bluuebunny/crossref_metadata_2025 huggingface dataset:
Relapse of Herpes Simplex Encephalitis in Children
Authors: Kimura Hiroshi , Aso Kosaburo , Kuzushima Kiyotaka , Hanada Naoki , Shibata Motohiro , Morishima Tsuneo
Published: December 2021

The polymerase chain reaction method was used to diagnose herpes simplex encephalitis in children. Initial samples of cerebrospinal fluid from 15 patients with herpes simplex encephalitis were all positive for the herpes simplex virus DNA by polymerase chain reaction assay. In terms of early diagnosis, polymerase chain reaction assay became positive significantly earlier than the detection of intrathecally produced anti-herpes simplex virus antibody using the enzyme-linked immunosorbent assay (4.4 vs 8.9 days after onset; P < .01). Serial examinations showed that the presence of virus DNA in cerebrospinal fluid continued for 3 to 18 days after the neurologic onset (mean 10.1 days). Four of the 15 patients had a relapse of encephalitis after completing acyclovir therapy. The mean duration of initial acyclovir therapy in the recurrent group was significantly shorter than that in the nonrecurrent group. In recurring cases, herpes simplex virus DNA reappeared temporarily in the cerebrospinal fluid of two patients. These results show that polymerase chain reaction assay is a useful diagnostic tool for the early and noninvasive diagnosis of herpes simplex encephalitis in children. Results also suggest that a comparatively short duration of acyclovir therapy may be related to a relapse of herpes simplex encephalitis in some children.
Radiofrequency Current for Catheter Ablation of Accessory Atrioventricular Connections in Children and Adolescents. Emphasis on the Single-Catheter Technique
Authors: Schlüter Michael , Kuck Karl-Heinz
Published: December 2021

Catheter ablation of an accessory atrioventricular connection using 500-kHz radiofrequency current was attempted in 10 children and adolescents aged between 6 and 15 years (mean 10.5 years). Six children had the Wolff-Parkinson-White syndrome and four had tachyarrhythmias related to a retrograde-only conducting ("concealed") accessory connection. No child had associated structural heart disease. Symptoms ranged from disabling palpitations to episodes of syncope (three patients) and cardiac arrest (one patient). Ablation was attempted from the left ventricle in all children; in one child, ablation of a second, right-sided pathway was attempted via a right atrial approach. Ten of the 11 accessory connections were interrupted successfully. A single complication was encountered in a 10-year-old girl in whom the procedure had to be terminated because a thrombotic occlusion of the right internal iliac artery had evolved.

A simplification of the ablation procedure associated with reduced procedure duration and radiation exposure time was achieved in three children with th Wolff-Parkinson-White syndrome and a left free-wall accessory pathway when a single catheter placed in the left ventricle was used for pathway localization as well as ablation. It is concluded that catheter ablation using radiofrequency current is effective and safe and may supersede surgery as the curative treatment for children with serious symptoms mediated by an accessory atrioventricular connection.
Changes in Acquired Immunodeficiency Syndrome-Related Risk Behavior After Adolescence: Relationships to Knowledge and Experience Concerning Human Immunodeficiency Virus Infection
Authors: Stiffman Arlene Rubin , Earls Felton , Dore' Peter , Cunningham Renee
Published: December 2021

This paper explores the extent of change in acquired immunodeficiency syndrome (AIDS) risk level and in the numbers of AIDS-related risk behaviors in 602 inner-city adolescents as they enter young adulthood. Youths' risk level for human immunodeficiency virus (HIV) infection during adolescence was categorized as high (engaging in prostitution, male homosexual or bisexual activity, or injectable drug use or having ulcerative sexually transmitted diseases), moderate (having six or more sex partners in a 1-year period or nonulcerative sexually transmitted diseases), or low (none of the above). Although a proportion at high or moderate risk during adolescence did move to lower risk levels by young adulthood, the overall risk level stayed fairly stable: 45% were at high or moderate risk levels during adolescence, and 35% were at those levels by young adulthood. Then change in the total number of risk behaviors engaged in by the youths was examined. Knowledge about AIDS or HIV infection and its prevention was not associated with any change in risk behavior, nor were the number of sources of information about the epidemic, acquaintance with those who are infected, estimates of personal risk, or exposure to HIV-test counseling. In fact, youths whose risk behaviors increased the most were more likely to know someone who had died of AIDS and to estimate their own risk as high. Most youths reported that they did not use condoms regularly, disliked them, and had little confidence in their protective ability. Changes in preventive strategies and further research on the causes of behavior change are needed.
Different Opinions and Thoughts on the Management of Hyperbilirubinemia
Authors: Lucey Jerold F.
Published: December 2021

What is the standard of care for an infant with a high bilirubin level? Numerous "guidelines" based on well-intentioned opinions certainly exist, but should these really define a standard of care? I don't think so. We still don't have enough solid evidence to make rules!

