bluuebunny/crossref_metadata_2025 huggingface dataset:
Surfactant Replacement Therapy for Meconium Aspiration Syndrome
Authors: Findlay Richard D. , Taeusch H. William , Walther Frans J.
Published: December 2021

Objective. The pathophysiology of meconium aspiration syndrome (MAS) is related not only to mechanical obstruction of the airways and chemical injury to the respiratory epithelium but also to surfactant inactivation by meconium. A randomized, controlled study was performed to determine whether high-dose surfactant therapy improves the pulmonary morbidity of term infants ventilated for MAS.

Methods. Forty term infants receiving mechanical ventilation for MAS were enrolled in this trial, in which the infants in the study group (n = 20) received up to four doses of 150 mg (6 mL)/kg beractant (Survanta), instilled every 6 hours by continuous infusion for 20 minutes via a side hole endotracheal tube adapter, and the infants in the control group (n = 20) received 6 mL/kg air placebo.

Results. Mean arterial-to-alveolar Po2 ratio values increased from 0.09 to 0.11 at 1 and 6 hours with a concomitant slight decrease in oxygenation index values from 23.7 to 19.7 at 1 hour and 20.7 at 6 hours after the first dose of surfactant. Oxygenation improved cumulatively after the second and third dose of surfactant, with mean arterial-to-alveolar Po2 ratios and oxygenation indices of 0.18 and 12.1 at 6 hours after the second dose of surfactant and 0.31 and 5.9 at 6 hours after the third dose of surfactant, eliminating the need for a fourth dose in any infant in the study group. After three doses of surfactant, persistent pulmonary hypertension had resolved in all but one of the infants in the study group versus none of the infants in the control group. No air leaks developed in any of the 20 infants in the study group after surfactant therapy, and only 1 infant required extracorporeal membrane oxygenation. Air leaks developed in 5 of the 20 infants in the control group, and 6 underwent extracorporeal poreal membrane oxygenation. The duration of mechanical ventilation, oxygen therapy, and admission was significantly shorter in the surfactant group than in the control group.

Conclusion. Surfactant replacement therapy, if started within 6 hours after birth, improves oxygenation and reduces the incidence of air leaks, severity of pulmonary morbidity, and hospitalization time of term infants with MAS.
COLLATERAL DAMAGE
Authors: Joffe Alain
Published: December 2021

As the welfare-reform debate begins to boil, the place to begin is with an elemental fact: no child in America asked to be here.

Each was summoned into existence by the acts of adults. And no child is going to be spiritually improved by being collateral damage in a bombardment of severities targeted at adults who may or may not deserve more severe treatment from the welfare system.

Phil Gramm says welfare recipients are people "in the wagon" who ought to get out and "help the rest of us pull." Well. Of the 14 million people receiving Aid to Families with Dependent Children, 9 million are children. Even if we get all these free-riders into wee harnesses, the wagon will not move much faster.
Lead Poisoning Risk Determination in a Rural Setting
Authors: Schaffer Stanley J. , Kincaid Martha S. , Endres Nathan , Weitzman Michael
Published: December 2021

Objectives. To determine the prevalence of elevated blood lead levels among children living in a rural area and to determine the effectiveness of the Centers for Disease Control and Prevention (CDC) Lead Risk Assessment Questionnaire and additional questionnaire items in correctly identifying rural children having elevated blood lead levels.

Research Design. Comparison of results of a questionnaire that is intended to identify children as being at low or high risk for lead poisoning with children's blood lead levels.

Setting. The three practice sites of the only pediatric group in a rural county of upstate New York.

Patients. A consecutive sample of 705 children ages 6 to 72 months who were seen for health supervision visits between June and September 1993.

Results. Sixty-nine percent of the children were considered to be at high risk for lead poisoning by the CDC questionnaire. Overall, 8.4% of the children in the study had blood lead levels of 10 µg/dL (0.48 µmol/L) or higher, and 2.1% had blood lead levels of 15 µg/dL (0.72 µmol/L) or higher. No significant difference was noted between the percentages of high-and low-risk children who had elevated blood lead levels. To devise a more effective lead risk assessment tool for children in this setting, the two items from the CDC questionnaire and the two additional items that had the greatest predictive utility were combined to form a short alternative questionnaire. The alternative questionnaire thus consisted of items concerning whether the child has a sibling or playmate with lead poisoning, whether the child lives near an industry that potentially may release lead, whether the child lives in rented or owner-occupied housing, and whether the child has a parent who is a migrant farm worker. Children categorized as high risk with the alternative questionnaire were much more likely to have elevated blood lead levels than those who were categorized as low risk. The alternative questionnaire was very effective in correctly identifying children with elevated blood lead levels. Eighty-eight percent of children having blood lead levels of 10 µg/dL or higher and 100% of children having blood lead levels of 15 µg/dL or higher were classified as high risk by the questionnaire. Children classified as low risk were very unlikely to have elevated blood lead levels; 98% of low-risk children had blood lead levels of less than 10 µg/dL, and 100% had blood lead levels of less than 15 µg/dL.

