bluuebunny/crossref_metadata_2025 huggingface dataset:
PREMATURE INFANTS IN LATER LIFE
Authors: HOWARD PHILIP J. , WORRELL CALIER H.
Published: December 2021

Physically: A few physical defects were found consisting of malnourishment, dwarfism, obesity, hypothyroidism, congenital absence of tooth buds, scoliosis and cryptorchidism. One child showed keratitis at birth. Eleven children were hyperopic. The condition of the eyes leads to the conclusion that the eyes of the premature may be frequently defective. Otherwise it is difficult to say that prematurity itself effects the physical growth.

Intellectually: The I.Q.'s of the 22 children studied ranged from two of the high grade moron group, upward, with a fair distribution, to two I.Q.'s in the very superior intelligence group. Prematurity per se seemingly has neither a beneficial nor detrimental effect on intelligence except that a more than average percentage of premature infants suffer intracranial hemorrhage as a result of being born prematurely. In these studies, one was definitely diagnosed as having brain damage at birth, and others were suspected of this damage. This seemingly appears in the I.Q. results with a higher than expected incidence of mild mental retardation. Using birth weight as a criterion there was no relation between the degree of prematurity and the resultant I.Q.

Emotionally: Personality test results in addition to the information gleaned from the psychologic interviews and the histories show that over half have made unsatisfactory or below average personality adjustment. Contributing factors were found including prematurity, overprotection by the parents, and poor physical endowment. Twelve of the 22 had personalities of the submissive passive type. Eight of the 22 showed unusual aggressive tendencies. Other behavior aberrations uncovered were nail biting, two cases of habit spasms and one case of chronic masturbation. It is suggested that study of premature infants who are necessarily deprived of immediate postnatal maternal tenderness may finally offer a basis for assessing the theory that such tenderness is necessary.
Sexual Abuse and Corporal Punishment During Childhood: A Pilot Retrospective Survey of University Students in Costa Rica
Authors: Krugman Scott , Mata Leonardo , Krugman Richard
Published: December 2021

A sample of 497 students at the University of Costa Rica completed a survey on perceptions and experiences with various forms of punishment and experiences with sexual abuse during childhood. Spanking was shown to be the most widely accepted and most common form of discipline. The majority of the students considered most types of punishment forms of abuse. This study lacks a comparison group and cannot be generalized to the entire Costa Rican population. The section on sexual abuse demonstrated that 32% of the women and 13% of the men experienced some type of sexual abuse during childhood. The abuse mainly occurred between the ages of 5 and 10, and men were most often perpetrators.
Syringe Caps: An Aspiration Hazard
Authors: BOTASH ANN S.
Published: December 2021

The accurate administration of medications to infants and young children is often a difficult task. Patient resistance to medications as well as parental compliance factors are best met by utilizing the most convenient means to deliver medication. For infants, the oral dosing syringe is considered the best device for delivery of liquid medications.1 When used properly, syringes provide the most accurate measured doses and reduce the risk of choking and of aspirating medication.2 Oral medication syringes may be dispensed by a pharmacist or may be available directly to the consumer. These syringes are dispensed with a plastic cap or "shield" to seal the end of the container.
Oxygen Desaturation Complicates Feeding in Infants With Bronchopulmonary Dysplasia After Discharge
Authors: Singer Lynn , Martin Richard J. , Hawkins Suzanne W. , Yamashita Toyoko S. , Benson-Szekely Laura J. , Carlo Waldemar A.
Published: December 2021

Recurrent episodes of hypoxemia may affect the growth, cardiac function, neurologic outcome, and survival of infants with bronchopulmonary dysplasia (BPD). As oral feeding might stress these infants by compromising pulmonary function even after hospital discharge, we measured oxygen saturation (Sao2) via pulse oximetry before, during the initial 10 minutes of, and immediately after oral feeding in 11 patients with BPD, 12 very low birth weight infants, and 23 healthy full-term infants. All infants with BPD had been previously discharged from the hospital after weaning from supplemental oxygen. Studies were done at a mean postconceptional age of 43 weeks while the infants were fed at home by one of their parents. Levels of Sao2 for the three groups were comparable before and during feeds. After feeding, the infants with BPD had significantly lower mean levels of Sao2 (84 ± 8% [SD] vs 93 ± 4% and 93 ± 3%, respectively; P < .01). They also spent more time after feeding with an Sao2 <90% (64 ± 34% of time vs 27 ± 33% for the very low birth weight and 22 ± 20% for the term group; P < .01) and greater time with an Sao2 <80% (37 ± 28% vs 4 ± 10% and 4 ± 8%, respectively; P < .01). Desaturation in infants with BPD was related to larger volume and faster oral intake during feeding. Thus, the data indicate that desaturation after feeding remains a recurrent problem for survivors of BPD after discharge. Individual approaches which incorporate parental education and behavioral interventions might decrease the risk of significant hypoxemia during oral feeding in infants with BPD.
Diagnostic Imaging in the Evaluation of the First Urinary Tract Infection in Infants and Young Children
Authors: Andrich Mary P. , Majd Massoud
Published: December 2021