After more than 40 years of research, Newman and Maisels are suggesting new guidelines for healthy fullterm infants. They have critically reviewed the evidence available and make some new recommendations. I was curious to learn the reactions of a number of "bilirubin experts" and the opinions of an American Academy of Pediatrics Task Force on the subject. I thought it might be worthwhile to have all of these published in the same issue to demonstrate the wide spectrum of opinions which exist.
Position for Lumbar Punctures
Authors: PINHEIRO JOAQUIM M.B.
Published: December 2021

To the Editor.—

In "A Controlled Clinical Trial of Local Anesthesia for Lumbar Punctures in Newborns"1 Porter et al reported on their attempt to decrease lumbar puncture-induced physiologic instability by using lidocaine. While the cardiorespiratory measures of physiologic instability were not affected by local anesthesia, they were influenced significantly and adversely by the preparatory procedure (ie, being held flexed in the fetal position). As pointed out by the authors, the position chosen for the procedure, which included knees to chest plus flexion of head and neck has been shown to induce more adverse physiologic responses than either the sitting or the modified lateral (neck not flexed) position.2,3
Position for Lumbar Punctures
Authors: PORTER FRAN , MILLER J. PHILIP , COLE F. SESSIONS , MARSHALL RICHARD E.
Published: December 2021

in Reply.—

Dr Pinheiro correctly points out that alternative positions for performance of lumbar punctures in newborns have been shown to result in less physiologic perturbation than the position for lumbar puncture used in our study. Although we did not select specifically to study the fully flexed lateral position, it was the most common position for lumbar punctures in our Neonatal Intensive Care Unit at the time our study was conducted.
Diarrhea Care in Private Practice
Authors: SNYDER JOHN D.
Published: December 2021

In Reply.—

I applaud Dr Tochen, Mr Tsukamaki, and Ms Feil for developing such a thoughtful, practical and relatively inexpensive approach to acute diarrhea in their practice. We also have incorporated an educational program on the assessment and treatment of acute diarrhea as one of the core components of our well-child clinic teaching.1 The use of packets of oral rehydration salts has a number of advantages cited by Dr Tochen, Mr Tsukamaki, and Ms Feil, and packets have been used with great success in more than 100 countries.
Lomotil Overdose
Authors: AHMAD SYED RIZWANUDDIN
Published: December 2021

To the Editor.—

I was amazed and disappointed to read the concluding paragraph of Dr Wasserman's Letter to the Editor, `Lomotil Overdose,'1 wherein he states that Lomotil (diphenoxylate/atropine) intoxications "are rarely seen" now. The 1990 Annual Report of The American Association of Poison Control Centers National Data Collection System2 lists 1654 cases of diphenoxylate-atropine poisonings which include 1004 cases (61% approximately) involving children less than 6 years old, and two deaths. Talking about loperamide Dr Wasserman asks, "Will Imodium prove to be less dangerous to infants and young children than Lomotil? So far it seems that way."
Lomotil Overdose
Authors: WASSERMAN GARY S.
Published: December 2021

In Reply.—

I would like to thank Dr Rizwanuddin for his timely comments; actually I am in his corner in the battle against the use of antidiarrheal preparations for young infants and children. I1 did not intend to trivialize 1004 pediatric diphenoxylate-atropine cases in 1990,2 but this does not compare with the early 1970s when these intoxications were fairly frequent. My original review3 included 49 pediatric cases during a 42-month period (23 of those cases in 1973) in comparison with Dr McCarron's 8 cases in more than 12 years.4.
Immunization Opportunities Missed Among Urban Poor Children
Authors: McConnochie Kenneth M. , Roghmann Klaus J.
Published: December 2021

Low immunization rates among US preschool children suggest a need for improved immunization practices. Immunization and encounter records were reviewed to ascertain immunization rates and missed opportunities for vaccine administration among 515 preschool children who were active patients at a hospital-based primary care center serving lower socioeconomic status families in Rochester, NY. The point prevalence at a mean age of 4.4 years for lack of one or more recommended immunizations was 27%; 7% were missing measles-mumps-rubella, 18% were missing Haemophilus influenzae type b, 8% were missing two or more diphtheria-tetanus-pertussis, and 4% were missing two or more oral poliovirus immunizations. A visit was counted as a missed opportunity if an immunization was due but not given. Over the period from birth through age 36 months, 422 (82%) of children missed at least one immunization opportunity. For these 422 children, there was a mean of 7.2 missed opportunities per child. Although 64% of missed opportunities occurred at an acute illness visit, 36% occurred at well-child, administrative, follow-up, or chronic illness visits. Review of 200 medical records randomly selected from all opportunities at acute illness visits found no contraindication in 63% (50% nonfebrile infectious disease, 13% minor noninfectious problems). Findings for random samples of 100 missed diphtheria-tetanus-pertussis opportunities for children aged 2 to 6 months and 100 missed measles-mumps-rubella opportunities for children 15 to 24 months were similar to findings for the sample of all acute illness visits. Emergency department visits, where immunization records were not readily available, accounted for 18% of missed opportunities. Thoughtful evaluation of immunization contraindications at acute illness visits, better availability of immunization data, and better use of immunization opportunities at nonacute illness and nonillness visits would reduce undervaccination substantially.
Standard Definitions for Childhood Injury Research: Excerpts of a Conference Report
Authors: Christoffel Katherine Kaufer , Scheidt Peter C. , Agran Phyllis F. , Kraus Jess F. , McLoughlin Elizabeth , Paulson Jerome A.
Published: December 2021

