bluuebunny/crossref_metadata_2025 huggingface dataset:
Low-Level Lead Exposure and Children's Cognitive Function in the Preschool Years
Authors: Bellinger David , Leviton Alan , Sloman Jone , Rabinowitz Michael , Needleman Herbert L. , Waternaux Christine
Published: December 2021

In a cohort of 170 middle and upper-middle class children participating in a prospective study of child development and low-level lead exposure, higher blood lead levels at age 24 months were associated with lower scores at age 57 months on the McCarthy Scales of Children's Abilities. The mean blood lead level at age 24 months was 6.8 µg/dL (SD = 6.3; 75th, 90th, and 99th percentiles: 8.8, 13.7, 23.6, respectively) and for all but 1 child was less than 25 µg/dL, the current definition of an "elevated" level. After adjustment for confounding, scores on the General Cognitive Index decreased approximately 3 points (SE = 1.4) for each natural log unit increase in 24-month blood lead level. The inverse association between lead level and performance was especially prominent for visual-spatial and visual-motor integration skills. Higher prenatal exposures were not associated with lower scores at 57 months except in the subgroup of children with "high" concurrent blood lead levels (ie, ≥10 µg/dL). The concentration of lead in the dentine of shed deciduous teeth was not significantly associated with children's performance after adjustment for confounding.
Detection of Phenylketonuria in the Very Early Newborn Blood Specimen
Authors: Doherty Lauren Barnico , Rohr Frances J. , Levy Harvey L.
Published: December 2021

Early hospital discharge of newborns is leading to collection of the newborn screening blood specimen during the first day of life in increasing numbers of newborns. There is concern that neonates with phenylketonuria who are tested this early may be missed. To examine this question, the authors screened specimens collected during the first 24 hours of life from 23 neonates at risk for hyperphenylalaninemia. The blood phenylalanine level in each of the 6 neonates with phenylketonuria and a seventh with mild hyperphenylalaninemia was greater than 2 mg/dL as early as 4 hours of age and 6 mg/dL or greater by 24 hours of age. A newborn screening phenylalanine cutoff level of 2 mg/dL would have identified all of these neonates within the first 24 hours of life, but a cutoff level of 4 mg/dL would have missed 2 of the 6 with phenylketonuria before 24 hours of life. Newborn screening programs should adopt a blood phenylalanine level of 2 mg/dL as the cutoff for suspicion of phenylketonuria and request for a second specimen. Breast-fed affected neonates had higher early blood phenylalanine elevations than formula-fed neonates, perhaps reflecting the higher protein (phenylalanine) content of colostrum.
Guidelines for the Evaluation of Sexual Abuse of Children
Authors:   Committee on Child Abuse and Neglect
Published: December 2021

There are few areas of pediatrics that have so rapidly expanded in clinical importance in recent years as sexual abuse of children. What Kempe referred to in 1977 as a "hidden pediatric problem"1 is certainly less hidden. Recent incidence studies, while imperfect, suggest approximately 1% of children will experience some form of sexual abuse each year.2 Children may be sexually abused either in intrafamilial or extrafamilial settings and are more frequently abused by males. Boys may be victimized nearly as often as girls. Adolescents are perpetrators in at least 20% of reported cases,2 and women may be perpetrators, especially in day-care settings.3 Pediatricians will encounter these cases in their practices and will be asked by parents and other professionals for their opinions. These guidelines are prepared for use by the primary care pediatrician. Pediatricians who "specialize" in the area of child abuse or child sexual abuse have generally developed their own protocols for their referral practices. In addition, specific American Academy of Pediatrics guidelines for the evaluation of rape of the adolescent are published and should be used for this age-group.4

Because a pediatrician has unique skills and a trusted relationship with patients and families, he or she will often be in a position to provide essential support and gain information not readily available to others involved in the investigative, evaluative, or treatment processes. By the same token, the pediatrician may feel inadequately prepared to perform a medical examination of a sexually abused child. The pediatrician should think about these issues when determining how best to utilize his or her skills while avoiding actions that may obstruct the collection of essential evidence.
Race, Culture, and Ethnicity
Authors: MADANSKY DEBORAH , EDELBROCK CRAIG
Published: December 2021

In Reply.—

We agree with Dr Pachter's point about the distinction between race and culture and about the relative insensitivity of race as a variable where ethnicity is the relevant concern. The division of our sample into white and nonwhite categories provided only the crudest measure of ethnicity. Our findings of a difference between the two groups certainly warrants further exploration of the beliefs about cosleeping among different ethnic/cultural groups.
Anabolic Steroid Education and Adolescents: Do Scare Tactics Work?
Authors: Goldberg Linn , Bents Robert , Bosworth Eric , Trevisan Louis , Elliot Diane L.
Published: December 2021