Conclusions. These results suggest that the CDC lead risk assessment questionnaire is of limited benefit in identifying rural children with blood lead levels 10 µg/dL or higher or 15 µg/dL or higher. An alternative questionnaire, however, seems to have marked clinical utility for identifying rural children with elevated blood lead levels.
Injuries to Children Related to Shopping Carts
Authors: Smith Gary A. , Dietrich Ann M. , Garcia C. Teresa , Shields Brenda J.
Published: December 2021

Study Objective. To describe the epidemiology of shopping cart-related injuries among children and to consider targeted prevention strategies based on these epidemiologic findings.

Design. A consecutive series of patients.

Setting. The emergency department of a large, academic children's hospital.

Participants. Sixty-two children treated for shopping cart-related injuries during a 15-month period.

Results. Children ranged in age from 4 months to 10 years (mean, 2.8 years). Thirty-three children (53%) were boys. Twelve patients (19%) arrived via ambulance. Forty-nine children (79%) had injuries to the head, including one child admitted to the hospital. Eleven children (18%) had fractures, including 5 (8%) with skull fractures. Nine patients (14%) had lacerations, and 30 patients (48%) had superficial injuries (ecchymoses or abrasions). The most common mechanism of injury was falling out of the carts (58% of children), followed by cart tip-overs (26% of children). Injuries caused by falls from the carts occurred across the entire age range, whereas injuries caused by cart tip-overs were most frequent among children 1 year of age or younger. The sitting position was associated with tip-over injuries, and standing in the cart basket was associated with falling from the cart.

Conclusions. Shopping cart-related injuries cause serious pediatric morbidity, especially among children younger than 5 years of age, and are potentially fatal. Based on identified age-specific mechanisms of injury, currently used prevention strategies are not sufficient. The use of infant seats and restraining belts is an inadequate strategy for prevention of shopping cart-related injuries among children 1 year of age or younger, because cart tip-over is an important mechanism of injury in this age group. Shopping carts should be redesigned to decrease the tip-over hazard. Transportation of children in shopping carts of current design should be prohibited.
Bicycle Helmet Use Patterns Among Children
Authors: Rodgers Gregory B.
Published: December 2021

Objective. To describe and evaluate the helmet use patterns of children younger than 15 years of age in the United States.

Methods. A national telephone survey of bicycle riders was conducted by means of the Mitofsky-Waksberg method of random-digit dialing, a survey method intended to give all telephone numbers in the continental United States an equal probability of selection. Based on information collected in the survey, a logistic regression model was used to determine and quantify the factors associated with helmet use.

Results. Information was collected on the bicycle and helmet use patterns of a national sample of 399 children younger than 15 years of age who rode bicycles during the year preceding the survey. This sample projects to the approximately 26.4 million children who are estimated to have ridden bicycles in 1991. About 26% of all child riders owned or had the use of bicycle helmets, and about 15% were reported to have used their helmets all or more than half of the time when riding. Information is provided on the reasons the children did or did not wear helmets. The logistic regression analysis shows that helmet use by children is systematically related to their personal characteristics (eg, age and whether they had previously had bicycle-related accidents requiring medical attention), riding patterns (eg, riding surface), and household demographic characteristics (eg, geographic location and whether household members had attended college).

Conclusions. Helmet use rates among children remain low. Less than one fifth of the children who rode bicycles wore helmets all or more than half of the time in 1991. However, based on comparisons with earlier studies, the results of the analysis suggest that helmet use rates have been rising.
In Reply: Tetracaine, Adrenaline, and Cocaine (TAC) Confusion
Authors: ERNST AMY A.
Published: December 2021

I regret any potential problem created by use of the term TAC gel in my article that appeared in the February issue. It was meant to be a general term for a gel form of the topical mixture. I think it is important to point out that the first mention of TAC topical solution was in 1980 by Pryor et al. Since then countless articles have emerged comparing safety, efficacy, and variations in formulation, including a gel form.
MORE SIBLINGS..
Authors: L. J. F.
Published: December 2021

. . . more siblings usually means lower grades? The more sisters and brothers children have, the lower their school grades tend to be.
"Mild" Varicella—Does It Protect?
Authors: JOSEPH PAUL R.
Published: December 2021

I read "Recommendations for the Use of Live Attenuated Varicella Vaccine" by the Committee on Infectious Diseases, which appeared in the May 1995 issue of Pediatrics. The recommendations do not address the problem of children who have had very mild cases of varicella and whether or not they should be immunized with the varicella vaccine.

About 10 years ago I began to keep records of children who had had very mild cases of varicella (under 20 lesions).
The Delivery of Immunizations and Other Preventive Services in Private Practices
Authors: Bordley W. Clayton , Margolis Peter A. , Lannon Carole M.
Published: December 2021

Objectives. To measure the proportion of children cared for in private pediatric practices who are fully immunized and have been screened for anemia, tuberculosis (TB), and lead poisoning by 2 years of age.

Design. Cross-sectional chart review.

Setting. Fifteen private pediatric practices in central North Carolina (11 chosen randomly).

Patients. One thousand thirty-two randomly selected 2-year-old children.

Main Outcome Measures. Proportion of children immunized and screened for anemia, TB, and lead poisoning by 24 months of age and immunization and screening rates of the practices.