As awareness of the huge human and other costs of injury has grown, research has expanded. There has not been any standard set of terminology for use in this research. As a result, research and surveillance data are too often difficult to interpret and compare. To overcome this impediment to gains in needed knowledge about childhood injuries, a conference was held in 1989 by the National Institute of Child Health and Human Development to develop a set of standard definitions. The full conference report is available from the US Government Printing Office. This report presents excerpts, emphasizing those—core—variables likely to be of use to the largest number of investigators. The conference recommendations presented address cross-cutting factors (age, race/ethnicity, location, socioeconomic status, and biopsychosocial development), effect modifiers (exposure, medical risk factors, substance abuse, time, injury severity, and social risk factors), and specific injuries (motor vehicle injuries, central nervous system injuries, falls, fire/burns, drowning, and violence). It is expected that childhood injury investigators will strive to meet the recommendations of this conference and that use of these definitions will lead to improvements in research and, ultimately, to revision of the definitions.
Utility of an End-Tidal Carbon Dioxide Detector During Stabilization and Transport of Critically III Children
Authors: Bhende Mananda S. , Thompson Ann E. , Orr Richard A.
Published: December 2021

Critically ill children often require endotracheal intubation prior to transport to a medical center. Correct endotracheal tube placement and maintenance during transport are essential. The utility of a portable colorimetric end-tidal CO2 detector during transport of critically ill children was evaluated. Fifty-eight children with spontaneous circulation (aged 1 day to 12 years, weight 0.9 to 26 kg) who underwent 59 intubations during transport by ground (n = 31) or air (n = 27) were studied. Tube position was confirmed by physical examination, arterial blood gas values, or arterial oxygen saturation, and sometimes by chest radiograph. The detector was attached and readings were obtained after intubation; readings were repeated if endotracheal tube position was rechecked during transport. Fifty-seven of 58 tracheal positions and the 1 esophageal tube position were correctly identified. One false-negative result occurred in a severely hypocarbic 900-g premature newborn. On each occasion that the detector was used en route, the endotracheal tube position was correctly identified. It is concluded that the end-tidal CO2 detector is a useful tool for confirming endotracheal tube position during transport of critically ill children weighing more than 2 kg who are not in cardiopulmonary arrest.
Etiology of Red Blood Cell Macrocytosis During Childhood: Impact of New Diseases and Therapies
Authors: Pappo Alberto S. , Fields Barbara W. , Buchanan George R.
Published: December 2021

Although an elevated erythrocyte mean corpuscular volume has been noted in many conditions, the relative frequency of various causes of macrocytosis in the pediatric population has not been defined. Therefore, the different medical conditions associated with red cell macrocytosis were retrospectively reviewed. One hundred forty-six children between 6 months and 12 years of age with a mean corpuscular volume ≥ 90 fL were identified during a 13-month period. The most common association with macrocytosis was drug ingestion (anticonvulsants, zidovudine, immunosuppressive agents), observed in 51 (35%) of the cases. Other conditions associated with macrocytosis were congenital heart disease (20), Down syndrome (12), reticulocytosis (11), and marrow failure/myelodysplasia (6). Miscellaneous diseases were identified in 21 children. Twenty-four cases had no apparent cause of their macrocytosis; 21 of them had just a slight elevation of the mean corpuscular volume (91 or 92 fL), suggesting that these values probably represent the upper limit of normal. No cases of vitamin B12 or folate deficiency were observed. The use of relatively new drugs such as valproate, zidovudine, and immunosuppressants (for the treatment of diverse medical conditions) accounted for more than half of the cases of drug administration and 24% of the children with macrocytosis. Three children with bone marrow failure had macrocytosis and pancytopenia, suggesting that this finding might be the first manifestation of serious but treatable disorders such as aplastic anemia.
Infants with Anencephaly as Organ Sources: Ethical Considerations
Authors:   Committee on Bioethics
Published: December 2021

This Policy Statement was retired May 2009.

BACKGROUND

Pediatric organ transplantation offers an increasing number of seriously ill children the opportunity for a healthy life. However, there is currently a severe shortage of pediatric organs. Young children rarely die in circumstances that would make them medically acceptable sources of organs. Among the children younger than 2 years of age registered to receive transplants, an estimated 30% to 50% die before an organ becomes available.1 In April 1990, the United Network for Organ Sharing reported 320 children younger than 5 years of age waiting for kidney (99), liver (178), heart (34), or heart-lung (9) transplants. Although improved organization of the organ procurement system could partially ameliorate the problem, in all likelihood, pediatric organs will remain a scarce medical resource.2

Anencephaly is a congenital defect in which the cranium is absent and the cerebral cortex is virtually absent. However, vital organs, such as the heart and kidneys, are often normal. About 1000 to 2000 live anencephalic births occur annually in this country. Brain stem function enables many anencephalic infants to survive for hours or days and, in rare cases, for a few weeks.3

In recent years, some parents of anencephalic infants, as well as some transplant surgeons, medical ethicists, and state legislators, have proposed that these infants' organs be used for transplantation.4,5 Some parents have poignantly expressed their wish that some good might come of their loss. In their opinion, there is no compelling reason for failing to use an anencephalic infant's organs to give life and health to other children.
Strategies to Reduce Hyperkalemia-Induced Cardiac Arrhythmias in Premature Infants and Newborns
Authors: LACKMANN G. -M. , TÖLLNER U.
Published: December 2021

With great interest we have read the paper by G.J. Kost1(Pediatrics l991;88:597-603) about critical limits, especially potassium in newborns, for emergency clinician notification at United States children's hospitals.

