bluuebunny/crossref_metadata_2025 huggingface dataset:
Extracorporeal Membrane Oxygenation and Conventional Medical Therapy in Neonates With Persistent Pulmonary Hypertension of the Newborn: A Prospective Randomized Study
Authors: O'Rourke P. Pearl , Crone Robert K. , Vacanti Joseph P. , Ware James H. , Lillehei Craig W. , Parad Richard B. , Epstein Michael F.
Published: December 2021

Thirty-nine newborn infants with severe persistent pulmonary hypertension and respiratory failure who met criteria for 85% likelihood of dying were enrolled in a randomized trial in which extracorporeal membrane oxygenation (ECMO) therapy was compared with conventional medical therapy (CMT). In phase I, 4 of 10 babies in the CMT group died and 9 of 9 babies in the ECMO group survived. Randomization was halted after the fourth CMT death, as planned before initiating the study, and the next 20 babies were treated with ECMO (phase II). Of the 20, 19 survived. All three treatment groups (CMT and ECMO in phase I and ECMO, phase II) were comparable in severity of illness and mechanical ventilator support. The overall survival of ECMO-treated infants was 97% (28 of 29) compared with 60% (6 of 10) in the CMT group (P< .05).
High-Frequency Oscillatory Ventilation and Extracorporeal Membrane Oxygenation for the Treatment of Acute Neonatal Respiratory Failure
Authors: Carter Jan M. , Gerstmann Dale R. , Clark Reese H. , Snyder Maj Gary , Cornish J. Devn , Null Donald M. , deLemos Robert A.
Published: December 2021

Forty-six (92%) outborn and four (8%) in-born term or near-term neonates were admitted for extracorporeal membrane oxygenation (ECMO) treatment to a neonatal intensive care unit between July 1, 1985, and November 1, 1987. All infants had Pao2 - Pao2 ≥ 600 mm Hg in spite of aggressive conventional ventilatory and pharmacologic therapy. All patients were offered rescue treatment with high-frequency oscillatory ventilation (HFOV), and only if there was no improvement in Pao2 Pao2 with HFOV were infants treated using ECMO. Four patients died before receiving an adequate trial of HFOV and before emergency ECMO support could be initiated; 21 patients, all of whom survived to hospital discharge, responded to HFOV; 25 patients ultimately required ECMO therapy for cardiopulmonary support, with 22 (88%) surviving to discharge. Neonates responding to HFOV were of slightly younger gestational age (38 ± 2 weeks vs 40 ± 2 weeks, mean ± SD; P < .001) and more frequently had clinical evidence of pneumonia (11 of 21 vs 2 of 25; P < .002). There was no statistically significant difference in outcome with respect to the number of ventilator days, hospital days, or survival between patients responding to HFOV and patients who required ECMO. Morbidity was increased in ECMO patients, with bleeding abnormalities, seizures, and renal failure occurring more frequently than in HFOV-treated infants. Overall, 92% (46 of 50) of the patients were treated with a staged protocol using HFOV before ECMO. A total of 46% (21 of 46) responded to HFOV treatment alone and did not require ECMO therapy. This study demonstrates that a substantial proportion of extremely ill term and near-term infants who did not respond to conventional supportive measures could be successfully treated with HFOV. Alternate, staged, or combined treatment modalities may allow greater flexibility in directing life-support therapy toward specific cardiopulmonary disease, while maintaining for the patient the best possible risk to benefit ratio.
Childhood Survival in Haiti: Protective Effect of Measles Vaccination
Authors: Holt Elizabeth A. , Boulos Reginald , Halsey Neal A. , Boulos Louis-Marie , Boulos Carlo
Published: December 2021

To evaluate the impact of measles vaccination on survival of children residing in a periurban slum in Haiti, a total-population survey was conducted 2.5 years after completion of a one-time study of the serologic response to measles vaccine administered in the same population. Pregnancy histories from the 16 400 women in the population revealed that 1499 children had been born during a 7-month interval that would have made them eligible for participation in the measles vaccine program. Of these children, 1381 (92.1%) survived to 9 months of age, the median age that measles vaccine had been administered. Seventy-three infants had died between 9 and 39 months of age. Mortality of infants who were seronegative before receiving measles vaccine was significantly lower (P = .0013) than that of unvaccinated infants (3/235 vs 70/1056, respectively). Other factors positively associated with survival between 9 and 39 months of age included socioeconomic status (P = .0002), maternal literacy (P = .0020), maternal knowledge and use of oral rehydration solution (P = .0002), and an interval of greater than 24 months to the birth of the next younger sibling (P = .0012). Multivariate stepwise logistic regression analysis was used to evaluate the independent association of measles vaccination by adjusting for other factors that also correlated with survival and that might have been associated with maternal seeking of vaccinations. Children who survived were more likely to have received measles vaccine than children who died, independent of the effects from socioeconomic status, maternal knowledge of oral rehydration solution, maternal literacy, and birth interval (adjusted odds ratio = 6.5, 95% confidence interval 1.6 to 27.1). Estimates of the efficacy of measles vaccine for prevention of mortality from 9 through 39 months of age ranged from 84.7% to 90% by different methods of analysis. Therefore, measles vaccination appears to be an effective intervention for improving the survival of children residing in developing countries. Efforts should be increased to eliminate this disease from all countries.
Prenatal Care Evaluation and Cohort Analyses
Authors: Tyson Jon , Guzick David , Rosenfeld Charles R. , Lasky Robert , Gant Norman , Jiminez Juan , Heartwell Stephen
Published: December 2021