Results. Sixty-one percent of the children were fully immunized at 24 months of age; the rates among practices varied widely (38% to 82%). Sixty-eight percent of the children had been screened for anemia, 57% had been screened for TB, and 3% had been screened for lead poisoning. Physicians overestimated the proportions of fully immunized children in their practices by an average of 10% (range, -3% to 17%). The median number of well child visits by 2 years of age was 5 (range, 0 to 14), and only 19% of the entire sample made 8 or more well child visits, the number recommended by the American Academy of Pediatrics in the first 18 months of life. The numbers of well child and non-well child visits were the strongest predictors of complete immunization. Practice characteristics associated with being fully immunized included the use of preventive services prompting sheets (eg, flow sheets) in the medical records, not seeing the same physician for all well child care, and having nurses review patients' immunization status during their visits to the office.

Conclusions. Underimmunization and inadequate screening are significant problems in private pediatric practices in North Carolina. Physicians are unaware of the rates of underimmunization in their offices.
Informing Subjects of Epidemiologic Study Results
Authors: Bunin Greta R. , Kazak Anne E. , Mitelman Olga
Published: December 2021

Objective. To assess the feasibility and process of providing feedback to parents regarding the results of epidemiologic research, in particular to look at the importance and clarity of the information provided, parental reactions to the results, and utilization of the data provided.

Methodology. Parents who participated in an epidemiologic study of pediatric brain tumors (patient and control mothers) were sent a letter summarizing the results of the study and the Parent Study Results Survey to complete and return. The final sample used for analyses was 109 (patient) and 90 (control) mothers. Analyses were conducted to determine differences between patient and control mothers and differences among subsets defined by educational level and vital status of the patient.

Results. Mothers rated the importance and clarity of the information very highly, although patient mothers were more likely than control mothers to want more information and a telephone contact. Patient and control mothers were similar in reported sadness, anxiety, and being overwhelmed, but patient mothers felt less satisfied and relieved. Patient mothers expressed feeling more guilt and anger than control mothers, although even the levels among the patient mothers were only moderate. Close to half of all mothers commented on the inconclusiveness of the study results. Nearly all mothers indicated they would suggest that other parents participate in epidemiologic research.

Conclusions. It is valuable to many parents that they receive information about results of research in which they have participated. We found little evidence of strong negative effects to a detailed feedback letter. We recommend that evaluative data be used to guide the process of informing research participants about study results and that investigators consider making feedback letters a standard part of research protocols.
Timing of Elective Surgery on the Genitalia of Male Children With Particular Reference to the Risks, Benefits, and Psychological Effects of Surgery and Anesthesia
Authors:   Section on Urology
Published: December 2021

Technical considerations are no longer the major limiting factors in determining the timing for the surgery of undescended testes or hypospadias, because experienced pediatric urologic surgeons can perform these operations on young children safely and reliably. Important theoretical considerations suggest that early orchidopexy is preferable, particularly in minimizing the histologic injury that occurs with increasing age. There does not seem to be an increased risk when orchidopexy is performed in children 6 to 12 months of age, compared with the risk in older children, provided that it is performed by surgeons, nurses, and anesthesiologists with pediatric training and experience.

Emotional, cognitive, and body image development may be affected profoundly by both the genital deformity and the reconstructive surgery. These psychological factors are of considerable importance, in that a child's reaction to both the surgery and the anesthetic trauma varies dramatically with age. Postoperative behavioral problems such as aggressive or regressive behavior, night terrors, and anxiety may be more common at certain ages, particularly at 1 to 3 years of age. The period from 6 weeks to 15 months is a relatively good time for surgery from the viewpoint of emotional development, provided parentchild separation is minimized; this period has the additional advantage that the child's "defective status" within the family is not prolonged. The importance of the care giver's attitude toward the child may be of particular importance to the child's developing body image. Superimposed on all of these factors is the developing sexual identity of the individual, which again suggests that, in the absence of any other health factors, successful early genital surgery minimizes disturbances in the patient's psychological development.

The best time for surgery for hypospadias is between 6 and 12 months of age. Orchidopexy should be performed at or near 1 year of age. If the improved risk-to-benefit ratio for this early genital surgery is to be achieved, it is essential that children undergoing this surgery be cared for at facilities with experienced pediatric support personnel, particularly in the areas of anesthesia, urology, and nursing, who are sensitive to the special needs of children.
Committee Report: Population-to-Pediatrician Ratio Estimates: A Subject Review
Authors:   Committee on Careers and Opportunities
Published: December 2021

This statement is intended to assist pediatricians, health care administrators, and policymakers in evaluating an area's or a population's demand for pediatricians; it is not meant to recommend an ideal number of children per pediatrician based on need. This statement provides a variety of numbers to work with, ranging from low ratios, reflecting the number of children currently in the health care system that can be seen realistically by pediatricians (see Table), to high ratios, reflecting the current use of pediatricians by the entire population younger than 21 years of age (see the models of Miller et al8 and Hicks and Glenn6,7).

In applying the models, it is important to keep in mind the several previously discussed factors that affect the ratio of children per pediatrician. Other factors that also must be considered when examining ratios are differences in physician productivity that may vary according to gender, personal characteristics or lifestyles, and geographic location. In addition, local differences in demand for pediatric services will vary according to child health status and use of services. Finally, universal access to health care and/or managed care would increase the demand for pediatric services. Limitations in available data prevent the ability of the models to be used for subspecialty care or for outpatient care provided in hospitals.

