bluuebunny/crossref_metadata_2025 huggingface dataset:
Sequential Serum Aluminum and Urine Aluminum: Creatinine Ratio and Tissue Aluminum Loading in Infants With Fractures/Rickets
Authors: Koo Winston W.K. , Krug-Wispe Susan K. , Succop Paul , Bendon Robert , Kaplan Lawrence A.
Published: December 2021

Aluminum toxicity is associated with the development of bone disorders, including fractures, osteopenia, and osteomalacia. Fifty-one infants with a mean (± SEM) birth weight of 1007 ± 34 g, gestational age of 28.5 ± 0.3 weeks, and serial radiographic documentation at 3, 6, 9, and 12 months for the presence (n = 16) or absence (n = 35) of fractures and/or rickets were studied at the same intervals to determine the serial changes in serum aluminum concentrations and urine aluminum-creatinine ratios. Autopsy bone samples were used to determine the presence of tissue aluminum. Serum aluminum concentrations from 46 infants were stable and similar between groups, with mean values between 15 and 22 µg/L. Urine aluminum-creatinine (micrograms per milligram) ratios from 14 infants were higher in infants with fractures and/or rickets (0.26 ± 0.06 vs 0.12 ± 0.04) at onset, and rate of decrease in aluminum-cratinine ratio was faster in infants without fractures and/or rickets. All but three infants were tolerating complete enteral feeding at all sampling points. One infant who received aluminum-containing antacid had marked increase in serum aluminum to 83 µg/L while urine aluminum-creatinine ratio increased from 0.09 to a peak of 8.53. Vertebrae from three infants at autopsy (full enteral feeding was tolerated for 37 and 41 days in two infants, respectively) showed aluminum deposition in the zone of provisional calcification and along the newly formed trabecula. It is concluded that in enterally fed very low birth weight infants, serum aluminum levels and urine aluminum-creatinine ratios were similar in infants with and without fractures and/or rickets, presumably in part from modulation of aluminum absorption. However, aluminum absorption can be increased as indicated by increased serum and urine aluminum concentrations from aluminum antacid therapy. Bone accumulation of aluminum is possible with currently used enteral and parenteral nutrients, but the critical level of tissue aluminum loading associated with development of fractures and/or rickets remains to be determined.
A Simple Method of Estimating Cerebrospinal Fluid Pressure During Lumbar Puncture
Authors: Ellis Robert W. , Strauss Lewis C. , Wiley Joseph M. , Killmond Thomas M. , Ellis Robert W.
Published: December 2021

It is often difficult to measure cerebrospinal fluid (CSF) pressure in children. CSF flow through a spinal needle is described by the equation: Flow = pressure/(needle constant x relative viscosity). Thus, CSF flow rate during lumbar puncture can be used to estimate CSF pressure. Because the viscosity of CSF is approximately the same as that of normal saline, 0.9% NaCl was used to model CSF flow in vitro. Flow of saline through various spinal needles was measured as pressure and temperature were varied to determine needle constants and variation in viscosity with temperature. Counting periods for which the number of drops counted equals the pressure (in centimeters of H2O) then were determined for each needle size. At patient temperatures less than 40°C, counting periods were calculated at 21, 39, and 12 seconds, for 22-gauge 1.5-inch, 22-gauge 3.5-inch, and 20-gauge 3.5-inch spinal needles, respectively. Viscosity decreased slightly above 40°C, and counting periods became 20, 37, and 11 seconds. Finally, the method was tested prospectively in 12 patients by comparing drop count (over the calculated counting period) to manometric pressure measurement. Drop counts were within 15% of manometric pressure in all patients. This method allows simple and rapid estimation of CSF pressure during lumbar puncture.
Apolipoprotein A-I, A-II, B, C-II, and C-III in Children with Insulin-dependent Diabetes Mellitus
Authors: Muhtaseb Najah Al , Yousuf Abdul Razak Al , Bajaj J. S.
Published: December 2021

This study was conducted to determine whether changes in the levels of plasma apolipoproteins (apo) A-I, A-II, B, C-II, and C-III, along with cholesterol and triglycerides, could provide additional information on these parameters in relation to the control of glycemia. Plasma and lipoprotein lipids and apolipoprotein levels were measured in 123 insulin-dependent diabetic childern (4- to 12-years-old), classified into good, fair, and poor diabetic control based on HbAlc and fructosamine levels, and in 62 comparable healthy controls. Total cholesterol, very low density lipoprotein cholesterol, and low density lipoprotein cholesterol, as well as total triglycenides, very low density lipoprotein, low density lipoprotein, and high density lipoprotein (HDL) triglycerides, and apo B and apo C-III were increased significantly in children with fair and poor diabetic control. While in diabetic children with good control, only very low density lipoprotein cholesterol was elevated significantly compared with healthy control subjects. Conversely, the levels of cholesterol in HDL, HDL2, HDL3, and apo A-I were decreased significantly in the three diabetic groups, but apo A-II and apo C-II did not change. We conclude that in children with insulin-dependent diabetes mellitus, abnormalities in plasma lipid, lipoprotein, and apolipoprotein levels occur, the extent of which depends on the degree (extent) of glycemic control (the poorer the control the more substantial the abnormality). We suggest that measurement of apo C-III level along with apo B and apo A-I in these patients may be a sensitive indicator to alterations in glycemic control.
Facing Tragic Decisions with Parents in NICU: Clinical Perspectives
Authors: NARKEWICZ RICHARD M.
Published: December 2021

To the Editor.—

As a primary care physician I read with great interest the article by Dr Jellinek et at1 about the tragic decisions in neonatal intensive care units. Their perspective seems to be very worthwhile and helpful both to physicians, parents, and patients.

