bluuebunny/crossref_metadata_2025 huggingface dataset:
Annual Summary of Vital Statistics—1993
Authors: Wegman Myron E.
Published: December 2021

A new low in the infant mortality rate was reached again in 1993, at 828.8 deaths per 100 000 live births, a decline of 2% from 848.7 in 1992. Births, marriages, and divorces were all lower, both in number and rate. Deaths and the death rate, however, both increased and, more significantly, the age-adjusted death rate increased. A likely explanation is the occurrence of influenza epidemics in early and late 1993. The rate of natural increase declined 8%, to a level of 6.9 per 1000 population. Final figures on births for 1992 indicate that, for the first time in many years, birth rates to teen-agers declined, more among black mothers than white. Increase in birth rate among older mothers continued at a somewhat slower rate than recently; older mothers tended to be better educated than the general population in their age groups. Total fertility rates were higher among mothers of Hispanic origin than among non-Hispanic blacks who, in turn, had higher rates than non-Hispanic whites. Among Hispanics the highest rates were in those of Mexican origin. Unlike recent years, birth rates to unmarried mothers did not increase in 1992. Prenatal care coverage improved, with more mothers seeking care early and fewer receiving late or no care. Electronic and fetal monitoring was performed on more than three-quarters of all births and ultrasound on more than half. Life expectancy decreased slightly, in contrast to recent years. Among major causes of death, increases were recorded in 1993 for chronic obstructive pulmonary diseases, pneumonia and influenza, and HIV infection, the latter having the largest percentage increase. Internationally, infant mortality rates in most other industrialized countries declined further in 1992. Comparatively, as in 1991, 21 other countries had infant mortality rates lower than the United States.
Short Stature: A Psychosocial Burden Requiring Growth Hormone Therapy?
Authors: Sandberg David E. , Brook Amy E. , Campos Susana P.
Published: December 2021

Background. Changes in the diagnosis of endocrine-based growth disorders and the advent of biosynthetic growth hormone have altered the long-standing policy of treating only those individuals with "classic" growth hormone deficiency. One justification for treating short children is to improve their psychosocial adaptation. The present investigation assessed the positive and negative behavioral adaptation, self-perceptions of domain-specific competencies, and global self-worth of a large, diagnostically heterogeneous sample of children and adolescents referred to pediatric endocrinologists for a growth evaluation.

Methods. All patients seen in a pediatric endocrine clinic (180 boys and 78 girls; 4 to 18 years) with a height at the fifth percentile or lower were included. Parents of all participating children completed the Child Behavior Checklist. Patients 8 years and older completed the Self-Perception Profile and those 11 years and older, in addition, completed the Youth Self Report. Short-stature (SS) subjects were compared with normative and psychiatric samples.

Results. The SS boys were described by parents as being significantly less socially competent and showing more behavioral and emotional problems than a normative sample selected for mental health. However, they were significantly more socially competent and showed fewer psychopathologic symptoms than a psychiatric referred sample of comparable age. The SS boys described themselves as less socially active but did not report more behavior disturbance than the normative sample. The SS boys' self-perceptions of domain-specific competencies and global self-worth were comparable to a normative comparison group with the exception that older subjects (13 years or older) described their athletic abilities more positively and their work competence more negatively. The SS girls were, with few exceptions, indistinguishable from the normal comparison groups on both parent- and self-report measures of social competency and behavior disturbance. Younger SS girls (ages 8 to 12 years) described their athletic competence and behavioral conduct more positively than the comparison group on the self-esteem questionnaire. Patient height deficit was unrelated to scores on the three questionnaires. Finally, no statistically significant differences in psychosocial functioning were detected between children with "normal-variant" SS and those with pathologic growth disorders.

Conclusions. Short-stature girls show more adaptive psychosocial functioning than SS boys. In either sex, SS does not appear to be associated with clinically significant psychosocial morbidity. Severity of the height deficit does not correlate with the level of behavioral adaptation. These observations challenge the justification of providing growth hormone therapy for all short children to improve their psychosocial functioning.
Homeopathy Study Questions
Authors: Layton Richard E.
Published: December 2021

After reading the double blind control study regarding the treatment of acute childhood diarrhea with homeopathic medicine published in the May 1994 issue, I am pleased to see Pediatrics publish a practical clinical study that will help pediatricians utilize treatment previously thought to be useless. Specifically, homeopathy has been looked upon with skepticism for many years as a form of voodoo medicine.

As a board-certified pediatrician, I have practiced primary care pediatrics for 15 years and, for the past 7 years, have been evaluating children with problems such as attention deficit hyperactivity disorder and recurrent ear infections, but taking a different approach than is generally accepted.
Efficacy of Tryptophan for the Treatment of Nonketotic Hyperglycinemia: A New Therapeutic Approach for Modulating the N-Methyl-D-aspartate Receptor
Authors: Matsuo Satoshi , Inoue Fumio , Takeuchi Yoshihiro , Yoshioka Hiroshi , Kinugasa Akihiko , Sawada Tadashi
Published: December 2021