There is currently a lack of information examining ratios, quality of care, and health outcomes. Studies linking these three issues are greatly needed. Also needed are studies that focus on the appropriate number of children per pediatric subspecialist.
Colic Is Pain
Authors: Rogers William B.
Published: December 2021

In August 1993 and again in September 1994 Pediatrics featured articles on colic.1,2 Like most articles on this subject the only treatments discussed were behavioral management, distraction techniques, and reassurance.1-3 Primary care doctors are never told what to do when we get a call at 1 AM and are asked, "Doctor, my baby has been crying now for 2 hours and I can't get him to stop! What can I do?"

I will not believe that colicky crying is due to some vague disturbed parent-infant relationship that needs only counseling and reassurance.1-6
More Questions Than Answers
Authors: Raju Tonse N. K.
Published: December 2021

Although the study by Goldstein et al1 that appeared in the February 1995 issue of Pediatrics is quite interesting, I am afraid that more questions remain unanswered in their article. I have a few concerns:

1) The authors do not provide data regarding the frequency of abnormal neurologic outcome, nor do they provide any paradigms based on sensitivity, specificity, and predictive values of the variables considered to "predict" neurologic outcome in their cohort. I think that this is a major weakness of the article, which makes one wonder whether there was any such predictive ability for the studied variables.
Letter To The Editor
Authors: Young Paul C.
Published: December 2021

Dr Benjamin polled the residents in his program using my scenarios and came up with some similarities and some differences. Most disturbing to him was the second case, in which he found management by his residents and the Utah pediatricians1 most at variance with Baraff's guidelines.2 However, I think he may have misinterpreted the issue of otitis media and how it applies to using the guidelines. The guidelines are designed to deal with the issue of managing "serious" bacterial infections, not otitis media.
An Evaluation of Measles Revaccination Among School-entry-aged Children
Authors: Watson John C. , Pearson John A. , Markowitz Lauri E. , Baughman Andrew L. , Erdman Dean D. , Bellini William J. , Baron Roy C. , Fleming David W.
Published: December 2021

Background. A two dose measles vaccination schedule is recommended routinely for all schoolentry-aged children. We evaluated this recommendation by determining both measles antibody seroprevalence and the response to revaccination in seronegative children in this age group.

Methods. Children 4 to 6 years of age who had received a single dose of measles vaccine between the ages of 15 to 17 months were tested for measles antibody by using an enzyme-linked immunosorbent assay (ELISA) microneutralization technique. Seronegative children were revaccinated and again tested for measles antibody (immunoglobulin M [IgM] and neutralizing).

Results. Of 679 children tested, 37 (5.4%) were seronegative. Seronegativity was not significantly associated with age, sex, race, age at initial vaccination, time since vaccinalion, or maternal year of birth. However, children of mothers with a college degree were 12 times more likely to be seronegative than children of mothers who never attended college (P< .01). Of the 37 seronegative children, 36 seroconverted after revaccination—33 producing IgM measles antibody, suggestive of a primary immune response. The cost per seroconversion would have been an estimated $415 if all 679 children had been revaccinated.

Conclusions. Revaccination reduces the pool of children who are susceptible to measles. Although the cost per seroconversion is high, a two-dose schedule should reduce the substantial costs of controlling measles outbreaks by reducing the number of outbreaks.
HEALTH MAINTENANCE ORGANIZATIONS TURN TO SPIRITUAL HEALING
Authors: L. J. F.
Published: December 2021

The psychological and spiritual sides of healing, long poor cousins of mainstream medicine, are finding new support from some institutions with growing power in medical care: health maintenance organizations (HMOs).

At a recent conference here, Dr Herbert Benson, President of the Harvard Medical School's Mind/Body Medical Institute, said that his office at Harvard was now getting five or six calls a week from HMOs that were interested in the medical uses of relaxation and other nontraditional treatment methods. The reason, he said, is clear: if such methods succeed reliably in reducing workload, they are "just plain money in the bank for the HMOs."

. . . The recent conference in Boston was a milestone in the growth of interest in what is sometimes called behavioral medicine.

A few years ago this would have been the farthest fringe of medicine. And even now there was a hint of sideshow. There were snake handlers here, and some recommended the snakes as a way to induce relaxation.
Antenatal Phenobarbital Therapy and Neonatal Outcome II: Neurodevelopmental Outcome at 36 Months
Authors: Shankaran Seetha , Woldt Eunice , Nelson Jay , Bedard Mary , Delaney-Black Virginia
Published: December 2021

Objective. To evaluate the effect of antenatal phenobarbital (PB) therapy on neurodevelopmental outcome at 36 months.

Design. Prospective, randomized, controlled trial.

Setting. Single-institution study.

Subject and Interventions. Children born to women who participated in the study evaluating the effect of antenatal phenobarbital (PB) on neonatal intracranial hemorrhage were prospectively followed to 3 years of age.

Outcome Measures. Physical growth, neurologic examinations, and developmental testing (McCarthy Scales of Children's Abilities). Comparisons between groups were made on all children and those born to multiple gestations.

