bluuebunny/crossref_metadata_2025 huggingface dataset:
Group A β-Hemolytic Streptococcal Bacteremia: Historical Overview, Changing Incidence, and Recent Association With Varicella
Authors: Doctor Allan , Harper Marvin B. , Fleisher Gary R.
Published: December 2021

Objective. To quantitate the increase in invasive group A β-hemolytic streptococcal (GABHS) infections and to define a possible association between GABHS bacteremia and primary varicella zoster virus (VZV) infections.

Methods. This was a retrospective chart review conducted at Children's Hospital. Participants were patients with documented GABHS bacteremia occurring from January 1977 through December 1993.

Measurements/Main Results. We identified 63 episodes of GABHS bacteremia in 62 patients. From 1977 to 1992, a mean of 3.2 ± 2 cases occurred per year (range, 0 to 6), increasing by a factor of 3 (10 cases) in 1993. The median age was 4 years (range, 1 day to 20 years; mean, 8 years ± 3 months); 36 were male; five children were immunocompromised. One child was dead on arrival and one had a cardiac arrest during evaluation in the emergency department. Primary sites of infection (oropharynx, skin, or middle ear) were identified in 40 (75%) of the cases; in addition, 10 cases occurred in patients with primary VZV. From 1977 to 1992, we identified five VZV-associated cases; an average of 7 ± 11.5% of the patients with GABHS had concurrent VZV infection annually, with no more than one case per year. In 1993, 50% of the 10 new GABHS cases were in children with VZV infection (P = .003, Fisher's exact test). The diagnosis of invasive GABHS infection in patients with VZV was not readily recognized, requiring a median of two (range, one to four) physician visits before admission and the administration of antibiotics. All 10 children were diagnosed on the fourth or fifth day of the exanthem and were febrile (39.6 ± 1.1°C, range, 38.3 to 40.8°C), with a mean white blood cell count (WBC) of 11 500 ± 8 400/mm3 (8 of 10 cases had a WBC less than 15 000/mm3). None of the five VZV-associated cases in 1993 had signs of cutaneous bacterial superinfection; among these were two cases of streptococcal toxic shock syndrome (one death), one case of osteomyelitis, and two cases of occult bacteremia. Of the five VZV-associated cases before 1993, one patient was diagnosed with supraglottitis, one with septic arthritis, one with orbital cellulitis, and two solely with impetiginized or cellulitic lesions.

Conclusions. We found that the incidence of invasive GABHS infections has risen dramatically, increasing by a factor of 3 over the past year. In 1993, 50% of new cases of invasive GABHS disease were associated with VZV infection. Invasive GABHS should be considered in children with VZV who manifest fever on or beyond the fourth day of the exanthem. The absence of an elevated WBC and impetiginized or cellulitic lesions should not eliminate this diagnosis from consideration.
Pediatrician Involvement in Breast-Feeding Promotion: A National Study of Residents and Practitioners
Authors: Freed Gary L. , Clark Sarah J. , Lohr Jacob A. , Sorenson James R.
Published: December 2021

Objective. Physician support for breast-feedings mothers has been shown to improve breast-feeding rates, but no evaluation of the adequacy of physicians' breast-feeding-related training has been conducted. This study was designed to assess pediatricians' knowledge, attitudes, training, and activities related to breast-feeding promotion.

Methods. Surveys were mailed to a national random sample of pediatric residents (n = 999) and practitioners (n = 610) who were board certified within the previous 3 to 5 years.

Results. Response rates were 74% for residents and 69% for practitioners. Although more than 90% of respondents agreed that pediatricians should be involved in breast-feeding promotion, their clinical knowledge and experience did not suggest a high degree of competency. For example, practitioners were only slightly more aware of breast-feeding's protective effect against otitis media (71% vs 60%), and more than one quarter of both groups did not agree that exclusive breast-feeding is the most beneficial form of infant nutrition. Clinical advice often included inappropriate recommendations for breast-feeding termination or formula supplementation; only 64% of practitioners and 52% of residents knew that supplementing during the first few weeks of life may cause breast-feeding failure. For both groups, prior personal breast-feeding experience (ie, respondent or spouse had breast-fed an infant for 2 or more weeks) was a major determinant of improved clinical knowledge, more frequent activity, and greater self-confidence and perceived effectiveness in the area of breast-feeding promotion. Residents reported that the breast-feeding instruction provided during training was primarily in lecture format, with limited clinical opportunities to practice skills needed to assist breast-feeding mothers. Reflecting on their own training, more than 70% of practitioners recommended that more time be devoted to direct patient interaction and practice of counseling and problem-solving skills.