Nonketotic hyperglycinemia (NKH) is a rare inherited disease caused by a defect of the glycine cleavage enzyme.1 Especially in the neonatal type, neurological symptoms such as muscular hypotonia, seizures, respiratory distress, and lethargy develop rapidly, and the prognosis is unfavorable.1 Elevation of glycine in the cerebrospinal fluid (CSF) is thought to be responsible for these symptoms. However, management is quite difficult, because it is not well understood how elevation of glycine causes these symptoms. Lowering of the glycine level in CSF with sodium benzoate is not enough to avoid severe psychomotor and mental retardation. The N-methyl-D-aspartate (NMDA) receptor, which is one of the excitatory amino acid receptors, has a glycine binding site.2
Dexamethasone Therapy for Children With Bacterial Meningitis
Authors: Wald Ellen R. , Kaplan Sheldon L. , Mason Edward O. , Sabo Diane , Md Lawrence Ross , Arditi Moshe , Wiedermann Bernhard L. , Barson William , Kim Kwang Sik , Yogev Ram , Hofkosh Dena ,   Meningitis Study Grouo
Published: December 2021

Objective. To determine whether treatment with dexamethasone and ceftriaxone for children with bacterial meningitis reduces the frequency of either sensorineural hearing loss or other neurologic sequelae.

Design. This was a prospective, multicentered, placebo-controlled clinical trial. Subjects were followed for 1 year.

Setting. The study was conducted in six children's hospitals located in Pittsburgh, Houston, Los Angeles, Chicago, Washington, D.C., and Columbus, Ohio.

Patients. Enrolled were 173 children, 8 weeks to 12 years of age, with suspected bacterial meningitis; 143 children were evaluable. Eighty-seven percent of patients were followed for at least 6 weeks to 3 months, and 67% were followed for 1 year.

Interventions. Subjects were randomized to receive ceftriaxone with or without dexamethasone (0.15 mg/kg every 6 hours for 4 days). Auditory brainstem responses (ABR) were measured within 24 hours of admission.

Main outcome measures. Hearing, development, and neurologic sequelae were assessed at the time of discharge and 6 weeks and 1 year later.

Main results. One hundred forty-three patients (69 received dexamethasone and 74 received placebo) with bacterial meningitis were evaluable: Haemophilus influenzae type b (83), Streptococcus pneumoniae (33), Neisseria meningitidis (24), and three others. Overall, there was no significant difference in auditory outcome between dexamethasone and placebo recipients. Twenty-two children had bilateral moderate or more severe hearing loss at the time of the first ABR. At follow-up, the resolution of hearing impairment was nearly identical for each group. Nine of ten children who remained persistently deaf were deaf at the time of the first ABR. There were no differences in neurologic or developmental outcome between groups.

Conclusion. All but one child with persistent bilateral moderate or more severe hearing loss had demonstrable deafness at the time of the first ABR. Dexamethasone did not significantly improve audiologic, neurologic, or developmental outcome in children with bacterial meningitis.
Effect of Infant Formula on Stool Characteristics of Young Infants
Authors: Hyams Jeffrey S. , Treem William R. , Etienne Nancy L. , Weinerman Harry , MacGilpin Douglas , Hine Peter , Choy Karin , Burke Georgine
Published: December 2021

Background. Many infants are switched between multiple formula preparations early in life because of perceived abnormalities in stooling pattern as well as gastrointestinal symptoms.

Objective. To investigate the relationship between the type of formula consumed and the stooling characteristics and gastrointestinal symptoms of young infants.

Methods. Healthy 1-month-old infants were fed one of four commercial formula preparations (Enfamil, Enfamil with Iron, ProSobee, and Nutramigen) for 12 to 14 days in a prospective double-blinded (parent/physician) fashion. Parents completed a daily diary of stool characteristics as well as severity of spitting, gas, and crying for the last 7 days of the study period. A breast-fed infant group was studied as well.

Results. Two hundred eighty five infants were enrolled and 238 completed the study. Infants receiving breast milk or Nutramigen had twice as many stools as other formula groups (P < .001). Infants receiving ProSobee had hard/firm stools more often than breast-fed or other formula-fed groups (P < .00001). Watery stools were more common in infants fed Nutramigen than other formula groups (P < .04). Green stools were more common in 12 mg/L iron preparations (Enfamil with iron, ProSobee, Nutramigen) than in those with 1 mg/L (Enfamil, breast milk) (P < .00001). Spitting, gassiness, and crying were of equal severity in all formula groups.

Conclusions. The interpretation of stool frequency, color, and consistency must take into account the infant's formula type as significant variations in normal infants occur. Parental education on the range of infant stooling characteristics as well as the common occurrence of spitting, gas, and crying may alleviate concern for formula intolerance and underlying gastrointestinal disease.
Iodine-Induced Hyperthyroidism in a Newborn
Authors: Bryant William P. , Zimmerman Donald
Published: December 2021

While hypothyroidism is a common result of neonatal iodine excess, hyperthyroidism may occur, possibly primarily in cases of marked iodine excess.
Letters to the Editor
Authors: Pearson Howard , Dewitt Thomas G.
Published: December 2021

Dr Bustamante's comments are quite timely and add an important dimension to the debate on graduate medical education (GME) and pediatric work force training issues. In creating the Work Force Statement, the Task Force on Organizations spent a significant portion of its deliberations on the 110% allocation and its relationship to the international medical graduate. The Task Force and the Federation were cognizant of the very critical role that IMGs serve in the care of our nations's underserved children.
QUEBEC TO PAY MOTHERS TO BREAST-FEED
Authors: L. J. F.
Published: December 2021

In a sharp departure from the traditional role of government, Quebec pays mothers to nurse their infants ... Since breast-fed babies tend to be healthier babies, encouraging nursing could ultimately save the publicly financed health care system millions of dollars a year.