Results. Forty-one children born to women who received 10 mg/kg PB before delivery and 55 children in the control group were evaluated. Three children, all in the control group, had growth parameters (height, weight, and head circumference) below the fifth percentile. The McCarthy General Cognitive Index (standard, 100 ± 16) was 93 ± 20 in the PB group and 85 ± 18 in the control group. The subscores tended to be higher in the PB group than in the control group, with higher quantitative scores in the PB group (44 ± 11 vs 39 ± 8). Neurologic deficits were noted in 2 of 41 in the PB group and in 6 of 55 in the control group.

Conclusions. Infants born to women who received antenatal PB therapy had similar neurodevelopmental outcomes as infants born to women who did not receive PB. No adverse effects of PB exposure were detected.
Epidural Hemorrhage: Is It Abuse?
Authors: Shugerman Richard P. , Paez Angela , Grossman David C. , Feldman Kenneth W. , Grady M. Sean
Published: December 2021

Objective. To determine whether children presenting with epidural hemorrhage (EDH) are as likely to have been abused as are children presenting with subdural hemorrhage (SDH).

Design. Retrospective chart review. Setting. Level I regional trauma center and a regional children's hospital.

Patients. All children at both institutions 3 years old or younger with a diagnosis of EDH or SDH identified by a search of the computerized trauma registry and hospital medical records from 1985 through 1991.

Measurement and Results. Complete records were found for 93 of 94 eligible subjects. The diagnosis of accidental or inflicted injury was ascertained from the patient's hospital medical record or the records of Child Protective Services. Of all subjects (n = 93), 52% (48/93) were male and the median age was 15 months. Abuse was diagnosed in 47% (28/59) of children with SDH and 6% (2/34) of those with EDH. Other significant injuries were found in 47% of children with SDH and 18% of children with EDH. There was no statistically significant difference between the two groups with respect to the likelihood of identifying a skull fracture, the need for surgical evacuation of the hemorrhage, or mortality.

Conclusions. Our data are consistent with current biomechanical concepts of intracranial injury. EDHs result from brief linear contact forces that commonly occur in unintentional falls. SDHs are caused by global high-energy rotational acceleration/deceleration forces that are commonly generated in episodes of abuse. Compared with SDH, EDH rarely results from abuse.
NEW HEART FOR RETARDED WOMAN
Authors: L. J. F.
Published: December 2021

A woman with Down syndrome who was at first refused a heart-lung transplant because doctors did not think she was smart enough to handle the effects underwent the operation today.

The woman, Sandra Jensen, 35, is believed to be the first seriously retarded person in the United States to receive a major transplant. She was listed in critical but stable condition after the five-hour operation, which occurred after Stanford Medical Center reversed course.

"I'm ecstatic," said Dr. William Bronston, a state rehabilitation administrator and friend of Ms. Jensen who had helped lead the fight for her transplant. "This is a miracle. The struggle to get Sandra on the transplant list was really a struggle to get everyone in the country on the list."
Changing Hospital Practices to Increase the Duration of Breastfeeding
Authors: Wright Anne , Rice Sydney , Wells Susan
Published: December 2021

Objective. To change the breastfeeding policy in a university teaching hospital in accord with the Ten Steps to Successful Breastfeeding of the United Nations Children's Fund and World Health Organization and to assess the impact of hospital practices on the duration of breastfeeding.

Methods. One hundred ninety-two and 392 postpartum women in a maternity ward were interviewed in 1990 and 1993, respectively, regarding how they were feeding their infants and feeding practices in the hospital. Between these two periods, the hospital infant-feeding policy was reviewed and revised in accord with the Ten Steps. Two hundred seventy of the mothers interviewed in 1993 were interviewed again when their infants were 4 months old regarding the duration of full and partial breastfeeding.

Results. By 1993, more newborns were put to the breast in the first hour of life (63.2% vs 24.8%); fewer breastfed infants were fed foods other than breast milk (27.9% vs 46.7%); and more mothers received breastfeeding guidance from hospital staff (81.9% vs 61.3%). The duration of breastfeeding in 1993 was longer for women who did not receive formula in the hospital, who were not given discharge packs containing formula and/or coupons, and who roomed-in more than 60% of the time. These associations persisted after controlling for confounding.

Conclusion. Infant-feeding policies and practices are amenable to change, and policies such as the Baby Friendly Hospital Initiative may contribute to an increase in the duration of breastfeeding.
Gram-negative Bacteremia in Four Patients With Klippel-Trenaunay-Weber Syndrome
Authors: Bird Lynne M. , Jones Marilyn C. , Kuppermann Nathan , Huskins W. Charles
Published: December 2021

Klippel-Trenaunay-Weber syndrome (KTWS) is a sporadically occurring congenital malformation syndrome consisting of hemangiomata, venous varicosities, and hypertrophy of soft tissues and/or overgrowth of bone.1-3 Although the list of potential complications is long, KTWS is generally a nonprogressive condition. The problems, which include edema, stasis dermatitis, skin ulceration, cellulitis, anemia, thrombosis, phleboliths, phlebitis, bone and joint abnormalities, scoliosis, and paresthesias, tend to be chronic in nature.4 Recognized life-threatening complications include disseminated intravascular coagulation (DIC)5 and gastrointestinal bleeding as a result of hemangiomata in the intestine.6,7 Systemic infection has not been reported as a major cause of morbidity and mortality. The purpose of this report is to present 4 patients with KTWS who had invasive infection with gram-negative organisms to document another life-threatening complication of this syndrome.
Homeopathic Medicine
Authors: Chapman Edward H.
Published: December 2021