Stimulated by a study about life-threatening hyperkalemias in asphyxiated newborns from 1990,1 we have analyzed specifically the results of another prospective study about laboratory investigations and clinical findings in asphyxiated (N = 98) and healthy (N = 87) newborns during the first 144 hours of life in view of serum potassium levels.2
Strategies to Reduce Hyperkalemia-Induced Cardiac Arrhythmias in Premature Infants and Newborns
Authors: KOST GERALD J.
Published: December 2021

In Reply.—

Several investigators1-7 have shown that in premature infants and newborns hyperkalemia is associated with unacceptably high morbidity and mortality due to cardiac arrhythmias. These arrhythmias can occur at potassium levels below the high critical limit for newborns (see Figure). Critical limits were obtained from two independent surveys of 55 children's hospitals.8 and 134 US medical centers.9 Mean high critical limits for newborns were 7.8 ± 0.5 mmol/L at children's hospitals8 and 7.7 ± 0.7 mmol/L at US medical centers.9
Peripheral Intravenous Catheter Complications in Critically Ill Children: A Prospective Study
Authors: Garland Jeffery S. , Havens Peter , Dunne W. Michael , Hintermeyer Mary , Bozzette Mary Anne , Wincek Jeni , Bromberger Tina , Seavers Michelle
Published: December 2021

Six hundred fifty-four peripheral Teflon catheters in 303 pediatric intensive care unit patients were examined to determine complication rates and associated risk factors. Phlebitis, extravasation, and bacterial colonization occurred at rates of 13%, 28%, and 11%, respectively. Logistic regression of factors that increased phlebitis risk revealed infusion of hyperalimentation (odds ratio 2.9) or lorazepam (odds ratio 2.2) and catheter location (odds ratio 2.9) as the most important determinants of phlebitis risk. Age (≤1 year, odds ratio 2.0), catheter time in situ (≤72 hours, odds ratio 2.1), and infusion of antiepileptics (odds ratio 2.1) were the most important determinants of extravasation. Catheters were colonized most frequently with coagulase-negative Staphylococcus (51/54). Sepsis attributable to catheter colonization occurred in 1 patient. Duration of catheter placement (≥144 hours, odds ratio 5.8) was an important determinant of catheter colonization. Colonization risk increased from 11% in catheters that were in situ for 48 to 144 hours to 34% for catheters that were in for longer than 144 hours. Infusion of diazepam (odds ratio 11.0) or lipid emulsions (odds ratio 2.5) and age (≤1 year, odds ratio 2.2) were also important determinants of colonization risk. Replacing catheters in critically ill children every 72 hours would not decrease phlebitis, bacterial colonization, or catheter-induced sepsis and could increase extravasation risk. Catheters can be safely maintained with adequate monitoring for up to 144 hours in critically ill children.
Respiratory Health and Lung Function in 8-Year-Old Children of Very Low Birth Weight: A Cohort Study
Authors: Kitchen William H. , Olinsky Anthony , Doyle Lex W. , Ford Geoffrey W. , Murton Laurence J. , Callanan Catherine , Slonim Leon
Published: December 2021

In comparison with a cohort of normal birth weight children, those of very low birth weight (<1501 g birth weight) had more wheezing illnesses and hospital readmissions for respiratory problems in the first 2 years of life; from 2 years to 8 years of age respiratory health was unrelated to birth weight. Lung function measurements at 8 years of age in very low birth weight children were similar to expected values; few children had severely abnormal lung function. On univariate analyses, forced vital capacity (FVC) and forced expired volume in 1 second (FEV1), but not flow rates, were lower in children who had survived bronchopulmonary dysplasia. However, the univariate analyses were misleading, because bronchopulmonary dysplasia occurred more frequently with lower birth weight, and lower birth weight in turn was strongly related to reduced FVC and FEV1. After adjusting for birth weight and other potential confounding variables, FVC and FEV1 were unrelated to bronchopulmonary dysplasia, and to neonatal ventilation. Flow rates were largely uninfluenced by perinatal events, but were reduced in children with asthma or recurrent bronchitis at 8 years of age. Passive smoking was unrelated to lung function at 8 years of age. However, the effects of passive or active smoking, or perinatal events, on respiratory function or health beyond 8 years of age in very low birth weight survivors remain to be determined.
Parents' Behavior and Attitudes Toward Screening Children for High Serum Cholesterol Levels
Authors: Lannon Carobe M. , Earp JoAnne
Published: December 2021