Quebec has paid supplements to nursing mothers and subsidized the cost of some infant formula for the last quarter-century. What is new—and highly appreciated by nursing mothers on low incomes—is the policy shift in favor of breast milk. When the cash incentive for breast-feeding rose to $37.50 a month, the subsidy for formula was reduced.

... To prevent abuses, the ministry requires that a new mother present an affidavit from her doctor to the local office of the Income Security Ministry that confirms that she is nursing.
The Effects of Birth Condition on Infants' Cortisol Response to Stress
Authors: Ramsay Douglas S. , Lewis Michael
Published: December 2021

Objective, design, and subjects. To examine the effects of nonoptimal birth condition on cortisol response to routine inoculation in a longitudinal sample of full-term healthy infants at 2, 4, and 6 months of age.

Measurement and main results. Optimal versus non-optimal birth condition was defined by a large versus small head circumference and a high versus low 1-minute Apgar score. An optimal birth condition was associated with a high cortisol response at 2 months, but a low cortisol response by 6 months of age.

Conclusions. The findings indicate a reversal in the meaning of high adrenocortical reactivity between 2 and 6 months of age: high cortisol response may index optimal functioning at 2 months, but nonoptimal functioning by 6 months of age. Together with other results, this reversal provides evidence for a developmental shift in adrenocortical functioning during this period. The findings also show that the effects of a nonoptimal birth condition in otherwise healthy full-term infants persist for at least the first 6 months of life.
Clinical Monitoring of Inhaled Nitric Oxide
Authors: Etches Philip C. , Finer Neil N. , Ehrenkranz Richard A. , Wright Linda L.
Published: December 2021

Inhaled nitric oxide (NO) is being increasingly utilized for the treatment of pulmonary hypertension and ventilation-perfusion mismatch in association with respiratory failure in adults, children, and neonates.1,2 The three major areas of potential toxicity of NO are the formation of methemoglobin, the production of free radicals such as peroxynitrite, and the formation of nitrogen dioxide (NO2) by reaction with oxygen (O2) in the delivery system. NO2 is toxic,3 with a maximum 8-hour, time-weighted, average exposure recommendation of 5 ppm.4
Antenatal Steroids Are Associated With Less Need for Blood Pressure Support in Extremely Premature Infants
Authors: Moïse Alicia A. , Wearden Mary E. , Kozinetz Claudia A. , Gest Alfred L. , Welty Stephen E. , Hansen Thomas N.
Published: December 2021

Objective. To determine if antenatal steroids decrease the amount of blood pressure support required by extremely premature infants between 23 and 27 weeks' gestation.

Design. Retrospective cohort study.

Setting. Texas Children's Hospital neonatal intensive care unit from January 1986 to December 1991.

Participants. Two hundred forty premature infants between 23 and 27 weeks' gestation who survived at least 48 hours.

Main outcome measures. The amount of blood pressure support received in the form of dopamine and colloid. Secondary analysis investigated differences in mortality, respiratory support requirements, the incidence of intraventricular hemorrhage, necrotizing enterocolitis, infection, retinopathy of prematurity requiring surgery, and the length of hospitalization.

Results. During the first 48 hours of life, premature newborns exposed to antenatal corticosteroids were less likely to receive dopamine for blood pressure support (47% vs 67%), and if they did, the amount of dopamine expressed as a dopamine score was less than that received by those infants not exposed to antenatal corticosteroids (281 ± 240 vs 407 ± 281). Those exposed to antenatal corticosteroids also had a lower mortality rate (8% vs 24%) and lower respiratory support requirements. The incidence of grade 3 or 4 intraventricular hemorrhage was 8% in infants exposed to antenatal corticosteroids and 17% in infants not exposed. No difference was found in the incidence of necrotizing enterocolitis, infection, or retinopathy of prematurity requiring surgery, or length of hospitalization.

Conclusion. Receipt of antenatal corticosteroids is associated with less need for blood pressure support during the first 48 hours after birth in premature infants between 23 and 27 weeks' gestation.
Workshop on Conflicting Guidelines for the Use of Vaccines
Authors: Halsey Neal A. , Hall Caroline B.
Published: December 2021

Pediatricians and other professionals providing care for children and adolescents refer to a variety of information sources for guidelines regarding optimal therapy on preventive care. In some instances, the guidelines from expert groups (including American Academy of Pediatrics [AAP] recommendations) may differ from material included in the manufacturer's package inserts, and the guidelines from different expert committees may be inconsistent on even conflicting. During recent months, the Committee on Infectious Diseases (COID) of the AAP has worked closely with the Advisory Committee on Immunization Practices (ACIP) of the US Public Health Service and the American Academy of Family Practice to unify the recommendations on the immunization schedule for infants and children.
A Comparison of Cathartics in Pediatric Ingestions
Authors: James Laura Phillips , Nichols Michele H. , King William D.
Published: December 2021

Objective. To compare the mean time to first stool, number of stools, and side effects of three commonly used cathartics in pediatric ingestions.

Design. This prospective clinical trial was a randomized, double-blinded comparison of sorbitol, magnesium citrate, magnesium sulfate, and water, administered with activated charcoal in the treatment of pediatric patients 1 to 5 years of age with acute ingestions. Outcome parameters were mean time to first stool, mean number of stools during 24 hours, and side effects.

