bluuebunny/crossref_metadata_2025 huggingface dataset:
Determinants of Growth From Birth to 12 Months Among Breast-Fed Honduran Infants in Relation to Age of Introduction of Complementary Foods
Authors: Cohen Roberta J. , Brown Kenneth H. , Canahuati Judy , Rivera Leonardo Landa , Dewey Kathryn G.
Published: December 2021

Objectives. To evaluate the impact of introducing complementary foods to exclusively breast-fed infants at 4 vs 6 months on growth from 6 to 12 months, and to compare growth patterns of Honduran infants with those of breast-fed infants in the United States.

Design. Randomized intervention trial from 4 to 6 months and longitudinal study of infants from birth to 12 months.

Setting. Low-income communities in San Pedro Sula, Honduras.

Subjects. Primiparous, breast-feeding mothers and their infants (n = 141) recruited from public maternity hospitals.

Intervention. Infants were randomly assigned to exclusive breast-feeding to 6 months, or exclusive breast-feeding with addition of hygienically prepared, nutritionally adequate complementary foods at 4 months, with or without maintenance of baseline breast-feeding frequency. After 6 months, mothers continued to breast-feed and also fed their infants home-prepared foods after receiving instruction in appropriate feeding practices.

Outcome Measures. Infant weight was measured monthly during the first year of life and infant length monthly from 4 to 12 months.

Statistical Analysis. Growth parameters were compared between the Honduran and US cohorts using multiple-regression and repeated-measures analysis of variance. Stepwise multiple regression was used to identify determinants of infant growth.

Results. There were no differences in growth patterns by intervention group. Mean birth weight of the Honduran infants was significantly less than that of a cohort of breast-fed infants in an affluent US population (n = 46) (2889 ± 482 vs 3611 ± 509 g), but the Honduran infants exhibited rapid catch up in weight in the first few months of life, and the cohorts were similar in weight by 3 months. Mean weight and length gain were similar to those of the US cohort from 4 to 9 months but were lower from 9 to 12 months. Mean length for age was significantly less than that of the US cohort from 4 to 12 months; this was attributable to the difference in maternal height (12 cm shorter in Honduras on average). Within the Honduran cohort, growth velocity of low birth weight infants (<2500 g; n = 28) was similar to that of their normal birth weight peers; thus, the former subgroup remained smaller than the latter throughout the first year of life.

Conclusions. In poor populations, when breast-feeding is exclusive for the first 4 to 6 months, continues from 6 to 12 months, and is accompanied by generally adequate complementary foods, faltering in weight does not occur before 9 months among infants born with birth weights of more than 2500 g.
Pediatric Office-Based Smoking Intervention: Impact On Maternal Smoking and Relapse
Authors: Wall Michael A. , Severson Herbert H. , Andrews Judy A. , Lichtenstein Ed , Zoref Leslie
Published: December 2021

Objective. To determine the impact of a brief smoking intervention delivered by pediatricians in the context of usual well baby office visits on postnatal maternal smoking and relapse.

Setting. Forty-nine private pediatric practices including 128 practitioners.

Design. Randomization of pediatric practices into minimal and extended intervention sites with all enrolled mothers of newborns within a practice receiving the same level of intervention.

Intervention. Smoking mothers in minimal condition received a hospital packet containing written information about passive smoking and a letter advising them to quit. Those in extended condition received the hospital packet plus oral and written advice at usual well baby visits: 2 weeks, 2, 4, and 6 months.

Measurements. Smoking and relapse rates at 6 months postpartum, demographics associated with smoking status, attitudes, and knowledge in regard to passive smoking, and recall surveys of mothers in regard to receiving advice or written materials.

Results. Two-thousand nine-hundred-one mothers of newborns were enrolled in the study. Those in the extended condition had higher quit rates (5.9% vs 2.7%, P < .01) and lower relapse rates (45% vs 55%, P < .01) than those in the minimal condition. Mothers' educational status and the presence of a smoking partner in the home were the major demographic variables associated with smoking status at enrollment and at follow-up. Compared with smokers in the minimal condition, those in extended at 6 months postpartum had significantly better attitudes and knowledge regarding passive smoking and allowed less smoking in the home. Mothers attending extended practices reported much higher rates of receiving oral advice and written materials than those in the minimal condition.

Conclusions. A brief program can lead to major increases in the willingness of pediatricians to deliver smoking advice. A 1- to 2-minute intervention delivered in the context of usual well baby care can have a positive impact on maternal smoking and especially upon relapse prevention. A recent smoking history should be obtained from all mothers of newborns so that interventions can be aimed at both cessation and relapse prevention.
Surface Electrical Capacitance as a Noninvasive Beside Measure of Epidermal Barrier Maturation in the Newborn Infant
Authors: Okah Felix A. , Wickett R. Randall , Pickens William L. , Hoath Steven B.
Published: December 2021

Objective. The classical studies of epidermal barrier function in infants have relied on measurement of transepidermal water loss by evaporimetry. This technique, although valuable, is, in practice, slow, expensive, and susceptible to error because of convective air currents. In this prospective study, we evaluated gestation-dependent and postnatal age-dependent changes in epidermal barrier function by measurement of skin surface electrical capacitance (SEC) in 40 newborn infants ranging from 25 to 40 weeks' gestational age. SEC was measured in picofarads with a dermal phase meter.