I was disappointed, however, that the family's primary care pediatrician was relegated to the next to the last paragraph, almost an afterthought. Family pediatricians have a great perspective on the interaction between families and their children.
Babesiosis: An Underdiagnosed Disease of Children
Authors: Krause Peter J. , Telford Sam R. , Pollack Richard J. , Ryan Raymond , Brassard Peter , Zemel Lawrence , Spielman Andrew
Published: December 2021

Babesiosis is a malaria-like illness caused by the intraerythrocytic parasite Babesia microti and is transmitted by the same tick that transmits Borrelia burgdorferi, the causative agent of Lyme disease. Babesiosis is well recognized in adult residents of southern New England and New York but has been described in only five children. To determine whether children are infected with B microti less often than are adults, a prospective serosurvey was carried out on Block Island, RI, where babesiosis is endemic. Randomly recruited subjects completed a questionnaire and provided a blood sample. Antibodies against B microti and B burgdorferi were measured using a standard indirect immunofluorescence assay and enzyme-linked immunosorbent assay, respectively. Of 574 subjects, 9% tested positive for B microti, including 12% of the 52 children (7 months through 16 years) and 8% of the 522 adults (not significant, P < .6). Although babesiosis had not been diagnosed in any of the Babesia-seropositive subjects, 25% of the children and 20% of the adults reported symptoms compatible with this infection during the previous year. Of the 6 children and 45 adults seropositive for B burgdorferi, 17% and 14%, respectively, were also seropositive for B microti. It is concluded that children are infected with B microti no less frequently than are adults and that this infection is underdiagnosed in all age groups. Physicians who practice where Lyme disease is endemic should become familiar with the clinical presentation and diagnosis of babesiosis, both in adults and children.
Renal Tubular Acidosis in Children Treated With Trimethoprim-Sulfamethoxazole During Therapy for Acute Lymphoid Leukemia
Authors: Murphy Jerome Linus
Published: December 2021

The antibiotics trimethoprim (TMP) and sulfamethoxazole (SMZ), when used in combination, can cause metabolic acidosis, renal bicarbonate wasting, and growth failure. Retrospective review of repeated random serum chemistries from 10 children receiving TMP-SMZ and maintenance chemotherapy for acute lymphoid leukemia revealed low serum bicarbonate (P = .0002) and elevated serum chloride (P < .0005) concentrations. These values normalized after all medications were discontinued. Prospective study of 8 children receiving TMP-SMZ and chemotherapy for acute lymphoid leukemia revealed lower serum bicarbonate concentrations and higher urine pH following a dose of TMP-SMZ than paired values obtained more than 3 days after a dose. Four children (50%) met serum bicarbonate and urinary pH criteria for the diagnosis of renal tubular acidosis soon after a dose of TMP-SMZ. The occurrence of TMP-SMZ-induced renal tubular acidosis has implications for the acid-base balance of children receiving TMP-SMZ on a long-term basis.
What Is the Legal `Standard of Medical Care' When There Is No Standard Medical Care? A Survey of the Use of Home Apnea Monitoring by Neonatology Fellowship Training Programs in the United States
Authors: Meadow William , Mendez David , Lantos John , Hipps Robert , Ostrowski Michele
Published: December 2021

In treating a patient, a doctor is obliged to use the skill and care that is ordinarily used by reasonably well-qualified doctors in similar cases. In addition, the only way in which a juror may decide whether the defendant used the skill and care which the law required of him or her is from evidence presented by doctors called as expert witnesses (cf Illinois Pattern Jury Instructions). However, what should be done if expert opinions differ concerning the care that is "ordinarily used"? Home apnea monitoring (HAM) is prescribed at times for graduates of neonatal intensive care units despite the fact that indications for its use are not well established and efficacy is completely unknown. The authors attempted to determine standards for HAM as it is currently practiced in neonatology training programs. The primary teaching hospital for each of the 99 neonatology training programs in the United States was identified. Both the medical director (MD) and a neonatal intensive care unit nurse manager (RN) were asked about the use of HAM in their own nursery for four clinical vignettes. Each vignette depicted a 1000-g birth weight infant, currently 7 weeks old and ready for discharge. In three vignettes, the infant had demonstrated no apnea, mild apnea (resolved by 2 weeks of age), or moderate apnea (requiring theophylline therapy at discharge) during the hospital course. In the fourth vignette, the infant had no apnea but was to be discharged home with supplemental oxygen. For 67 of 99 training programs, paired responses of RN managers and MD directors were obtained. For infants with no apnea or mild apnea, approximately 85% of RN/MD pairs agreed that HAM would not be used at their institution, 2% would use HAM, and 12% responded that they might use HAM depending on individual circumstances. In contrast, for the premature infant with moderate apnea, there was much less agreement. Sixteen percent of RN/MD pairs responded that HAM would not be used, 39% would use HAM, and 19% might. Remarkably, for this vignette 25% of the RN/MD responses disagreed on the practice of HAM at their own center. Similarly, for the infant with home oxygen, 15% of RN/MD responses agreed that HAM would not be used, 49% answered that HAM would be used, 10% were uncertain, and 25% disagreed on the use of HAM at their own center. It is concluded that (1) for premature infants with no or mild apnea, HAM is currently prescribed by a minority of fellowship-associated neonatology programs, and (2) no obvious consensus exists for HAM in the context of moderate apnea or home oxygen therapy. For many infants, there is no "standard care" for HAM in the neonatology community at this time. "Expert" opinions of the legal "standard of care" for HAM should reflect this fact.
Humor in the Pediatric Emergency Department: A 20-Year Retrospective
Authors: Nelson Douglas S.
Published: December 2021