Results. One hundred sixteen patients completed the study. Significant differences in mean time to the first stool were detected among cathartic agents (F = 9.29), with sorbitol-treated patients having a shortest mean time to the first stool (mean, 8.48 hours). Sorbitol produced a significantly higher number of stools (mean, 2.79) in the 24-hour follow-up period than other cathartics (F = 3.49). The most common side effect of cathartic administration was emesis, which occurred more commonly in sorbitol-treated patients.

Conclusion. Sorbitol, when administered with activated charcoal in the treatment of children with acute ingestions, produced a shorter time to first stool and more stools than magnesium citrate, magnesium sulfate, or water.
Health Supervision for Children With Neurofibromatosis
Authors:   Committee on Genetics, 1994 to 1995
Published: December 2021

This set of guidelines is designed to assist the pediatrician in caring for the child in whom the diagnosis of neurofibromatosis has been made. Although the pediatrician's first contact with the child is usually during infancy, occasionally the pregnant woman who has been given the prenatal diagnosis of neurofibromatosis will be referred for advice. Therefore, these guidelines offer advice for this situation as well.

At least two distinct types are recognized—neurofibromatosis 1, or NF-1 (previously known as von Recklinghausen disease or generalized neurofibromatosis), and neurofibromatosis 2, or NF-2 (previously known as bilateral acoustic neurofibromatosis). This discussion addresses only issues concerning the diagnosis and management of NF-1.1-8

Neurofibromatosis 1 is a progressive, multisystem disorder affecting about 1 in 3,000 individuals.9 A National Institutes of Health (NIH) Consensus Development Conference10 regarding NF-1 demarcated seven features, of which two or more are required to establish firmly the diagnosis of NF-1:

1. Six or more cafe-au-lait spots (CLS) or macules, greater than or equal to 5 mm in diameter in prepubertal patients and 15 mm in diameter in postpubertal patients;

2. Two or more neurofibromata of any type, or one plexiform neurofibroma;

3. Freckling in the axillary or inguinal region;

4. Optic glioma;

5. Two or more Lisch nodules (iris hamartomas);

6. A distinctive osseous lesion such as sphenoid dysplasia or cortical thinning of long bones, with or without pseudarthrosis; or

7. A first-degree relative (parent, sibling, or child) with NF-1 according to the preceding criteria.

Diagnosis in nonfamilial pediatric cases may be difficult because certain clinical features are age-pendent.
EUTETIC MIXTURE OF LOCAL ANESTHETICS (EMLA) CREAM FOR PAINLESS SKIN TESTING: A PRELIMINARY REPORT
Authors: Miller Betty
Published: December 2021

This study confirms the anesthetic efficacy and safety of EMLA cream. The EMLA cream did not interfere with the formation of wheals and flares and therefore did not jeopardize the purpose of intradermal skin testing. The recommended 1-hour wait was best for effective anesthesia. EMLA is not recommended for infants less than 1 month or for infants under 1 year of age who are receiving sulfonamide or methemoglobin-inducing agents. Because this is only a preliminary report, larger numbers of children need to be evaluated for false negative results when EMLA is used in conjunction with intradermal testing.
RISK FACTORS FOR ACUTE WHEEZING IN INFANTS AND CHILDREN: VIRUSES, PASSIVE SMOKE, AND IMMUNOGLOBULIN E (IgE) IgE ANTIBODIES TO INHALANT ALLERGENS
Authors: Kettelhat Brett , Lee Napoleon , Kobayashi Roger H.
Published: December 2021

Study Population. Ninety-nine children from age 2 months to 16 years who presented to the Pediatric Emergency Room of the University of Virginia and received treatment for acute wheezing, were enrolled in this study. Fifty-seven control patients were enrolled from the same setting who did not previously or currently manifest wheezing/respiratory symptoms.

Method. Serum for immunoglobulin E (IgE) and radioallergosorbent test (RAST) IgE for D. Pteronyssinus/Farinae, cat epithelium, short ragweed, rye grass, and mixed Cockroach was collected. Nasal saline washes were obtained for respiratory syncytial virus (RSV) antigen detection and respiratory viral cultures. Nasal smears for eosinopils were obtained as well as saliva samples for the nicotine metabolite, cotinine.

Results. IgE RAST testing identified an increasing number of study patients with IgE specific antibodies. Nasal smears revealed similar but not identical findings. Patients over 2 years of age demonstrated a family history of atopy, IgE levels, and positive RAST significantly greater than control (P < .001). Viral infections were more common in younger children <2 years of age (positive in 90% vs 50% in the >2 years 0.05). RSV isolates were greatest in children <2 years old. Seventy five percent of patients compared with 58% of controls had one or more smokers at home. Children <2 were more likely to have an elevated salivary cotinine level than children >2 years old, despite the presence of smokers in the home. Combination risk factors found 66% of patients with two or more risk factors as compared with only 28% of controls (P < .001).
MASSIVE COVERT INFECTION OF HELPER T LYMPHOCYTES AND MACROPHAGES BY HIV DURING THE INCUBATION PERIOD OF AIDS
Authors: Van Kerckhove Catherine , Liu Andrew
Published: December 2021