Methodology. The measurements were recorded continuosuly during a 12-second period from the forehead at 12 to 24 hours of life. The baseline (CBL) surface hydration at 1 second and the rate of change of SEC during probe occlusion (CSL) were used as measures of surface hydration and transepidermal water movement, respectively. In the most premature infants (<30 weeks), these measurements were repeated daily for 5 days. Data were analyzed by analysis of variance after logarithmic (Ln) transformation.

Results. We found a significant difference in Ln(CBL) in infants born before and after 30 weeks' gestation (4.91 ± 0.36 Ln[pF] vs 2.67 ± 0.21 Ln[pF], respectively). Similarly, CSL was significantly different in infants born before and after 30 weeks' gestation (16.42 ± 5.55 pF/s vs 1.59 + 0.22 pF/s, respectively). In infants born at less than 27 weeks, both Ln(CBL) and CSL decreased significantly by postnatal day 5. In the term group (n = 25), CSL was significantly greater in white than in black infants (1.96 ± 1.32 pF/s vs. 0.95 ± 0.55 pF/s, respectively).

Conclusion. These results demonstrate impaired epidermal barrier properties in immature infants, less than 30 weeks' gestation, and reveal a remarkable rate of barrier maturation of this group in the first few days of postnatal life. Also, the finding of decreased CSL in black infants supports the hypothesis of differences in barrier function attributable to skin types. Overall, these findings demonstrate the feasibility of bedside SEC measurements in the evaluation of epidermal barrier properties in the newborn infant.
Letters to the Editor
Authors: Schunk Jeff E. , Harrison A. Marc , Corneli Howard M. , Nixon G. William
Published: December 2021

We appreciate these comments. We agree with the suggestion of Drs Conners, Chamberlain, and Ochsenschlager; in fact, we employ this method ourselves!

Drs Arnold and Radkowski restate our proviso that manipulation of foreign bodies in the esophagus should not occur remote from physicians and equipment needed for resuscitation, although we note this is a somewhat theoretic precaution: no actual resuscitation or airway manipulation was required in our 415 cases. We are not sure that resident training justifies cost or inconvenience to the patient.
Etiology of Bronchopulmonary Dysplasia
Authors: Papoff Paola , Pacifico Lucia , Bucci Giovanni
Published: December 2021

We read with great interest the article by Groneck et al (Pediatrics. 1994;93:712-718). The authors concluded that an inflammatory reaction is present in the lungs of preterm infants prone to develop bronchopulmonary dysplasia (BPD), and they suggested that this concept of inflammation could link the pathophysiological gap between barotrauma- and oxygen toxicity-induced injury and subsequent lung fibrosis. In their study, a total of 12 neonates developed BPD: 11 of 24 neonates in the BPD-risk group and 1 of 35 in the control group.
Response to Drs Bergman and Zurhellen
Authors: Coombs John B.
Published: December 2021

In composing a response to these two articles, I must congratulate both presenters. Each created a stimulating summary of key components of what I consider to be the greatest challenge for practicing physicians in the future: information management. Dr Zurhellen has described an office information system that, in all probability, is enjoyed by fewer than 1 in 50 practitioners currently. Taking advantage of his position as a solo practitioner with a strong interest in computers, he has developed a system that brings greater simplicity, efficiency, and—I dare say—accuracy and precision to his office practice. The greatest challenge for the rest of us will be how to create the transition and the tremendous investment of time, financial resources, and risk that it will surely take to get where he is today.

Given the need for improvement in the daily handling of office information, and given the estimated 7500 new articles entered daily in the peer-reviewed biomedical literature, futurists predict that practitioners during the next 15 years will need to adjust both their practice style and their continuing education. They will need to assimilate new information in accordance with this estimate: 75% of what one needs to know to provide top-quality care in any given patient encounter will change during a 12-month period. Dr Bergman has provided an up-to-date glimpse of how we are preparing to meet this challenge. Practice parameters condense new acientific information that is evidence based into defined best practice for a given medical condition. Gaps in evidence-based information are filled by selected expert opinion.
Nurse Practitioners and Physician Assistants: Do They Have a Role in Your Practice?
Authors: Stone Elsa L.
Published: December 2021

During the next decade, pediatricians will confront the difficult challenge of providing quality health care services to more children with more diverse and difficult problems, and they will have little or no additional funding to accomplish this task. Despite earlier predictions of surpluses in the pediatric work force, there are now shortages that will worsen if the current trend persists. Pediatric nurse practitioners (PNPs) and some physician assistants are being trained to perform health supervision care and to diagnose and treat the common illnesses of children. Substantial evidence suggests that PNPs provide quality health care services, and that collaborative teams of pediatricians and PNPs can provide high-quality, cost-effective care to a broader spectrum of children than can be served by either professional alone.
AGENCY FACING REVOLT AFTER REPORT
Authors: L. J. F.
Published: December 2021

Representative Henry Bonilla, a San Antonio Congressman in his second term, was home for a visit early this year when he received a small stream of visitors who wanted to complain about a federal agency. The visitors were local back surgeons and some physical therapists angry over a study by the agency that said most back surgery and much physical therapy used by Americans for back pain was unnecessary.