Conclusions. These results indicate that residency training does not adequately prepare pediatricians for their role in breast-feeding promotion. Improvements in residency training and innovative continuing education programs should be implemented to help pediatricians meet the needs of their breast-feeding patients.
Growth of Breast-Fed Infants Deviates From Current Reference Data: A Pooled Analysis of US, Canadian, and European Data Sets
Authors: Dewey Kathryn G. , Peerson Janet M. , Brown Kenneth H. , Krebs Nancy F. , Michaelsen Kim F. , Persson Lars A. , Salmenpera Leena , Whitehead Roger G. , Yeung David L. ,   World Health Organization Working Group on Infant Growth
Published: December 2021

The sample sizes of infants from the selected studies are shown in Tables 2-4, categorized by duration of breast-feeding, timing of introduction of solid foods, and use of infant formula or other milks. Table 5 shows the cross-tabulation by duration of breast-feeding and age of introduction of supplemental milk or formula. In total, 453 infants were included, of whom 226 were breast-fed for at least 12 months. Of these 226, 141 were not regularly given other milks or formula during the first year of life. Of the total sample, solid foods were introduced at 4 to 5 months to 42% (Table 3), at 6 to 7 months to 38%, at 8 to 9 months at 17%, and after 9 months to 2%.

The samples were relatively homogeneous with respect to average maternal weight, height, and age. Mean pregnancy weight gain in the three studies reporting this ranged from 12.7 to 15.0 kg. Maternal educational levels were generally high: in the studies reporting this as a continuous variable, the overall mean was 15.4 ± 2.4 years of education. Mean birth weight ranged from 3414 to 3605 g. Characteristics of infants categorized by breast-feeding duration are shown in Table 6 (the group breast-fed for 4 to 5 month is not shown, because there were only 10 infants in this category). Mothers who breast-fed for 12 or more months were older and had higher parity and educational levels than mothers who breast-fed for less than 12 months, but birth weight did not differ significantly among groups.
Validity of Brain Death Criteria in Infants
Authors: Fishman Marvin A.
Published: December 2021

Okamoto and Sugimoto report a 3-month-old infant who developed apnea presumably secondary to hypoglycemia and then had a cardiopulmonary arrest. She regained sinus heart rhythm and spontaneous respirations 40 minutes after the apnea was first noted. Examination revealed evidence of neurologic function, including spontaneous respiration. There was subsequent deterioration in the infant's status and the patient met the clinical criteria for brain death on hospital day 3 and this persisted for 48 hours. Ancillary tests, including electroencephalogram (EEG) and brainstem auditory-evoked responses supported the clinical diagnosis. The infant survived for an additional 71 days after meeting the criteria for brain death formulated by the Task Force on Brain Death in Children.
Scopolamine Patch-Induced Unilateral Mydriasis
Authors: Thiele Elizabeth A. , Riviello James J.
Published: December 2021

Tnansderm Scōl patches, containing scopolamine, have become a very popular and effective treatment for nausea and vomiting accompanying chemotherapy. We report two patients in whom unilateral fixed and dilated pupils related to scopolamine developed while undergoing chemotherapeutic protocols for bone marrow transplant (BMT). Both patients had neurologic consultations and neuroimaging as a result of the mydriatic pupils.

CASE REPORTS

Patient 1, a 20-year-old woman, was undergoing allogenic BMT for acute lymphocytic leukemia. She had a history of common migraine but had never experienced visual symptoms with her migraine. On the day before receiving her BMT, she had a headache and blurred vision and was found to have a fixed and dilated pupil on the left.
Letters to the Editor
Authors: MacLean William C.
Published: December 2021

In the statement by the American Academy of Pediatrics' (AAP) Work Group on Cow's Milk Protein and Diabetes Mellitus,1 it was concluded that "The substitution of soy-based formulas for milk-based formulas is not advised for either general or high-risk infant feeding practices because of animal studies linking the ingestion of soy protein intake to the development of diabetes." This AAP statement leaves the impression that there is evidence that soy protein causes insulin-dependent diabetes mellitus (IDDM) and that it is sufficient to conclude that soy formulas should no longer be fed to human infants.
Letters to the Editor
Authors: Robertson William O.
Published: December 2021

Without any doubt, Drs Seidman and Stevenson have raised many pertinent questions about the issue of hyperbilirubinemia—just as Dr Stevenson did to the Subcommittee as it deliberated its guidelines. Each issue was, in fact, carefully considered by the Subcommittee as it searched for "ever-increasing certainty." Unfortunately, no such panacea was discovered and the Committee concluded—with the vast majority of its consultants agreeing— that some "prudent professional guidelines using the best information available as it was interpreted by recognized experts" would be more beneficial to both patients and practitioners than no guidelines at all.
Multicenter Acellular Pertussis Vaccine Trial: A National Institutes of Health Perspective
Authors: Klein David L.
Published: December 2021

The Pertussis Program within the Division of Microbiology and Infectious Diseases of the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health, is responsible for the development, management, and monitoring of several research and training initiatives in the field of pertussis. As directed by Congress through the National Childhood Injury Act, and with support by the National Vaccine Program Office, the NIAID has a mandate to accelerate scientifically and systematically the development and clinical testing of new candidate acellular pertussis vaccines, with the goal of licensure of an improved product that is less reactogenic than, and equally effective as, conventional whole-cell vaccine. A major portion of this activity is done through contracted Vaccine Treatment and Evaluation Units (VTEUs) in the form of phase I and II clinical trials. Much of this effort involves close collaboration with vaccine manufacturers and the US Food and Drug Administration (FDA). The success of the NIAID's vaccine evaluation program has relied heavily on this unique interaction with industry during the past 14 years, which has proved beneficial for all parties. Furthermore, this interaction has provided vaccines and antigens for use in the clinical setting and the laboratory, respectively, promoting the rapid evaluation and testing of many of these products.