HIV virus is active in lymphoid tissues even during the asymptomatic stage of the disease. Therefore, a state of true microbiological latency does not exist during the course of HIV infection. The best way to fight HIV-1 disease, therefore, appears to be through prevention and early treatment.
ZIDOVUDINE AND DIDANOSINE COMBINATION THERAPY IN CHILDREN WITH HUMAN IMMUNODEFICIENCY VIRUS INFECTION
Authors: Love Jamie , Shearer William T.
Published: December 2021

Combination therapy compares favorably with monotherapy with regard to clinical outcome and side effects. The dose of AZT and ddI used in combination therapy may approximate that of monotherapy without increasing the frequency of side effects. The children in Arm B had more advanced disease, and possibly had developed resistance to the AZT they had previously been prescribed. Arm B showed much less benefit from therapy than Arm A, both in immunologic parameters and survival.
CONVERGENT COMBINATION THERAPY CAN SELECT VIABLE MULTIDRUG-RESISTANT HIV-1 IN VITRO
Authors: Van Kerckhove Catherine , Liu Andrew
Published: December 2021

These in vitro experiments suggest that triple drug combination therapy may result in coresistant HIV-1 virus. However, the authors emphasize that the in vivo clinical effect of simultaneous administration of three reverse transcriptase inhibitors may yet prove beneficial in the treatment of HIV-1 disease.
MATERNAL VITAMIN A DEFICIENCY AND MOTHER-TO-CHILD TRANSMISSION OF HIV-1
Authors: Cotton Mark F.
Published: December 2021

Maternal vitamin A deficiency contributes to mother-child transmission of HIV.
THE USE OF PULSE OXIMETRY IN THE PREVENTION OF HYPEROXAEMIA IN PRETERM INFANTS
Authors: L. J. F.
Published: December 2021

When deciding an appropriate upper limit for pulse oxygen saturation (SpO2) in preterm infants the usefulness of current data is limited by the fact that previous studies have examined a population of more mature infants and children or have applied various exclusion criteria that produce results unrepresentative of clinical practice. We tested the hypothesis of previous workers that maintaining the SpO2 below 98% would ensure an arterial oxygen tension (PaO2) less than 12 kPa. A total of 477 simultaneous measurements of PaO2 and SpO2 were made using Ohmeda Biox oximeters on 43 infants who were less than 33 weeks gestation and receiving supplementary oxygen. Of 435 measurements performed when the SpO2 was 97% or less, 26 (6%) had a PaO2 greater than 12 kPa. Further examination of the data showed that of 108 estimations performed when the SpO2 was less than 94%, none had a PaO2 greater than 12 kPa.

Conclusion. When using Ohmeda Biox pulse oximeters an upper limit of 97% for SaO2 is not effective in preventing hyperoxaemia; however, a limit of 93% is likely to maintain the PaO2 below 12 kPa.
Patterns of Care Received by Medicaid Recipients With Urinary Tract Infections
Authors: Fargason Crayton A. , Bronstein Janet M. , Johnson Victoria A.
Published: December 2021

Background. Urinary tract infections (UTIs) occur commonly in children and may lead to substantial morbidity. Most experts recommend urine cultures for diagnosing UTIs in children. In addition, most experts recommend imaging studies in a portion of children diagnosed with UTIs.

Purpose. The purpose of this study was to assess how rates of performance of urine cultures and imaging studies for children in the Alabama Medicaid program diagnosed with a UTI vary by patient demographics, provider characteristics, and service locations.

Methods. The study design was a retrospective review of Alabama Medicaid claims data. Children were included as UTI cases if they had a Medicaid claim for urinary tract infections during 1991, were continuously enrolled in Medicaid for that year, and were younger than 8 years of age. Claims were grouped into episodes of care, and episodes were assigned to a diagnosing physician. Physician locations were classified as rural, suburban, or urban using demographic data. Specific laboratory and imaging procedures were identified using CPT codes (Physician's Current Procedural Technology Codes, 4th Edition).

Results. We identified 404 episodes of UTI occurring in 380 children. Only 47% of episodes were associated with claims for urine cultures. Claims for urine cultures were more frequently filed by pediatricians in urban locations. In the subset of 114 patients with multiple UTI episodes, only 68% had imaging studies specific for the urinary tract. Only 44% received both a voiding cystourethrogram and renal ultrasound.

Conclusions. Claims data suggest that physicians underuse urine cultures in diagnosing UTIs in Alabama pediatric Medicaid recipients. Urban-based pediatricians perform better than other types of physicians. Imaging studies are also used less frequently than is commonly recommended.
Early Discharge of Newborns and Mothers: A Critical Review of the Literature
Authors: Braveman Paula , Egerter Susan , Pearl Michelle , Marchi Kristen , Miller Carol
Published: December 2021

Objective. To determine whether research supports the advisability of early discharge of healthy newborns and mothers.

Methods. Critical review of English-language literature cited in the Index Medicus or the International Nursing Index.

Findings. No adequately designed studies have examined discharge before 48 hours after delivery without additional postdischarge services. Few studies have examined the consequences of recommending a clinic visit within the first days after discharge; studies of this practice among low-income populations found high no-show rates. Some small studies suggest that early discharge is likely to be safe for selected populations at low psychosocial, socioeconomic, and medical risk, with careful antenatal screening and preparation and multiple postpartum home visits. Some studies suggested adverse outcomes associated with early discharge even with early follow-up.