The evaluation of infants and children after the first urinary tract infection has undergone change in recent years. Standard diagnostic imaging studies are being utilized on a more frequent basis, because these procedures can provide information which often has a direct impact on patient care. Selection of the proper tests requires an understanding of how they are performed and the basis for their choice. The rationale for the use of different imaging studies and their application to patient care are discussed.
Urine Sodium Excretion in Response to an Oral Glucose Tolerance Test in Obese and Nonobese Adolescents
Authors: Finta Kathleen M. , Moorehead Catherine , Key Jane , Rocchini Albert P. , Katch Victor
Published: December 2021

To determine if physiologic changes of insulin are capable of inducing sodium retention in insulin-resistant patients, we evaluated the ability of an oral glucose tolerance test to alter urine sodium excretion in 32 obese subjects (13.3 ± 1 years, weight 82 ± 5 kg, mean arterial pressure 89.3 ± 1.5 mm Hg) and 13 nonobese subjects (13.8 ± 2 years, weight 46 ± 4 kg, mean arterial pressure 74.5 ± 2.6 mm Hg).

After an overnight fast, subjects were placed in water diuresis and fasting insulin and glucose levels were drawn. Three 30-minute urine collections were obtained for baseline urine sodium excretion. The oral glucose tolerance test was administered with glucose and insulin levels drawn at 15, 30, 45, 60, 90, and 120 minutes. During the oral glucose tolerance test, four 30-minute urine collections were obtained for urine sodium excretion.

Serum glucose levels at baseline and throughout the glucose tolerance test did not differ between obese and nonobese subjects. Baseline insulin levels were elevated significantly in the obese (20 ± 3 µU/mL) compared with the nonobese (5 ± 0.7 µU/mL) subjects. Furthermore, insulin levels remained significantly elevated in the obese subjects compared with the nonobese subjects throughout the glucose tolerance test (118 ± 19 vs 49 ± 6 µU/mL, obese vs nonobese subjects at 1-hour post-glucose tolerance test). Prior to the oral glucose tolerance test, urine sodium excretion was not different between obese (249 ± 13 µEq/min) and nonobese (225 ± 28 µEq/min) subjects; however, during the oral glucose tolerance test there was a significant decrease in urine sodium excretion in the obese (158 ± 15 µEq/min) subjects, but no significant change in urine sodium excretion in the nonobese (221 ± 31 µEq/min) subjects.

The data support the hypothesis that, in the obese, changes in insulin associated with eating can result in sodium retention. This insulin-mediated sodium retention may participate in the development of hypertension in obese subjects.
Early Rearing Conditions Alter Immune Responses in the Developing Infant Primate
Authors: Coe Christopher L. , Lubach Gabriele R. , Schneider Mary L. , Dierschke Donald J. , Ershler William B.
Published: December 2021

The influence of early rearing conditions on immunologic development was investigated in infant monkeys. Lymphocyte proliferation, natural killer cell activity, and antibody responses to tetanus vaccination were compared in 30 rhesus monkeys reared under five different conditions. Lymphocyte responses to two mitogens (concanavalin A and pokeweed) were significantly increased in infants from disturbed rearing conditions compared with control infants that had been reared in an undisturbed manner by their mothers. The largest increases occurred in nursery-reared monkeys that had been fed Similac infant formula. The nursery-reared monkeys also tended to show lower natural killer cell activity, but there were no significant differences in response to vaccination. These findings support other research indicating that psychologic and nutritional aspects of the early rearing environment may have long-lasting effects on some, but not all, immune responses in the developing infant.
Evaluation of the Reconstructed Carotid Artery Following Extracorporeal Membrane Oxygenation
Authors: Taylor Bonnie J. , Seibert Joanna J. , Glasier Charles M. , VanDevanter Stephen H. , Harrell James E. , Fasules James W.
Published: December 2021

Over a 12-month period, 28 neonatal patients in respiratory failure were supported with extracorporeal membrane oxygnation (ECMO), and 11 of these underwent successful repair of the right carotid artery post-ECMO. Nine of 11 were studied with duplex color-flow Doppler imaging between 14 and 109 days of age and again at 1 year of age. A velocity ratio (A/B) of the peak systolic velocity above the level of the anastomosis to the peak systolic velocity below the anastomosis was measured to assess the degree of stenosis, if any, at the repair site. Antegrade flow through the carotid was detected post-ECMO in 8 of 9 infants, and antegrade and retrograde flow was documented in 1 infant. A/B ratios ranged from 1.00 to 8.60 (A/B ratio of 1 is normal; 2.0 indicates at least a 50% obstruction to flow). Four of 9 patients had ratios greater than 2.0, and 8 of 9 exhibited some evidence of obstruction. Follow-up scans were performed on 8 of 9 infants between 12 and 18 months of age. All infants examined showed marked improvement in A/B ratio and patency of the vessel, documenting that initial narrowing of the vessel is reversible. No infant had evidence of embolic phenomena to the right side of the brain by magnetic resonance imaging. Repair of the common carotid artery post-ECMO is technically feasible without increasing the risk of brain injury.
Treatment of Theophylline Poisoning
Authors: SHANNON MICHAEL , WERN0VSKY GIL
Published: December 2021