The value of prenatal care has been obscured by multiple factors, including the limitations of birth certificate data, large socioeconomic disparities between women who seek prenatal care and those who do not, and the "preterm delivery bias", ie, the reduced pregnancy duration and opportunity for prenatal care among women who give birth prematurely. Perinatal mortality and morbidity (neonatal intensive care unit admission; ventilator therapy) were carefully assessed in an indigent population (28 838 deliveries at Parkland Memorial Hospital). To avoid the preterm delivery bias, a cohort of all women whose pregnancy reached a specific week of gestation was identified and their prenatal care status (zero vs one or more visits) by that week was related to pregnancy outcome. Separate cohorts were defined at 26, 30, 34, 38, and 42 weeks. Prenatal care was associated with improved pregnancy outcomes in only the 34-, 38-, and 42-week cohorts (P < .01) Findings suggest substantial benefit from prenatal care after 30 weeks' gestation but not from early prenatal care. Unfortunately, it may not be possible to assess prenatal care accurately in observational studies even if cohort analyses are used. Clinical trials are needed to assess the effects of strategies for increasing or improving prenatal care, especially in early pregnancy.
Between a "Rock" and a Hard Place: Perinatal Drug Abuse
Authors: CHAVKIN WENDY , KANDALL STEPHEN R. , KANDALL STEPHEN R.
Published: December 2021

In July 1989 in Sanford, Florida, in a trial at which one of us served as an expert witness for the defense, a woman was convicted of having administered cocaine to a minor—via the umbilical cord in the seconds between the infant's delivery and the clamping of the cord. Although she did not receive a jail sentence, the mother was sentenced to 15 years' probation, 200 hours of community service, mandatory drug treatment, and mandatory high school equivalency education. This prosecution is not an isolated example. The District Attorney of Butte County, California, announced his intention to prosecute all mothers of neonates with illegal drugs found in their urine; conviction would carry a mandatory minimum sentence of 90 days in jail.
Bone Marrow Transplants
Authors: OGDEN ANGELA KENT , STEUBER C. PHILIP
Published: December 2021

To the Editor.—

Bone marrow transplantation has been increasingly undertaken and found effective for a variety of otherwise incurable diseases. As with all new therapies, the economic and ethical impact of the procedure requires continuing reevaluation. Durbin1 clearly stated the dilemmas faced by transplantation centers, insurance carriers, government agencies, and the public in general. Furman2 offered a limited view of transplantation and stated that bone marrow transplantation "may be neither ethical nor imperative as a therapy for dying children."
Current and Potentially New Management Strategies for Perinatal Hypoxic-Ischemic Encephalopathy
Authors: Vannucci Robert C.
Published: December 2021

Given the current dilemma in the brain-oriented therapy of newborn infants sustaining cerebral hypoxia-ischemia, it is not surprising that management strategies vary widely among neonatal intensive care units.9 Thus, there is no uniform standard of care, and it remains for future research to uncover new and effective modes of therapy for the neurologically compromised infant. Prevention, or at least optimal management, of prepartum and intrapartum asphyxia remains the best available means of reducing the incidence and severity of peninatal hypoxic-ischemic brain damage.
Infant Feeding and Infectious Disease
Authors: AGRE FRED
Published: December 2021

To the Editor.—

In the article "Relationship Between Infant Feeding and Infectious Illness: A Prospective Study of Infants during the First Year of Life" the authors comment on the methodologic failures of other studies.1

These failures include: (1) prospective data on infection and feeding, (2) specifying what is meant by infectious illness and breast-feeding, (3) controlling for other variables, and (4) exposure to illness through time.

Such a study accounting for the above methodologic flaws was conducted by me and reported in the American Journal of Diseases of Children.2
Infant Feeding and Infectious Disease
Authors: MULFORD CHRIS
Published: December 2021

To the Editor.—

I read with interest the article "Relationship Between Infant Feeding and Infectious Illness: A Prospective Study of Infants During the First Year of Life" by Rubin et al in the April issue.1 Two things puzzle me. The first is that, despite the authors' stated goal of paying close attention to methodology, their definition of breast-feeding fails to meet the standards set forth by most experts on lactation. The second is that, given their substantial investment of time and money in obtaining detailed data on 500 babies for a full year, the authors chose to ask their particular research question.
Childhood Injuries: Where We Are
Authors: Rosenberg Mark L. , Rodriguez Juan G. , Chorba Terence L.
Published: December 2021

INJURY RESPONSIBLE FOR EXCESS CHILD MORTALITY IN THE UNITED STATES

Child mortality rates are higher in the United States than in most European industrialized countries. This excess in mortality is not due to a difference in death rates from all natural causes; rather, all the excess mortality among US children can be attributed to injury (Fig 1). These differences are particularly notable for children 15 to 19 years of age. Suicide rates among 15- to 19-year-olds are higher in the United States than in most other industrialized countries (Fig 2). Excess homicide mortality among 15- to 19-year-olds is particularly striking (Fig 3). In 1985, 1579 homicides occurred among males and females aged 15 to 19 years in the United States. In the same year, only 150 homicides occurred among 15- to 19-year-old males and females in the Federal Republic of Germany, France, England and Wales, Sweden, Canada, and Japan, despite the fact that the combined population of these countries is 1.4 times the populations of the United States.