The opinions (level of agreement) of high school varsity football players with regard to reported effects of anabolic steroids were assessed before and after two different education interventions. Lectures and handouts of a balanced education program (potential risks and benefits) were compared with a risks-only (negative or "scare tactics") presentation, in a controlled manner. Those receiving the balanced review significantly increased their agreement with 5 of 10 targeted adverse effects, while no change occurred for any risks among those taught by the negative intervention. A teaching model that only emphasizes the untoward consequences of anabolic steroids is ineffective, even in the short-term. A balanced education approach can improve understanding of the potential adverse effects of these drugs. Additional strategies may be required to change young athletes' attitudes toward anabolic androgenic steroid use.
Maternal Employment During the Early Postpartum Period: Effects on Initiation and Continuation of Breast-feeding
Authors: Gielen Andrea Carlson , Faden Ruth R. , O'Campo Patricia , Brown C. Hendricks , Paige David M.
Published: December 2021

This study sought to determine whether and to what extent maternal employment in the early postpartum period is associated with the initiation and continuation of breast-feeding in a heterogeneous, urban population. A panel of women were interviewed twice during the first 3 months postpartum. In analyses adjusted for maternal demographic characteristics, there was no association between planning to be employed within the first 6 months postpartum and initiation of breast-feeding. However, actually being employed was significantly associated with cessation of breast-feeding as early as 2 or 3 months postpartum, even after adjustment for maternal demographic variables. Less than one half of mothers who were employed were still breast-feeding at the second postpartum interview, whereas two thirds of those who were not employed were still breast-feeding. Among employed mothers, working no more than 20 hours per week appeared to be protective for continued breast-feeding.
Neuropsychological Outcome of Pediatric Liver Transplantation
Authors: Stewart Sunita M. , Waller David A. , Uauy Ricardo , Andrews Walter S. , Hiltebeitel Cheryl , Nici Janice
Published: December 2021

Children with end-stage liver disease who undergo liver transplantation may have unrecognized neuropsychological and academic deficits, for which remediation programs may be available. Intellectual, academic, and neuropsychological measures of 28 pediatric patients who had received successful liver transplantation at least 1 year previously were compared with those of 18 patients with cystic fibrosis (to control for effects of growth retardation and chronic illness) matched for age, age at diagnosis, physical growth, and parents' socioeconomic status. Liver transplant patients had significantly lower scores on nonverbal intelligence tests (mean ± SD for liver transplant vs cystic fibrosis patients: 89.1 ± 19.1 vs 105.8 ± 17.6), lower academic achievement, and lower z scores for age in the areas of learning and memory (-0.68 ± 1.09 vs 0.19 ± 1.24), abstraction and concept formation (-1.73 ± 1.58 vs -0.79 ± 1.37), visual-spatial function (-0.66 ± 1.09 vs 0.10 ± 0.69), and motor function (-0.13 ± 0.85 vs 0.36 ± 0.57). No differences were found on tests of verbal intelligence, or in alertness and concentration, perceptual-motor, and sensory-perceptual areas. Cyclosporine levels were found to correlate positively with motor speed (r = .41, P < .05). Thorough psychoeducational and neuropsychological evaluations should be considered for pediatric patients who receive liver transplantation to allow these children to maximize their potential.
Outcome of ≤800-Gram Birth Weight Infants
Authors: KILBRIDE HOWARD W. , DAILY DONNA K.
Published: December 2021

To the Editor.—

The article by Hoffman and Bennett1 suggests that there has been increased morbidity accompanying improved survival for infants ≤800 g birth weight. We reported survival and neurodevelopmental outcome for infants of this birth weight born at our institutions in 1983 to 1985 compared with an earlier 3-year period.2 Our recent survival was comparable with that of Hoffman and Bennett (40% and 46%). Using similar definitions, we found that 13% of infants >1 year of age who were tested had major disabilities.
Secular, Means What?
Authors: MORRIS CYNTHIA
Published: December 2021

In Reply.—

I would like to thank Dr Shaw for his catholic comments on the terminology in our article. Because the study population originated from both church and state institutions during a period of 16 years, we are confident that there were neither secular1 nor secular2 effects on survival.
Prospective Observations of 100 High-Risk Neonates by High-Field (1.5 Tesla) Magnetic Resonance Imaging of the Central Nervous System: I. Intraventricular and Extracerebral Lesions
Authors: Keeney Susan E. , Adcock Eugene W. , McArdle Craig B.
Published: December 2021