Humorous events often take place in pediatric emergency departments without being recorded. A written account of amusing situations occurring in an emergency department has been compiled over 20 years by personnel at a large urban children's hospital. Data from this reference were analyzed for humorous content and presented in the following categories: most interesting chief complaints, suspicious sounding chief complaints, favorite telephone inquiries, and illustrative cases. This study demonstrates that an emergency department may be a fertile source of medical humor. Recognition of these statements and events helps to relieve the stress of medical training and emergency department work.
Zinc Deficiency in a Full-Term Breast-Fed Infant: Unusual Presentation
Authors: KHOSHOO VIKRAM , KJARSGAARD JOHN , KRAFCHICK BERNICE , ZLOTKIN STANLEY H.
Published: December 2021

Zinc is an essential trace mineral for all mammals. The activities of many enzymes, including those needed for protein synthesis, are zinc dependent. It is therefore not surprising that zinc deficiency is cinically expressed in rapidly growing tissues. Zinc deficiency commonly presents with specific skin lesions, diarrhea, growth failure, alopecia, irritability, and anorexia.

Acquired zinc deficiency is an uncommon entity. It has most often been described in patients receiving total parenteral nutrition with inadequate or no zinc in the nutrient mixture.1,2 It has also been described in breast-fed premature babies3,4 in whom symptoms become apparent by 4 to 5 months of age.
Eosinophilic Pustular Folliculitis
Authors: DARMSTADT GARY L. , TUNNESSEN WALTER W. , SWEREN RONALD J.
Published: December 2021

Eosinophilic pustular folliculitis is a cutaneous disorder that consists of recurrent crops of pruritic, sterile, papulopustules in a follicular distribution. In pediatric patients, EPF presents primarily in the scalp and is confused with several other more common dermatoses in children. The diagnosis of EPF rests on its inclusion in the differential diagnosis of papulo-pustular disorders, the recognition of the clinical presentation, and the presence of an eosinophilic infiltrate on biopsy. Treatment with midpotency topical coticosteroids has thus far met with modest success.

This is the first report on EPF in the pediatric literature. As pediatricians become more aware of EPF as a distinct clinical entity and as our clinical experience and insight into the pathogenesis of EPF grows, perhaps more effective treatment modalities will be devised.
The Use of Whole Cow's Milk in Infancy
Authors:   Committee on Nutrition
Published: December 2021

The pediatrician is faced with a difficult challenge in providing recommendations for optimal nutrition in older infants. Because the milk (or formula) portion of the diet represents 35% to 100% of total daily calories and because WCM and breast milk or infant formula differ markedly in composition, the selection of a milk or formula has a great impact on nutrient intake.

Infants fed WCM have low intakes of iron, linoleic acid, and vitamin E, and excessive intakes of sodium, potassium, and protein, illustrating the poor nutritional compatibility of solid foods and WCM. These nutrient intakes are not optimal and may result in altered nutritional status, with the most dramatic effect on iron status. Infants fed iron-fortified formula or breast milk for the first 12 months of life generally maintain normal iron status. No studies have concluded that the introduction of WCM into the diet at 6 months of age produces adequate iron status in later infancy; however, recent studies have demonstrated that iron status is significantly impaired when WCM is introduced into the diet of 6-month-old infants. Data from studies abroad of highly iron-deficient infant populations suggest that infants fed partially modified milk formulas with supplemental iron in a highly bioavailable form (ferrous sulfate) may maintain adequate iron status. However, these studies do not address the overall nutritional adequacy of the infant's diet. Such formulas have not been studied in the United States.

Optimal nutrition of the infant involves selecting the appropriate milk source and eventually introducing infant solid foods. To achieve this goal, the American Academy of Pediatrics recommends that infants be fed breast milk for the first 6 to 12 months. The only acceptable alternative to breast milk is iron-fortified infant formula. Appropriate solid foods should be added between the ages of 4 and 6 months. Consumption of breast milk or iron-fortified formula, along with age-appropriate solid foods and juices, during the first 12 months of life allows for more balanced nutrition. The American Academy of Pediatrics recommends that whole cow's milk and low-iron formulas not be used during the first year of life.
Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation For Diagnostic and Therapeutic Procedures
Authors:   Committee on Drugs
Published: December 2021

In the last 5 years there has been an increase in invasive diagnostic, radiologic, and minor surgical procedures on pediatric patients outside the traditional operating room setting. As a consequence, there has been a marked increase in the use of sedatives and general anesthetic agents in physician offices, dental offices, subspecialty procedure suites, imaging facilities, emergency departments, and ambulatory surgery centers.1-17 In recognition of the expanding need for both the elective and emergency use of these agents in nontraditional settings, the American Academy of Pediatrics guidelines for the use of depressant agents in children, first presented in 1985 under the title "Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients,"18 have been revised.