Our successes in infectious disease control dramatize our failures to control injuries effectively and increase the relative importance of injury. Injury is now the leading cause of childhood mortality and disability and a leading cause of childhood morbidity. In the last 60 years, death rates due to infectious diseases declined 90%, but death rates due to injuries declined only 40%. Since 1968 rates of injury deaths among children declined 25%, but death rates for diseases declined 56% (Fig 4). Deaths from diseases have decreased in the United States, but deaths from injuries have not decreased as much.
Neonatal Ethics: Development of a Consultative Group
Authors: Edens Myra J. , Eyler Fonda D. , Wagner James T. , Eitzman Donald V.
Published: December 2021

Experience of a neonatal ethics advisory group in a tertiary care setting was reviewed to identify which aspects of the experience have been most valuable in the development of a consultative group. Consultations were requested for 31 patients seen from August 1984 through December 1988. Review of these patients indicated that 21 of 31 infants were born after full-term gestations, 11 of 31 infants were seen beyond the neonatal period, and some type of congenital anomaly was the principal diagnosis for 64.7% of the patients. The reasons for seeking consultation primarily involved decisions regarding withdrawal or withholding of treatment. For 22 of the 31 patients, the consensus of the group supported the decision of the health care team. In the remaining consultations, the recommendation of the group was that more information and/or communication was needed. In the analysis of the neonatal ethics advisory group's experience with consultations the characteristics of neonatal patients were identified and the value of having a forum for discussing the difficult ethical issues facing members of the health care team were validated.
Social Acceptability of Methylphenidate and Behavior Modification for Treating Attention Deficit Hyperactivity Disorder
Authors: Liu Christina , Robin Arthur L. , Brenner Sheldon , Eastman Jay
Published: December 2021

The social acceptability of methylphenidate, behavior modification, and methylphenidate plus behavior modification was evaluated. Fifty mothers of children with attention deficit hyperactivity disorder (ADHD) and 50 control mothers, along with 21 children with ADHD and 20 control children, read a case vignette of an 8-year-old boy with ADHD and descriptions of the three treatment conditions. Subjects then rated the acceptability of each treatment. The mothers of children with ADHD were reassessed 3.5 months later, after experience with interventions for their children. Both ADHD and control families rated behavior modification as the most acceptable, methylphenidate as least acceptable, and the combined condition intermediate between the other two. At follow-up, there was a significant improvement in the acceptability of methylphenidate and the combined condition. The increased acceptability of methylphenidate at follow-up was related to increases in parents' knowledge about ADHD but not to the significant improvements that occurred in the children's hyperactive behavior.
Can Adolescent Suicide Attempters Be Distinguished From At-Risk Adolescents?
Authors: SCHONBERG S. KENNETH
Published: December 2021

Suicide is among the leading causes of death among adolescents and young adults. Beyond considerations of mortality is the morbidity of those young people who survive an attempt at suicide. At times this morbidity relates to anatomic or physiologic sequelae from the unsuccessful attempt; but far more often young people recover completely from the ingestion or trauma of their self-destructive episode, only to leave a residue of acute and chronic morbidity in the form of the psychological, educational, social, and financial after effects of hospitalization, absence from school, and disruption of the fabric of personal and family life. The detection of the young person at risk for even an unsuccessful attempt is therefore of some importance, and Dr Swedo and her co-authors show us in this issue of Pediatrics that such detection should be possible.
Vaccination Levels and Missed Opportunities for Measles Vaccination: A Record Audit in a Public Pediatric Clinic
Authors: Farizo Karen M. , Stehr-Green Paul A. , Markowitz Lauri E. , Patriarca Peter A.
Published: December 2021

A record audit of 254 children attending a public clinic in Los Angeles was conducted to assess immunization levels prior to a measles outbreak in the community. Coverage with all vaccines appropriate for age decreased from 67%at 3 months to 25% at 19 months. Delay in initiating vaccination was associated with increasing risk for delayed measles-mumps-rubella vaccine beyond age 2 years (P < .05). In one third of children, health care providers missed an opportunity to administer measles-mumps-rubella vaccine. Recall systems and elimination of missed opportunities may increase vaccination levels in clinic populations. Record audits should be considered for use in guiding the management of immunization programs.
A Varicella-Induced Pupil Abnormality
Authors: CAPUTO ANTHONY R. , MICKEY KEVIN J. , GUO SUQUIN
Published: December 2021

To the Editor.—

The varicella virus is a well known cause of ophthalmologic complications in its classic recurrent form of herpes zoster ophthalmicus. Ocular complications may also accompany the primary infection, however, and have been well documented. These conditions include vesicular lid lesions with corresponding irritation, phlyctenular keratoconjunctivitis, superficial punctate keratitis, uveitis, optic neuritis, and external ophthalmoplegia from encephalitic cranial nerve palsies.1,2 Internal ophthalmoplegia, a rare complication affecting pupillary constriction and accommodation, has also been
Fumarase Deficiency: Two Siblings With Enlarged Cerebral Ventricles and Polyhydramnios In Utero
Authors: Remes Anne M. , Hiltunen J. Kalervo , Rantala Heikki , Leisti Jaakko , Ruokonen Aimo
Published: December 2021