In Reply.—

We appreciate the comments of Strauss and Modanlou on the role of multiple-dose activated charcoal in the treatment of infants with severe theophylline intoxication. We are aware of both studies which they have published in this area and have also used multiple-dose charcoal in neonates.1-3 The infant in our case report was not considered a candidate for multiple-dose activated charcoal because of the absence of bowel sounds. He was also not a candidate for hemodialysis or hemoperfusion because of problems with vascular access which resulted from his complex congenital heart disease (including inferior vena cava occlusion and inaccessible subclavian veins).
The Biobehavioral Interface in Behavioral Pediatrics
Authors: Porges Stephen W. , Matthews Karen A. , Pauls David L.
Published: December 2021

Behavioral pediatrics begins, as a discipline, with at least two important assumptions: (1) that all human experiences have psychosocial as well as biological or organic contexts; and (2) that the biological substrate with which the child is born is modifiable. Thus, behavioral pediatrics, by its own definitions and assumptions, initiates research questions at the biobehavioral interface.1 This paper attempts to delineate a number of research directions that may be used to investigate the complex relationships between behavioral and biological factors in behavioral pediatrics.

Research investigating biobehavioral processes can be approached on a number of different levels. The research can be organized in terms of the following specific causal assumptions relating behavioral and biological factors: (1) a parallel model; (2) a causal model in which behavioral factors influence biological factors; (3) a causal model in which biological factors determine behavior; and (4) a causal model in which there is bidirectional causality.

1. Parallels Between Behavior and Biology. This model assumes that there is no directional causality. Behavioral and biological factors represent parallel systems sharing a common underlying organization. Behavioral and physiological variables may be viewed as different levels of the same system, mediated by central nervous system processes. Various screening methods are based on this model. Research questions dealing with this model focus on indexing and predicting developmental outcome. Techniques such as the Neonatal Behavioral Assessment Scale2 or the identification of sleep patterns3 evaluate behavioral patterns and attempt to identify neurophysiological or neurological dysfunction. Similarly, physiological response patterns such as infant cry patterns4 or heart rate variability measures such as cardiac vagal tone5 have been used to predict developmental outcome when the behavioral repertoire is too limited to be useful in predicting subsequent behavior.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: ZWELLING LEONARD A.
Published: December 2021

To the Editor.—

I have just finished reading Dr Brent's article on chairmanships in the July issue of Pediatrics (1992;90:50-57). As someone who aspires to this role in the future, I found his advice invaluable. The reading list at the end was large and I wondered if he could prioritize it for me. Where should I start?

I would like to read some of the suggested books on academic administration that are listed. Please guide me to some of the best (and most available) of the ones that are listed.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: TARNOWSKI KENNETH J.
Published: December 2021

To the Editor.—

Just a quick note of congratulations to Robert L. Brent concerning his outstanding article on department chairmen which appeared in Pediatrics (1992;90:50-57). Without a doubt, the finest article I have encountered on the sociopolitical realities of department/medical school administration. Unfortunately, too many of the negative scenarios that were described were all too familiar.

Again, an outstanding piece of work. I do hope that the appropriate audience reads this piece. Moreover, I hope they are receptive to Dr Brent's sage advice.
The Use of Cow's Milk in Infancy
Authors: ROBSON WM. LANE M. , LEUNG ALEXANDER K. C.
Published: December 2021

To the Editor.—

In June 1992, the Committee on Nutrition of the American Academy of Pediatrics recommended that if breast-feeding is not possible then an infant formula is the appropriate alternative, and that cow's milk is not suitable as an alternative to breast milk for the first year of life.1

We agree with this recommendation and with the rationale included in the June 1992 statement. In lieu of the recent evidence that cow's milk protein may be implicated in the pathogenesis of diabetes mellitus,2 we believe that the Committee on Nutrition should clarify whether cow's milk is ever appropriate for children and whether or not infant formulas that are based on cow's milk protein are appropriate alternatives to breast milk.
Anaphylaxis at School: Etiologic Factors, Prevalence, and Treatment
Authors:   AMERICAN ACADEMY OF PEDIATRICS,   SECTION ON ALLERGY AND IMMUNOLOGY,   AD HOC COMMITTEE ON ANAPHYLAXIS IN SCHOOL, Wynn Susan Rudd , Frazier Claude A. , Munoz-Furlong Anne , Ostrom Nancy K. , Sampson Hugh A. , Yunginger John W.
Published: December 2021

To the Editor.—

Anaphylaxis in children and adolescents is a medical emergency which requires immediate attention. Anaphylactic reactions caused by allergens such as foods, insect venoms, medications, and exercise may occur in susceptible children and adolescents while they are at school. Because children spend a significant percentage of their waking hours in a school setting, pediatricians should pay special attention to the unique features of the risks of anaphylaxis at school, as well as the possible obstacles to effective treatment.
Behavioral and Emotional Problems Among Preschool Children in Pediatric Primary Care: Prevalence and Pediatricians' Recognition
Authors: Lavigne John V. , Binns Helen J. , Christoffel Katherine Kaufer , Rosenbaum Diane , Arend Richard , Smith Karen , Hayford Jennifer R. , MCGuire Patricia A. ,   The Pediatric Practice Research Group
Published: December 2021