As a Republican member of the Appropriations subcommittee that deals with the agency's budget, Mr Bonilla was a good choice for the surgeons' complaints that the Agency for Health Care Policy and Research was a waste of money.

As far as battles in the current multibillion-dollar budget war go, the fight over the agency is only a tiny skirmish, because its budget is $165 million dollars.... The agency, which is supposed to evaluate the effectiveness of medical treatments, issued a set of guidelines for the public last December that said, in effect, that most of the back surgery performed in the country is unnecessary ... The agency's director, Dr Clifton Gaus, has gone on the offensive, depicting the situation as one in which back surgeons were trying to undercut his agency simply to maintain their substantial incomes... The agency was created by a law signed in 1989 by President George Bush and is supposed to study the effectiveness of medical treatments.... Dr Robert B. Keller said that the guidelines were the result of the best science available. "Those who have attacked the study," he said, "are simply trying to protect their livelihoods."
Adverse Factors Associated With Forced Sex Among Southern Adolescent Girls
Authors: Nagy Stephen , DiClemente Ralph , Adcock Anthony G.
Published: December 2021

Objective. To identify adverse behavioral and psychological factors associated with forced sex experiences of adolescent girls compared with their sexually active counterparts.

Method. An anonymous self-report survey examining an array of psychosocial items, to which 3124 grade 8 and grade 10 female students responded.

Results. Sexually abused girls were more likely to have been pregnant, to have initiated sexual intercourse at a younger age, to indicate illegal drug use, to have feelings of depression, to express more frequent suicidal ideation, and to have been physically abused.

Conclusions. Behaviors such as gateway drug use, truancy, binge drinking of alcohol, and participation in violent episodes that were previously identified as indicators of sexual abuse did not distinguish between sexually active adolescents and those who had been sexually abused. Physicians should consider carefully a structured series of questions relating to behaviors as one approach in determining the risk of sexual abuse. Positive responses to young sexual initiation, pregnancy, illegal drug use, negative mental health states, and evidence of physical abuse are potential markers of sexual abuse in adolescent female clients.
Increased Incidence of Severe Breastfeeding Malnutrition and Hypernatremia in a Metropolitan Area
Authors: Cooper William O. , Atherton Harry D. , Kahana Madelyn , Kotagal Uma R.
Published: December 2021

Objective: To identify common characteristics among infants with breastfeeding malnutrition in a region with an increasing incidence of breastfeeding malnutrition.

Design. Retrospective case series.

Setting. A 361-bed regional tertiary care children's hospital in a 1.7 million population metropolitan area.

Patients. Case series: five infants with severe breast-feeding malnutrition and hypernatremia admitted to a tertiary care children's hospital over a 5-month period. Retrospective case review: 166 infants admitted between 1990 and 1994 with the diagnosis of dehydration, hypernatremia, or malnutrition.

Main Outcome Measures. Maternal characteristics, age at presentation, percent loss from birth weight, serum sodium, average age at birth hospital discharge, neurologic, or cardiovascular complications.

Results. Five infants were admitted to a children's hospital over a 5-month period with severe breastfeeding malnutrition and hypernatremia. The average weight loss at time of readmission was 23% (± 8%) from birth weight. The average presenting sodium was 186 ± 19 mmol/L. Three suffered significant complications. From 1990 through 1994, there was a statistically significant (P < .05) annual increase in the number of infants admited with breastfeeding malnutrition and hypernatremia.

Conclusions. While breastfeeding malnutrition and hypernatremia is not a new problem, this cluster of infants represents an increase in frequency and severity of the problem and could be a consequence of several factors, including inadequate parent education about breastfeeding problems and inadequate strategies for infant follow-up.
Ultrasound Screening for Congenital Dysplasia of the Hips
Authors: Schimmer Michael
Published: December 2021

I strongly disagree with the conclusion of Rosendahl et al1 concerning the efficacy of ultrasound screening of the hip (USH) in neonates.

I am engaged in a neonatal unit in a small hospital here (about 600 births per annum). In 1990 we started USH for all newborns. Nearly all babies are controlled after 6 to 12 weeks by an experienced orthopedist. There was a clear discrepancy between clinical and sonographic diagnoses in both directions (false positive and false negative by clinical investigation).
Esophageal Detector Device in Pediatric Tracheal Intubation
Authors: Koetter Katharina P. , Maleck Wolfgang H.
Published: December 2021

Bhende and Thompson's article in Pediatrics (1995;95:395-399) showed problems associated with the use of capnometry for initial control of tube position in cardiac arrest. They found a failure to detect carbon dioxide (CO2) in six of 39 patients with correct tracheal tube position.1 This is similar to their earlier publication with a failure in two of 17 cardiac arrest patients with tracheally placed tubes.2 We found a 13% incidence of failure to detect CO2 with the EASYCAP (Nellcor, Hayward, CA) in cardiac arrest despite tracheal intubation in pooled data.3
Antiphospholipid Antibodies in Pediatric Systemic Lupus Erythematosus
Authors: Seaman David E. , Londino A. Vincent , Kwoh C. Kent , Medsger Thomas A. , Manzi Susan
Published: December 2021

Objective. Antiphospholipid antibodies (aPLs) have been extensively studied in adults with systemic lupus erythematosus (SLE) and have been associated with arterial and venous thrombosis, thrombocytopenia, neurologic disorders, and recurrent fetal loss. In contrast, very little is known about the frequency and clinical significance of aPLs in pediatric SLE. This study was designed to determine the frequency of aPLs in pediatric SLE and the temporally associated clinical manifestations.