A family having two boys with progressive encephalomyopathy and fumaric aciduria due to fumarase deficiency is described. Both patients initially presented with polyhydramnios and enlarged cerebral ventricles in utero, with subsequent cerebral atrophy, severe developmental delay, infantile spasms, and hypsarythmia on electroencephalogram. Fumarase activity in blood mononuclear cells and In the mitochondrial and cytosolic fractions of cultured skin fibroblasts was less than 0.5% of the control mean or undetectable. The older boy died at the age of 5 years and 4 months and the younger one is now 2 years and 10 months. The unrelated parents are symptomless and the other three children in the family are clinically healthy. Fumarase activities in the blood mononuclear cells of the father, mother, sister, and two brothers were 59%, 52%, 52%, 120%, and 44% of the control mean, respectively. The results strongly support autosomal recessive inheritance of fumarase deficiency and suggest its consideration in children with congenital hydrocephalus, progressive brain atrophy, and infantile spasms.
Hypercholesterolemia Screening Questioned
Authors: HARVEY BIRT
Published: December 2021

In Reply.—

r. Sheps is concerned that policy may develop based on the results and interpretation of the study by Steiner and her colleagues. Another unmentioned concern might be that physicians will unhesitatingly follow the recommendation of these authors that all adolescents be screened.

This recommendation for screening is accompanied by a caveat: "Until all of the related controversies surrounding cholesterol testing are more clearly understood ...," and both the authors and Dr Sheps share concern about one of those controversies, the safety and efficacy of intervention for hypercholesterolemia.
The Diaper Controversy
Authors: NEWMAN ELIZABETH
Published: December 2021

To the Editor.—

An article encouraging pediatricians to advocate cloth diapers was published recently in Pediatrics.1 Embarrassing, but true ... we, too, used to look down upon those who used disposable diapers, along with Cadillac owners, cigar smokers, and lepers. Six months ago little Rebecca came into our lives and we have learned alot from her. It's not the stuff they teach in medical school or prenatal classes. We'd like to share some observations with you. We still don't drive a Cadillac or smoke cigars, but we think that Pampers are simply amazing! We were going to be the best parents and also politically correct: breast-feeding and cloth diapers (there was no doubt about it).
FAMILIAL PAROXYSMAL CHOREOATHETOSIS OF MOUNT AND REBACK
Authors: PRYLES CHARLES V. , LIVINGSTON SAMUEL , FORD FRANK R.
Published: December 2021

A case is described of familial paroxysmal choreoathetosis identical to that described by Mount and Reback. This patient also had attacks of petit mal. There was a history of epilepsy in other members of the family and a maternal aunt had seizures similar to those of the case described herein. It appears that this disease may be related to epilepsy.
CONGENITAL DISLOCATION OF THE HIP
Authors: PRAY L. G.
Published: December 2021

Limited hip abduction, when present, is a valuable early sign of congenital hip dysplasia. Other signs and symptoms should be looked for.

Confirmation by roentgenographic studies should be sought in all patients. Roentgen changes may be equivocal or lacking during the first three months of life in patients with hip dysplasia.

The Frejka pillow splint is a convenient and effective means of treating hip dysplasia or subluxation in early infancy. It is as effective as a cast during this period, and is cleaner and more comfortable.

It would seem that a high percentage of cases of congenital hip dysplasia recover spontaneously. However, in view of the seriousness of hip dislocation and the value of early treatment of hip dysplasia, it seems best to treat all infants with clinical signs of this disease.
EFFECT OF APNEA NEONATORUM ON INTELLECTUAL DEVELOPMENT
Authors: USDIN GENE L. , WEIL MARVIN L.
Published: December 2021

The intelligence of a group of 41 children who had been apneic for three or more minutes at birth was compared with that of a control group of 43 children who had breathed spontaneously at birth. The children were 13 and 14 years old at the time of the study. All the children had been born in the Cincinnati General Hospital in 1937 and therefore should derive from an essentially similar socio-economic strata. Insofar as seemed possible, all cases with factors that might in themselves have impaired the child's motor or intellectual development were excluded. Individual intelligence tests were administered. A statistical analysis of the results of these tests revealed no significant difference between the intelligence of the apneic and control group.
EFFECTS OF PENICILLIN AND BROAD-SPECTRUM ANTIBIOTICS ON THE EMERGENCE OF A GRAM-NEGATIVE BACILLARY FLORA IN THE UPPER RESPIRATORY TRACT OF INFANTS
Authors: MCCURDY ROBERT S. , NETER ERWIN
Published: December 2021

A study was undertaken on 107 infants to determine the effect of penicillin and broad-spectrum antibiotics (aureomycin, chloromycetin and terramycin), alone and in combination, on the emergence of a predominant gram-negative, bacillary flora of the upper respiratory tract. The following data were obtained:

1. Such a change of the flora took place in 4 out of 12 patients treated with penicillin, 15 out of 22 treated with penicillin and a broad-spectrum antibiotic, and in only 4 out of 21 infants who received a broad-spectrum antibiotic exclusively.

2. Of the 32 cases whose flora had thus changed, members of the E. coli-A. aerogenes group were found in 30 instances, members of the genus Proteus in 3; Ps. aeruginosa in 2; Paracolobactrum in 1; and combinations thereof in four cases.