The American Academy of Pediatrics, concerned that pediatric cholesterol screening may lead to mislabeling and overly restrictive diets, stresses laboratory confirmation and nutritional follow-up for children with elevated cholesterol levels. Parents' behavior and attitudes toward screening children for high cholesterol were studied. During an 8-week period in summer of 1989 all children 2 through 15 years of age seen for well-child examinations at a community pediatric group practice were offered cholesterol screening by finger-stick method. Most parents were well-educated and white. Of 439 children screened, 134 (31%) had cholesterol levels above the recommended cutoff point of 175 mg/dL (75th percentile). Only 63 children returned for confirmatory lipid panels; parents of children who did not return were interviewed. Reasons for noncompliance included "not sure test machine was accurate" (67%); "child too traumatized by finger stick" (47%); and "will try low-cholesterol diet before recheck" (40%). A third of these parents believed that confirmation of an elevated cholesterol level "would make the child worry too much." Only 29% of these parents talked with a dietician. In this middle-class, well-educated population, a large proportion of children had elevated screening cholesterol values, but few complied with American Academy of Pediatrics guidelines. As a result, many children may be mislabeled as hypercholesterolemic and may not benefit from screening.
Standardized Instructions: Do They Improve Communication of Discharge Information from the Emergency Department?
Authors: Isaacman Daniel J. , Purvis Kathy , Gyuro Jane , Anderson Yvonne , Smith Douglas
Published: December 2021

To determine whether standardized instructions enhance communication of discharge information, we provided 197 parents of children in whom otitis media was diagnosed with one of three types of instruction at the time of discharge from a pediatric emergency department: (1) instruction by individual housestaff and medical students after consultation with an attending physician (control group); (2) standardized verbal instructions given by housestaff and students trained in their use (verbal group); or (3) the same instructions given to the verbal group, together with a type-written copy of the information to take home (verbal + written group). Prior to leaving the emergency department and, again, by phone, 1 and 3 days later, parents were questioned concerning the prescribed medication's name, dose, frequency, and duration of administration (medication data), three signs of improvement, and eight signs indicating the need for medical advice (worrisome signs). The mean percentage of correct responses per parent in each group was computed for each information category. Both at exit interview and at follow-up, parents receiving either form of standardized instructions showed significantly greater knowledge of information related to their child's illness than did controls. Information regarding medication data was more likely to be communicated to parents in all groups than were signs of improvement or worrisome signs. The addition of written instructions to standardized verbal instructions did not improve parental recall of discharge information.
Bicycle Helmet Use Among Maryland Children: Effect of Legislation and Education
Authors: Coté Timothy R. , Sacks Jeffrey J. , Kresnow Marcie-jo , Lambert-Huber Deborah A. , Schmidt Ellen R. , Dannenberg Andrew L. , Lipsitz Cynthia M.
Published: December 2021

Although bicycle helmets are effective in preventing head injuries, use of helmets among children remains infrequent. In response to the bicycling deaths of two children, Howard County, Maryland, became the first US jurisdiction to mandate use of bicycle helmets for children. Schoolchildren were lectured by police about the law before its enactment. Prelaw and postlaw helmet use was observed in Howard County and two control counties: Montgomery (which sponsored a community education program) and Baltimore County (nohelmet activities). Prelaw crude helmet use rates for children were 4% (95% confidence interval [CI] 0% to 10%) for Howard, 8% (95% CI 3% to 13%) for Montgomery, and 19% (95% CI 5% to 33%) for Baltimore. Postlaw rates were 47% (95% CI 32% to 62%), 19% (95% CI 11% to 27%), and 4% (95% CI 0 to 11%), respectively. The rate of bicycle helmet use by Howard County children is now the highest documented for US children. A similar increase in helmet use among children younger than 16 years nationwide could prevent about 100 deaths and 56 000 emergency-department-treated head injuries annually. Physicians and other health professionals should consider proposing and supporting the Howard County approach in their communities.
Extracorporeal Piezoelectric Lithotripsy in Unanesthetized Children
Authors: Starr Nancy T. , Middleton Richard G.
Published: December 2021

Extracorporeal piezoelectric lithotripsy is an effective method for treating renal pelvic stones in children. Treatment with the Wolf lithotriptor is essentially painless and can be performed without anesthesia on an outpatient basis. Real-time ultrasound is used to localize stones. In a 1-year period at the University of Utah, extracorporeal piezoelectric lithotripsy was administered to eight children with nine renal units. Of the eight children, aged 5 to 17½ years, only two required sedation and only one received retreatment. No stents were placed. At 1 month posttreatment, all children were stone-free, and no significant complications occurred.
Infant Acceptance of Postexercise Breast Milk
Authors: Wallace Janet P. , Inbar Galit , Ernsthausen Kim
Published: December 2021

The purpose of this study was to observe the infant acceptance of postexercise breast milk. Twenty-six lactating postpartum women exercised to maximum (maximum oxygen consumption = 35.1 ± 9.2 [SD] mL min-1 kg-1) on a treadmill. Breast milk was collected via self-expression at rest before exercise and at 10 and 30 minutes postexercise and analyzed for lactic acid by enzymatic methods. Following exercise, infants were presented with their mothers' pre-exercise and postexercise milk in a double-blind design. The mother rated the infant's acceptance of the milk samples. There was a significant difference in acceptance of pre-exercise and postexercise milk as analyzed by analysis of variance. Maximal exercise resulted in a significant increase in lactic acid concentration in breast milk that may be high enough to affect the taste of the milk. The decreased acceptance of postexercise milk was associated with increased lactic acid concentration. Suggestions to circumvent the decreased acceptance are offered.
Bordetella bronchiseptica Pneumonia in a Patient with Down Syndrome: A Case Report and Review
Authors: WINTERS JEFFREY L. , O'CONNOR WILLIAM N. , BROUGHTON ROBERT A. , NOONAN JACQUELINE A.
Published: December 2021