Design. We studied 29 consecutive patients with onset of SLE in childhood seen in the Pediatric Rheumatology Clinic at the University of Pittsburgh, Children's Hospital, between 1985 and 1992. We defined aPL as the presence of a lupus anticoagulant (LAC), immunoglobulin G or immunoglobulin M anticardiolipin antibodies (aCLs), or a biologic false-positive serologic test for syphilis determined by a VDRL test. Clinical manifestations were temporally correlated to the presence of aPLs if they occurred within 6 months.

Results. Overall, 19 (65%) of 29 children with SLE had one of the three laboratory abnormalities defining aPL. LAC was detected in 16 (62%) of 26, aCL in 18 (66%) of 27, and false-positive VDRL test results in 11 (39%) of 28. Twenty-five of the 29 patients had all three tests performed. In 10 patients, all three tests were abnormal. The presence of thrombosis in 7 patients (4 venous, 2 arterial, and 1 both) was associated with a positive aPL, specifically aCL. The presence of an aPL was significantly associated with anti-double-stranded DNA antibodies, but not with neuropsychiatric manifestations or with thrombocytopenia. The presence of an aCL was significantly associated with hemolytic anemia. A prolonged prothrombin time, in the setting of an LAC (all with a prolonged activated partial thromboplastin time), was associated with life-threatening disease in 6 of 15 patients.

Conclusion. Sixty-five percent of 29 consecutive pediatric patients with SLE had evidence of aPL. The presence of aPL, specifically aCL, was significantly associated with thrombotic events. The presence of a prolonged prothrombin time in the setting of an LAC may be a marker of more serious disease in pediatric SLE.
Partial Deficiency of Surfactant Protein B in an Infant With Chronic Lung Disease
Authors: Ballard Philip L. , Nogee Lawrence M. , Beers Michael F. , Ballard Roberta A. , Planer Benjamin C. , Polk Lori , deMello Daphne E. , Moxley Michael A. , Longmore William J.
Published: December 2021

Objective. To evaluate components of pulmonary surfactant and identify mutations in the surfactant protein B gene (SP-B) of a term infant with severe respiratory distress and chronic lung disease.

Patient and Testing. Respiratory distress developed in an infant delivered at term, and he required extracorporeal bypass support for 2 weeks. Until his unexpected death at 9.5 months, he was ventilator and oxygen dependent and required continual dexamethasone therapy. Tracheobronchial lavage samples were analyzed for content of surfactant proteins (SPs), and DNA from blood samples were sequenced and analyzed by polymerase chain reaction restriction analysis for the presence of SP-B gene mutations. Surfactant lipid composition and function, the contents of SPs and their messenger RNAs (mRNAs), and the immunostaining pattern for SPs were determined in postmortem lung tissue.

Results. The lavage sample contained SP-A but not SP-B, and DNA restriction analysis indicated that the patient and his mother were heterozygous for the previously described 121ins2 mutation of SP-B. Postmortem lung tissue contained normal levels of SP-A and its mRNA, a low but detectable level of SP-B, and near normal content of SP-B mRNA. SP-C was abundant on staining, and some 6-kd precursor was present in tissue. A surfactant fraction was deficient in phosphatidylglycerol and was not surface active. On DNA sequencing, a point mutation was found in exon 7 of the patient's SP-B gene allele without the 121ins2 mutation, resulting in a cysteine for arginine substitution, and the father was a carrier for the same mutation.

Conclusions. We describe a patient who is a compound heterozygote with a new mutation and only a partial deficiency of SP-B. Some forms of inherited SP-B deficiency may have low expression of immunoreactive and possibly functional SP-B with milder lung disease and longer survival. These infants may benefit from glucocorticoid therapy and may not develop antibodies to SP-B after either lung transplant or gene therapy.
Life Events, Cardiovascular Reactivity, and Risk Behavior in Adolescent Boys
Authors: Liang Sai-Woon , Jemerin John M. , Tschann Jeanne M. , Irwin Charles E. , Wara Diane W. , Boyce W. Thomas
Published: December 2021

Background. Risk behavior contributes to injuries, one of the most important sources of morbidity and mortality in adolescents. Although research has shown that environmental stress makes adolescents more likely to engage in risk behavior and to sustain injuries, the magnitude of these associations has been small. Little is known about the role of individual differences in psychobiologic reactivity to stress in moderating the impact of stressful events. In this study, we examined associations among environmental stressors, cardiovascular reactivity to stress, and the level of risk behavior in adolescent boys.

Methods. Twenty-four 14- to 16-year-old boys underwent a laboratory protocol designed to measure responses to psychologically and physically stressful tasks. Changes in heart rate and mean arterial blood pressure were measured serially at standard points in the protocol, and levels of positive and negative life events and recent risk behavior were measured using self-report questionnaires.

Results. Neither life events nor cardiovascular reactivity were independently associated with risk behavior. Positive life events and mean arterial blood pressure reactivity significantly interacted, however, in predicting risk behavior (R2 increment = .25). Boys with high reactivity who reported numerous positive life events engaged in markedly less risk behavior than their peers.