3. This change of the flora took place in 18 out of 71 infants suffering from respiratory infection and in 14 out of 36 children suffering from other diseases.

4. Reappearance of clinical manifestations was observed in 6 out of 19 patients whose respiratory tract flora changed following the use of penicillin and in none of the four individuals who were treated with a broad-spectrum antibiotic alone. In view of the small number of cases this observation requires confirmation.

5. It is concluded that in infants the use of penicillin used in conjunction with a broad-spectrum antibiotic is followed rather frequently by the emergence in the upper respiratory tract of a predominant gram-negative, bacillary, aerobic flora; such a change occurs less frequently after the use of a broad-spectrum antibiotic alone. The clinical significance of these data is discussed.
ECMO and Sepsis. If Differences Could Be Due to Chance Alone, Are Trends Worth Discussing?
Authors: HOCKER JAMES R. , SIMPSON PIPPA M. , RABALAIS GERARD P. , STEWART DAN L. , COOK LARRY N.
Published: December 2021

In Reply.—

We agree with Dr Weiss that from a purely statistical standpoint, our retrospective data do not offer proof that ECMO is superior to conventional medical therapy in improving the survival of neonates with overwhelming group B streptococcal sepsis. If this study had more power (ie, more patients), a statistically significant difference may have been noted. Of course, with this particular study design, we had no control over sample size. It is up to the reader to decide if there is a clinically significant difference between the two therapeutic strategies.
Perinatal Human Immunodeficiency Virus Infection: Ruminations on Mechanisms of Transmission and Methods of Intervention
Authors: Borkowsky William , Krasinski Keith
Published: December 2021

Perinatal human immunodeficiency virus (HIV) infection is undoubtedly a multifactorial process. Neither the quantity of viremia nor the level of neutralizing antibody in the infected mother is alone predictive of HIV transmission to her offspring. Additional cofactors may include the ability of maternal immunity to control the host cell range and rate of viral replication. The placenta probably constitutes an effective barrier to viral transmission unless disrupted by processes such as syphilis. Prevention of such breaks in the trophoblast barrier and efforts to stimulate maternal and newborn HIV-specific immunity may further decrease the perinatal transmission rate
Tracking of Serum Cholesterol Levels in a Multiracial Sample of Preschool Children
Authors: Freedman David S. , Byers Tim , Sell Karen , Kuester Sarah , Newe1l Eva , Lee Sheryl
Published: December 2021

The relation of an initial measurement of serum total cholesterol to subsequent levels over a (mean) 13-month interval was examined in a multiracial (white, Hispanic, American Indian, and black) sample of 1680 one- to four-year-olds. Although the relation of the initial level to the final measurement (r = .54) did not vary by race, sex, relative weight, or changes in relative weight, the association increased with age at the time of the initial measurement (eg, r .64 among 4-year-olds). Based on the initial and final total cholesterol determinations, the within-person standard deviation was 21 mg/dL and the coefficient of variation was 13%. Although the final total cholesterol level was within 5 mg/dL of the initial level for 18% of the children, the two determinations differed by ≥25 mg/dL for about 35% of the children and by ≥50 mg/dL for about 8%. Of the 149 children who had an initial cholesterol level ≥200 mg/dL, 34% (about five times the expected number) had a follow-up level that was similarly elevated whereas 25% had a subsequent measurement below 170 mg/dL. The results indicate that although an initial cholesterol level in early life is moderately predictive of subsequent levels, it may be difficult to interpret a single total cholesterol determination because of substantial within-person variability.
The Occurrence of High Levels of Acute Behavioral Distress in Children and Adolescents Undergoing Routine Venipunctures
Authors: Humphrey G. Bennett , Boon Chris M. J. , van Linden van den Heuvell G. F. E. Chiquit , van de Wiel Harry B. M.
Published: December 2021

While there is no question that children dislike needles, there are very little data available on the occurrence of high levels of distress experienced by children undergoing routine venipunctures. To provide some insight into this problem, trained observers evaluated distress in 223 different children and adolescents undergoing this procedure. An observational distress scale of 1 to 5 was developed; 1 = calm, 2 = timid/nervous, 3 = serious distress, but still under control, 4 = serious distress with loss of control, and 5 = panic. We observed a strong relation between distress and age but not between distress and gender. During the actual venipuncture. half the subjects (113/223) were scored as having high levels of distress (3 or more). Our subjects were also grouped into three age ranges: toddlers; 2½ to 6 years, N = 70; preadolescents; 7 to 12 years, N = 55; and adolescents; 12 years and older, N = 98. The percent of subjects experiencing high levels of distress for each age group were: 83%, 51%, and 28%, respectively. We conclude that for venipunctures: 1) high levels of distress are common, and 2) age and not gender correlates with distress. Other correlations are discussed. Toddlers and pre-adolescents should be the targets for new interventions to reduce distress.
Potential Role of Intrapulmonary Shunting in the Genesis of Hypoxemic Episodes in Infants and Young Children
Authors: Poets Christian F. , Samuels Martin P. , Southall David P.
Published: December 2021