I appreciate the willingness of the editor of Pediatrics to print this response to Sampson and London's five-page critique1 of the Nicaragua diarrhea study by Jacobs et al. Unfortunately, Jacobs et al 2 were not offered space to respond in the same issue, and the authors were not identified as members of an organization with a mission to debunk complimentary medicine. The publication of their article in a prestigious journal appears a deliberate attempt to discredit the evidence available to defend homeopathy in a lawsuit in which one author is a plaintiff.
Letters To The Editor
Authors: Coté Charles J. , Berlin Cheston M.
Published: December 2021

Parks and Snodgrass are disappointed that the Committee on Drugs did not "bite the bullet" regarding the fact that it is perhaps past time for the use of DPT cocktail.1 The reason that the Committee was unable to make such a definitive statement is the fact that there is a general lack of science demonstrating safety and efficacy of alternative medications. Parks and Snodgrass point out that rectal methohexital was a reasonable medication and cite the work of Manuli and Davies.2
Cerebral Palsy in Very Low Birth Weight Infants, Pre-eclampsia and Magnesium Sulphate
Authors: Blair Eve , Palmer Lyle , Stanley Fiona
Published: December 2021

Nelson and Grether1 (Pediatrics 1995;95:263-269) hypothesize that magnesium sulphate administered to mothers before delivery of very low birth weight ([VLBW] <1500 g) infants reduces their risk of cerebral palsy (CP). This hypothesis is supported by their analysis of retrospective data pertaining to VLBW Californian infants. Although it is an exciting proposition, it needs to be approached with caution. A causal explanation for the observed association needs to be confirmed with a randomized controlled trial of magnesium sulphate in preterm delivery because it is conceivable that the apparently robust association may have resulted from their study design.2
Acute Isoniazid Neurotoxicity in an Urban Hospital
Authors: Kurbasic Mirzada Pasic , Badgett J. Thomas
Published: December 2021

In the May issue of Pediatrics, Dr Shah and collaborators pointed out an increased incidence of isoniazid (INH) neurotoxicity.1

At the Children's University Hospital in Tuzla, Bosnia, and Herzegovina, four patients (age range, 6 to 9 years) were admitted for INH neurotoxicity in a 15-month period.2 None of them had liver dysfunction or metabolic disturbance, such as acidosis or hyperglycemia. All intoxications were accidental. Patients responded well to high doses of intravenous pyridoxine, including two with seizures and coma that had been unresponsive to treatment with phenobarbital and diazepam, respectively, before admission.
Progress Toward Integrating Hepatitis B Vaccine Into Routine Infant Immunization Schedules in the United States, 1991 Through 1994
Authors: Woodruff Bradley A. , Stevenson John , Yusuf Hussain , Kwong Sandy L. , Todoroff Karen P. , Hadler James L. ,   Connecticut Hepatitis B Project Group, Hoyt Muriel A. , Mahoney Frank J.
Published: December 2021

Objective. We assessed progress toward universal infant immunization against hepatitis B, which was first recommended in November 1991.

Methods. Multiple data sources were used to describe vaccination policies and trends in infant hepatitis B vaccine coverage.

Results. As of June 1993, 51% of the 63 local, state, and territorial immunization programs recommended hepatitis B vaccination of all newborns shortly after birth. The number of first dosages of hepatitis B vaccine administered to infants in public sector clinics increased rapidly from late 1992 to 1993, and at the end of 1993 was approximately two thirds the number of first dosages of other infant antigens. In a nationwide survey of hospital nurseries 47% offered hepatitis B vaccine to all newborns. Of 3982 sampled newborns in these hospitals, 36.2% had been vaccinated before discharge. In San Francisco and Connecticut, where public health officials encouraged hospitals to offer hepatitis B vaccination, first-dose coverage at discharge was 82.3% in 1994 and 69.1% in 1993, respectively. Coverage was higher in healthier infants and lower in infants of older or bettereducated mothers. Results from the National Health Interview Survey demonstrate that three-dose completion at 12 months of age increased from less than 1% of children born in 1989 to 40% of children born in the fourth quarter of 1992. Vaccination at birth increased from less than 1% of infants born in 1989 to 32% of infants born in the second half of 1993.

Conclusions. Infant hepatitis B vaccination has expanded rapidly since national recommendations were made; however, universal coverage has not been achieved.
Fetal Alcohol Syndrome—An Ophthalmological and Socioeducational Prospective Study
Authors: Strömland Kerstin , Hellström Ann
Published: December 2021

Background. The eye is a sensitive indicator of adverse effects of prenatal alcohol exposure. Anomalies of the eyes and their adnexa are known to be associated with the fetal alcohol syndrome (FAS), although long-term effects of these malformations are unknown.

Design. A prospective ophthalmologic follow-up (median, 11 years; range, 4 to 19 years) was performed in 25 children with FAS. Their social situation and educational status were also investigated.