Although the conventional whole-cell pertussis vaccine used in the United States is efficacious in preventing disease, there is concern about its safety. Recent advances in the characterization of the antigenic and biologically active components of Bordetella pertussis have allowed for the development and production of a new generation of more highly purified acellular vaccines, which we hope will prove to be much safer.
Comparison of 13 Acellular Pertussis Vaccines: Adverse Reactions
Authors: Decker Michael D. , Edwards Kathryn M. , Steinhoff Mark C. , Rennels Margaret B. , Pichichero Michael E. , Englund Janet A. , Anderson Edwin L. , Deloria Maria A. , Reed George F.
Published: December 2021

Objective. To compare the reactogenicity of a licensed conventional whole-cell (WCL) and 13 acellular pertussis vaccines that differed in the source, manufacture, and quantity of included antigens; all vaccines included diphtheria and tetanus toxoids.

Methods. Healthy infants were enrolled through six university-based vaccine and treatment evaluation units and were randomized to receive one of the study vaccines at 2, 4, and 6 months of age. Parents recorded the occurrence of fever, redness, swelling, pain, fussiness, drowsiness, anorexia, and use of antipyretics for 2 weeks after each inoculation; nurses interviewed parents on the third day and at each succeeding visit; long-term follow-up information was collected from parents and medical records 1 year after the third immunization.

Results. Of 2200 vaccinated infants, 2189 contributed reaction data after 6375 vaccinations. For every acellular vaccine, every monitored reaction except vomiting occurred at a significantly lower frequency and severity than was seen with WCL. The groups receiving acellular pertussis vaccines differed significantly with respect to redness, swelling, pain, and vomiting, but not with respect to fussiness, antipyretic use, drowsiness, or anorexia.

Conclusion. Although there were differences among the acellular vaccines, none was consistently the most or least reactogenic; all were associated with substantially fewer and less severe adverse reactions than a standard commercial whole-cell vaccine. Selection of acellular vaccines for further development and for introduction into efficacy trials can give priority to assessments of immunogenicity and purity, with comparative reactogenicity a secondary consideration.
Gastrostomy Tube Supplementation for HIV-infected Children
Authors: Miller Tracie L. , Awnetwant Ester L. , Evans Sylvia , Morris Vivien M. , Vazquez Isabel M. , McIntosh Kenneth
Published: December 2021

Objective. Malnutrition is common in pediatric human immunodeficiency virus (HIV) infection, and little is known of effective nutritional interventions. We sought to determine whether enteral supplementation with gastrostomy tube feedings would provide improvements in weight, height, body composition, immune parameters, morbidity, and mortality.

Methods. We collected clinical data on 23 HIV-in-fected children who were fed chronically by gastrostomy tube. The main outcome measures included weight, height, triceps skinfold thickness (TSF), arm-muscle circumference (AMC), hospital days, caloric intake, and CD4-positive T-lymphocyte count. Each of these parameters was measured or evaluated at four points: 6 months before nasogastric tube feeding, at the time nasogastric tube feeding was initiated, at the time gastrostomy tube feeding was initiated, and 6 months after gastrostomy tube feedings began.

Results. Weight z score [-2.1 (0.14) to -1.58 (0.14)] and weight-for-height z score [-0.98 (0.16) to -0.15 (0.17)] improved with gastrostomy tube feedings. There was a trend toward improvement in weight z score with nasogastric tube feedings. Caloric intakes increased progressively with nasogastric and gastrostomy tube feedings. No improvement in height, TSF, AMC, hospital days, or CD4 counts was seen in the follow-up period. However, children who had the greatest increase in weight had the most improvement in fat stores (TSF) (r = .65, P = .002) and a decrease in hospital days after the gastrostomy tube was placed (r = -.48, P = .025). Higher age-adjusted CD4 counts and lower weight-for-height z scores at the time of enteral supplementation were significant predictors of a positive response to gastrostomy tube feedings(r = .85, P = .0001). Children who responded favorably had a 2.8-fold reduction in the risk of dying for every positive unit change in weight z score (P = .005).

Conclusion. Gastrostomy tube supplementation for HIV-infected children can improve weight and fat mass when other oral methods fail. Weight gain is coincident with greater caloric intakes. HIV-infected children with higher CD4 counts and lower weight-for-height z scores are likely to respond favorably to gastrostomy tube feedings. Early nutritional intervention is indicated for HIV-infected children.
Parental Stress and Growth Outcome in Growth-deficient Children
Authors: Bithoney William G. , Van Sciver Margaret M. , Foster Susan , Corso Stephen , Tentindo Christine
Published: December 2021

Objective. In order to examine the relationship between parental stress, child psychosocial factors, anemia, lead poisoning, and growth deficiency (GD), 48 children attending a GD referral program were recruited consecutively and matched with 50 comparison subjects from a primary care program.