Conclusions. Published research provides little knowledge of the consequences of short maternal/newborn hospital stays or varying postdischarge practices for the general population. The studies that have concluded that early discharge was safe were applied under restricted circumstances or were too small to detect clinically significant effects on important outcomes. Further research is needed to inform clinical and reimbursement policy on health services in the first days of life and parenting. Rigorous studies of sufficient size are needed to examine the impact of different hospital stays and different postdischarge practices on a range of outcomes for mothers and newborns in diverse populations and settings. Given a priori concerns, decisions on neonatal/obstetric discharge planning should be made cautiously.
Hospital Readmission Due to Neonatal Hyperbilirubinemia
Authors: Seidman Daniel S. , Stevenson David K. , Ergaz Zivanit , Gale Rena
Published: December 2021

Severe neonatal hyperbilirubinemia can occur without apparent reason in term healthy breast-fed infants and some develop kernicterus. The aim of our study was to assess the incidence of severe hyperbilirubinemia in term healthy newborns discharged from the hospital. From January 1 through December 31, 1994, 6705 infants were delivered at Bikur-Cholim and Misgav-Ladach Community Hospitals. All 1448 newborns discharged with a serum bilirubin level >10.0 mg/dL were instructed to return to the hospital within 3 days for follow-up, as well as bilirubin determination. Twenty-one newborns with a bilirubin level >18.0 mg/dL were identified and readmitted at mean ± standard deviation (SD) 5.5 ± 1.8 (range, 5 to 10 days of life). This represents 1.7% of the 1220 infants who returned for follow-up examination. Mean ± SD serum bilirubin levels at readmission were 19.6 ± 2.5 mg/dL. All but one of the infants were breast-fed. No cases of ABO incompatibility were found and two newborns were glucose-6-phosphate dehydrogenase (G6PD)-deficient. Sepsis work-up and direct Coomb's tests were negative in all cases. None had hemolysis or were found to have any cause for hyperbilirubinemia other than breast-feeding. Phototherapy was provided in all but two cases, and an exchange transfusion was performed in one case. Three additional infants, with bilirubin levels <10 mg/dL at discharge, were readmitted due to hyperbilirubinemia. One was diagnosed with neonatal hepatitis. We conclude that, based on our study population, 0.36% of term infants may subsequently develop severe neonatal hyperbilirubinemia in the first postnatal week. Adequate follow-up programs should be available when early discharge of healthy term newborns is considered.
Kernicterus in Otherwise Healthy, Breast-fed Term Newborns
Authors: Maisels M. Jeffrey , Newman Thomas B.
Published: December 2021

Objective. To document the occurrence of classical kernicterus in full-term, otherwise healthy, breast-fed infants.

Methods. We reviewed the files of 22 cases referred to us by attorneys throughout the United States during a period of 18 years, in which neonatal hyperbilirubinemia was alleged to be responsible for brain damage in apparently healthy, nonimmunized, full-term infants. To qualify for inclusion, these infants had to be born at 37 or more weeks' gestation, manifest the classic signs of acute bilirubin encephalopathy, and have the typical neurologic sequelae.

Results. Six infants, born between 1979 and 1991, met the criteria for inclusion. Their peak recorded bilirubin levels occurred 4 to 10 days after birth and ranged from 39.0 to 49.7 mg/dL. All had one or more exchange transfusions. One infant had an elevated reticulocyte count (9%) but no other evidence of hemolysis. The other infants had no evidence of hemolysis, and no cause was found for the hyperbilirubinemia (other than breast-feeding).

Conclusions. Although very rare, classic kernicterus can occur in apparently healthy, full-term, breast-fed newborns who do not have hemolytic disease or any other discernible cause for their jaundice. Such extreme elevations of bilirubin are rare, and we do not know how often infants with similar serum bilirubin levels escape harm. We also have no reliable method for identifying these infants early in the neonatal period. Closer follow-up after birth and discharge from the hospital might have prevented some of these outcomes, but rare, sporadic cases of kernicterus might not be preventable unless we adopt an approach to follow-up and surveillance of the newborn that is significantly more rigorous than has been practiced. The feasibility, risks, costs, and benefits of this type of intervention need to be determined.
Recommended Guidelines for Uniform Reporting of Pediatric Advanced Life Support: The Pediatric Utstein Style
Authors: Zaritsky Arno , Nadkarni Vinay , Hazinski Mary Fran , Foltin George , Quan Linda , Wright Jean , Fiser Debra , Zideman David , O'Malley Patricia , Chameides Leon , Cummins Richard O.
Published: December 2021

This consensus document is an attempt to provide an organized method of reporting pediatric ALS data in out-of-hospital, emergency department, and in-hospital settings. For this methodology to gain wide acceptance, the task force encourages development of a common data set for both adult and pediatric ALS interventions. In addition, every effort should be made to ensure that consistent definitions are used in all age groups. As health care changes, we will all be challenged to document the effectiveness of what we currently do and show how new interventions or methods of treatment improve outcome and/or reduce cost. Only through collaborative research will we obtain the necessary data.