Bordetella bronchiseptica is primarily an animal pathogen, responsible for canine tracheobronchitis (kennel cough) and bronchopneumonia, as well as porcine atrophic rhinitis and otitis media. It readily colonizes the upper respiratory tract and oropharynx of these species.1 This organism rarely has been recognized as a human pathogen, causing mild upper respiratory tract infections in animal caretakers,1 subacute bacterial endocarditis,2 and a pertussis-like illness in children.3 Although asymptomatic nosocomial colonization of humans occurs,4 it also has been reported in immunocompromised Patients as a cause of sepsis,5 peritonitis,6 bronchitis,4,7 and pneumonia.4,8-13

To date, seven cases of human B bronchiseptica pneumonia have been reported in the literature with five of these occurring in immunocompromised patients.
Questions Collaborative Dexamethasone Trial
Authors: MACMAHON PAUL
Published: December 2021

To the Editor.—

I read the timely article by the Collaborative Dexamethasone Trial group1 with great interest. However, I am concerned that the trial cannot possibly fulfill its stated aim of clarifying the benefits and hazards of dexamethasone treatment for neonatal chronic lung disease. The trial specifically excluded those infants in whom the administration of steroids was judged to be mandatory by the responsible clinician. No information whatsoever was given on these infants and, for all we know, dexamethasone might well have been extremely effective and perhaps lifesaving in this group.
BRAIN ABSCESS ASSOCIATED WITH CONGENITAL HEART DISEASE
Authors: GLUCK REGINA , HALL JOHN W. , STEVENSON LOUIS D.
Published: December 2021

A review of the literature reveals 41 adequately documented cases of cerebral abscess associated with congenital heart disease. Three cases of cerebral abscess occurring in 39 autopsied cases of congenital heart disease are reported in this paper.

The clinical signs and symptoms of cerebral abscess are presented with special emphasis on the need for early surgical intervention. The occurrence of persistent headache or lethargy in a patient with congenital heart disease should be thoroughly investigated. Spinal tap, EEG and cranial air studies should be done before the diagnosis of cerebral abscess is excluded.

Several authors believe that an area of infarction in the brain precedes the development of an abscess although this process alone has not been reported in congenital heart disease. Five instances of cerebral infarction were observed in 39 autopsies on individuals with congenital heart disease.

A number of possible explanations have been offered for the development of infarction: paradoxic emboli, emboli from the lungs through the systemic arterial circulation by way of the pulmonary vein, left auricle and ventricle, emboli from the lungs through the spinal veins and finally, as a result of thrombosis of the cerebral arteries.

In addition to pulmonary and cerebral thrombosis, thrombi were found in the iliac, popliteal and renal arteries. The tendency to systemic and pulmonary thromboses in cases of congenital heart disease is best explained on the basis of decreased flow of blood due either to polycythemia or to decreased pulmonary blood flow.

Significant cerebral lesions of various kinds were found in 22 of 39 cases of congenital heart disease.
PHYSIOLOGICAL CONSIDERATION OF RESPIRATORY DISEASE
Authors: COMROE JULIUS H.
Published: December 2021

A. Physiologic Factors Concerned in the Regulation of Respiration

Physiologists now agree that there is a medullary respiratory center which has intrinsic rhythmicity. Nevertheless this center can be influenced profoundly by many chemical and nervous factors. One of the most important of these is carbon dioxide. Under ordinary conditions the medullary center is exquisitely sensitive to changes in carbon dioxide pressure. When the respiratory center is depressed (by deep anesthesia, large doses of morphine or barbiturates, trauma, cerebral edema, increased intra-cranial pressure, severe anoxia or by high concentrations of carbon dioxide itself) it is no longer responsive to carbon dioxide though it may still permit reflex activity and continuation of respiration.

Anoxemia may also stimulate respiration; this occurs through reflexes originating in chemoreceptors of the carotid and aortic bodies. It appears certain that these chemoreceptors are functioning in the normal full-term newborn though they may not be functioning or functioning properly in prematures. When these chemoreceptors are in operation, anoxia will stimulate respiration and oxygen therapy will abolish such hyperpnea. When the chemoreceptors are not in action, one would expect no reflex effects from either oxygen or anoxia; oxygen therapy, however, might relieve cerebral ischemia and permit respiration to improve.

B. Physiologic Methods for Evaluating Respiratory and Pulmonary Function

The function of the lungs is primarily to oxygenate the venous blood and to remove excess carbon dioxide from it. To accomplish this, there must be normal respiratory volumes, normal lung volumes and aerating surface, even distribution of the inspired gas to the alveoli, unimpaired diffusion across the alveolar capillary membrane, and uniform distribution of pulmonary capillary blood flow to the functioning alveoli.
THE PEDIATRICIAN AND THE PUBLIC
Authors: ROTHMAN PHILLIP E.
Published: December 2021

THESE are days of brilliant achievements in medical science. Research progresses with incredible rapidity. Each advance creates additional problems; former gains are often neglected. The attention of the medical profession is occupied with so many issues of immediate importance that the problems affecting the quality of medical care have been pushed aside. In an attempt to appraise the present difficulties, it is helpful to recall past experiences.