This revised statement reflects our current understanding of appropriate monitoring needs, both during and after a procedure, for children receiving sedatives and general anesthetic agents.19-29 The monitoring and care outlined in these guidelines may be exceeded at any time, based on the judgment of the responsible physician. Although they are intended to encourage high-quality patient care, observing these guidelines cannot guarantee a specific patient outcome. They are subject to revision from time to time, as warranted by the evolution of technology and practice.

These guidelines are proffered with the awareness that regardless of the intended level of sedation or route of administration, the sedation of a patient represents a continuum, and may result in the loss of the patient's protective reflexes;30 a patient may move easily from a light level of sedation to obtundation.1-6,8,12,14,15,26,29
Positioning and SIDS
Authors:   AAP Task Force on Infant Positioning and SIDS
Published: December 2021

SUMMARY STATEMENT

Based on careful evaluation of existing data indicating an association between Sudden Infant Death Syndrome (SIDS) and prone sleeping position for infants, the Academy recommends that healthy infants, when being put down for sleep, be positioned on their side or back. The most common position currently used in the United States is prone.

This recommendation is made with the full recognition that the existing studies have methodologic limitations and were conducted in countries with infant care practices and other SIDS risk factors that differ from those in the United States (eg, maternal smoking, types of bedding, central heating, etc). However, taken as a group the studies are convincing. No reports show an advantage to the prone position with regard to SIDS incidence and there are no data proving, or even strongly suggesting, that sleeping in the lateral or supine position is harmful to healthy infants. Thus, assessment of the risk/benefit balance for prone vs nonprone positioning for such infants favors the latter. It should be stressed that, the actual risk of SIDS for an infant placed prone is still extremely low.

There are still good reasons for placing certain infants prone. For premature infants with respiratory distress, for infants with symptoms of gastroesophageal reflux or with certain upper airway anomalies, and perhaps for some others, prone may well be the position of choice. A nonprone sleeping position is recommended for healthy infants only.

REPORT

Health care professionals frequently are asked how it is best to place an infant down for sleep, prone or supine.
Interdisciplinary Evaluations of Alleged Sexual Abuse Cases
Authors: Jaudes P. Kienberger , Martone M.
Published: December 2021

Children who are alleged to have been sexually abused often go through gruelling interrogations to relate their experiences to adults and, even then, most are not viewed as reliable sources of information. The Victim Sensitive Interviewing Program (VSIP) was initiated to decrease the number of interviews endured by a child who allegedly had been sexually abused. The program brought together the disciplines involved in the evaluation of these cases: hospital-based social worker and pediatrician, state child protective agency worker, police, and assistant state's attorney. This team established a protocol for an investigative interview to be conducted by a team member. Pre-VSIP sexual abuse evaluations from 1985 and 1986 (38) were compared with VSIP evaluations (226) from 1987 and 1988. There was no significant difference between the two groups in relation to gender or age of victim, physical symptoms, physical findings, sexually transmitted diseases present, age of perpetrator, or length of stay in hospital. However, there were significant differences between the two groups in (1) number of interviews, 11% pre-VSIP vs 79% VSIP receiving only one interview (P < .001); (2) number of interviewers, 24% pre-VSIP vs 88% VSIP were interviewed by only one interviewer (P < .001); (3) indicated cases of sexual abuse, 68% pre-VSIP vs 88% VSIP (P < .006); (4) identification of the perpetrator, 71% pre-VSIP vs 85% VSIP (P < .035); and (5) charges pressed if perpetrator identified, 33% pre-VSIP vs 60% VSIP (P < .010). It is concluded that interdisciplinary evaluations of alleged sexual abuse in children not only decreased the number of interviews a child must undergo but also increased the likelihood of indicated cases, identification of the perpetrator, and charges being pressed. Therefore, it is strongly recommended that interdisciplinary teams be formed to assess alleged sexual abuse in children.
Pediatric Equestrian Injuries
Authors: Bixby-Hammett Doris M.
Published: December 2021

Using data from four sources, horse-related injuries are summarized for persons younger than 25 years of age. Head injury caused 57% of deaths. The upper extremity was the most common area injured, with the next most frequent areas the lower extremity (National Park Service data) and the head (United States Pony Clubs [USPC] data). Injured females outnumbered injured males and had a greater percentage of participants injured (USPC data). Injuries occurred at home in 41% (National Electronic Injury Surveillance System data). USPC figures suggest that greater knowledge may reduce the severity of horse-related injuries. Previous horse-related injury had occurred in 1 of 4 of those injured (USPC data). One third of accidents occurred during lessons (USPC data). Riding instructors should be certified by a recognized organization, and parents should evaluate an instructor's personal riding and their safety records with students. The pediatrician's role should be in counseling parents with children who ride and in offering recommendations for safety to governing boards of youth horse activities.
Delayed Diagnosis of Pediatric Cervical Spine Injury
Authors: Orenstein Julian B. , Klein Bruce L. , Ochsenschlager Daniel W.
Published: December 2021