This study examined how well private-practice pediatricians can identify emotional/behavioral problems among preschool children. Children aged 2 through 5 (N = 3876) were screened during a visit to 1 of 68 pediatricians who rendered an opinion about the presence of emotional/behavioral problems. Subsequently, children who scored above the 90th percentile for behavioral problems on the Child Behavior Checklist, along with children matched on age, sex, and race who had screened low, were invited for an intensive second-stage evaluation. There were 495 mothers and children who participated in that evaluation, which included a behavioral questionnaire, maternal interview, play observation, and developmental testing. Two PhD-level clinical child psychologists rendered independent opinions about the presence of an emotional/behavioral disorder. The psychologists identified significantly higher rates of problems overall—13.0% when the criterion was independent agreement that the child had an emotional/behavioral problem and a regular psychiatric diagnosis was assigned, vs 8.7% based on pediatricians' ratings. Prevalence rates based on psychologists' independent ratings were significantly higher than pediatricians' for both sexes, 4- through 5-year-olds, and whites, but not for 2- through 3-year-olds, African-Americans, and all minorities. Prevalence rates based on psychologists' ratings were significantly higher than the pediatricians' for all subgroups when V-code diagnoses were included in the psychologists' ratings. Overall, pediatricians' sensitivity was 20.5%, and specificity was 92.7%. At least 51.7% of the children who had an emotional/behavioral problem based on the psychologist's independent agreement had not received counseling, medication, or a mental health referral from the pediatrician. It is concluded that a substantial number of preschool children with behavior problems in primary care are not being identified or treated.
Maternal and Neonatal Hyperparathyroidism as a Consequence of Maternal Renal Tubular Acidosis
Authors: SAVANI RASHMIN C. , MIMOUNI FRANCIS , TSANG REGINALD C.
Published: December 2021

Neonatal hyperparathyroidism secondary to maternal hypocalcemia in pregnancy is a rare disorder.1 The effects of secondary hyperparathyroidism in patients with renal failure, including renal osteodystrophy, are well described.2 Neonatal hyperparathyroidism in the presence of maternal renal disease and secondary hyperparathyroidism has not previously been reported. We here present a unique situation in which a neonate developed congenital hyperparathyroidism secondary to maternal hypocalcemia as a consequence of renal tubular acidosis. This report emphasizes the significance of maternal serum calcium concentrations in pregnancy in determining the parathyroid state of the fetus and neonate.

METHODS

For this report, the following biochemical methods were employed and normal ranges, as measured in our laboratory, are indicated in the tables.
Partial Methylcrotonyl-Coenzyme A Carboxylase Deficiency in an Infant With Failure to Thrive, Gastrointestinal Dysfunction, and Hypertonia
Authors: TUCHMAN MENDEL , BERRY SUSAN A. , THUY LE PHUC , NYHAN WILLIAM L.
Published: December 2021

Analysis of urinary organic acids will occasionally detect an unexpected metabolic abnormality reflecting an enzyme deficiency in a child with a nonspecific phenotype. We recently found an infant with failure to thrive, gastroesophageal reflux and vomiting, diarrhea, oral candidiasis and lower extremity hypertonia to have a mild organic aciduria of methylcrotonylglycine and 3-hydroxyisovaleric acid unresponsive to pharmacological doses of biotin. Most patients with methylcrotonylglycinuria have defects in biotin metabolism affecting biotin-dependent carboxylase enzymes such as holocarboxylase synthase or biotinidase deficiency and are responsive to biotin administration.1 Enzymatic investigations in the patient described below revealed an isolated partial deficiency of 3-methylcrotonyl-coenzyme A (CoA) carboxylase (MCC) (EC 6.4.1.4) (McKusick 21020) which is biotin resistant, a very rare disorder of leucine degradation.
An Environmental Intervention to Reduce Dietary Fat in School Lunches
Authors: Whitaker Robert C. , Wright Jeffrey A. , Finch Anita J. , Psaty Bruce M.
Published: December 2021

Objective. To determine whether making a low-fat entree available as one of two choices in an elementary school lunch program would reduce the fat content of meals selected by children.

Design. In this before-after trial, students had a daily choice between two entrees, one of which was sometimes low-fat. For 93% of school days during 14 consecutive school months, daily entree choices were recorded for 619976 student meals. The fat content of entrees was assessed with a computerized nutrient database supplemented by food manufacturer's data.

Setting. Sixteen elementary schools in the Bellevue (Washington) School District.

Participants. The number of students eating school lunch averaged 2440 per day, of whom 25% were less than 185% of poverty.

Intervention. After a baseline period of 6 months, the intervention increased the number of days per month when one of the two entrees had 30% or fewer calories from fat.

Main outcome measures. Data for the entire district were combined to estimate for each month the percent of students who selected low-fat entrees and the percent of calories from fat in the average meal selected by students.

Results. During the 6 months before the intervention, a low-fat entree was available on 23% of days; it was selected by 39% of students; and the average meal selected by students had 36% of calories from fat. By the end of the 8-month intervention, a low-fat option was available on 71% of days; it was selected by 29% of students; and the fat content of the average meal dropped from 36% to 30% of calories from fat (P = .02).

Conclusions. In this school district, many students, given the choice, selected low-fat entrees. Recommendations for dietary fat were met simply by the environmental intervention of increasing the availability of low-fat foods. Pediatrics 1993;91:1107-1111; child nutrition, food preferences, diet surveys, schools, dietary fat, child, nutrition.
Duration of Positive Throat Cultures for Group A Streptococci After Initiation of Antibiotic Therapy
Authors: Snellman Leonard W. , Stang Howard J. , Stang Jill M. , Johnson Dwight R. , Kaplan Edward L.
Published: December 2021

Objective. To determine if it is appropriate to recommend that patients with group A β-hemolytic streptococcal pharyngitis, who are clinically well by the morning after starting antibiotic treatment, can return to school or day care, or if they should wait until they have completed 24 hours of antibiotics as recommended by the American Academy of Pediatrics Committee on Infectious Diseases.