The results of observations of the first 100 neonates at the University of Texas Health Science Center (Houston) who received magnetic resonance imaging of the central nervous system by means of a high-field image (1.5 T) are reported. All were assessed prospectively to be at risk for neurodevelopmental delay. This first report specifically addresses the appearance of primarily hemorrhagic intracranial lesions, including intraventricular hemorrhage (n = 28), and extracerebral lesions, which include 3 cases of venous sinus thrombosis (n = 20). The signal intensities of hemorrhage underwent a characteristic evolution with time with only minor variations in the study group. Magnetic resonance imaging detected direct evidence of hemorrhage for up to 2 months, but hemosiderin was detected as a late indicator of hemorrhage for up to 9 months. Magnetic resonance imaging was equal in benefit to head ultrasonography and computed tomography for the diagnosis of intraventricular hemorrhage, but magnetic resonance imaging was also able to approximate the time of onset of hemorrhage. Magnetic resonance imaging was superior for the evaluation of extracerebral hemorrhage; ultrasonography failed to detect any of these lesions and computed tomography detected only 3 of 7. Short-term neurological abnormality was assessed, but the ability of magnetic resonance imaging to predict long-term neurodevelopmental delay is unknown and is the subject of an ongoing project.
Human Breast Milk Contains Bovine lgG. Relationship to Infant Colic?
Authors: Clyne Patrick S. , Kulczycki Anthony
Published: December 2021

Previous studies have suggested that an unidentified cow's milk protein, other than β-lactoglobulin and casein, might play a pathogenetic role in infant colic. Therefore, a radioimmunoassay was used to analyze human breast milk and infant formula samples for the presence of bovine IgG. Milk samples from 88 of the 97 mothers tested contained greater than 0.1 µg/mL of bovine IgG. In a study group of 59 mothers with infants in the colic-prone 2- to 17-week age group, the 29 mothers of colicky infants had higher levels of bovine IgG in their breast milk (median 0.42 µg/mL) than the 30 mothers of noncolicky infants (median 0.32 µg/mL) (P < .02). The highest concentrations of bovine IgG observed in human milk were 8.5 and 8.2 µg/mL. Most cow's milk-based infant formulas contained 0.6 to 6.4 µg/mL of bovine IgG, a concentration comparable with levels found in many human milk samples. The results suggest that appreciable quantities of bovine IgG are commonly present in human milk, that significantly higher levels are present in milk from mothers of colicky infants, and that bovine IgG may possibly be involved in the pathogenesis of infant colic.
Appearance of the Hymen in Newborns
Authors: Berenson Abbey , Heger Astrid , Andrews Sally
Published: December 2021

This study was undertaken to evaluate the genital anatomy of female newborns. Hymenal configuration and the number and location of clefts, bumps, tags, and ridges were observed in 468 neonates; photographs for confirmation were obtained for 449 neonates (96%). Hymenal configurations observed included an annular hymen with a central or ventrally displaced orifice in 80% (372/468) of neonates, a fimbriated hymen in 19% (90/468), and a septated or cribriform hymen in 1% (6/468). Configurations significantly differed by race (P < .001) but no difference was noted by gestational age or weight. Clefts, which occurred only on the ventral 180 degrees of the rim, were observed in 34% of neonates with an annular hymen. Fifty-six percent of neonates had a longitudinal intravaginal ridge, 87% had an external hymenal ridge, and 13% had a tag extending from the rim or a ridge. Periurethral ligaments were frequently observed. It is concluded that lateral and ventral clefts, intravaginal and external ridges, and periurethral bands are normal anatomical findings in the newborn.
Olfactory Classical Conditioning in Neonates
Authors: Sullivan Regina M. , Taborsky-Barba Suzanne , Mendoza Raffael , Itano Alison , Leon Michael , Cotman Carl W. , Payne Terrence F. , Lott Ira
Published: December 2021

One-day-old, awake infants underwent an olfactory classical conditioning procedure to assess associative learning within the olfactory system of newborns. Experimental infants received ten 30-second pairings of a novel olfactory conditioned stimulus (a citrus odor of neutral value) and tactile stimulation provided by stroking as the reinforcing unconditioned stimulus (a stimulus with positive properties). Control babies received only the odor, only the stroking, or the stroking followed by the odor presentation. The next day, all infants, in either the awake or sleep state, were given five 30-second presentations of the odor. Results were analyzed from video tapes scored by an observer unaware of the infants' training condition. The results indicate that only those infants who received the forward pairings of the odor and stroking exhibited conditioned responding (head turning toward the odor) to the citrus odor. The performance of the conditioned response was not affected by the state of the baby during testing, because both awake and sleeping infants exhibited conditioned responses. Furthermore, the expression of the conditioned response was odor specific; a novel floral odor presented during testing did not elicit conditioned responses in the experimental babies. These results suggest that complex associative olfactory learning is seen in newborns within the first 48 hours of life. These baseline findings may serve as normative data against which observation from neonates at risk for neurological sequelae may be compared.
Primary Vesicoureteral Reflux in the Black Child
Authors: Skoog Steven J. , Belman A. Barry
Published: December 2021