Thirty-three years after Roentgen's announcement of "a new kind of ray," Thayer issued the following warning: "It is a sad commentary on human weakness, the manner in which the discovery of a new method of investigation of great help, such as roentgenology, has led the medical public to neglect those fundamental methods of study which are far more important in themselves. . . . The information supplied by an X-ray plate is often of immense complementary value. Alone and without the information afforded by the history, the appearance of the patient and the results of physical examination, it is often of no more value than that afforded by percussion alone—indeed less. For he who percusses the chest cannot fail to observe the patient."

In a similar manner, the course of events that followed the development of electrocardiography has been described by Levine:
INFECTIVE GANGRENE OF THE MOUTH (Cancrum Oris)
Authors: JELLIFFE D. B.
Published: December 2021

The clinical features of infective gangrene of the mouth are described as seen in malnourished children in Ibadan, Nigeria. The etiology is discussed with reference to malnutrition in general and seasonal food shortage in particular. Successful treatment with a remarkable degree of natural healing occurred with penicillin and a high protein diet.
PRIMARY HERPETIC VULVOVAGINITIS
Authors: KRUGMAN SAUL
Published: December 2021

A case of primary herpetic vulvovaginitis is reported. This diagnosis was confirmed by isolation of the virus and demonstration of the development of neutralizing antibodies.
ORTHODONTIC PROBLEMS IN PEDIATRIC PRACTICE
Authors: GRABER T. M.
Published: December 2021

ONE of the most important phases of oral health is the form and function of the oral mechanism. That specialty of dentistry which has as its goal the correction of dental malformations and restoration of the continuity and proper function of the teeth and jaws is called orthodontics. While parents have long been concerned with the obvious esthetic disabilities of malposed teeth, the pathologic implications of these malposed teeth have been the primary concern of the orthodontist. Frequently, tooth malpositions or dental malocclusions reflect growth and developmental disturbances of the upper and lower jaws. Crooked teeth are unsightly, but more important, they probably are functioning improperly, or not at all, which seriously impairs the health and longevity of the teeth and investing tissues.

Recent studies of facial growth indicate that dental malocclusions may be grouped in three morphologic categories, on the basis of jaw development and individual tooth malpositions. First, are those types of disturbances which are primarily skeletal in nature. These are problems where the maxilla or mandible has assumed an abnormal relationship to one another, usually through an upset in the timetable of normal development. The teeth in each dental arch may be normal in their position when compared to their respective jaws, but the abnormal jaw relationship means that the upper and lower teeth meet improperly during mastication, deglutition and speech. The second group consists of relatively local disturbances, with the teeth malposed, but with normal jaw relationship. The third group is a combination of the first two, with both improper jaw relationship and with teeth in abnormal positions. Within these three broad categories one may find all sorts of tooth malpositions and jaw relationships; the premaxillary segment may be displaced anteriorly, the whole lower dental arch may be retruded, the upper cuspids may be erupting in the palate, etc. Such conditions may be separate or occur in combination.
STUDIES OF THE IMMUNOLOGY OF THE NEWBORN INFANT
Authors: OSBORN JOHN J. , DANCIS JOSEPH , JULIA JUAN F.
Published: December 2021

Forty infants from 1 week to 6 months of age who had no circulating antitoxin were immunized with one injection of a high titer diphtheria toxoid on alum and their antitoxin responses were followed at regular intervals up to six months afterwards.

The ability to form antitoxin improved significantly during the first two months of life. No significant difference could be demonstrated between the response of infants 2 to 4 months of age and that of infants 6 months of age. (In the statistical tests, the 5% level was adopted as indicating significance.)

Twenty-seven of these infants were immunized at the same time in the opposite arm with a single dose of tetanus toxoid on alum. The response to tetanus immunization was faster and better in infants from 2 to 6 months of age than in infants 1 month of age and younger. The response to the tetanus toxoid preparation was faster and better than the response to the diphtheria toxoid preparation.

The following conclusions are drawn: A. The infant can form antibodies from birth. B. The ability to form antibodies improves during early life. For diphtheria and tetanus antitoxin, the improvement is rapid during the first two months and then is much slower. C. The advisability of early immunization is related to the potency of the antigen to be used.
Retained Spur Following a Rooster Attack
Authors: COOLER JOSEPH O. , KLEIMAN MARTIN B. , WEST KAREN , GROSFELD JAY
Published: December 2021

In many rural areas, families raise poultry as a source of income and food. Chickens are often kept close to living quarters. Children, especially those who are young and unaware of the territorial behavior displayed by roosters, are especially vulnerable to attacks. Although such injuries are common, most do not require medical attention. However, serious claw-and peck-induced injuries to the face and upper torso may occur. Injuries caused by rooster attacks have been reported rarely.1-3 We recently have cared for a child with extensive facial lacerations who developed a polymicrobial, chronic wound infection. Evaluation revealed a retained rooster spur, an unexpected and previously unreported complication of such injuries.
Learning Disabilities, Dyslexia, and Vision
Authors:   Committee on Children With Disabilities
Published: December 2021