Methods. We examined the duration of positivity of the throat culture after antibiotics were begun as a means of assessing the potential risk of transmission to close school contacts. Forty-seven children (4 to 17 years of age) with pharyngitis and a positive throat culture for group A streptococci in an outpatient, staff model health maintenance organization clinic were enrolled and were randomly selected to receive therapy with either oral penicillin V, intramuscular benzathine penicillin G, or oral erythromycin estolate. Additional throat cultures were obtained and clinical findings were recorded for each child during three home visits in the 24 hours after their initial clinic visit. Acute and convalescent sera were obtained for determination of anti-streptolysin O and anti-DNase B titers.

Results. Seventeen (36.2%) of the 47 patients had a positive culture the morning after initiating antibiotic therapy. However, thirty-nine (83%) of the patients became "culture negative" within the first 24 hours. Neither the time interval to the first negative culture nor the presence or absence of group A streptococcal organisms on any single convalescent culture could be predicted by clinical findings. Six of the eight children who failed to convert to a "negative" throat culture within 24 hours of initiating therapy were receiving erythromycin. We could detect no difference in either time to conversion to a negative culture or the presence of a positive culture 24 hours after starting antibiotics between those who demonstrated a significant antibody increase and those who did not.

Conclusion. The data from this study strongly suggest that children with group A β-hemolytic streptococcal pharyngitis should complete a full 24 hours of antibiotics before returning to school or daycare.
Measles Severity and Serum Retinol (Vitamin A) Concentration Among Children in the United States
Authors: Butler Jay C. , Havens Peter L. , Day Susan E. , Chusid Michael J. , Sowell Anne L. , Huff Dan L. , Peterson Dan E. , Bennin Robert A. , Circo Richard , Davis Jeffrey P.
Published: December 2021

Background. Studies in developing countries have shown that children with measles have low serum retinol concentrations and that lower retinol levels are associated with measles-related mortality. Vitamin A therapy has been shown to reduce mortality among African children with acute measles.

Objectives. To determine whether serum retinol concentration is low among children with measles in the United States and to determine whether retinol concentration is associated with illness severity.

Setting. Pediatric referral hospital and clinic in Milwaukee, WI, during the measles outbreak of 1989-1990.

Patients. One hundred fourteen patients ≤5 years of age evaluated for serologically confirmed measles with serum obtained within 5 days following rash onset.

Methods. Serum retinol concentration was determined by high-performance liquid chromatography. Clinical data were collected by hospital record review. A modified Pediatric Risk of Mortality (PRISM) score was used to assess physiologic instability as a measure of illness severity.

Results. Retinol concentrations ranged from 0.25 to 1.18 µmol/L (median 0.58 µmol/L); 82 (72%) patients had low retinol concentration (≤0.70 µmol/L). Median retinol concentrations were lower among hospitalized patients (0.56 vs 0.70, P = .006) and patients with pneumonia (0.52 vs 0.64, P = .02) but higher among children with otitis media (0.63 vs 0.54, P = .01). Higher modified PRISM scores, reflecting greater physiologic instability, were associated with lower retinol concentration (β coefficient -.0147, P = .025). In multivariate analysis, higher modified PRISM scores were associated with lower retinol concentration (β coefficient -.0144, P = .025) even after controlling for hospitalization, presence of complications, race, age, receipt of Aid to Families With Dependent Children, gender, and interval from rash onset until serum was collected.

Conclusions. Among these children with measles in an urban United States community, retinol concentrations were depressed, and the degree of depression was associated with illness severity. Vitamin A therapy should be considered for children with measles in the United States who require hospitalization.
First Aid for the Choking Child
Authors:   Committee on Pediatric Emergency Medicine
Published: December 2021

There are more than 300 annual deaths of children in the United States due to choking.1 Prompt, effective first aid provided by a bystander may and often does prevent morbidity or death. Pediatricians should review the risk of choking with parents during routine health care visits and encourage families to obtain formal training from local agencies such as the American Red Cross and American Heart Association.

Toys, food, or other foreign objects find their way into youngsters' airways. Any child who has choked on a foreign body and is coughing, crying, or speaking is best left to his/her own reflexes to relieve the obstruction. If the child or infant is unable to make sounds or if complete obstruction develops, without evidence of respiratory air movement, immediate first aid is required to avoid permanent disability or death.

CURRENT TECHNIQUES

Abdominal Thrust Technique

Most experts agree that the abdominal thrust maneuver (Fig 1), as originally described by Henry Heimlich, MD, is the most effective method of relieving airway obstruction in children more than 1 year of age.2-8 This method utilizes the following concepts: (1) four fifths of normal respiration occurs using the diaphragm; (2) abdominal pressure compresses the diaphragm upward, thereby raising intrathoracic pressure; (3) rapid increase in intrathoracic pressure may expel the obstructing object; and (4) as a patient becomes hypoxic, muscle tone diminishes. Thus, repeated abdominal thrusts that may be ineffective initially become effective minutes later.