Results. All but one of the children had ophthalmologic abnormalities. Fundus anomalies were observed in 23 children, of whom 19 had optic nerve hypoplasia. Thirteen children had concomitant strabismus. Microphthalmos, buphthalmos, phthisis, microcornea, coloboma of the iris and uvea, blepharoptosis, cataract, persistent hyperplastic primary vitreous, and nystagmus were observed in single cases. The dysmorphology of the eyes remained unchanged during the follow-up period. In 2 children with severe mental retardation and, initially, very poor vision, the severe visual handicap persisted. Seventeen children had an initial visual acuity ≥20/70, which remained unchanged in 10 children and improved in 7 children, despite the presence of optic nerve hypoplasia in 14 of the children. Ten mothers died, 8 of them because of alcohol-related diseases, and only 4 of the mothers were able to take care of their children. Sixteen children went to schools for the mentally retarded, and only 3 children had a normal school education without extra teaching assistance.

Conclusions. In children with FAS, the major sequela, ie, brain damage, remains despite extensive medical, educational, and social support. The presence of ophthalmic signs, which persisted but did not deteriorate during the follow-up period, strengthens the diagnosis of FAS, and the high frequency of ocular involvement indicates the importance of a complete ophthalmologic evaluation in children with FAS.
Ingredients of Urban Pediatric Health Care: Fourth World Pediatrics
Authors: Rosen John F.
Published: December 2021

The article by Fairbrother et al1 is an indictment of the quality of care provided to disadvantaged children in "Medicaid Mills" in New York City. The missed opportunities to immunize and to test for lead poisoning and tuberculosis represent misused opportunities that are avoidable and tragic.

The International Covenant on the Rights of the Child was adopted by the United Nations (UN) General Assembly on November 19, 1989.2 This covenant stated the principle that children require safeguards and care, including the highest attainable standard of health and access to facilities to ensure that no child is deprived of her or his right to such health services.
Letter To The Editor
Authors: Halsey Neal A.
Published: December 2021

A three-dose series of the 10-µg Engerix-B hepatitis B vaccine induced antibody concentrations of ≥10 milli-international units per mL (mIU/mL) in 97% of adolescents, and this regimen has been approved by the Food and Drug Administration for routine immunization.1,2

Because vaccine cost is an important factor, it makes sense to vaccinate with the lowest approved dose that will induce high rates of immunity. The approval of the 10-µg dose should be welcomed by pediatricians and others providing health care for adolescents as it will be easier to provide vaccine to all adolescents at a lower cost.
Letter To The Editor
Authors: Wiswell Thomas E. , Baumgart Stephen , Gannon Catherine M. , Spitzer Alan R.
Published: December 2021

We are pleased with the interest in our recent publication. Concerning the seven asymptomatic infants whose lumbar punctures (LPs) were performed solely for maternal risk factors: They were deemed to be asymptomatic based on careful review of the written medical records, with particular attention to the nurses' and physicians' notes and assessments, as well as the vital signs.1 We sought to identify signs and symptoms that were apparent before the child's LP. Pediatricians and nurses did assessments in every case.
Varicella Vaccination
Authors: Sohn William J.
Published: December 2021

I have a concern regarding Dr Kohl's statement about a Varivax booster. I agree that this would be the "obvious remedy," but would everybody get a booster?

In my practice, I ask all my young mothers who have had one dose of measles vaccine whether they have received their second dose. Although this is anecdotal, only 30% say yes. The reason is twofold. One is that young healthy adults don't go to doctors very often, and, two, adult practitioners are not as "phobic" as pediatricians concerning immunizations.
Acute Pharyngitis: Etiology and Diagnosis
Authors: Bisno Alan L.
Published: December 2021

Acute pharyngitis may be caused by a wide variety of microbial agents (Table 1). The relative importance of each of these agents varies greatly depending on a number of epidemiologic factors, including age of the patient, season of the year, and geographic locale.

Viruses

Most cases of acute pharyngitis are viral in etiology and involve the pharynx as well as other portions of the respiratory tract as manifestations of the common cold, influenza, or croup. Examples include the rhinoviruses, coronaviruses, influenza A and B, and the parainfluenza viruses. Certain viral infections causing sore throat may exhibit clinical manifestations that are rather distinctive. Examples include enteroviruses (herpangina due to Coxsackie A), Epstein-Barr virus (infectious mononucleosis), cytomegalovirus (cytomegalovirus mononucleosis), adenovirus (pharyngoconjunctival fever, acute respiratory disease of military recruits), and herpes simplex virus (pharyngitis, gingivitis, and stomatitis). In many instances, however, the illnesses caused by these agents may overlap so broadly with that of streptococcal pharyngitis as to be clinically indistinguishable. Thus, Epstein-Barr virus, adenovirus, and herpes virus may all cause fever, exudative pharyngitis, and cervical adenitis.

Several studies have documented the role of primary herpesvirus type 1 infection as a cause of acute pharyngitis in college students.1-4 Herpesvirus type 2 can occasionally cause a similar illness as a consequence of oral-genital sexual contact.5 Although herpesvirus infections may involve the anterior oral cavity (vesicular or ulcerative gingivostomatitis) as well as the posterior pharynx, they do not routinely do so. Only about one-fourth of students with culturally and serologically proven primary herpes simplex type 1 pharyngitis studied by Glezen et al,2 for example, had gingivostomatitis.
Clinical and Virologic Features of Hepatitis C Virus Infection Associated With Intravenous Immunoglobulin
Authors: Jonas Maureen M. , Baron Miriam J. , Bresee Joseph S. , Schneider Lynda C.
Published: December 2021

Objective. To characterize the clinical features of hepatitis C virus (HCV) infection associated with the administration of intravenous immunoglobulin (IVIG) in patients with varied immunodeficiencies.

