (4) primary and secondary centers that have the level of expertise to care for the bulk of pediatric patients; (5) the development of pediatric tertiary care facilities with pediatric subspecialist availability for the complex patients; (6) pediatric rehabilitation and long term care programs; and (7) audit and quality assurance programs to review the care rendered.

This document only addresses one part of a system, the classification of hospital capabilities. The systems implementation process involves a triphasic approach:

1. The identification of the capabilities of an institution by that institution which will provide information on its compliance with the guidelines.

2. Verification of a given hospital's compliance or noncompliance with the guidelines by outside, noninvolved individuals, the verification site review.
Circumcision
Authors: WISWELL THOMAS E.
Published: December 2021

To the Editor.—

The recent Report of the Task Force on Circumcision1 represents a substantial change from the previous (1975) statement.2 There are several points regarding the latest report which I would like to address. The seemingly low risk for developing cancer of the penis among American men (1 in 600)3 does not reflect the magnitude of the problem. Of the almost 60 000 men with this malignancy diagnosed in the United States since 1930, fewer than 10 are known to have been circumcised.4-6
Inadequate Breast Feeding and Jaundice
Authors: AUERBACH KATHLEEN G.
Published: December 2021

To the Editor.—

The article by Kemper et al1 is thought-provoking and timely.

One method of avoiding interruption of breast-feeding when a neonate is jaundiced holds promise for reducing the frequency of untimely termination of lactation. As reported in an earlier publication,2 a series of 20 mothers whose infants had bilirubin levels greater than 12 mg/dL used a Medela Supplemental Nutrition System (SNS) to provide additional milk to the infant before discharge from the hospital.
SECTION ON ALLERGY AND IMMUNOLOGY
Authors:   American Academy of Pediatrics
Published: December 2021

The Section on Allergy and Immunology was one of the first sections formed (1948) within the American Academy of Pediatrics. It now has almost 600 members. Its objective is to improve the care of children with asthma, allergies, and immunologic disorders.

The Section aims to serve as a major informational and educational resource for the 34 000 members of the American Academy of Pediatrics. The Section sponsors a 2-day scientific program and symposium at each Anual Meeting of the Academy; and, for the past several years, it has also presented a symposium at the Annual Meeting of the American Academy of Allergy and Immunology, as well as the annual "Synopsis Book." Other educational activities by the Section include publishing position papers (most recently, "Exercise and the Asthmatic Child"), assisting the National Asthma Education Task Force of the National Institutes of Health, and developing informational pamphlets for patients. In addition, the Section sponsors visiting professorship programs to medical schools which do not have a division of pediatric allergy and immunology.

The membership of the Section on Allergy and Immunology consists of Fellows of the American Academy of Pediatrics who have been certified by the American Board of Pediatrics and by the American Board of Allergy and Immunology. Any and all qualified American Academy of Pediatrics Fellows are invited to apply for membership in the Section. If interested, please write to:

DIRECTOR, DIVISION OF SECTIONS

American Academy of Pediatrics

141 Northwest Point Blvd

PO Box 927

Elk Grove Village, IL 60009-0927

The reviews contained in this 1988 to 1989 synopsis were written by 28 Fellows of the American Academy of Pediatrics Section on Allergy and Immunology and by 5 senior fellows in allergy and immunology who contributed reviews under the aegis of their mentors.
Failure of Infant Observation Scales in Detecting Serious Illness in Febrile, 4-to 8-Week-Old Infants
Authors: Baker M. Douglas , Avner Jeffrey R. , Bell Louis M.
Published: December 2021

All infants aged 29 to 56 days with rectal temperatures in excess of 38.2° Cwho presented to the Emergency Department of The Children's Hospital of Philadelphia from July 1987 through July 1988 were studied. Each infant was scored (1 to 5) on each of the six items in the Yale Observation Scale by an Emergency Department attending physician before history and physical examination. Individual scores were then added to yield a total score for each patient. An observation score of 10 or less was indicative of a generally well-appearing child, and a score of 16 or more represented an ill-appearing child. Of 126 infants enrolled, 37 (29%) had serious illness; 12 (9.5%) had culture-proven bacterial disease. Of all infants with an observation score ≤10 (n = 91), 22% had serious illness, and of all infants with an observation score ≥16 (n = 20), only 45% had serious illness. The findings suggest that even in experienced hands, the Yale Observation Scale alone does not provide sufficient data to identify serious illness in febrile, 1-to 2-month-old infants.
Health and Developmental Outcomes of a Surfactant Controlled Trial: Follow-Up at 2 Years
Authors: Ware Janice , Taeusch H. William , SoIl Roger F. , McCormick Marie C.
Published: December 2021