Controversy exists concerning first aid management for a choking child less than 12 months of age: abdominal thrust technique versus back-blow and chest thrust technique.
Plasma Phenylalanine and Tyrosine Responses to Different Nutritional Conditions (Fasting/Postprandial) in Patients With Phenylketonuria: Effect of Sample Timing
Authors: van Spronsen F. J. , van Rijn M. , van Dijk T. , Smit G. P.A. , Reijngoud D. J. , Berger R. , Heymans H. S.A.
Published: December 2021

Objective. To evaluate the adequacy of dietary treatment in patients with phenylketonuria, the monitoring of plasma phenylalanine and tyrosine concentrations is of great importance. The preferable time of blood sampling in relation to the nutritional condition during the day, however, is not known. It was the aim of this study to define guidelines for the timing of blood sampling with a minimal burden for the patient.

Design. Plasma concentrations of phenylalanine and tyrosine were measured in nine patients with phenylketonuria who had no clinical evidence of tyrosine deficiency. These values were measured during the day both after a prolonged overnight fast, and before and after breakfast.

Results. Phenylalanine showed a small rise during prolonged fasting, while tyrosine decreased slightly. After an individually tailored breakfast, phenylalanine remained stable, while tyrosine showed large fluctuations.

Conclusion. It is concluded that the patient's nutritional condition (fasting/postprandial) is not important in the evaluation of the phenylalanine intake. To detect a possible tyrosine deficiency, however, a single blood sample is not sufficient and a combination of a preprandial and postprandial blood sample on the same day is advocated.
Shunts in Patients With Respiratory Distress Syndrome
Authors: WALTHER FRANS J. , LEIGHTON JOHN O.
Published: December 2021

In Reply.—

We agree with Dr Evans that bidirectional ductal shunting is more common than net right-to-left ductal shunting in premature neonates with severe RDS and persistent pulmonary hypertension. Our conclusion that large right-to-left shunts via the ductus are common findings in these cases was not intended to exclude the presence of concomitant left-to-right shunting. In our study population the incidence of right-to-left ductal shunting at 12 and 24 hours of age was 86% and 94% in premature neonates with fatal RDS, 39% and 34% in the severe RDS group, 4% and 0% in the no/mild RDS group, and 6% and 0% in the full-term neonates without RDS.
Control of Jaundice in Preterm Newborns by an Inhibitor of Bilirubin Production: Studies With Tin-Mesoporphyrin
Authors: Valaes Timos , Petmezaki Sophia , Henschke Claudia , Drummond George S. , Kappas Attallah
Published: December 2021

Background. Studies in vitro, in animal models, and in adult and newborn humans have demonstrated that certain tin(Sn)-porphyrins that competitively inhibit the activity of heme oxygenase, the rate-limiting enzyme in heme catabolism, reduce production of bilirubin and can thereby substantially diminish plasma levels of the bile pigment.

Objectives. To assess the effectiveness of increasing doses of the heme oxygenase inhibitor, Sn-mesoporphyrin (SnMP), in moderating the development of significant hyperbilirubinemia and thus the requirements for phototherapy in preterm newborns.

Methods. In five randomized, blinded, placebo-controlled trials, SnMP in increasing doses from 1 µmol to 6 µmol/kg body weight was administered intramuscularly in the first 24 hours of life in preterm newborns of 210 to 251 days gestational age. "Special blue" lamps (Phillips F20T12/BB) were used for phototherapy in newborns exceeding a predetermined plasma bilirubin concentration, irrespective of study group.

Results. A total of 517 newborns were randomized in the five trials carried out sequentially over a 4-year period. SnMP in a dose-related manner significantly ameliorated the course of hyperbilirubinemia in the treated newborns Of all gestational ages. With a SnMP dose of 6 µmol/kg body weight, the mean peak incremental plasma bilirubin concentration was reduced by 41% and the phototherapy requirements were decreased by 76% compared to control subjects. Erythema observed in a few SnMP-treated newborns who required phototherapy was mild, transient, and without sequelae. No other untoward effects were observed during hospitalization or at a follow-up at post-term age of 3 and 18 months.

Conclusions. SnMP, by inhibiting the production of bilirubin, substantially moderates the development of hyperbilirubinemia in preterm newborns. This compound and similarly acting enzyme inhibitors merit further clinical study as agents for controlling neonatal hyperbilirubinemia, particularly in neonatal populations for whom other treatment modalities are not available.
Letter to the Editor
Authors: Hansen Thor Willy Ruud
Published: December 2021

Dr Aschner has some very interesting comments on the role of glial cells in bilirubin neurotoxicity. His suggestion that bilirubin researchers should focus some of their interest on this group of cells, given the increase in knowledge about their more complex role in nervous system homeostasis, is well taken. It would certainly be quite welcome if investigators with relevant research experience would include bilirubin in their future experimental designs.

It seems appropriate in this context to mention the fact that bilirubin researchers in the past have given attention to glial cells, although perhaps with a more limited scope than that suggested by Dr Aschner.
Letter to the Editor
Authors: Merenstein Gerald B. , Hathaway William E. , Miller Robert W.
Published: December 2021

We thank Dr Israels for his thoughtful comments on the AAP Vitamin K Task Force statement. He raises two issues: the risk of cancer from currently recommended doses of intramuscular vitamin K1 and the need for the task force to reconsider the physiology of vitamin K.