Method. Parents completed the Parenting Stress Index (PSI) with subscales and provided demographic data. Children received developmental screening, hemoglobin levels, Pb levels, and growth evaluation. They also received medical evaluation for GD. T tests were used to evaluate group differences. Spearman Rho correlation analyses were computed between group coefficients and PSI scales, Pb, and hemoglobin levels.

Results. No differences were found on the PSI with regard to overall parental stress. GD parents perceived themselves as less competent (P < .001), and their children as less adaptable (P < .006). They also reported more social isolation (P < .05). The GD group had more anemia and Pb poisoning (P < .002 and P < .001, respectively); however, these variables were not related to differences in child adaptability or growth outcome. A high sense of parental competence and high child adaptability were associated with improved growth outcomes (P < .001 and P < .02, respectively).

Conclusions. We conclude that parents of GD children seen in an outpatient referral setting show no difference in overall perceived stress levels versus comparison subjects. Increased parental competence and child adaptability are strongly associated with improved growth outcome. Decreased child adaptability may contribute to GD pathology. These findings challenge the traditional view of GD etiology.
THE EVIL EYE
Authors: McNamara John J.
Published: December 2021

Poorly understood cultural practices may mystify the pediatrician. The wearing of "charms" to ward off the evil eye is common among many cultures. In our area a large number of Cape Verdean infants wear a small black ceramic bead with twenty-four white dots on a cord either around the waist or around the arm.

Recently, in changing an IV, a nurse cut off this charm to the extreme consternation of the parents. The bead is viewed as an early warning device to alert the parents to the existence of an evil eye directed at their child. I am told that if "twenty-four evil eyes have been applied" the ceramic bead will burst.
Letters to the Editor
Authors: Clark Frank I.
Published: December 2021

I have grouped and answered the issues raised by Drs De Ville and Moskop as follows:

1. I have previously noted that the Federal Child Abuse Amendments (FCCA) can be construed as a funding statute.1 The reference quoted by Drs De Ville and Moskop came as dicta in a civil rights case and is not a holding. However, the majority viewpoint suggests the act has additional significance. An authoritative review found the FCAA "were designed to prevent the withholding of medically indicated treatment" and refers to them as "The Federal Standard."2
A Summary of Conference Recommendations on Dietary Fiber in Childhood
Authors: Williams Christine L. , Dwyer Johanna , Agostoni Carlo , Hillemeier Craig , Kimm Sue Y. S. , Kwiterovich Peter O. , McClung Juhling , Nicklas Theresa A. , Saldanha Leila
Published: December 2021

Fiber Has Important Health Benefits in Childhood

Diet in childhood and adolescence influences not only the health of the child, but also the future health of the adult. Therefore, the optimal diet during these formative years must be adequate to support normal growth and development during childhood, as well as to establish a nutritional foundation for the prevention of diet-related chronic diseases among adults, such as coronary heart disease, some cancers, stroke, adult-onset diabetes, obesity, and hypertension.1-10

During the course of this conference the current diet of US children was reviewed. Compared with national guidelines, children consume higher than recommended amounts of total and saturated fat and cholesterol and less than recommended amounts of complex carbohydrate and fiber (Table 1, Figs 1-6). Data on trends over time reveal that children's diets are currently lower in total fat, particularly saturated fat, compared with previous years. From 1974 to 1988 the percent of energy from total fat in children's diets has decreased from 38% to 36% and from 16% to 13% for percent of energy from saturated fat. Total sodium intake has increased slightly from 3.3 g (1974) to 3.7 g (1988), but there have been virtually no changes in dietary fiber intake, averaging about 12 g/d or 5 g/1000 calories (kcal).11-17

National food consumption surveys show that consumption of vegetables among children has decreased significantly between 1977 and 1987. In addition, although there have been positive changes in children's diets toward reduced fat intake, approximately 73% still have fat intakes greater than 30% kcal; 66% had saturated fat intake greater than 10%; and 54% had dietary cholesterol intake greater than 100 mg/1000 kcal.11,12
A Community-based Survey of Infant Sleep Position
Authors: Chessare John B. , Hunt Carl E. , Bourguignon Cheryl ,   Pediatric Research in Office Practices Network
Published: December 2021

Objective. To determine prevalent infant sleep positions before and after the American Academy of Pediatrics position statement of 1992 and to identify determinants of sleep position.

Method. Design: cross-sectional survey. Setting: private and hospital-sponsored general pediatric offices. Participants: parents of infants younger than 7 months of age.

Results. Eight hundred fifty-two care givers completed surveys during the 5-week study. Fifty-four percent of the study infants were put to sleep in the prone position. In 416 families with more than one child, however, 75% of the youngest siblings had been put to sleep in the prone position at the same age. Gender, race, family income, maternal smoking, and birth weight were not associated with choice of sleep position.

Conclusions. There has been a change in infant sleep positioning in the desired direction since the American Academy of Pediatrics statement. However, 54% of the study infants were still being put to sleep prone.
DOCTORS FOR SALE
Authors: L. J. F.
Published: December 2021

Medpartners Inc, a fast-growing company that manages the practices of doctors' groups in the Southeast and Midwest, said yesterday that it had agreed to acquire Mullikin Medical Enterprises LP, which has a similar business in the West.