Several randomized clinical trials have shown that surfactant therapy improves the pulmonary status of infants with respiratory distress syndrome and has the potential to reduce morbidity and mortality in these infants. Relatively little is known, however, about the long-term consequences of surfactant treatment. In this report, the results of health and developmental assessment are described at 1 and 2 years of age of 32 survivors of an initial group of 41 infants enrolled in a randomized clinical trial of bovine surfactant therapy. The frequencies of abnormal findings were comparable in the two groups although there was a trend toward a greater frequency of allergic manifestations in the control group (6 of 16 (38%) vs 1 of 15 (7%), P = .08). Similarly, no differences were seen in the mental and motor scores of the Bayley Scales of Infant Development at either 1 or 2 years of age. This study and other recently published reports of follow-up studies of infants treated with surfactant provide encouraging evidence that major long-term side effects do not result from surfactant therapy.
What's New in Pediatric Surgery—1989
Authors: Altman R. Peter
Published: December 2021

The recent developments in pediatric surgical research as well as new concepts and clinical applications in the specialty are emphasized in this report. There is no attempt to make this review all inclusive. Rather, it focuses on specific areas in which new data or techniques will influence future investigations or the management of patients.

EXTRACORPOREAL MEMBRANE OXYGENATION

No area has commanded more investigational effort than extracorporeal membrane oxygenation (ECMO). By oculopneumoplethysmography Foglia et al1 assessed the effects of right internal carotid artery ligation on cerebral perfusion in lambs during ECMO. Postnormoxic lambs had good right hemispheric perfusion after right internal carotid artery ligation, and posthypoxic animals showed marked initial depression of ipsilateral hemispheric perfusion which improved progressively and was comparable to the normoxic model at 20 hours. Foglia et al postulated a loss of autoregulation and/or intracranial edema, both of which were reversible. It is known that ECMO is associated with an early increase in inflammatory mediators. Simoni et al2 documented a second peak of complement activation and prostaglandin synthesis after 72 hours of high-flow ECMO. They reported increased levels of endotoxin, free radical activity, and tumor necrosis factor, all markers of systemic sepsis. Early weaning, meticulous technique, and periodic replacement of the ECMO circuit for the extended run are emphasized. Crombleholme and co-workers3 proposed using ECMO as a bridge to transplantation with reduced-size lung grafts. They demonstrated the technical feasibility of the procedure in immature swine recipients. The graft was ventilated preferentially and accepted the entire cardiac output. Ongoing studies by Stolar and Dillon4 demonstrated a biphasic prostanoid response in newborn lambs undergoing ECMO perfusion.
Cholesterol Screening?
Authors: GARCIA RICHARD E.
Published: December 2021

In Reply.—

Dr Dennison points out the complexity of the issue of pediatric cholesterol screening. The total cholesterol value of 200 mg/dL is the 95th percentile for children according to the lipid research clinic's population data book. The adult screening strategy was not extrapolated to the pediatric population; we simply felt that children whose total cholesterol exceeded 200 mg/dL should have a lipid profile to verify the finding and possibly to help define the lipid abnormality.
Congenital Brain Anomalies Associated With the Hypoplastic Left Heart Syndrome
Authors: Glauser Tracy A. , Rorke Lucy B. , Weinberg Paul M. , Clancy Robert R.
Published: December 2021

This study details the type, frequency, and clinical presentation of developmental brain anomalies in 41 infants with the hypoplastic left heart syndrome encountered during a 52-month interval. Overall, 29% of the infants had either a major or minor central nervous system abnormality. Overt central nervous system malformations, including 3 cases of agenesis of the corpus callosum and 1 case of holoprosencephaly, were seen in 4 infants (10%). Micrencephaly (brain weight at autopsy more than 2 SDs below the mean for age) was found in 27% of the infants. An immature cortical mantle was seen in 21% of the study group. Seven infants (17%) had specific recognizable patterns of malformation. The absence of dysmorphic physical features did not preclude overt or subtle central nervous system malformations. Conversely, the presence of dysmorphic features did not reliably indicate an underlying brain anomaly. Infants who had hypoplastic left heart syndrome as one of multiple nonneurologic malformations were more likely to have micrencephaly than those infants with hypoplastic left heart syndrome as an isolated abnormality. Occurrence of developmental neuropathology was elevated in those infants with hypoplastic left heart syndrome who did not have a recognizable pattern of malformation but who were small for gestational age, microcephalic, or had ocular abnormalities. Infants with hypoplastic left heart syndrome deserve careful genetic, ophthalmologic, and neurologic evaluations, imaging of their intracranial anatomy, and long-term neurologic follow-up.
Serologic Responses to an Haemophilus influenzae Type b Polysaccharide-Neisseria meningitidis Outer Membrane Protein Conjugate Vaccine in Very Young Gambian Infants
Authors: Campbell Harry , Byass Peter , Ahonkhai Vincent I. , Vella Philip P. , Greenwood Brian M.
Published: December 2021