The ultimate measure of carcinogenicity in the human is an excess of cancer in the human—not predictive tests in vitro or in animals, useful though they may be to raise suspicions.
Aspartame, Behavior, and Cognitive Function in Children With Attention Deficit Disorder
Authors: Shaywitz Bennett A. , Sullivan Colleen M. , Anderson George M. , Gillespie Sheila M. , Sullivan Barbara , Shaywitz Sally E.
Published: December 2021

Objective. To determine the effects of large doses of aspartame on behavior, cognition, and monoamine metabolism in children with attention deficit disorder.

Design. A randomized, double-blind, placebo-controlled crossover study of unmedicated children meeting Diagnostic and Statistical Manual of Mental Disorders (3rd ed) criteria for attention deficit disorder.

Setting. Behavioral assessments were performed in the child's home by their parents and in the classroom by a teacher. Cognitive tests were administered and blood drawing was performed during a 2-day inpatient admission to our Children's Study Center.

Interventions. Administration of aspartame (single morning dose, 34 mg/kg) or placebo for alternate 2-week periods.

Main outcome measures. Behavioral and cognitive tests included the Matching Familiar Figures Test (MFFT), Children's Checking Task (CCT), the Airplane Test, the Wisconsin Card Sorting Test (WCST), the Subjects Treatment Emergent Symptom Scale (STESS), the Multigrade Inventory for Teachers (MIT), and the Conners Behavior Rating Scale. Blood was drawn for complete blood cell count and liver function tests, as well as amino acid, methanol, formate, serotonin, and monoamine metabolite analyses, and urine was collected for measurement of catecholamine and monoamine metabolite excretion.

Results. No clinically significant differences between aspartame and placebo were found for the STESS, MIT, or Conners ratings, or for the MFFT, CCT, WCST, or Air-plane cognition tests. Also, no differences were noted for any of the biochemical measures, except for the expected increase in plasma phenylalanine and tyrosine following aspartame.

Conclusions. The findings indicate that aspartame at greater than 10 times usual consumption has no effect on the cognitive and behavioral status of children with attention deficit disorder. In addition, aspartame does not appear to affect urinary excretion rates of monoamines and metabolites.
Coronary Risk Factors in Adolescents Related to Their Knowledge of Familial Coronary Heart Disease and Hypercholesterolemia: The Muscatine Study
Authors: Muhonen Linda E. , Nelson Richard P. , Burns Trudy L. , Lauer Ronald M.
Published: December 2021

Objective. To determine the utility of a school-based questionnaire, to identify adolescents with adverse coronary risk factor levels.

Design. In Muscatine, IA, students (9th through 12th grade) completed a questionnaire providing medical history information about first- and second-degree relatives. Anthropometric measures were obtained and blood pressure, lipid, lipoprotein, and apolipoprotein levels were determined.

Results. A history of parental coronary heart disease (CHD) was rare and a history of parental high cholesterol frequently was unknown; however, when known, a history of high cholesterol or early (30 to 55 years of age) or later (>55 years of age) CHD (myocardial infarction, coronary bypass, or death from a heart attack) in grandfathers enriched the identification of adolescents with adverse coronary risk factors. Parental history of CHD was associated with an increased risk for high body mass index and low apolipoprotein A1 levels in their children. Grandfather history of early or later CHD was associated with an increased risk for low apolipoprotein A1 and high density lipoprotein cholesterol levels and high body mass index in their grandchildren. Students with positive grandfather histories of high cholesterol had higher total cholesterol, low density lipoprotein cholesterol, apolipoprotein B, and low density lipoprotein cholesterol to high density lipoprotein cholesterol ratios. Grandmother histories, because most were negative, did not help identify adolescents in this population with adverse coronary risk factors.

Conclusions. A parental history of CHD as well as a grandfather history of high cholesterol or CHD enriches the identification of children with adverse coronary risk factor levels. The positive predictive values associated with using a school-based history obtained from adolescents, many with the aid of their parents, are small and many adolescents do not know their family history. It is essential that pediatricians inquire about parental and especially grandparental medical histories in accordance with the National Cholesterol Education Program guidelines to help identify children at highest familial risk. The importance of determining parental and grandparental histories of CHD or hypercholesterolemia should be emphasized to families who are uncertain of their histories to identify children and adolescents who require a physician's care. It is also important for pediatricians to remind their colleagues who care for patients with premature ischemic heart disease to refer their progeny for pediatric care so that their lipids and lipoproteins may be screened and counseling provided.
MODERN WITCH HUNT—CHILD ABUSE CHARGES
Authors: L. J. F.
Published: December 2021

The 1974 act—sometimes known as the Mondale Act, after one of its sponsors—was implemented to fight a genuine problem. Up to that year, child abuse was rarely reported and frequently covered up. It was Congress's intent to rectify this deplorable situation by providing incentives for states to set up programs for child abuse research, identification, prosecution and treatment. Federal funding was made available to match state spending, and this served as an incentive for states to create such programs.