For these reasons, and to improve the quality of care and patient outcomes, it is the hope of the task force that clinical researchers will follow the recommendations in this document. It is recognized that further refinements of this statement will be needed; these recommendations will improve only when researchers, clinicians, and EMS personnel use them, work with them, and modify them. Suggestions, emendations, and other comments aimed at improving the reporting of pediatric resuscitation should be sent to Arno Zaritsky, MD, Eastern virginia Medical School, Children's Hospital of The King's Daughter, Division of Critical Care Medicine, 601 Children's Lane, Norfolk, VA 23507.
Water-Ski Douche Injury in a Premenarcheal Female
Authors: Perlman Sally E. , Hertweck S. Paige , Wolfe Walter M.
Published: December 2021

In the last 15 years, seven cases of deep vaginal lacerations after the so-called water-skiing douche have been reported.1-4 We report the first such case in the premenarcheal girl.

CASE REPORT

A 9-year-old girl, Tanner stage 2, in otherwise excellent health, was transferred to Kosair Children's Hospital (Louisville, KY) after falling while water skiing and sustaining an injury producing persistent vaginal bleeding. This young girl was on her fifth trial of being up on water skis. She was wearing a single-layer, one-piece cloth bathing suit. The boat was traveling approximately 40 to 50 mph. She never was able to reach a full standing position.
A Look at the Private Practice of the Future
Authors: Nazarian Lawrence F.
Published: December 2021

Powerful trends that have influenced pediatric care in recent decades will sweep us into the new century. By looking at the major forces at work today, we can predict where we will be 10 years from now. As infectious diseases continue to decline, psychosocial disorders will take a larger share of the pediatrician's efforts. Technology will allow more effective management, but it will require strong commitment to ongoing education. More children with chronic conditions and more young adults will fall under the care of pediatricians. Prevention will retain a central role in practice. Maintaining an independent practice will become more difficult, and a wide range of delivery schemes will emerge. Relationships among pediatricians and relationships with other health care providers will be influenced significantly by these systems, which carry potential for both positive and negative impact on the quality of care and on the lifestyles of pediatricians. It is crucial that pediatricians take an active and committed role in shaping the evolution of care systems, thereby making the future what it should be for children.
Response to Drs Pappelbaum and Nazarian
Authors: Green John L.
Published: December 2021

I liked Dr Pappelbaum's presentation a lot. My response? Read it; reread it; understand it; adjust to its doctrines; follow its prescriptions and program plan and be flexible and resilient. I totally concur with Dr Pappelbaum's belief that managed care need not be an end to one's pediatric career, but a program that can and must continue to work for our patients. Managed care will not go away; it is chronic, and we must adapt to it.

The theme of both Dr Pappelbaums's article and of this meeting—as a whole and for every part of it—is that change is the "here and now," and that we must adapt to it. The constant message is that pediatricians must go forward in their communities with all the peer help and all the consultative help that each can muster. They must work within the structure and boundaries of change, striving for the most benefit for the patients they care for and for themselves.

Dr Nazarian, whose presentation was equally excellent, has a good view of medicine now and medicine in the future. I have no challenge to his views or conclusions.

Like Dr Nazarian and like Dr Elsa Stone, who spoke yesterday, I employ pediatric nurse practitioners (PNPs) in my clinical practice. I am the senior partner of an eight-physician (four male and four female) practice in an academic community. We have two full-time PNPs and one physician assistant associated in our practice. As valued and contributing members of our health care team, they are true physician extenders.
Thriving in the 21st Century: Outcome Assessment, Practice Parameters, and Accountability
Authors: Bergman David A.
Published: December 2021

The past two decades have brought about major health care changes that have been driven by an ever-increasing cost of health care, practice variability, and medical malpractice litigation. These changes pose a challenge to pediatricians to contain costs, to reduce inappropriate use of health care services, and to demonstrate improved health care outcomes. To meet this challenge, a new "clinical tool kit" is required, one that will allow the pediatrician to analyze current practices and to document effective interventions. Two of the major tools in this kit are practice guidelines and outcomes assessment instruments.

Practice guidelines are optimal care specifications that provide an analytic framework for defining high-quality care and measuring health care outcomes. Ideally, these guidelines should be developed from scientific evidence. In practice, however, scientific evidence to support the majority of recommendations made in guidelines is insufficient. Consequently, these recommendations are instead developed by expert consensus.

Measurement of health outcomes includes clinical outcomes, patient satisfaction, cost and use, and quality of life. Health care organizations have become very sophisticated in measuring cost and use, but considerably less work has been done in the patient-centered areas of satisfaction and quality of life. This is particularly true for children, because measures are dependent on the viewpoint chosen (parent, child, or teacher), the age of the child, and the adjustment for severity of illness.

Analyzing practice patterns and improving health outcomes will not be easy tasks to accomplish. For the pediatrician to use these tools in an efficient and effective manner, a new research agenda and new skills will be required.
Is a High-fiber Diet Safe for Children?
Authors: Williams Christine L. , Bollella Marguerite
Published: December 2021

Objectives: Although dietary fiber is associated with important health benefits in childhood, there have been concerns that very high fiber diets may result in adverse health effects. This report reviews the major safety concerns associated with consumption of very high fiber diets, estimates the amount of fiber that may cause adverse physiologic effects in children, and proposes safe levels of dietary fiber intake for children and adolescents.

Methods. Published studies on dietary fiber intake in childhood were reviewed to determine major safety concerns, to document adverse effects, to characterize subjects involved and the dose and type of fiber consumed, and to estimate potential relevance to US children and adolescents. Levels of dietary fiber reported to have adverse health effects were compared with recommended levels of fiber intake for children older than 2 years of age.