Recent studies in the United States and Europe have shown that Haemophilus influenzae type b polysaccharide-protein conjugate vaccines can induce protective antibody levels in young infants, but it was not clear that this would be the case in African infants, to whom H influenzae vaccines must be given at a very early age to prevent disease caused by H influenzae. Therefore, antibody responses to an H influenzae type b polysaccharide-Neisseria meningitidis outer membrane protein conjugate vaccine were measured in very young Gambian infants. In the first group (n = 85), to whom the vaccine was given at the ages of 1 and 3 months, the geometric mean antibody level rose from a prevaccination level of 0.23 µg/mL to a postvaccination level of 1.27 µg/mL, and in the second group (n = 56), vaccinated at the ages of 2 and 4 months, the prevaccination level of 0.16 µg/mL rose to a postvaccination level of 1.59 µg/mL. These two final postvaccination levels did not differ significantly, and interpolation suggests that similar antibody levels were present in both groups of infants at the age of 3 months. This is the age by which protection would need to be achieved to protect against H influenzae meningitis in The Gambia and in other countries where the infection has similar epidemiologic characteristics. No significant side effects of vaccination were noted.
Toward a Comprehensive Emergency Medical System for Children
Authors: Haller J. Alex
Published: December 2021

Systems management of life-threatening injuries in children and adults is now accepted as state-of-the-art by those who care for trauma victims in the United States and Canada. A few regional trauma systems for adults have had several decades of experience and have recently served as models for inclusion of pediatric trauma.1 In certain instances, notably the state of Pennsylvania, an emergency medical services (EMS) system has come into being with fully integrated adult and children's components. That the National Pediatric Trauma Registry includes more than 12 000 children is indicative of the significant problem of trauma in childhood; the Registry has provided a necessary base for statistical analysis of injury severity and long-term rehabilitation needs.2

Since 1985, several federally funded state demonstration grants for EMS for children (EMSC) have attempted to establish guidelines for patient care and to suggest methods of ongoing monitoring of the effectiveness of these systems, surveillance of quality, and review of patient outcome.

A statewide designated pediatric trauma center for Maryland located in The Johns Hopkins Children's Center has been functional for 12 years.3 Data are now available for objective evaluation of the effectiveness and impact of this regional pediatric trauma program.

The level of compliance within Maryland's regionalized pediatric trauma system from 1979 through 1986 was recently examined using hospital discharge abstract data routinely recorded for all discharges from 58 acute care hospitals in the state of Maryland.4 Compliance with regionalization was measured by examining (1) the proportion of patients with injuries of varying injury severity scores5,6 who were treated at each of three levels of care (statewide pediatric trauma center, regional trauma center, and community hospital) and (2) the proportion of in-hospital deaths occurring at each level of care.
Half-Dose Immunization for Diphtheria, Tetanus, Pertussis
Authors: ROGERS WM. B.
Published: December 2021

To the Editor.—

I would like to praise Judy Bernbaum for the amount of work she has done on half-dose immunization for diphtheria, tetanus, pertussis as reported in Pediatrics.1 I feel, however, that the work she has begun is incomplete.

It is unfair to compare the effectiveness of diphtheria, tetanus, pertussis vaccine when given as three doses totaling 1.5 mL against three doses totaling only 0.75 mL.

I call upon Dr Bernbaum to complete her study by giving her half-dose recipients three more half-doses so that their total dosage is also 1.5 mL like the full-dose recipients.
Why Use Indomethacin?
Authors: VAN BEL FRANK , VAN DE BOR MARGOT , STIJNEN THE , BAAN JAN , RUYS JAN H.
Published: December 2021

In Reply.—

We are very grateful for the commentary by Dr Rosenfeld on our article1 and share his concern about the possible adverse effects of indomethacin in sick and compromised preterm neonates.