A number of physiologic phenomena during some apneic/cyanotic episodes in infants and young children cannot be explained sufficiently on the basis of a cessation or reduction in aveolar ventilation alone. These include (1) the extremely rapid development of hypoxemia during some episodes, (2) the occurrence of hypoxemic episodes despite continuous ventilation, (3) differences in the speed of desaturation between different forms of apneic episodes, (4) the presence of continued breathing efforts and yet absent airflow despite bypass of the upper airway, and (5) evidence that apnea and hypoxemia may begin simultaneously. Potential mechanisms to explain these phenomena include the sudden development of an unevenness in the matching between ventilation and lung perfusion, the flow of blood through unventilated areas of lung, and a sudden impairment in gas diffusion. Evidence from physiological and morphological studies suggests that all of these mechanisms, although to a different extent, may be involved in apneic/cyanotic episodes. The recognition that nonapneic mechanisms can cause sudden profound hypoxemia may alter our approach to the identification, treatment, and prevention of these episodes.
Authors' Correction
Authors: IRIGOYEN MATILDE , DAVIDSON LESLIE
Published: December 2021

To the Editor.—

In the article, "Randomized, Placebo-Controlled Trial of Iron Supplementation in Infants with Low Hemoglobin Levels Fed Iron-Fortified Formula" by Irigoyen et al (Pediatrics 1991;88:320-326), an error was made on Table 1 (p323) regarding the proportion of children fed milk-based and soy-based formulas. The corrected data follow:

[See table in the PDF file]

Although this error only relates to the dietary background informarion and does not affect the trial or its results, we would appreciate going on record as having the data corrected.
Meconium Aspiration Syndrome (MAS)
Authors: WISWELL THOMAS E.
Published: December 2021

In Reply.—

I am confused by Dr Waage's letter. What does he mean by "the literature supports that the majority of meconium-stained neonates fall into such a category?" Does he mean it is substantiated that the majority of these neonates do not require intubation? Yes, 95% of such neonates will not develop MAS, but how does one identify those at risk who "require" intubation. Clearly, depressed neonates born through thick meconium are at the highest risk for MAS, but MAS will occur in apparently vigorous newborns or those born through thin-consistency fluid.1,2
The Sit-up Test: An Alternate Clinical Test for Evaluating Pediatric Torticollis
Authors: Caputo Anthony R. , Mickey Kevin J. , Guo Suqin , Wagner Rudolph S. , Reynolds Karin , DeRespinis Patrick A. , Deluca Joseph A.
Published: December 2021

The sit-up test, a new evaluation method for differentiating between ocular and orthopaedic torticollis, was evaluated against the monocular occlusion test, using results of three-step testing for standardization. The study group consisted of 31 patients with torticollis between the ages of 4 and 12.5 years. Subjects were selected based only on their ability to cooperate with three-step testing. Three-step testing identified 27 of the 31 patients as having ocular torticollis, with the remaining 4 having an orthopaedic etiology. Sit-up testing correctly identified all 27 ocular torticollis patients, with no false positives or false negatives. Monocular occlusion testing detected at best 22 (81.4%) of the ocular torticollis patients, with no false positives.
Total Bone Mineral Content and Body Composition by X-ray Densitometry in Newborns
Authors: Venkataraman Pankaja S. , Ahluwalia B. Wally
Published: December 2021

Measurement of total body bone mineral content and body composition has not previously been convenient in the newborn. X-ray densitometry, otherwise known as dual-energy x-ray absorptiometry (DEXA), has been used in adults to assess with accuracy and precision the total body mineral content, lean mass, and fat. Body composition measurements were determined in vivo by DEXA in term newborns, and they were compared with values reported by chemical analysis of the cadaver, with skin-fold thickness measurements, and with bone mineral content measured by single photon absorptiometry. The intermeasurement coefficient of variation was ≤2.5% for bone mineral content, and ≤1% for fat and lean mass. The values for bone mineral content, fat, and lean mass fall within the ranges expected based on the reported values measured by chemical analysis of the infant cadaver. Triceps and quadriceps skin-fold measurements were best correlated with total body fat as measured by DEXA. The bone mineral content of the distal third radius site as measured by single photon absorptiometry in newborns showed significant correlation with total body bone mineral content. DEXA provides a reproducible and convenient method for the determination of body composition in newborns.
Neonatal Hyperparathyroidism and Skeletal Demineralization in an Infant With Familial Hypocalciuric Hypercalcemia
Authors: POWELL BERKLEY R. , BLANK EUGENE , BENDA GERDA , BUIST NEIL R. M.
Published: December 2021

Familial hypocalciuric hypercalcemia (FHH) is a benign dominantly inherited condition, in which the total and ionized calcium are maintained at values well above the normal range.1 When an affected mother is carrying an unaffected fetus, the fetus is chronically exposed to pathologically high calcium levels and neonatal hypoparathyroidism would be expected, as we2 and others have reported.3,4 Conversely, when a fetus is affected, but the mother is not, the fetus might be expected to develop hyperparathyroidism, which should manifest at birth. These infants may require emergency surgery5 or may be managed medically until the hyperparathyroidism subsides.6,7 We report here an infant with FHH, a first cousin of our previous case, who presented with hyperparathyroidism and skeletal demineralization.
Mythology of Lead Poisoning
Authors: LAKATOS LAJOS
Published: December 2021