Conclusion. We conclude that adolescents with exaggerated cardiovascular responses to laboratory stressors are associated with less risk behavior in a setting of positive life circumstances. This result suggests that reactivity may exert protective, rather than harmful, influences in some environments.
Prognosis With Preoperative Pulmonary Function and Lung Volume Assessment in Infants With Congenital Diaphragmatic Hernia
Authors: Antunes Michael J. , Greenspan Jay S. , Cullen James A. , Holt William J. , Baumgart Stephen , Spitzer Alan R.
Published: December 2021

Objectives. To determine whether fatal pulmonary hypoplasia, as assessed by functional residual capacity (FRC), can be distinguished from other reversible causes of respiratory failure in infants with congenital diaphragmatic hernia (CDH).

Methods. In the present study, 25 term neonates having CDH without other anomalies (mean birth weight ± SD, 3.25 ± 0.50 kg) were enrolled prospectively into a protocol evaluating pulmonary function. Lung compliance (CL) and FRC were measured before diaphragmatic repair and compared with the highest oxygenation index (OI) and lowest PaCO2, also obtained preoperatively. Pulmonary function assessment was repeated after diaphragm repair on postoperative days 3 and 7. CL was determined by esophageal manometry and pneumotachography, and FRC was determined by helium dilution.

Results. Fifteen infants (60%) survived to hospital discharge. Eighteen (72%) required extracorporeal membrane oxygenation (ECMO) for support, and of these, 8 (44%) survived. PaCO2 was similar preoperatively in infants grouped as survivors without ECMO, survivors with ECMO, and nonsurvivors. In nonsurvivors (all of whom received ECMO), the preoperative OI was significantly higher (51 ± 21), CL was less (0.11 ± 0.04 mL/cm of water per kg), and FRC was smaller (4.5 ± 1.0 mL/kg) than in the survivors who required ECMO (26 ± 18, 0.18 ± 0.08 mL/cm of water per kg, and 12 ± 5 mL/kg, respectively), as well as in the survivors without ECMO, (6 ± 2, 0.32 ± 0.16 mL/cm of water per kg, and 15.8 ± 4 mL/kg, respectively). The group surviving with ECMO had a higher OI than the infants surviving without ECMO. All nonsurviving infants had FRCs of less than 9.0 mL/kg preoperatively. In contrast, only 2 of the 15 survivors had preoperative FRCs less than 9 mL/kg.

Conclusions. The results of this study suggest that preoperative assessment of FRC may predict fatal pulmonary hypoplasia in most infants with CDH.
Fasting Insulin Concentration Is Related to Cardiovascular Reactivity to Exercise in Children
Authors: Gutin Bernard , Islam Syed , Treiber Frank , Smith Clayton , Manos Tina
Published: December 2021

Objective. One mechanism through which hyperinsulinemia is linked to hypertension is through its stimulation of sympathetic nervous activity. Thus, insulin concentration may be correlated with indices of sympathetic activity before it is associated with resting blood pressure. We tested this hypothesis by determining the relationship of insulin concentration and sympathetically mediated cardiovascular reactivity to exercise in children.

Design. Survey.

Setting. General community.

Participants. Volunteer sample of 46 black and white boys and girls, 9 to 11 years of age.

Interventions. None. Fasting insulin concentration was the main independent variable.

Main outcome measures. Systolic blood pressure and heart rate during a standard submaximal bout of treadmill exercise, and systolic blood pressure at peak effort.

Results. The hypothesis was tested by multiple regression analyses controlled for resting values. Insulin contributed significantly to the regression models for submaximal heart rate (P < .001), submaximal systolic blood pressure (P = .001), and peak systolic blood pressure (P = .006).

Conclusions. Fasting insulin concentration is associated with cardiovascular reactivity to exercise in young children. This supports the hypothesis that the relationship between hyperinsulinemia and hypertension is mediated by sympathetic nervous tone and that the process begins in childhood. Because percent body fat was positively associated with both insulin and cardiovascular reactivity to exercise, prevention of childhood obesity may be a valuable prophylactic measure for these health problems.
Using Characteristic Changes in Laboratory Values to Assist in the Diagnosis of Hemorrhagic Shock and Encephalopathy Syndrome
Authors: Jardine David S. , Bratton Susan L.
Published: December 2021

Objectives. (1) To determine whether the laboratory abnormalities in hemorrhagic shock encephalopathy syndrome (HSES) follow a characteristic pattern of evolution; and (2) to describe the clinical characteristics and outcome of this group of children.

Design. Retrospective review of hospital records.

Setting. Pediatric intensive care unit in an academic children's hospital.

Patients. Seventeen children who received the diagnosis of HSES.

Measurements. (1) To support the diagnosis of HSES, the following laboratory tests were obtained: creatine phosphokinase, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, creatinine, anemia, thrombocytopenia, coagulation abnormalities, and a metabolic acidosis; and (2) patient characteristics at the time of admission and during the illness and patient outcome were recorded.

Results. The median time for laboratory abnormalities in HSES to reach the most aberrant levels was 1.2 to 1.4 days. After reaching maximal deviation, the laboratory values gradually returned to normal. The severity of laboratory abnormalities was not predictive of mortality. All patients were comatose, had seizures, and required fluid resuscitation. Respiratory failure occurred in 12 (71%) of 17 patients. Vasopressor infusions were used for 8 (47%). Viral cultures were performed in 15 patients and were positive in 8 (53%). Eleven (64%) patients survived.