The deal, in which Medpartners agreed to pay $360 million in stock for Mullikin, would create, in terms of revenue, the nation's largest physician-management company. Revenue in 1996 is projected to reach about $1 billion. A merged company would also be in a position to build a national network of doctors' group practices.

The Medpartners move is part of a wave of consolidations that is reshaping all quarters of the health industry. Many anxious doctors—fearful of being squeezed by cost-control efforts—have decided to heal themselves by contracting out for management services.
Parental Leave for Residents and Pediatric Training Programs
Authors:   Committee on Early Childhood, Adoption, and Dependent Care Resident Section
Published: December 2021

The Family and Medical Leave Act of 19931 and a growing number of state laws will have an impact on training programs and their policies regarding parental leave for pediatric residents. As an advocate for children and their families, the American Academy of Pediatrics (AAP) supported the Family and Medical Leave Act and is concerned with the need to ensure healthy outcomes for pediatricians and their families. In accord with its expertise in the areas of child development and family dynamics, the Academy is committed to the development of rational, equitable, and effective parental leave policies that enable parents to spend adequate and good quality time with their new children.

At least half of all female physicians are having their first children during their residency or fellowship training years.2,3 Furthermore, an increasing number of male residents are requesting parental leave to spend more time with their newborns. In 1989, a position statement on parental leave for residents by the American College of Physicians noted the increasing number of residents having children and raised concerns about both the health outcomes of the children and the emotional outcomes of their parents.4 The AAP believes that each residency training program should establish specific written guidelines on parental leave to address these concerns. Most program directors, however, have preferred to deal with the circumstances of each pregnancy leave on an individual basis. In 1990, the American Medical Association adopted a policy on maternity leave for residents.5
Perinatal Care at the Threshold of Viability
Authors:   American Academy of Pediatrics,   Committee on Fetus and Newborn,   American College of Obstetricians and Gynecologists,   Committee on Obstetric Practice
Published: December 2021

The survival rate for infants at the threshold of viability has been improving. However, there are insufficient data regarding the cost(s) of initial and ongoing care of these infants and the long-term outcome of survivors. Furthermore, there has been little study of the impact of obstetric management on the survival rates of extremely low birth weight infants and on long-term morbidities. Continued research on these issues is imperative, and physicians need to remain informed of changing statistics.
SUIT CLAIMS RESEARCH-HOSPITAL DOCTORS SUBMITTED PHONY BILLS TO GET U.S. FUNDS
Authors: L. J. F.
Published: December 2021

Physicians at dozens of prominent research hospitals nationwide allegedly submitted phony bills and sometimes even falsified patients' records to obtain as much as $1 billion in federal payments for sophisticated, but still experimental, cardiac procedures, a newly unsealed whistleblower suit claims.

The allegations of years of systematic fraud involving as many as 130 major medical centers nationwide, accusations that already have prompted a previously reported criminal investigation, are likely to shine a spotlight on the controversial issue of which cutting-edge devices and procedures currently are, or should be, eligible for Medicare or Medicaid claims.

Existing regulations say that the government generally won't pay for treatment considered to be "experimental" or for the use of medical devices that haven't been formally approved by the Food and Drug Administration...
DISEASE AND WELLNESS MANAGEMENT FIRMS!?
Authors: L. J. F.
Published: December 2021

In 1993 Eli Lilly publicly announced that it was turning itself from a drug firm into a "disease-management" one. The idea is that rather than focusing a company on a specific part of the health-care market, such as drugs or hospitals, a firm should deal with all aspects of a disease. Chronic diseases that require lots of attention could produce the biggest savings (and hence profits). Eli Lilly has launched five disease-management programmes, for asthma, pulmonary disease, depression, diabetes, and ulcers. Several small firms are already thriving in "disease management"...

The "wellness-management" school is led by KPMG and Andersen Consulting. They believe that the disease-management approach fails in several respects. Health care involves maintaining health as well as treating diseases; patients often suffer from several diseases, which cannot easily be isolated and managed separately; and "disease-management" is an unappealing notion for companies that want to associate themselves with health, not illness.

Instead, companies that promote "wellness" should organize their product portfolios around groups of patients, trying to deal with all their medical needs. Some drug firms are doing this.
Neurologic Manifestations in Children With Lyme Disease
Authors: Bingham Peter M. , Galetta Steven L. , Athreya Balu , Sladky John
Published: December 2021

Objective. Lyme disease (LD) is a tickborne spirochetal infection with a wide range of neurologic and non-neurologic manifestations. The clinical diversity of LD and limitations in serologic diagnosis often make it difficult to document the diagnosis of neurobor-reliosis with certainty.

Methods. We reviewed clinical manifestations in 97 seropositive children with particular attention to neurologic manifestafions. Diagnostic criteria used in other case surveys were applied to determine how often a definitive diagnosis of neuroborreliosis could be made in children.