We report on nine patients in whom there were delays in establishing a diagnosis of cervical spine injury and discuss the causes that contributed to the delays, their clinical significance, and whether or not asymptomatic injury occurs.
Developmental Screening: (Still) Expecting the Impossible?
Authors: DWORKIN PAUL H.
Published: December 2021

The widespread popularity of the Denver Developmental Screening Test (DDST) during the past 25 years has been accompanied by considerable scrutiny. Certain criticisms, such as the lack of updated norms, the limited extent to which norms may apply to groups such as disadvantaged children, and the difficulty in administering some items, appear justified.1 However, a number of studies critical of the DDST examine applications beyond the intended purpose of this instrument, such as identifying developmental delay among biologically vulnerable infants, screening for speech and language problems, and identifying children with moderate to severe delays.2 The inaccurate or inappropriate way in which the test has been administered and interpreted has troubled the test's developers.3
Questions Collaborative Dexamethasone Trial
Authors: JONES ROSAMOND , GRANT ADRIAN ,   Collaborative Dexamethasone Trial Group
Published: December 2021

In Reply.—

We are glad to respond to Dr MacMahon's letter about the generalizability of the results of our trial. Basing trial entry on `clinical uncertainty' is actually one of the strengths of this trial.1

No trial can ever include a random sample of all human beings who meet the eligibility criteria; there is always selection of subjects (whatever the entry criteria). Inevitably, therefore, at some point there has to be a leap of faith from the evidence to clinical practice.2
Pediatricians in Court
Authors: BENJAMIN JOHN T.
Published: December 2021

To the Editor.—

I have been a practicing pediatrician for 18 years. There have been many changes in our specialty during that time. Some of the changes have been good and others more troublesome. Good changes have included greater recognition of the importance of our specialty; higher pay scale for residents, and, for that matter, practitioners; our greater ability to diagnose and treat patients: computed tomography, magnetic resonance imaging, and marvelous laboratory tests not even imagined 20 years ago; increased numbers and complexities of medications and methods of monitoring those medications—all of these changes have contributed to improved medical care for children.
More to be Learned from Crigler-Najjar Patients
Authors: HANSEN THOR WILLY RUUD
Published: December 2021

To the Editor.—

In a recent study by Galbraith et al,1the use of tin-mesopor-phyrin in two patients with the Crigler-Najjar type I syndrome is described. The feasibility of this kind of treatment is documented, and their comments on the size of the total-body bilirubin pool as well as their calculations on bilirubin production and clearance in these patients are very interesting and illuminating.

However, I am personally as much intrigued by aspects of the case reports, about which the authors do not comment, probably because it is outside the focus of their paper.
Comparison of Pediatric Poisoning Hazards: An Analysis of 3.8 Million Exposure Incidents A Report from the American Association of Poison Control Centers
Authors: Litovitz Toby , Manoguerra Anthony
Published: December 2021

This analysis of life-threatening and fatal pediatric poisonings was conducted to aid poison prevention educational efforts, guide product reformulations and aversive agent use, reassess over-the-counter status for selected pharmaceuticals, and identify research areas for clinical advances in the treatment of pediatric poisonings. A hazard factor was devised to assess more objectively the pediatric poisoning hazard posed by pharmaceutical and nonpharmaceutical products. By considering the frequency and extent of injury following actual exposures, the hazard factor reflects more than the acute toxicity of individual ingredients and is also influenced by such variables as packaging, accessibility, availability (as a reflection of marketing), formulations, and closure types. Of the 3 810 405 exposures involving children younger than 6 years of age reported to poison centers in 1985 through 1989, 2117 patients experienced a major outcome (life-threatening effect or residual disability) and an additional 111 fatalities occurred. The three most commonly implicated substance categories, accounting for 30.4% of reported exposures, include cosmetics and personal care products, cleaning substances, and plants. All had low hazard factors, with significant hazards being limited to a small number of products identified herein. Thus this analysis of hazard factors demonstrates that frequent exposure does not imply toxicity. Iron supplements were the single most frequent cause of pediatric unintentional ingestion fatalities, accounting for 30.2% of reported pediatric pharmaceutical unintentional ingestion fatalities reported over an 8-year period. Antidepressants, cardiovascular medications, and methyl salicylate follow in frequency of pediatric pharmaceutical deaths. Hydrocarbons (including five lamp oil deaths) and pesticides were each implicated in 12 pediatric ingestion fatalities during the 8-year period. Selenious acid-containing gun bluing was involved in four deaths. These data allow a more informed approach to poison prevention efforts in the 1990s.
PSEUDOMONAS MENINGITIS IN AN INFANT SUCCESSFULLY TREATED WITH NEOMYCIN
Authors: DITKOWSKY SOL , GOLDMAN ALBERT , GOLDIN MILTON
Published: December 2021

A case of meningitis caused by Ps. aeruginosa in an infant treated successfully with neomycin is reported. The present-day therapy of this infection is discussed and the value of intramuscular neomycin in this condition is illustrated.
THE PEDIATRICIAN AND THE PUBLIC
Authors: BAUER LOUIS H.
Published: December 2021

The American Medical Association was organized in 1847. Its original aim was the improvement of medical education in the United States. This still remains one of its important activities but the Association has expanded tremendously since its formation.

It now consists of 2,011 component county and district societies and 53 constituent associations in the States, Territories and Possessions. County and district societies elect delegates to the state associations and the whole membership of these county societies takes part in their election. These delegates form a State House of Delegates which in turn elects delegates to the American Medical Association.