We have some indication that the acute systemic effect of indomethacin (an increase in peripheral vascular resistance) also has an acute effect on ductal tissue. In most of the infants we observed, a negative diastolic flow velocity in the anterior cerebral artery existed before indomethacin treatment, suggesting a ductal steal phenomenon.
Drugs and Breast Milk
Authors: DORFMAN JOAN S.
Published: December 2021

To the Editor.—

I have just reviewed the the article, "Transfer of Drugs and Other Chemicals Into Human Milk," from the American Academy of Pediatrics Committee on Drugs, which appeared in the November issue of Pediatrics.1

I would appreciate further information on a change that has appeared since the previous publication in the September, 1983 issue of Pediatrics.2 Naproxen has been deleted from the current table of maternal medication usually compatible with breast-feeding under the category "narcotics, nonnarcotic analgesics, anti-inflammatory agents."
Birth Weight Less Than 800 Grams: Changing Outcomes and Influences of Gender and Gestation Number
Authors: Hoffman Edward L. , Bennett Forrest C.
Published: December 2021

Mortality and neurodevelopmental morbidity were compared in two cohorts of neonates with birth weights of less than 800 g. The neonates, born in the years 1977 through 1980 (original cohort) and 1983 through 1985 (current cohort), were patienta in the same university intensive care nursery. Mortality was 80% in the original cohort and 64% in the current cohort (P = .01). In the current cohort, survival was significantly better for neonates with birth weights of more than 749 g (58% vs 27%; P = .001). Survival was also significantly associated with gender and with gestation number (female survival was 48% and male survival was 23%, P = .003; singleton survival was 41% and twin survival was 21%, P = .03). Prevalence of major central nervous system handicaps did not significantly differ between the two study groups, but severity of handicap was worse for the current study group. Morbidity in the current cohort was most severe for twins (67% with a major central nervous system handicap) and was least severe for singleton girls (4% with a major central nervous system handicap, P = .002). Delivery mode appeared to affect outcome. Although there were more nursery admissions and more survivors among neonates with birth weights of less than 800 g during the period 1983 through 1985 compared with the period 1977 through 1980, overall neurodevelopmental morbidity worsened.
Psychological Development of Children Who Were Treated Antenatally With Corticosteroids to Prevent Respiratory Distress Syndrome
Authors: Schmand B. , Neuvel J. , Smolders-de Haas H. , Hoeks J. , Treffers P. E. , Koppe J. G.
Published: December 2021

Potential side effects of antenatal administration of corticosteroids to prevent neonatal respiratory distress syndrome were studied in 10- to 12-year-old children whose mothers had participated in a randomized, double-blind, placebo-controlled trial of betamethasone. Aspects of the children's intellectual and motor development, school achievement, and social-emotional functioning were investigated. There were no differences between the corticoid group and the placebo group on these variables, nor were there more children with learning difficulties and behavioral disturbances in either of the groups.
Succinylacetone and δ-Aminolevulinic Acid Dehydratase in Hereditary Tyrosinemia: Immunochemical Study of the Enzyme
Authors: Sassa Shigeru , Fujita Hiroyoshi , Kappas Attallah
Published: December 2021

Immunochemical determinations of δ-aminolevulinic acid (ALA) dehydratase were performed in erythrocytes and in liver of a patient with hereditary tyrosinemia who underwent liver transplantation for correction of this metabolic disorder. Both erythrocytic and hepatic ALA dehydratase activities were extremely low before liver transplantation, but they appeared normal after transplantation. According to results of immunochemical quantification of ALA dehydratase, the level of the enzyme protein in erythrocytes was not different before, during, and after liver transplantation. Immunoguantifiable enzyme concentrations were not substantially different in the patient's own liver as compared with the transplanted liver. These findings indicate that although succinylacetone, an abnormal metabolite produced in tyrosinemia, is a potent inhibitor of the activity of ALA dehydratase, it has a far less effect on the synthesis of the enzyme protein.
Elevated Liver Transaminase Levels in Children With Blunt Abdominal Trauma: A Predictor of Liver Injury
Authors: Hennes Halim M. , Smith Douglas S. , Schneider Kathleen , Hegenbarth Mary A. , Duma Michael A. , Jona Juda Z.
Published: December 2021