The law, however, has had results that its authors did not intend. In America today, child sex-abuse accusations are burgeoning. In many cases, it is probable that the charges are valid. But when the charges arise from vicious child custody disputes, where the vengeance element and the opportunity for exclusion of a hated spouse is operative, or in venues such as day-care centers, where the potential pedophile has little opportunity for contact with the child alone, the prevalence of child abuse is in reality quite low.

The Child Abuse Establishment

Nevertheless, the number of charges in these areas escalate. The primary reason: The Mondale Act has strengthened the "child abuse establishment"—a network of social workers, psychiatrists, psychologists and law enforcement officials—that through its very existence frequently validates an individual's charges. In other words, this establishment, unintentionally or intentionally, encourages charges of child abuse whether they are reasonable or not.
Brain Injury Caused by Intraventricular Hemorrhage: Is Indomethacin the Silver Bullet for Prevention?
Authors: Volpe Joseph J.
Published: December 2021

After a series of promising but inconclusive reports concerning the role of neonatal administration of indomethacin in prevention of IVH (see earlier discussion), the largest and most recent study (n = 431), reported by Ment et al,4 indicates that indomethacin led to a decrease in incidence and severity of the lesion. The clinically important grade 4 IVH appeared to be nearly eliminated in the indomethacin-treated group. Thus, is it now clear that indomethacin should be administered at 6 to 12 hours of life to all very low birth weight neonates? Although such a recommendation might be appropriate, I have several concerns.

First, as discussed earlier, experimental studies and observations of human infants indicate that indomethacin is a cerebral vasoconstrictor, leads to a decrease in cerebral blood flow, blunts adaptive vasodilatory responses, and may cause decreases in cerebral oxygen delivery marked enough to impair oxygen utilization. The threat of cerebral ischemia after indomethacin seems real, but notably in the study of Ment et al4 the frequency of ultrasonographic evidence of cerebral ischemic injury was no different in the indomethacin versus the placebo-treated neonates. This reassuring finding must be tempered by the awareness that cranial ultrasonography is somewhat insensitive in the detection of periventricular ischemic injury in the premature infant.41,42

A second concern relates to factors associated with the study of Ment et al.4 As discussed earlier, the placebo-treated group had an unusual preponderance of grade 4 versus grade 3 IVH, and the relatively large proportion of neonates with onset of IVH before 6 to 11 hours of age were not included in the study. Would earlier administration of indomethacin benefit the neonates with early IVH, or would complications be more prominent?

A third concern relates to the recent study of the neonatal complications in infants exposed antenatally to indomethacin for treatment of preterm labor.43 Thus, when compared with a matched group of untreated infants, infants exposed to indomethacin before delivery exhibited a higher incidence of IVH (28% vs 9%, P = .02) and of necrotizing enterocolitis (29% vs 8%, P = .005). However, it is quite possible that the adverse effect of antenatal indomethacin on the occurrence of IVH related to the interaction of factors associated with labor and delivery (eg, increases in cerebral venous pressure) and associated with indomethacin (eg, inhibition of platelet aggregation). Such an interaction of factors would not occur with postnatal administration of indomethacin. Nevertheless, the findings of Norton et al43 are arresting in this context.

Finally, Ment et al4 are to be congratulated for a carefully designed and well-executed study. The data are very promising and indicate the importance of a multicenter study to evaluate the role of indomethacin administered at or very shortly after birth on the subsequent occurrence of IVH and periventricular hemorrhagic infarction.
Letter to the Editor
Authors: Katcher Avrum L.
Published: December 2021

Helen Harrison and her associates are to be congratulated on the thoughtful, useful, and appropriate "Principles for Family Centered Neonatal Care," which were published in the November 1993 issue of Pediatrics. I suggest that these principles, with some slight modifications, could well apply to the care of all newborn babies and really, by extension, to all the work that pediatricians do.

Mrs. Harrison and her associates might consider two additional principles:

11. Parents and professionals must work together to overcome the barriers caused by discrepancy between parent and professional, social status, educational level, cultural, religious, or ethnic backgrounds.
Role of Panic Attacks in the Intractability of Asthma in Children
Authors: Baron Chantal , Marcotte Jacques-Édouard
Published: December 2021

Many authors have stressed the impact of anxiety on asthma. Kinsman has demonstrated how a "panicky" life-style could interfere with asthma management and even result in an increase in use of medications.1 Similar findings were observed in children at our institution.2,3

Contrary to the concept of a "panicky" patient as used by Kinsman,1 the American Psychiatric Association defines a specific entity called panic state or panic disorder remarkable by its intensity and painfulness as well as in the intense fear of resurgence it provokes in patients.

The official criteria of panic disorder in DSM3-R4 in the adult classification are:

A) One or more panic attacks (discrete periods of intense fear or discomfort) that were unexpected, ie, did not occur immediately on exposure to a situation that almost always caused anxiety.
Policy for Vitamin K in Newborns
Authors: Arroll Bruce , Thompson J.
Published: December 2021

We are writing to express our concerns about the recommendations of the Vitamin K Ad Hoc Task Force (Pediatrics 1993;91:1001-1002). Although we agree with some of their arguments, we feel that recommendation 3, which gives guidelines for using oral vitamin K, is both premature and unwarranted given the problems with the Golding et al1 paper. The design has numerous points for concern as does the interpretation because vitamin K in the United Kingdom contains three vehicles; any one of which could be the causative agent if indeed injected vitamin K does cause cancer.