The A.M.A. House of Delegates is the legislative body of the Association and is responsible for all official policies. All reports, resolutions and recommendations are referred by the House to several Reference Committees who hear testimony on both sides of every question and then render reports to the House. Here all reports are debated again and brought to a vote. Any member of the Association, whether or not a member of the House, can appear before a Reference Committee and state his opinions and recommendations on the matter under discussion.

Between sessions of the House of Delegates, the Board of Trustees is the governing body.
HYPOTONIC CEREBRAL PALSY IN MENTAL DEFECTIVES
Authors: YANNET HERMAN , HORTON FRANK
Published: December 2021

The relative importance of the hypotonic type of cerebral palsy among the mentally defective is stressed. This type of cerebral palsy manifests itself in either of three clinical pictures with some overlapping, namely, atonic, ataxic and athetoid. The etiology is variable in each of these groups and may be effective in either the prenatal, paranatal or postnatal periods.

The severity of the mental defect, the high incidence of convulsive disorders, and the tendency toward microcephaly point towards the widespread nature of the pathologic process regardless of etiology.

The syndrome of atonic diplegia, as herein described, is probably invariably associated with the more severe degrees of mental deficiency.
EXOGENOUS HEMOCHROMATOSIS IN MEDITERRANEAN ANEMIA
Authors: FRUMIN ABRAHAM M. , WALDMAN SYDNEY , MORRIS PAUL
Published: December 2021

A patient with Mediterranean anemia who received many blood transfusions over a period of years is presented.

The pigment deposition in Mediterranean anemia, originally thought due to an inherited defect, is attributed to multiple blood transfusions.

It is maintained that this abnormal pigment deposition represents another instance of exogenous hemochromatosis.
GASTROINTESTINAL ALLERGY IN INFANCY
Authors: ROSENBLUM ARTHUR H. , ROSENBLUM PHILIP
Published: December 2021

The syndrome of gastrointestinal allergy as observed in 60 infants is a clinical entity characterized by diarrhea, colic or vomiting, alone or in varying combinations. Diarrhea is almost twice as common as colic or vomiting.

The syndrome may be suspected upon the demonstration of clumps of eosinophiles, or large numbers of scattered eosinophiles in the stools. The stools are generally high in mucus content, and the eosinophiles are most numerous in the mucus. A rapid, easy method for demonstrating eosinophiles in the stool mucus is described.

The allergic nature of the signs and symptoms is further suggested by:

a. The positive family background of allergy.

b. The development of other major allergic manifestations in the subsequent course of these patients.

c. The striking frequency with which symptoms disappear after the removal of the offending food from the diet. This may be anything in the diet, but is generally cow's milk. Results may not be apparent until a week has elapsed after specific food elimination.

d. Recurrence of symptoms may be demonstrated upon readministration of the offending substance.

The ultimate fate of these babies with regard to the development of later allergic disturbances will have to await long range follow-up studies. It is hoped that the control of these early allergic manifestations may minimize later allergic symptomatology.

Evidence is presented that the first allergic disturbances may occur in the newborn period.
Round Table Discussion
Authors: NAJJAR VICTOR A. , MCQUARRIE IRVINE , HOLT L. EMMETT , GARDNER LYTT I. , BAKWIN RUTH , NOONE ERNEST L.
Published: December 2021

The administration of ACTH or 11-oxygenated steroids to animals results in: (a) increased blood sugar and liver glycogen concentrations, partially as a result of decreased glucose oxidation; (b) increased urinary N excretion; (c) increased total body fat, and (d) tendency toward Na retention and K deficit. In clinical studies these findings have been largely confirmed, using indirect technics. Children on long-term treatment with full doses of adrenal hormones present a special problem, since the foregoing metabolic abnormalities cause inhibition of somatic growth. Periodic clinical appraisal of these patients with careful longitudinal measurements, body weight and x-rays for bony maturation are suggested. The importance of a food intake adequate to offset a negative N balance is stressed, as well as the provision of added K to prevent chronic K deficiency.

Question: How soon after you start treatment does K deficiency develop? That is. if you are using cortisone.

Dr. Gardner: Compared with desoxycorticosterone, cortisone is a relatively weak K depleting agent, and the development of clinically measurable K deficiency on full doses of cortisone may take several weeks or even longer. This variability of K depleting effect may depend to a great extent upon the dietary intake of Na, since K deficit appears to develop much more readily in the presence of adequate or more than adequate Na intake.

Chairman Najjar: In bringing this discussion to an end, I would like to repeat some of the highlights presented here. We know now that some cases of hypoglycemia show absence of the alpha cells of the islet tissue of the pancreas. When pancreatic tissue is obtained under circumstances requiring surgical exploration, one must look for the alpha cells. These cells excrete a hormone, heretofore unsuspected, the hyperglycemic hormone. This is in the process of being produced commercially and should be available in the future. This hormone may well have the therapeutic potentialities for those cases, as insulin has for diabetic patients. Cases with glycogen disease may show severe and irreversible hypoglycemia. Some cases show abnormal glycogen and there is a good possibility that a defect in the enzyme system is responsible. Hormones play a significant role in carbohydrate metabolism and, when uncontrolled, may have a deleterious effect as witnessed by the development of Cushing's syndrome following ACTH therapy.
ACUTE BENIGN PERICARDITIS IN CHILDHOOD: COMPARISONS WITH RHEUMATIC PERICARDITIS, AND THERAPEUTIC EFFECTS OF ACTH AND CORTISONE
Authors: FRIEDMAN SIDNEY , ASH RACHEL , HARRIS T. N. , LEE HENRY F.
Published: December 2021

Six cases of acute benign pericarditis in childhood have been studied.