To the Editor.—

I read with interest the recent paper by Drs Glotzer and Bauchner and enjoyed reading the excellent commentary by Drs Needleman and Jackson.1,2 It is stated correctly that "the overall consensus is that elevated lead burdens in childhood . . . can result in adverse neurodevelopmental outcomes." Of even more concern is the detrimental effect of lead on developing and growing nervous systems: behavioral and learning disorders have been attributed to lead exposure in utero and in early infancy.
Epidemiology of Rett Syndrome: A Population-Based Registry
Authors: Kozinetz Claudia A. , Skender Martha L. , MacNaughton Nancy , Almes Mary Jane , Schultz Rebecca J. , Percy Alan K. , Glaze Daniel G.
Published: December 2021

The Texas Rett Syndrome Registry maintains the largest population-based registry of cases and potential cases of Rett syndrome in the world. The most precise estimate of the prevalence of Rett syndrome of 1 per 22800 (0.44/10000) females aged 2 through 18 years of age was generated from this Registry. In addition, the first prevalence figures for black and Hispanic female cases were estimated. Registry cases are actively ascertamed from multiple sources. Registry staff identify presumptive cases from review of information provided to the Registry by the parent or guardian. Preliminary diagnostic evaluation includes standardized review of medical records and videotape of key behaviors. Diagnosis is confirmed at clinical evaluation. The active surveillance system is monitored with the two-source capture-recapture methodology and case ascertainment is projected. The 1990 prevalence estimate of Rett syndrome indicates that the syndrome occurs less frequently than previously estimated. Until a biologic marker for Rett syndrome is identified or a standard definition for an incident case of Rett syndrome is designated, the prevalence of Rett syndrome will remain a major investigative issue of its epidemiology, and the Registry will be an important, systematic mean to gather case material for clinical and laboratory studies providing the foundation for the development of preventive interventions.
Hyperbilirubinemia in the Breast-Fed Newborn: A Controlled Trial of Four Interventions
Authors: Martinez Jorge C. , Otheguy Lydia , Garcia Horacio , Savorani Monica , Mogni Beatriz , Martinez Jorge C. , Maisels M. Jeffrey
Published: December 2021

A controlled clinical trial was conducted to compare the effect of four different interventions on hyperbilirubinemia in 125 full-term breast-fed infants. Of 1685 term infants who met the inclusion criteria, 126 (7.4%) had a serum bilirubin concentration ≥291 µmol/L (17 mg/dL). When the bilirubin reached this level, babies were assigned at random to one of four interventions: (1) continue breast-feeding and observe; (2) discontinue breast-feeding, substitute formula; (3) discontinue breast-feeding, substitute formula and administer phototherapy; (4) continue breast-feeding, administer phototherapy. The serum bilirubin concentration reached 342 µmol/L (20 mg/dL) in 24% of infants in group 1, 19% in group 2, 3% in group 3, and 14% in group 4. When phototherapy was used, the decline in serum bilirubin was significantly larger and more rapid (compared with no phototherapy). In the majority of breast-fed infants whose serum bilirubin levels reach 291 µmol/L (17 mg/dL) the bilirubin will decline spontaneously and will not reach 342 µmol/L (20 mg/dL). If the infant is significantly jaundiced and a decision is made to intervene, parents can be given a number of options and can make an informed decision regarding which, if any, intervention they prefer.
TV or Not TV: Fat Is the Question
Authors: DIETZ WILLIAM H. , GORTMAKER STEVEN L.
Published: December 2021

The manuscript entitled "Does television viewing increase obesity and reduce physical activity?" published by Robinson and coauthors in this issue of Pediatrics1 is a careful and well-written study of the effect of television viewing on adiposity and physical activity among sixth- and seventh-grade adolescent girls. In contrast to two other large studies of children,2,3 the authors failed to find a significant association between hours of television viewed and adiposity, measured by body mass index. Physical activity was weakly and inversely correlated to time spent viewing television. The latter observation is consistent with prior data which demonstrate a reciprocal relationship of fitness and television viewing,4 perhaps because television viewing displaces more vigorous physical activities.5
The Changing Role and Responsibilities of a Chairman—Letters
Authors: ROSENQUIST GLENN C.
Published: December 2021

To the Editor.—

I enjoyed the article by Robert L. Brent in Pediatrics (1992;90:50-57) on the changing role and responsibilities of chairmen. The article is a "must read" for anyone contemplating the job—and for anyone who used to have the job (like me).

As usual Dr Brent has shown the insight we have all admired for years. Keep up the good work.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: LICHTMAN MARSHALL A.
Published: December 2021

To the Editor.—

Thank you to Robert Brent for his cogent analysis of the role and attributes of the department chair.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: ROIZEN MICHAEL F.
Published: December 2021

To the Editor.—

I have read the excellent article by Robert L. Brent with interest and admiration. I'd like to add two additional characteristics that I believe are important for a department chairman. (1) The ability of the chairman to seek and accept advice. None of us know all of the answers, many others have faced similar problems, and advice can easily be sought from ex-chairmen, chairmen, or individuals in other business fields who have had experience with similar problems.
Exercise and Breast-Feeding: A Different Experience
Authors: DEWEY KATHRYN G. , LOVELADY CHERYL
Published: December 2021