Conclusions. The laboratory abnormalities that are characteristic of HSES follow a distinctive pattern of evolution during the course of the illness. Although the sensitivity, specificity, and predictive value of this pattern of laboratory abnormalities are not known, it might provide a useful tool in diagnosing HSES and excluding other illnesses. Viral illness is common in HSES. The severity of illness and mortality in this group of patients is similar to other descriptions of HSES.
HOW TO ASK THE RIGHT QUESTIONS IN ASSESSING AN ACADEMIC JOB OFFER
Authors: L. J. F.
Published: December 2021

The relief and excitement afforded by a firm employment offer after at least 15 years of preparation account for the reluctance of many young scholars and scientists to examine the details critically. They are simply afraid that probing too deeply will ruin the deal and leave them without a job. So, perhaps some excessively cynical overkill is needed at this point to set the tone for the discussion to follow.

Naturally, once you are the recipient of such an offer, you want to assume that you were offered the position because you were the most meritorious candidate. Nothing could be farther from the truth. At best, you are the cheapest of several alternatives. Why is recruiting not being done at a higher level, say, full professor? Of course, cost is a factor; any competent department chairperson or director will seek to satisfy institutional requirements with the smallest possible outlay. At worst, you are seen as a potential sucker who might fall for a deal that no one else will accept. Intermediate possibilities are also distasteful—but you get the picture.

... Chairpersons come in innumerable styles, but only a few sources of motivation are strong enough to induce anyone to take such a thankless job. These are altruism, greed, ego, and survival instinct: corresponding chairperson types are Altruist, Parasite, Egoist, and Survivor. A leader motivated by one or another of these drives can affect departmental atmosphere and staff career development so strongly that this individual's personality must be considered part of the offer package.
The Preparticipation Sports Physical: Are We Dropping the Ball?
Authors: Cavanaugh Robert M. , Miller Merrill L. , Henneberger Paul K.
Published: December 2021

More than 7 million adolescents regularly compete in high school athletics each year in the United States.1 Most will undergo a limited, sports-oriented preparticipation evaluation before competition.2 This type of examination has been performed for many years to satisfy various legal, academic, and organizational requirements. However, the health care benefits to the teenagers themselves have not been analyzed objectively using direct comparison to the standard history and physical. At present, the value of the sports physical remains unproven and its efficacy has not been clearly established. In addition, the potential negative impact on delivery of comprehensive medical services to adolescents deserves further emphasis in the literature and, therefore, will be the focus of this commentary.
Assessment of Glomerular Filtration Rate in Preterm Infants by Serum Creatinine: Comparison With Inulin Clearance
Authors: van den Anker John N. , de Groot Ronald , Broerse Henriette M. , Sauer Pieter J. J. , van der Heijden Bert J. , Hop Wim C.J. , Lindemans Jan
Published: December 2021

Dosage regimens of drugs that are cleared mainly by glomerular filtration as well as fluid management in preterm infants should be based on the glomerular filtration rate (GFR) of the individual patient. However, GFR measurements and collection of urine in newborns are difficult to perform. The 24 to 48 h continuous inulin infusion technique does not require the collection of urine and is considered the most reliable indicator of GFR.1,2 This method is invasive, time-consuming, and expensive. In contrast, serum creatinine measurements can be obtained easily and determined quickly in the clinical chemistry laboratory. Most laboratories use an automated kinetic Jaffé method, which is subject to negative interference by plasma hemoglobin above 0.06 mmol/L, and to negative interference by bilirubin (about 35 µmol/L by a serum bilirubin of about 100 µmol/L).
Alveolar Capillary Dysplasia— A Cause of Persistent Pulmonary Hypertension Unresponsive to a Second Course of Extracorporeal Membrane Oxygenation
Authors: Chelliah Bhaktharaj P. , Brown David , Cohen Morris , Talleyrand Andre J. , Shen-Schwarz Susan
Published: December 2021

Recurrence of persistent pulmonary hypertension of the newborn (PPHN) after successful extracorporeal membrane oxygenation (ECMO) therapy has been reported.1,2 Payne1 treated the recurrence of PPHN with conventional therapy, and two of his three patients recovered. De La Cruz2 reported using a second course of ECMO to treat a recurrence of pulmonary hypertension and respiratory failure of other origins in three patients. Two of the three infants survived. As of January 13, 1993, there were a total of 47 infants reported to the Extracorporeal Life Support Organization (ELSO) who had undergone a second course of ECMO.3 The two most common diagnoses among these infants were congenital diaphragrnatic hernia and PPHN.
Esotropia in a Child Treated With a Scopolamine Patch for Drooling
Authors: Good William V. , Crain Lucy S.
Published: December 2021

Drooling in children who have neurodevelopmental disabilities can pose a substantial problem. Recent studies have indicated that, because of its anticholinergic effect, the use of a scopolamine patch may help eliminate drooling.1,2 The ease of administration of the patch, coupled with its very low side-effect Profile, adds to its desirability. However, we want to alert care givers to a problem we attribute to the scopolamine patch. Esotropia developed in one of our patients when scopolamine transdermal patching was done. The esotropia resolved shortly after cessation of patching.