The importance in childhood of the differentiation of acute benign pericarditis from acute rheumatic pericarditis has been emphasized and demonstrated by a comparison of the clinical findings and subsequent courses in patients with these two types of pericardial involvement.

The results of treatment of acute primary pericarditis with the hormones ACTH and cortisone are presented and discussed.

Some negative findings in the study of the etiology of this disease are presented.
STUDIES ON ABSORPTION AND DISTRIBUTION OF TERRAMYCIN IN CHILDREN
Authors: HUNT ANDREW D. , KELLEY RICHARD S. , CORIELL LEWIS L. , MURPHY M. LOIS , TASHMAN SYLVIA G. , STEVENS CAROLINE
Published: December 2021

The absorption of terramycin from the gastrointestinal tract is rather similar to that of aureomycin. Peak levels are low, tend to be achieved in 2 to 6 hours after ingestion, and are prolonged for several hours.

Single oral doses of 11 mg/kg. body weight give peak serum levels ranging from 0.20 to 1.95 µg./cc., with a mean of 1.0 µg./cc.

Doubling or tripling this single dose did not produce marked increases in serum levels.

Dosage of 11 mg./kg. orally every six hours (44 mg./kg./24 hours) resulted in peak serum levels on the third day which were essentially identical with those after the initial dose. However, when a dosage of 33 mg./kg. was given orally every six hours (132 mg./kg./24 hours), marked cumulation in the serum was noted. The mean serum level on the first day on this schedule was 2.7 µg./cc., and on the third day, 8.0 µg./cc.

Diffusion into the cerebrospinal fluid in three cases was poor. With spinal fluid and serum levels simultaneously obtained, the spinal fluid levels were ¼, ⅙ and ⅛, respectively of the serum levels.

Intravenously administered terramycin in dosage of 6.6 mg./kg. gave peak serum levels at one-half hour, ranging from 10.0 to 12.8 µg./cc. Six hours after injection, serum levels ranged from 1.8 to 4.4 µg./cc., and at 12 hours, from 0.78 to 2.6 µg./cc.

Terramycin given rectally in perforated capsules was well tolerated. However, in four patients given 66 mg./kg. by this route, peak serum levels ranged from 0 to 1.0 µg./cc.

Recommended terramycin dosage: (a) Oral: 11 mg./kg./dose every six hours (44 mg./kg./24 hours). Adequate antibacterial serum levels for most susceptible organisms are produced with this dosage.

Increasing the dosage to 33 mg./kg./dose every six hours (132 mg./kg./24 hours) may be done in cases when high serum levels seem indicated. (b) Intravenous: 6.6 to 11 mg./kg./dose every 6 to 8 hours.
CONGENITAL ABSENCE OF THE SPLEEN; SYNDROME WITH ATRIOVENTRICULARIS AND SITUS INVERSUS
Authors: POLHEMUS DONALD W. , SCHAFER WILLIAM B.
Published: December 2021

Four cases of congenital absence of the spleen are presented with a review of the literature. It is noted that this anomaly usually occurs as a syndrome with persistent atrioventricularis communis, partial situs inversus of the abdominal viscera, and accessory lobes of the lung.
AGAMMAGLOBULINEMIA
Authors: BRUTON OGDEN C.
Published: December 2021

A hitherto unrecognized entity manifested by complete absence of gamma globulin with otherwise normal serum proteins and recurrent pneumococcal sepsis is described in an 8 year old male. The patient appears to be normal in other respects and after extensive study no structural or functional change could be demonstrated in any body system although gamma globulin by electrophoretic analysis of his serum was consistently absent. He was unable to produce antibody for the pneumococcus with the four antigenic substances used; a positive Schick test persisted in spite of numerous attempts to reverse it with diphtheria toxoid. No antibody could be demonstrated following administration of typhoid vaccine in the usual manner and his serum was negative for complement-fixing antibodies of epidemic parotitis after he experienced a typical clinical picture of that disease.

Gamma globulin could be demonstrated in his serum after concentrated immune human serum globulin was administered subcutaneously, and its gradual disappearance could be followed by electrophoretic analysis over a period of approximately six weeks. Concurrently, and following the administration of human globulin (3.2 gm. gamma globulin) at monthly intervals, he has been free of pneumococcal sepsis for more than a year, whereas he had experienced clinical sepsis at least 19 times in the previous four years in which eight different types of pneumococci had been recovered from blood culture during 10 different episodes.