Results. Of 69 children who met criteria for LD, 32% (22) had new neurologic signs, 73% (16) of which were accounted for by facial palsy and aseptic meningitis. Five of those with neurologic findings also had erythema migrans (EM), and one had both EM and arthritis. Among those with neurologic involvement, boys outnumbered girls two to one. Neurologic abnormalities resolved spontaneously in five children before their serologic results were known.

Conclusion. In our series, only 27% of children with neurologic abnormalities due to LD had a history of EM or arthritis. Seropositivity commonly constituted the primary basis for diagnosis of LD. Despite its nonspecificity, seropositivity for LD in children with neurologic symptoms usually signifies active neuroborreliosis.
Psychological Response to HIV Positivity in Hemophilia
Authors: Drotar Dennis D. , Agle David P. , Eckl C. Lucy , Thompson Paul A.
Published: December 2021

Objective. To compare the psychological and family adaptation of children and adolescents with hemophilia who were seropositive for human immunodeficiency virus type 1 (HIV-1) with an HIV-negative group of comparable age, demographic characteristics, and disease severity in a multi-site study.

Design. Cross-sectional, controlled study.

Setting. Thirty-three hemophilia treatment centers throughout the United States.

Sample. Ninety-one children and adolescents with hemophilia who were seropositive for HIV and 92 children and adolescents with hemophilia who were seronegative and of comparable age, demographic characteristics, and disease severity.

Results. HIV-seropositive children and adolescents reported less positive affect [(lower well being) (P < .05) ], and more frequent hemophilia-related school absences were identified among HIV-infected patients (P < .005). However, the two groups demonstrated surprisingly comparable levels of psychological, social, hemophilia-related adjustment, general family relations, and hemophilia-related family adaptation, as reported by patients and parents. However, mothers of HIV-seropositive children and adolescents reported higher levels of general psychological distress (P < .008) and higher levels of distress related to hemophilia (P < .0002) than parents of HIV-negative children.

Conclusions. Seropositive children and adolescents with hemophilia demonstrate psychological resilience and levels of psychological adjustment that were comparable to seronegative counterparts. However, mothers of seropositive children were more distressed than mothers of HIV-negative children. Practitioners should ensure that stressed mothers obtain necessary psychological support.
Failure to Identify Human Immunodeficiency Virus-Seropositive Newborns: Epidemiology and Enrollment Patterns in a Predominantly White, Nonurban Setting
Authors: Coplan James , Dye Timothy D. , Contello Kathie A. , Cunningham Coleen K. , Kirkwood Kim , Weiner Leonard B.
Published: December 2021

Objective. To describe the epidemiology of newborn seroprevalence for human immunodeficiency virus (HIV) in a predominantly white, nonurban population, and to determine the factors associated with enrollment at a regional pediatric acquired immunodeficiency syndrome (AIDS) center serving that population.

Design. Retrospective case series of children enrolled at a regional pediatric AIDS center during a 6-year period and comparison with universal blind newborn screening data collected by the state of New York during the same time interval.

Setting. The Pediatric AIDS Center at State University of New York-Health Science Center at Syracuse, which serves as the only source of HIV-related pediatric care for children in a 16-county region of upstate New York totaling 1.8 million population.

Results. One hundred thirty-nine HIV-seropositive infants were born in the region during the 6-year study period; complete blind screening data were available for 138. Sixty-five (47%) of these infants were white. Thirty-nine (28%) of 138 had been enrolled at the Pediatric AIDS Center within the first 90 days of life. An additional 22 (16%) were enrolled at older than 90 days of life. The remaining 77 (56%) have never been seen at the center and are presumed to be unidentified. County enrollment rates varied from 0% to 100% and correlated with percent nonwhite births (r = .58; 95% confidence interval, 0.04-0.86). Children in outlying counties were at greater risk for nonenrollment than children from Onondaga County (site of the Pediatric AIDS Center) (adjusted relative risk, 1.38; 95% confidence interval, 1.05-1.85). White infants residing outside of Onondaga County were at the greatest risk of nonenrollment; of 50 seropositive white infants residing outside of Onondaga County, only 7(14%) were enrolled at the center within the first 90 days of life.

Conclusions. Local demographic factors can skew the racial distribution of HIV-seropositive infants dramatically compared with the national experience. White race and residence in counties away from the medical center each constituted risk factors for nonenrollment at the Pediatric AIDS Center. The epidemiology of HIV in this predominantly white, rural population, coupled with physician practices, probably contributed to low identification and enrollment rates. As the AIDS epidemic spreads into similar populations elsewhere, HIV infection in pregnant women or newborn infants is likely to become progressively harder to detect, unless universal screening is adopted.
Oxandrolone Therapy in Constitutionally Delayed Growth and Puberty
Authors: Wilson Darrell M. , McCauley Elizabeth , Brown David R. , Dudley Robert ,   Bio-Technology General Corporation Cooperative Study Group
Published: December 2021

Background. Male adolescents with constitutional delay of growth and puberty may have significant psychosocial difficulties related to their sexual immaturity and short stature. The purpose of this study was to test the hypothesis that 1 year of oxandrolone therapy would increase growth velocity and thereby improve psychosocial functioning in boys with constitutional delay of growth and pubertal development.