CASE REPORT

This 4-year-old boy has spastic quadriplegia, a significant developmental delay, a well-controlled seizure disorder, and microcephaly secondary to a neonatal cerebrovascular hemorrhage associated with a protein C deficiency clotting disorder.
Recommended Childhood Immunization Schedule
Authors:   Committee on Infectious Diseases
Published: December 2021

The Recommended Childhood Immunization Schedule for 1995 was developed by the Committee on Infectious Diseases (COID) of the American Academy of Pediatrics in collaboration with the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and the American Academy of Family Physicians (AAFP).1 Since the January 1995 publication, the AAP, ACIP, and AAFP have agreed on the following revisions:

1. The revised schedule is dated January-June 1996 and will be reprinted in July 1996 with any indicated changes. Incorporating dates in the chart will assure health care providers that they are using the most current schedule.

2. A column has been added to indicate that the second dose of hepatitis B vaccine can be administered at 1 month of age, provided that at least 1 month has elapsed since the first dose was given. Also, the doses of vaccine are provided in micrograms by individual product instead of volume, as several different concentrations of recombivax-HB (Merck, Sharp and Dohme) vaccine are available.

3. A bar has been added at 11-12 years of age to indicate that adolescents who have not previously received three doses of hepatitis B vaccine should initiate or complete the three-dose series.

4. Varicella zoster virus vaccine (Var) has been added to the schedule. In addition to the previously issued Academy recommendations, answers to commonly asked questions are addressed in a recent AAP News article.2,3

5. Information on inactivated poliomyelitis vaccine (IPV) has been added to reflect the Academy's current policy.
Letter To The Editor
Authors: Wald Ellen R.
Published: December 2021

We appreciate Dr Long's comments regarding our article "Dexamethasone Therapy for Children With Bacterial Meningitis." The purpose of the study was to determine the effect, if any, of dexamethasone on hearing loss and other neurologic sequelae. By performing auditory-evoked brainstem responses (ABR) on children with bacterial meningitis as soon as possible after admission to the hospital, we hoped to learn about the time course of hearing loss and whether it is preventable or reversible by the administration of dexamethasone.
Examination Findings in Legally Confirmed Child Sexual Abuse: It's Normal to be Normal
Authors: Hobbs C. J. , Wynne J. M.
Published: December 2021

This paper (Adams et al, Pediatrics. 1994;94:310-317) causes us great concern and if not challenged will be quoted by every advocate the world over to dismiss the validity of physical signs seen in association with child sexual abuse (CSA) at a time when experienced researchers are making sense of a difficult clinical area.

The legal data on the cases is incomplete, and any possible correlation between the physical signs and the crime committed was irrelevant because of plea bargaining but also poor clinical date.
How Safe Are Day Care Centers? Day Care Versus Home Injuries Among Children in Norway
Authors: Kopjar Branko , Wickizer Thomas
Published: December 2021

Objectives. The study's objective was to examine and compare injury rates of children ages 6 months to 6 years in day care centers and homes. More specifically, we tested the hypothesis that the injury rate is lower in day care centers than at homes, as suggested by previous studies.

Methods. A comprehensive prospective injury registration was carried out in Stavanger, Norway, during 1992. We obtained data from this system to identify injuries occurring in day care centers, homes, and other places during 1992. Exposure-adjusted incidence rates were calculated to compare the risk of injury at day care centers, homes, and other places. We also obtained data from medical records on use and costs of medical care. In addition, a parent questionnaire was developed and used to gather data on the amount of injury-related restricted activity.

Results. Among 9454 children ages 6 months to 6 years in Stavanger, 770 injuries occurred during 1992: 96 in day care centers, 472 at home, and 202 at other places. For children ages 6 months to 2 years, the rate of injuries was significantly lower in day care centers than at home (1.2 and 2.5, respectively, per 100 000 children-hours), but for children ages 3 to 6, the rates of injuries were similar in day care centers and at home (1.3 and 1.5, respectively, per 100 000 children-hours). The great majority of children attending day care centers were from 3 to 6 years of age. No significant differences were found in the severity of the injuries.

Conclusions. For children ages 3 to 6 years, which included most of the children attending day care centers in Stavanger, Norway, day care centers were not found to be safer than homes. We think continuing attention should be paid to injury control in day care centers.
Research in Pediatric Residency Programs
Authors: Brouhard Ben H. , Doylel Wilma , Aceves José , McHugh Michael J.
Published: December 2021

Background and Objectives. We have required residents in pediatrics at the Cleveland Clinic Foundation to give research presentations since 1989; this article reviews our experience with this program. Additionally, we sought to determine how many other accredited ted pediatric programs in the United States also require this.

Methods. Retrospective review of the Cleveland Clinic program; descriptive statistics of other United States residency programs, obtained by questionnaire.

Results. Pediatric residents at the Cleveland Clinic have given 108 research presentations since 1989, and have developed 33 (30.5%) of them into manuscripts or abstracts. We mailed questionnaires to 215 pediatric recidency program directors and received responses from 177 (82%). Of these, 48 (27%) indicated their programs had a research requirement; residents could present their findings in departmental meetings or submit an abstract or manuscript to a professional society or journal. Respondents cited several barriers to research: residents are too busy, there are too few faculty members to mentor them, financial resources are limited, and there is no residency review committee requirement.