To the Editor.—

Although we find the study of Wallace et al1 interesting, we are concerned that their finding of decreased infant acceptance of postexercise breast milk due to increased lactic acid concentration will be misinterpreted to mean that there are disadvantages to exercising during lactation. It is important to emphasize that the subjects in their study underwent a maximum exercise test before collection of breast milk samples. Lactic acid levels in milk are likely to be much higher following maximum exercise than they would be after the more moderate levels of exercise needed to maintain fitness and enhance weight loss.
Treatment Investigational New Drug Experience With Survanta (Beractant)
Authors: Zola Elizabeth M. , Overbach A. M. , Gunkel J. Harry , Mitchell Brian R. , Nagle Barbara T. , DeMarco Nicola G. , Henwood Geraldine A. , Gold Alan J.
Published: December 2021

From September 1989 through July 1991, before commercial availability, Survanta (beractant intratracheal suspension), a modified bovine-derived surfactant used for prevention and treatment of neonatal respiratory distress syndrome, was made available to 231 neonatal intensive care units in the United States and Canada under a Treatment Investigational New Drug protocol. Results of this open clinical experience are reported. Investigators could give one dose of Survanta soon after birth to neonates weighing 600 to 1250 g (prevention strategy). Neonates weighing 600 to 1750 g who were not treated at birth could begin Survanta therapy if respiratory distress syndrome developed within 8 hours of birth (rescue strategy). All neonates could receive up to three more doses over the first 48 hours of life at minimum intervals of 6 hours if they met retreatment criteria. Qualifications for enrollment closely matched those used in previous randomized controlled clinical trials. This report includes results from 8168 neonates who completed the study. Treatment Investigational New Drug rates for intracranial hemorrhage, patent ductus arteriosus, pulmonary hemorrhage, pulmonary air leaks, bronchopulmonary dysplasia, death or bronchopulmonary dysplasla, pulmonary interstitial emphysema, pretreatment sepsis, and posttreatment sepsis were less than for treated neonates in the controlled trials and survival was equivalent across studies. Problems with treatment administration were reported with 30.4% of doses, while adverse events were reported in 0.5% of neonates. The results of the Treatment Investigational New Drug protocol revealed no new safety concerns associated with the widespread use of Survanta and confirmed the safety profile established in earlier controlled trials.
Association Between Neonatal Care Practices and Efficacy of Exogenous Human Surfactant: Results of a Bicenter Randomized Trial
Authors: Hallman Mikko , Merritt T. Allen , Bry Kristina , Berry Charles
Published: December 2021

The purpose of this study was to analyze the impact of neonatal care practices on the efficacy of exogenous human surfactant. Two hundred newborns (gestational age 24.0 to 29.9 weeks, lecithin-sphingomyelin ratio less than 2 or absent phosphatidylglycerol, and requirement of mechanical ventilation at birth) participated in a randomized bicenter trial of human surfactant substitution. In only one of the two sites (site 2) surfactant substitution decreased the severity of respiratory failure and increased neonatal survival without bronchopulmonary dysplasia. For analysis of three-way association, continuous variables describing patient characteristics and treatment were dichotomized at the median. The following variables were significantly associated with good outcome in site 1 and 2 and with surfactant substitution in site 2: low oxygen requirement during first three neonatal days, low mean airway pressure during second and third day, low Paco2 during first two neonatal days, and no ligation of ductus arteriosus. Low fluid intake during the first three days and low colloid intake during the first two days of life were associated with good outcome in both sites. The ratio between mean airway pressure and the oxygen requirement was higher in site 2 than in site 1 during the first day of life. Fluid intake and ventilatory management may influence the efficacy of exogenous surfactant.
Arterial Partial Pressure of Oxygen Required to Achieve 90% Saturation of Hemoglobin in Very Low Birth Weight Newborns
Authors: Émond Daniel , Lachance Christian , Gagnon Jacynthe , Bard Harry
Published: December 2021

Since very low birth weight preterm newborns are prone to oxygen toxicity and have red blood cells that have a high oxygen affinity, the knowledge of the P90 (the Pao2 required for 90% saturation of hemoglobin) could result in a more optimal oxygenation. This information could diminish the incidence of bronchopulmonary dysplasia and retrolental fibroplasia. To determine P90 and P50 (the Pao2 required for 50% saturation of hemoglobin), cord blood was obtained from 10 preterm newborns who were of less than 30 weeks' gestation (26.4 ± 1.4 [SD] weeks) weighing less than 1000 g (816 ± 119 g). The P50 and P90 were determined by gas mixing tonometry and expressed in millimeters of mercury at a temperature of 37°C, a pH of 7.40, and Pco2 of 40 mm Hg. The tonometer permitted an equilibration and sampling of successive aliquots of blood at different oxygen tensions. Measurement of oxygen saturation, pH, and Pao2 provided the information for plotting the oxygen dissociation curve, the P50 and P90. There were at least six experimental points for each oxygen dissociation curve. The results showed that the mean P50 was 18.3 ± 1.9 mm Hg (2.5 ± 0.3 kPa) and the P90 was 40.8 ± 3.6 mm Hg (5.4 ± 0.5 kPa). This study demonstrates the fetal nature of the oxygen dissociation curve of very low birth weight newborns; but most importantly it also shows that when treating very low birth weight newborns with oxygen, a Pao2 of 41 mm Hg (5.5 kPa) is enough to saturate 90% of the hemoglobin at a physiological pH. This information could be of clinical importance to minimize oxygen toxicity.