Methods. Forty boys (ages 11 to 14.7 years) with delayed pubertal development and short stature were recruited from the pediatric endocrine clinics of 14 medical centers. The boys were randomized using a block design stratified for age to receive either oxandrolone (0.1 mg/kg daily for 1 year) or an identical-appearing placebo tablet, using a double-masked design.

Results. Growth velocity in the oxandrolone-treated boys was significantly greater than in the control boys (9.5 vs 6.8 cm/y). Likewise, the mean height SD score increased 0.41 in the oxandrolone group, whereas it decreased 0.03 in the control group. Those in the oxandrolone group gained 2.4 kg more than those in the placebo group. Mean predicted adult heights did not change in either group. The mean rates of pubertal progression were equivalent in both groups. Self-image (Piers-Harris Self Concept Scale) and social competence (Child Behavior Profile) were normal at baseline in both groups and did not change significantly over the course of the study in either group. No complications of oxandrolone therapy were identified.

Conclusions. This randomized, placebo-controlled trial demonstrates that low-dose oxandrolone can increase both height and weight velocity in boys with delayed puberty safely. Under the conditions of this study, however, the increased growth velocity in the oxandrolone-treated boys was not associated with a greater improvement in psychosocial status compared with the control boys.
Comparison of Immunogenicity and Efficacy of Rhesus Rotavirus Reassortant Vaccines in Breastfed and Nonbreastfed Children
Authors: Rennels Margaret B. , Wasserman Steven S. , Glass Roger I. , Keane Virginia A. ,   US Rotavirus Vaccine Efficacy Group
Published: December 2021

Objective. To evaluate whether breastfeeding affected the immunogenicity and/or efficacy of candidate rhesus-human rotavirus reassortant vaccines.

Methods. A total of 989 healthy infants between 4 and 26 weeks of age were enrolled into a 23-center, prospective, randomized, double-masked, controlled study of the safety, immunogenicity, and efficacy of three doses (4 x 104 plaque-forming units) of monovalent rhesushuman viral protein 7, or G, serotype 1 reassortant vaccine, (RRV-S1) or tetravalent vaccine (RRV-TV) consisting of rhesus-human reassortant G serotypes 1, 2, and 4, and the parent RRV G serotype 3. Vaccine efficacy was compared in the breastfed and nonbreastfed children as well as seroconversion rates and postvaccination geometric mean titers (GMTs) of neutralizing antibodies to human serotypes 1, 2, 3, and 4, RRV, and immunoglobulin A to RRV. GMTs in the two feeding groups were compared with and without adjustment for age at initiation of vaccination, prevaccination antibody titers, and the age and prevaccination titer interaction.

Results. The seroconversion rates to both vaccines by one or more assays were similar for the breastfed and the nonbreastfed groups (RRV-S1, 84% and 85%, respectively; RRV-TV, 94% and 93%, respectively). There were no significant differences in postvaccination GMTs to either vaccine, measured by any serologic assay, in the two feeding groups. The efficacy of the RRV-S1 vaccine was not significantly lower among the breastfed children than the nonbreastfed children (28% and 39%, respectively). RRV-TV, which is the vaccine being further evaluated for licensure, was equally protective in breastfed and nonbreastfed infants (50% and 51%, respectively). Logistic regression analysis, taking into account differences in age at vaccination and day 1 titer, revealed no evidence of differential vaccine efficacy in the two feeding groups for either vaccine.

Conclusions. These results indicate that the RRV-TV vaccine, given as three doses of 4 x 104 plaque-forming units, induces similar seroresponses and protection in breastfed and nonbreastfed US children.
Managed Care, Re-engineering and Downsizing: Will Medical Education Survive Change?
Authors: Greenberg Larrie W.
Published: December 2021

My daily reading of the Washington Post newspaper invariably leads me to the business section where I find, more often than not, articles about how companies in the business world are in a constant state of change. They are either merging, downsizing, reengineering or reducing in force their employees to stay competitive and, more importantly, survive. This is an example of how the change environment has permeated all areas of our lives and it is, in fact, not a passing fancy but a reality.

The health care industry has not been immune from this mindset although few would have believed that medicine in the 1980s would follow this path.
If HMOs Want Evidence-Based Medicine, They Should Pay for Studies!
Authors: L. J. F.
Published: December 2021

Some managed-care organizations are keen to support research. Kaiser-Permanente (which started life in California during the 1930s and now operates in many states) and Group Health Co-operative of Puget Sound (in Seattle) have for decades entered their patients in NIH-sponsored trials and conducted their own studies ... Several newer managed-care firms have followed suit.

... In the insurance industry, attitudes to research range from lukewarm to hostile. Lee Newcomer, medical director of United Health Care, a huge managedcare organization based in Minneapolis, says his firm would be more enthusiastic about paying for it if fewer clinical trials were "too small, too poorly designed, and too poorly organized" to answer questions about which treatments—particularly the most complex and costly—are worthwhile.