It is postulated that by some acquired "influence" the patient's antibody mechanism has been altered so that he is no longer able to synthesize and/or hold antibody to a specific organism. A complete defect of plasma proteins cannot be excluded.
PHAGOCYTIC AND AMEBOID ACTIVITIES OF THE LEUKOCYTES IN THE NEWBORN INFANT
Authors: MATOTH YEHUDA
Published: December 2021

Neonatal leukocytes obtained from cord blood were found to have lower ameboid and phagocytic activities when compared to maternal leukocytes and those of other adults.
Recurrent Ovarian Cysts in Childhood: Diagnosis of McCune-Albright Syndrome by Bone Scan
Authors: FRISCH LAUREN S. , COPELAND KENNETH C. , BOEPPLE PAUL A.
Published: December 2021

During the past decade, it has become clear that precocious puberty is a complex disorder with multiple pathophysiologic causes. Although gonadotropin-releasing hormone (GnRH)-dependent mechanisms account for the vast majority of precocious puberty in girls, GnRH-independent processes play an important role in a minority of patients. The recent availability of specific therapies for both GnRH-dependent and GnRH-independent precocious puberty has made it increasingly important for pediatricians to distinguish between these two subsets.1,2 Although most patients with precocious puberty neatly fall into one or the other subset, a significant minority of patients may present a diagnostic challenge even after an extensive evaluation is undertaken.
Lichen Striatus: Simultaneous Occurrence in Siblings
Authors: KANEGAYE JOHN T. , FRIEDEN ILONA J.
Published: December 2021

Lichen striatus is a benign, self-limited linear dermatosis of unknown etiology seen primarily in children. We report here the unusual simultaneous occurrence of this condition in siblings, a manifestation which may offer insight into the pathogenesis of this condition.

CASE REPORTS

Patient 1

A 2-year-old Japanese girl had a nonpruritic 0.5 x 5 cm hypopigmented band located on the right wrist and forearm, which had been present for several weeks. The past medical history was unremarkable, but family history was notable for atopic disease: asthma in a cousin and allergic rhinitis in her mother. A clinical diagnosis of lichen striatus was made, and the patient was observed without treatment.
ECMO for Infection
Authors: HOCKER JAMES R. , SIMPSON PIPPA M. , RABALAIS GeRARD P. , STEWART DAN L. , COOK LARRY N.
Published: December 2021

In Reply.—

Dr Fisher criticizes the manner in which we have grouped our patients to compare survival between patients treated with ECMO and conventional therapy. We feel we have adequately addressed this criticism in our reply to Dr LeBlanc.1 Regarding the degree of illness of patients referred from other centers during the ECMO era, 75% required mechanical ventilation and 83% of ventilated neonates were hypotensive. This is compared to 57% and 38%, respectively, during the pre-ECMO era when very few patients were referred to our center from outside our region.
The Crying of Infants With Colic: A Controlled Empirical Description
Authors: Barr Ronald G. , Rotman Audrey , Yaremko John , Leduc Denis , Francoeur T. Emmett
Published: December 2021

To obtain a controlled empirical description of some of the measurable clinical features of colic in a naturalistic context, 38 infants whose mothers considered crying a problem ("colic") and 38 pair-matched control infants were observed and videotaped at home 10 minutes before and after an evening feed. The parents kept a diary of infant behaviors (including crying and fussing) for 7 days following the visit. Following Wessel et al (Pediatrics. 1954;14:421-434), each "colic" infant was classified according to the number of days per week that crying and fussing duration was greater than 3 h/d. The distribution of infants with colic suggested that there were two subgroups: Wessel's colic infants, with 3 days or more per week of more than 3 hours of crying and fussing per day; and non-Wessel's colic infants, with fewer such days. Maternal measures of total daily crying/fussing duration, crying/fussing bout length, and infant temperament and objective analyses of facial activity showed a consistent pattern of differences in which Wessel's colic infants differed from both non-Wessel's colic and control infants, who in turn did not differ from each other. Both colic groups differed from control infants only in the perception of postfeed cries as being more "sick sounding." The results imply that the complaint of colic represents two (or more) groups and that there may be meaningfully distinct colic syndromes. They also provide the first independent empirical support for Wessel and colleagues' clinical distinction between "fussy" and "contented" babies.
Varicella Vaccine: Still at the Crossroads
Authors: Gershon Anne A.
Published: December 2021

Dr Saul Krugman was and continues to be a teacher, mentor, and inspiration to many in the field of infectious diseases, particularly with regard to viral infections and immunizations. It is therefore a great privilege to play a role in celebrating his 80th birthday, and it also seems appropriate to honor him with a presentation concerning live attenuated varicella vaccine. Dr Krugman was greatly responsible for bringing about clinical trials with varicella vaccine in the United States, and in fact, without his input it is unlikely that this vaccine would ever have been tested here. His recognition, in the 1950s, of the potential severity of varicella in adults was a landmark paper in the realization that varicella is not always a benign disease and is worth preventing.1 The conventional wisdom, however, has been that there was no need for a varicella vaccine because the disease is too mild to warrant immunization. There are, nevertheless, numerous well-recognized complications of varicella. The most common is bacterial superinfection which may be local and mild but on occasion may be systemic and even fatal (such as staphylococcal pneumonia). In 1984, Preblud and his colleagues2 estimated that each year in the United States, as the result of chickenpox, 56 otherwise healthy children die, 46 develop encephalitis, more than a quarter of a million children visit a physician, and physicians write a similar number of prescriptions for antipruritics and antibiotics. Moreover, children at high risk to develop severe or chronic forms of chickenpox, such as leukemics, those who have had organ transplants, and those with human immunodeficiency virus infection, are often denied such activities as attending school and social functions for fear of an unrecognized exposure to varicella.