Design. Prospective collection of clinical and virologic logic data in patients determined to have HCV exposure associated with Gammagard.

Setting. Outpatient department of children's Hospital tal, Boston.

Patients. Twenty-one patients with evidence of HCV infection were identified during a screening program initiated to detect infection in exposed individuals. They ranged from 5 to 53 years of age; 14 were children under age 18.

Results. Six patients presented with severe clinical hepatitis before detection by screening, 13 were detected by screening only, and 2 were first detected by screening and subsequently developed symptomatic hepatitis. Follow-up is available on 20 patients; 4 without viremia at identification have remained clinically well. Hepatitis and viremia have resolved in 2, 2 additional subjects have developed normal alanine aminotransferase (ALT) values with persistent viremia, and 13 have biochemical and/or virologic evidence of chronic hepatitis. Eight patients (7 children) have undergone liver biopsies; 7 have histologic findings of chronic hepatitis, 5 have mild fibrosis, and 2 have moderate fibrosis. HCV genotypes 1a and 1b were observed with equal frequency in this group.

Conclusions. Some HCV infections associated with IVIG had a more severe, acute course than is ordinarily described. This may be attributable to host factors, such as immunodeficiencies, or virologic factors, such as inoculum or genotype. Although a large percentage (87.5%) of these individuals developed chronic infection, the natural history is not as yet completely defined.
Neonatal Mortality and Length of Newborn Hospital Stay
Authors: Beebe Susan A. , Britton John R. , Britton Helen L. , Fan Pelly , Jepson Bryan
Published: December 2021

Objective. To investigate the effect of hospital discharge time on neonatal mortality of term newborns.

Design. Infants who were discharged home at 5 days of age or younger and who subsequently died were compared with control infants using a retrospective casecontrol design. Descriptive information was collected from records of infants who were not discharged home from the hospital of birth (because of death or transfer to a tertiary care hospital) to determine the age at which their illnesses presented.

Methods. We reviewed death certificates for all infacts with birth weights of 2500 g or greater born at 37 weeks' gestational age or greater who died in the first 28 days of life and who were born in one of four Utah counties (1985 through 1989). Of the 109 256 eligible births, 115 infants were found who had died in the neonatal period. Eighty-four infants had not been discharged home from the hospital of birth, 5 infants had had hospital stays of more than 5 days, 9 records could not be located, 17 presumed healthy infants were discharged from the hospital at 5 days of age or younger. These 17 infants were each matched with 3 control infants. Newborn nursery charts were reviewed to determine hospital discharge times for case and control infants. Descriptive information regarding the time of presentation of illness was collected for the other 89 infants.

Results. The mean age of hospital discharge was 43 ± 21 hours for the 17 case infants and 47 ± 25 hours for the 51 control infants. The odds ratio for neonatal mortality for discharge at less than 24 hours was 1.65 (95% confidence interval, 0.42 to 3.34) and for discharge at less than 48 hours was 1.16 (95% confidence interval, 0.4 to 3.34). Of the 84 infants who were not discharged home from the hospital of birth, 93% had been symptomatic by 12 hours of age, and 99% were symptomatic by 18 hours.

Conclusions. Most full-term infants who die in the neonatal period are symptomatic within the first 18 hours after birth. We could not demonstrate an association between early hospital discharge and neonatal mortality in those infants who died after discharge home.
THE ANAPHYLAXIS HYPOTHESIS OF SUDDEN INFANT DEATH SYNDROME (SIDS): MAST CELL DEGRANULATION IN COT DEATH REVEALED BY ELEVATED CONCENTRATIONS OF TRYPTASE IN SERUM
Authors: Bollinger Mary E. , Wood Robert A.
Published: December 2021

This study found that elevated concentrations of serum tryptase are associated with sudden unexplained infant death, and this may be consistent with anaphylaxis as a mechanism in some cases of SIDS. Further studies are needed to determine if mast cell degeneration in these cases is secondary to terminal respiratory failure or some other event common to most cases of SIDS. The measurement of 9α, 11β-PGF2, as a specific marker of mast cell activation was not helpful under the conditions of this study.
EFFICACY AND SAFETY OF HYDROLYZED COW MILK AND AMINO ACID-DERIVED FORMULAS IN INFANTS WITH COW MILK ALLERGY
Authors: Pham Timothy , Kaplan Michael
Published: December 2021

Extensively hydrolyzed formulas are safe and effective for most infants; amino acid-derived formulas may be preferable for infants with multiple food allergies, especially for the maintenance of normal growth.
SYSTEMIC REACTIONS TO SPECIFIC IMMUNOTHERAPY IN CHILDREN WITH RESPIRATORY ALLERGY: A PROSPECTIVE STUDY
Authors: Zeiger Robert S.
Published: December 2021

SIT with aeroallergens is relatively safe in children with respiratory allergies.