William Roper, a former health official in the Reagan and Bush administrations who is now Dr Newcomer's counterpart at the Prudential Health Care System in Roseland, New Jersey, goes further. He agrees that research is important, but he also argues that researchers have been too little accountable for how they have spent the public dollars that have flowed their way. "Why," he asks, "should society be paying extra for the delivery of health care at academic institutions merely on the presumption that it is getting something of value?" Prudential's position—unless Congress decides to tax all managed-care companies to support research—is that it will not pay for experimental medicine.
Relationships Between Functional Assays and Enzyme Immunoassays as Measurements of Responses to Acellular and Whole-Cell Pertussis Vaccines
Authors: Meade Bruce D. , Lynn Freyja , Reed George F. , Mink ChrisAnna M. , Romani Theresa A. , Deforest Adamadia , Deloria Maria A.
Published: December 2021

• Relationships Between Functional Assays and Enzyme Immunoassays as Measurements of Responses to Acellular and Whole-Cell Pertussis Vaccines (1995;96:595-600): In the introduction, "WCL" is used incorrectly in three instances as an abbreviation for whole-cell pertussis vaccines. On page 595 (15 lines from the bottom of the right-hand column), "WCL pertussis immunization" should have read "whole-cell pertussis immunization." Similarly, on page 596 (in lines 21 through 23 of the left-hand column), "WCL vaccines" twice should have read "whole-cell vaccines." All other references to WCL in this article mean the specific product listed in Table 1 on page 596.
Increased Plasma Levels of Pancreatic Polypeptide and Decreased Plasma Levels of Motilin in Encopretic Children
Authors: Stern H. Patrick , Stroh Suzanne E. , Fiedorek Stephen C. , Kelleher Kelly , Mellon Michael W. , Pope Sandra K. , Rayford Phillip L.
Published: December 2021

In the article entitled "Increased Plasma Levels of Pancreatic Polypeptide and Decreased Plasma Levels of Motilin in Encopretic Children" by H. Patrick Stern et al (Pediatrics, 1995;96:111-117), the hormone "thyroxine" was incorrectly listed in Figure 5 and in the text on page 115. The words "thyroid-stimulating hormone" should replace "thyroxine" in the Table and all subsequent references in the text.

H. Patrick Stern, MD, FAAP

Chief, Section of Behavioral Pediatrics

Arkansas Children's Hospital

Little Rock, AR 72202-3591
Letter To The Editor
Authors: Cordes Isabel , Roland Elke H. , Hill Alan , Lupton Brian A.
Published: December 2021

The comments of Dr Badawi et al draw attention to some of the ambiguities in the current understanding of potential significant factors associated with peninatal hypoxic-ischemic cerebral injury. Experimental animal data has demonstrated clearly that intrapartum hypoxic-ischemic insult may result in cerebral injury.1,2 However, epidemiologic studies have raised concerns that this relationship may not be as prevalent as was believed earlier.3-5 Nevertheless, it is important to consider that even if only 10% to 15% of cases of cerebral palsy are related to intrapartum hypoxic-ischemic cerebral injury, this would still constitute significantly large numbers in absolute terms.
An Every Other Year Cyclic Epidemic of Infants Hospitalized With Respiratory Syncytial Virus
Authors: Lyon Joseph L. , Stoddard Gregory , Ferguson David , Caravati Martin , Kaczmarek Allison , Thompson Geraldine , Hegmann Kurt , Hegmann Christine
Published: December 2021

We identified an every other year cyclic epidemic of infants hospitalized with respiratory syncytial virus (RSV) with peaking in even-year winters. Our observation agrees with every other year cyclic RSV epidemics reported by others who observed peaking in the winters of even-numbered years.1-3

We estimated rates of hospitalization for children less than age 1 for eight counties in the state of Utah, all counties being served by a single hospital system, Intermountain Health Care (IHC).
The Behavioral and Emotional Well-Being of School-age Children With Different Birth Weights
Authors: McCormick Marie C. , Workman-Daniels Kathryn , Brooks-Gunn Jeanne
Published: December 2021

Objective. To describe the mental and emotional well-being of children born at different birth weights assessed at school age and to identify neonatal, intervening health, and sociodemographic and environmental factors associated with mental and emotional well-being.

Methods. To address this issue, we used a prospective cohort study involving two previously studied cohorts, which were recontacted at 8 to 10 years of age to provide a multisite sample of 247 children weighing 1000 g or less at birth, 364 weighing 1001 to 1500 g, 724 weighing 1501 to 2500 g, and 533 weighing more than 2500 g. Maternal reports were obtained on three standardized measures of mental and emotional well-being (the Rand General Well-being Scale, the Behavior Problem Index, and the Harter Scale of Child Competence) and on intervening health, sociodemographic, and environmental variables. Neonatal variables were derived from records at birth. Statistical techniques included analysis of variance and ordinary least squares multiple regression.

Results. Lower birth weight children did not differ on the General Well-being Scale but were more likely to have behavior problems and to be considered less competent. Other important correlates of mental and emomotional well-being included childhood illness, maternal mental health, home environment score, and exposure to household cigarette smoking.

Conclusion. Although lower birth weight children have poorer mental and emotional well-being, a substantial portion of this adverse outcome reflects modifiable environmental factors.