Dyslexia and other related learning disabilities are serious problems. The American Academy of Pediatrics, through its Committee on Children with Disabilities and the Section on Ophthalmology, the American Academy of Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus strongly support the need for early diagnosis and educational remediation. There is no known eye or visual cause for dyslexia and learning disabilities, and no effective visual treatment. Multidisciplinary evaluation and management must be based on proven procedures demonstrated by valid research.
ECMO for Infection
Authors: FISHER DAVID G.
Published: December 2021

To the Editor.—

Dr Hocker and his colleagues1 are to be commended for taking on the difficult task of evaluating the success of ECMO in early-onset group B streptococcal infection when a controlled trial is ethically and practically not feasible. In their study they used historical controls (a commonly criticized method, but all that is realistically available) to identify risk factors for early-onset group B streptococcal sepsis and to evaluate the effectiveness of ECMO intervention.
Ibuprofen Safety
Authors: CASTEELS-VAN DAELE MARIA
Published: December 2021

To the Editor.—

I read with great interest the Letters to the Editor on ibuprofen and fever. In Europe the pharmaceutical companies also are active in promoting ibuprofen for the treatment of fever in children; and here too the debate goes on. Most physicians agree that young febrile children should be given antipyretics.3 We are left with a major problem. We banned aspirin because we were told it induces Reye's syndrome, and so we prescribe paracetamol despite its well-known hepatotoxicity.
Neonatal Screening for Dependents of Active-Duty Military Personnel
Authors: MCCABE EDWARD R. B.
Published: December 2021

In Reply.—

COL Pettett is to be applauded for bringing attention to the issue of newborn screening among dependents of military personnel. He provides the opportunity to reemphasize several points made in the statement from the Committee on Genetics1 including: the need for a standardized policy or program for these dependents, particularly those born outside the US; the value of dedicated regionalized labonatory facilities in a newborn screening program; and the components that require consideration in any such policy or program, which include not only the laboratory, but also educational, administrative, follow-up, management, and evaluative components.
Would Breast-Feeding Decrease Risks of Lead Intoxication?
Authors: GRAEF JOHN W. , SHANNON MICHAEL
Published: December 2021

In Reply.—

We thank Dr Newman for his comments and agree that, for many reasons, more can and should be done to encourage breast-feeding. Unfortunately, it is unclear that this practice protects infants from lead in any way and, inevitably, there will be some women who choose formula. While time did not permit us to rereview these cases, we estimate that, based on current data in our area, 60% to 70% of the infants in our study were breast-fed.
The Battered Child at Thirty: What Can Be Learned From Saul Krugman at Eighty?
Authors: Krugman Richard D.
Published: December 2021

Some years ago—10 to be exact—at a 70th birthday celebration for Saul Krugman, I reviewed his impressive CV and pointed out that the field of avian biology had lost a great star. His first paper was on the use of ethylene glycol vapor to eliminate Newcastle disease virus, a pathogen of chickens.1 A further review of the Senior Krugman's CV reveals an early case report that may well have been one of the first reported cases of sexual abuse of infants—a case of herpetic vulvovaginitis in a 6-month-old infant.2 It was an unusual and an interesting case. Thirty-five years later one would at least have to evaluate the possibility of sexual abuse in this infant, and it likely would have been discussed as part of the paper. Several years ago (23 actually), when I began my pediatric career, I was occasionally asked whether I was related to Saul Krugman. Those of us who have followed a similar professional path to one or both of our parents are used to being asked such questions. Ken McIntosh, David Hodes, Karen, Allison, and Jennifer Kempe, to name a few, have all faced quizzical looks when we were introduced to a group of pediatricians as if to say: "I know that name, but you don't look old enough to be...." Each of us deals with this relationship differently and indeed will do so at different stages of our lives. When I was asked the inevitable question, was I related to Saul Krugman, I used to respond, "yes, he is my wife's father-in-law."
Umbilical Morphology: Normal Values for Neonatal Periumbilical Skin Length
Authors: O'Marcaigh Aengus S. , Folz Lora B. , Michels Virginia V.
Published: December 2021

Malformations of the umbilicus are a feature of many dysmorphic syndromes including Rieger syndrome, Robinow syndrome, and Aarskog syndrome. The characteristic umbilical malformation in Rieger syndrome consists of redundant periumbilical skin which extends along the cord for an excessive distance. Although the measurement of umbilical skin length plays an important role in the neonatal diagnosis of Rieger syndrome, normal values for this measurement in healthy neonates have not been established. Umbilical skin length was measured in 104 healthy neonates. The length to which the umbilical skin extended along the cranial aspect of cord (mean 11.53 mm, SD 3.58) was significantly longer than the umbilical skin length along the caudal aspect (mean 8.71 mm, SD 2.89) (P < .05). Multiple regression analysis revealed a significant association between age and umbilical skin length. Birth weight, length, and gestational age were not significantly associated with umbilical skin length when adjusted for the other three variables. No significant differences in umbilical skin length were observed between male and female groups. The above normal values should aid in the neonatal diagnosis of Rieger syndrome, and furthermore it is recommended that cranial umbilical skin length measurement be included in the examination of the dysmorphic child.