Conclusions. Even though only approximately one fourth of the pediatric residency programs in the United States require research, we feel it is worthwhile experience. Despite barriers, residents can and do perform research and publish their findings.
Relationship Between Blood Lead and Nutritional Factors in Preschool Children: A Cross-sectional Study
Authors: Lucas Susan R. , Sexton Mary , Langenberg Patricia
Published: December 2021

Objective. The purpose of this study was to assess the relationships between selected nutritional factors and blood lead levels of preschool children.

Methodology. Data on 296 children, aged 9 to 72 months, who were cared for at the University of Maryland at Baltimore Pediatric Ambulatory Center were examined in this cross-sectional study. Nutritional status, socioeconomic aspects, medical history, and potential sources of lead exposure were assessed. Blood samples were evaluated for levels of blood lead, serum iron (ferritin), free erythrocyte photoporphyrin, calcium, and hematocrit.

Results. The average blood lead level was 11.4 µg/dL. Multicollinearity of nutritional factors was addressed using regression techniques. After adjusting for confounders, significant positive associations with blood lead were found for total caloric intake (P = .01) and dietary fat (P = .05).

Conclusions. The findings of this study suggest that even when behavioral and environmental exposures to lead were statistically controlled, total caloric intake and dietary fat each had an independent and significant association with the level of blood lead.
DOCTORS' INCOMES FALL AS MANAGED CARE GROWS
Authors: L. J. F.
Published: December 2021

For the first time in the 14 years that the American Medical Association (AMA) has been keeping track, doctors' incomes are falling as managed care organizations tighten their grip on the nation's health care system.

The median earnings of all physicians, from front-line general practitioners to highly-paid specialists like brain surgeons, dropped 3.8% last year to $150,000, from $156,000 in 1993, according to preliminary results from the AMA's latest annual survey.

The pressure on pay comes mostly from outside the profession: employers are demanding lower insurance premiums, and insurers are leaning on health care providers to cut costs.

But another factor is at work from within: an explosion in America's doctor population over the last 30 years. The number of physicians has soared to 660,582 today, or 252 for each 100,000 Americans—not counting federal government doctors—compared with 266,045, or 139 for each 100,000 in 1965.
Decreased Cardiac Responses to Auditory Stimulation During Prone Sleep
Authors: Franco Patricia , Groswasser Jose , Sottiaux Martine , Broadfield Ema , Kahn A.
Published: December 2021

Objective. To evaluate the relationship between body position during sleep and the infants' cardiac responses to auditory stimulation.

Methods. Thirty healthy infants with a median age of 11 weeks were studied polygraphically for one night, while sleeping successively prone and supine, or vice versa. Their behavioral and cardiac responses were recorded during rapid eye movement (REM) sleep, both before and after exposure to 90 dB (A) of white-noise.

Results. Ten infants were excluded from the study, because they woke up during the challenge. For the 20 infants included in the analysis, no significant difference was seen between the prone and the supine position for total sleep time, sleep efficiency, percent of REM and nonrapid eye movement sleep, number of gross body movements, transcutaneous oxygen saturation levels, mean cardiac rate, heart rate variability, number of heart rate drops; mean respiratory rate, and number or duration of central or obstructive apneas. Auditory challenges induced significantly less overall changes in heart rate, less heart rate drops, less heart rate variability, as well as fewer and shorter central apneas in the prone than in the supine position. Autoregressive power spectral analysis of the heart rate was consistent with a possible increase in orthosympathetic tone in the prone position.

Conclusion. Prone sleeping was associated with a decrease in cardiac responses to auditory stimulation and a possible increase in orthosympathetic activity. Prone positioning could favor a reduced reactivity to danger-signaling stimuli during REM sleep.
Congenital Unilateral Facial Paralysis
Authors: SHAPIRO NINA L. , CUNNINGHAM MICHAEL J. , PARIKH SANJAY R. , EAVEY ROLAND D. , CHENEY MACK L.
Published: December 2021

The initial optimal assessment of the neonate born with unilateral facial paralysis should be performed as soon after birth as possible by a multidisciplinary team with the goal being to distinguish between a traumatic or developmental etiology. Electrophysiologic studies, particularly ENOG testing, are essential for this differentiation; radiologic and audiologic studies are of potential diagnostic benefit. In children determined to have a unilateral facial paralysis of developmental origin, subsequent clinical exams complemented by electrophysiologic testing facilitate prognosis. Unfortunately, in the majority of developmental etiology cases, the likelihood of spontaneous improvement is negligible. In these children, reanimation procedures will need to be considered with limited information in the current literature to dictate the optimal age of such surgical intervention.
Condom Availability for Youth: A High-risk Alternative
Authors: COLLITON WILLIAM F.
Published: December 2021

The Committee on Adolescence might possibly have missed some of the data on teenage pregnancy and the alarming epidemic of sexually transmitted diseases occurring in that age group. Their report, "Condom Availability for Youth," could not be more incorrect. It is good to remember that 25 years have passed since the United States Congress adopted legislation establishing Title X of the Public Health Services Act. This act was to provide funding for sex education based on contraception as a solution to the teenage pregnancy problem.