Results and Conclusions. A review of the scientific literature suggests that a small loss of energy, protein, and fat may occur with a high intake of dietary fiber. However, this small loss of energy is unlikely to be significant to children consuming adequate levels of major nutrients, especially at conservative fiber intakes as recommended by the American Health Foundation's age plus 5 formula. In addition, it is estimated that even with a doubling of current dietary fiber, there is unlikely to be an adverse effect on serum vitamin and mineral concentrations in healthy US children consuming a balanced diet containing adequate levels of nutrients. Thus, evidence suggests that for US children, a moderate increase in dietary fiber is more likely to be healthful than harmful.
Effect of Urine Latex Agglutination Tests on the Treatment of Children at Risk for Invasive Bacterial Infection
Authors: Adcock Penny M. , Paul Ronald I. , Marshall Gary S.
Published: December 2021

Background. Identifying febrile children with invasive bacterial infection is difficult in the absence of telltale physical findings. Urine latex agglutination (ULA) tests have been used for rapid, on-site identification of such children.

Objectives. To study the performance of ULA tests in identifying children with Haemophilus influenzae, Streptococcus pneumoniae, and group B streptococcus infection and to examine how the results of ULA tests affect patient treatment.

Design. Retrospective review.

Setting. Urban children's hospital.

Patients. All emergency department and hospital patients tested by ULA in 1990, excluding patients in the neonatal units.

Results. Of 1629 patients, 36 had positive tests (20 H influenzae, 5 S pneumoniae, and 11 group B streptococcus). Thirteen of these were false positive based on culture results. Although ULA tests demonstrated excellent specificity, their sensitivity was poor. Positive predictive values for bacteremia ranged from 0.346 to 0.600, and negative predictive values ranged from 0.972 to 0.997. The decision to treat with antibiotics was made before ULA test results were available in 19 (53%) of the 36 patients with positive test results. Of 1593 patients with negative test results, 1211 (76%) were admitted to the hospital, and approximately 81% were empirically treated with parenteral antibiotics.

Conclusions. In clinical practice, treatment and disposition decisions are frequently made without regard to ULA test results.
Lack of Autoantibody Expression in Children Born to Mothers With Silicone Breast Implants
Authors: Levine Jeremiah J. , Lin Hun-Chi , Rowley Merrill , Cook Andrew , Teuber Suzanne S. , Ilowite Norman T.
Published: December 2021

Objective. We determined systematically the prevalence of autoantibodies in children born to mothers with silicone breast implants and the relationships with clinical symptoms and methods of exposure.

Methods. Autoantibody expression was determined in 80 children born to mothers with silicone implants and in 42 controls. A clinical assessment score was assigned to each patient. Antinuclear antibodies as well as antibodies to mitochondrial, smooth muscle, striational, myocardial, parietal cell, reticulin tissues, or subcellular compartments were measured by indirect fluorescent assay. Antibodies to nRNP (U1-RNP/snRNP); Sm; SS-A; SS-B; Scl-70; thyroid microsome; immunoglobulin (Ig)G, IgM, and IgA antibodies to cardiolipin; and antibodies to native and denatured human types I and II collagen were measured by enzyme-linked immunosorbent assay. Serum complement components C3 and C4 and IgM rheumatoid factor were measured by nephelometry.

Results. Autoantibody prevalence was not significantly different between children born to mothers with silicone implants and controls. The presence of autoantibodies was not related to the children's clinical symptoms or to the method of exposure.

Conclusions. Determination of autoantibody production is of limited clinical utility in the evaluation of children born to mothers with silicone breast implants.
The Role of 131 Iodine-Metaiodobenzylguanidine Scanning in the Correlative Imaging of Patients With Neuroblastoma
Authors: Andrich Mary P. , Shalaby-Rana Eglal , Movassaghi Nasser , Majd Massoud
Published: December 2021

Objective. Metaiodobenzylguanidine (MIBG) scans were studied to determine the impact of the scan results on the clinical treatment of pediatric patients with neural crest tumors.

Methods. Serial scans were reviewed retrospectively for 27 patients with neural crest tumors: 25 with initial diagnoses of neuroblastoma (NB), 1 with ganglioneuroblastoma, and 1 with ganglioneuroma (GN). Results were compared with bone scans and computed tomography scans, as well as surgical pathologic findings.

Results. At initial diagnosis, when compared with bone and computed tomographic scans, MIBG imaging did not identify any unsuspected lesions that resulted in a change in staging. Thirteen patients with NB who had initially positive MIBG scan results had serial studies that normalized during therapy. However, after completion of therapy, 8 of 13 had relapses of the disease. Although areas of active disease were well delineated by other standard imaging modalities for all 8, only 4 (50%) had MIBG study results that were positive in sites of relapse. There were 4 cases of GN (1 at diagnosis and 3 after therapy for NB) demonstrating an uptake of MIBG that was similar in appearance to that in NB.

Conclusions. MIBG imaging did not change the staging or alter treatment during therapy for any patient. Normalization of positive study results was an unreliable indicator of outcome for children with NB. Furthermore, when relapse occurred, MIBG scans identified only 50% of those with active NB. The uptake of MIBG in GN was indistinguishable from that in NB. In this series, the results of serial MIBG studies did not have a significant impact on patient treatment.