The medical records of 43 hemodynamically stable children with elevated serum transaminase levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) who underwent abdominal computed tomographic (CT) scan for blunt abdominal trauma were reviewed. Nineteen patients (44.2%) had AST levels >450 IU/L and ALT levels >250 IU/L, and 17 of these 19 patients had hepatic injury identified on abdominal CT scan. Of the 43 patients, 25 (58.1%) had AST and ALT levels of less than 450 IU/L and 250 IU/L, respectively, and none of these patients had evidence of hepatic injury on CT scan. Elevated serum transaminase levels (AST >450 IU/L and ALT >250 IU/L) identified all of the patients with hepatic injury visible on abdominal CT scan. The sensitivity and specificity of elevated serum transaminase levels were 100% and 92.3%, respectively, for predicting hepatic injury. It is recommended that hemodynamically stable pediatric patients with blunt abdominal trauma and AST levels >450 IU/L and/or ALT levels >250 IU/L undergo abdominal CT scan to determine the presence and extent of hepatic injury. Children with serum transaminase levels below these values are at decreased risk of liver injury.
Urinary N-Acetyl-β-glucosaminidase and the Selection of Children for Radiologic Evaluation After Urinary Tract Infection
Authors: Johnson Candice E. , Vacca Christina V. , Fattlar Deborah , Fulton Doris J. , Hall Philip W.
Published: December 2021

Urinary levels of N-acetyl-β-glucosaminidase (NAG) were measured in 147 consecutively enrolled children younger than 13 years of age with urinary tract infection to determine whether elevated levels were a predictor of urologic abnormalities. The children were classified as having cystitis if results of 0 or 1 of the following tests were positive and as having pyelonephritis if results of ≥2 tests were positive: (1) temperature >38°C, (2) serum C-reactive protein >1 mg/dL, (3) erythrocyte sedimentation rate >25 mm/h, and (4) 1-deamino-8-D-arginine vasopressin-renal concentrating protein <810 mOsm/kg. Urinary NAG to creatinine ratios did not distinguish cases of cystitis from those of pyelonephritis. Urinary NAG was useful in identifying children with cystitis who had vesicoureteral reflux of grades II through V. Of 6 children with cystitis and vesicoureteral reflux, 5 had levels of NAG more than 1 SD above the mean, whereas of 75 children without vesicoureteral reflux, only 15 had such an elevation (P = .003). Of those children with a normal NAG level, 60 (98.4%) had normal radiologic evaluation results, and only 1 child (1.6%) had vesicoureteral reflux. Levels of NAG did not identify children with pyelonephritis who had vesicoureteral reflux. It is concluded that (1) urinary NAG is of no value in localizing the site of urinary tract infection, and (2) an NAG level within 1 SD of the mean in a child with cystitis indicates a low risk of urologic abnormalities, and radiologic evaluation may be omitted unless infection recurs.
Sucrose and Delinquency: Oral Sucrose Tolerance Test and Nutritional Assessment
Authors: Gans Dian A. , Harper Alfred E. , Bachorowski Jo-Anne , Newman Joseph P. , Shrago Earl S. , Taylor Steve L
Published: December 2021

Claims that juvenile delinquency may be associated with reactive hypoglycemia or nutritional deficiencies have received widespread attention but little objective evaluation. To assess the validity of these claims, nutritional and psychological indices of juvenile delinquents have been measured. Serum glucose and insulin profiles during an oral sucrose tolerance test were measured in 137 delinquent and 41 nondelinquent male adolescents aged 14 to 19. In addition, nutritional status of both populations was assessed by anthropometry (height, weight, arm circumference, triceps skin fold) and biochemical measures (hematocrit, red-blood cell thiamin, and serum copper, ferritin, and zinc). Delinquent subjects had slightly but significantly lower serum glucose values at four of six time points (fasting, 60 minutes, 120 minutes, 180 minutes) and higher serum insulin values at one time point (30 minutes) compared with nondelinquent subjects. Changes in glucose from fasting levels indicate that these subjects were regulating serum glucose adequately, but doing so at lower values; changes in insulin from fasting levels indicate that black delinquents initially secreted more insulin than either white subject group. There were no significant associations between excursions in serum glucose or insulin and any adrenergic signs or symptoms of low blood glucose levels. Nutritional status of incarcerated delinquents did not differ from that of nonincarcerated subjects on most measures. Although the significantly lower serum glucose levels and higher serum insulin levels are intriguing, no support is offered by results of this study for allegations that sucrose ingestion causes reactive hypoglycemia in juvenile delinquents or that delinquent male adolescents are at greater risk nutritionally than male adolescents of the same age who are not delinquent. Results of the psychological studies described in the accompanying article in this issue support this conclusion.