Primary vesicoureteral reflux is a polygenic abnormality due to a deficiency of the ureterovesical junction which allows urine in the bladder to ascend into the ureter and kidney. Fifty-one black children with primary vesicoureteral reflux were evaluated and treated at Children's Hospital from 1976 to 1986. The results of the evaluation and treatment were compared with those of 493 white patients with primary vesicoureteral reflux seen during the same time interval. The general approach to management was nonsurgical. There were no radical differences in the mode of presentation, age at presentation, and age at resolution. The distribution of reflux by maximum grade was not affected by race. Overall, 19 (37%) black children experienced spontaneous resolution of reflux. The mean duration of reflux in black children who had spontaneous resolution was 14.6 months. This duration was statistically significantly shorter than that in white patients with spontaneous resolution of vesicoureteral reflux (P < .005). Surgical correction was believed to be required in 8 (16%) patients and 8 (16%) were lost to follow-up. Renal scarring demonstrated by intravenous pyelogram or renal scan was initially present in 12 (23%) black patients compared with 65 (13%) white patients. This was due to a higher percentage of renal scarring in black girls which was not explained by distribution of grades of reflux. There was no progression of scarring in our black patients, whereas 3 (0.6%) white patients had progression of scarring. Although vesicoureteral reflux is rarely seen in black patients (9% of series), it has similar demographic features. Renal scarring is more frequent in black girls, but one can anticipate a faster rate of spontaneous resolution than in the white population.
Hypovolemic Shock in a Child as a Consequence of Corporal Punishment
Authors: EICHELBERGER SCOTT P. , BEAL DOUGLAS W. , MAY RONALD B.
Published: December 2021

Corporal punishment is an accepted form of discipline in the American home and school despite numerous publications in various fields reporting concerns.1-7 We describe a case of paddling associated with hypovolemic shock.

CASE REPORT

The patient, a 5-year-old black girl with no known underlying health problems, was seen at a local emergency department for complaints of progressive weakness. The previous day she had been paddled by her mother for disciplinary reasons. Her mother had used a wooden paddle, spanking her on the buttocks and upper thighs. Neither mother nor daughter could recall the number of blows administered. Shortly after being spanked, the child complained of generalized soreness over the area of injury.
Collodion Baby, Sign of Tay Syndrome
Authors: KOUSSEFF BORIC G.
Published: December 2021

Contemporary pre- and neonatal care has prolonged the survival of newborns with severe genodermatoses, including the harlequin and collodion baby phenotypes.1 This has provided an excellent opportunity for longitudinal observations that have illustrated the nonspecificity of these clinical concepts and the limited number of ways integumentum commune has in responding to varied noxae. In addition, such observations reflect the long-term dynamics of skin changes. The dynamics could lead to a string of sometimes even contradictory morphologic diagnoses. I describe a collodion baby by phenotype, a girl who in time had several different diagnoses.2 Eventually, an 8-year period of reevaluations with several cutaneous biopsies and hair analysis resulted in a diagnosis considered accurate and etiologically sound.
Extraordinary Urinary Frequency
Authors: COLODNY ARNOLD H.
Published: December 2021

To the Editor.—

I certainly enjoyed reading the article, "Extraordinary Urinary Frequency" by Drs Zoubek, Bloom, and Sedman1 from the University of Michigan, published in Pediatrics in June, 1990.

I agree with most of what their article states. However, there are a few points of disagreement I would like to call to the attention of the readers of Pediatrics.

Number one is their statement that anticholinergics are ineffective. I have found that anticholinergics frequently are effective in breaking the cycle and alleviating the symptom of extraordinary frequency.
Extraordinary Urinary Frequency
Authors: BLOOM DAVID A. , SEDMAN AILEEN , ZOUBEK JERI
Published: December 2021

In Reply.—

Thank you for your letter and the comment on our paper. Dr Colodny raises some important points.

Our main point is that children with isolated extraordinary daytime frequency do not need extensive hematologic, radiologic, urodynamic, and psychiatric studies nor do they need routinely vigorous pharmacologic treatment. Even oxybutynin chloride is not innocuous. In addition to heat intolerance, facial flushing, and dry mouth, we have seen it cause attention deficits at school, hair loss, irritability, constipation, diarrhea, and dental problems, so we are reluctant to use this as liberally as we would a placebo.
Pierre Robin Sequence Management
Authors: BROOKS LEE J.
Published: December 2021

To the Editor.—

The recent report by Bull et al, "Improved Outcome in Pierre Robin Sequence: Effect of Multidisciplinary Evaluation and Management" (Pediatrics. 1990;86:294-301), emphasized the importance of multidisciplinary approach, including a sleep center evaluation for patients with complex craniofacial disorders. The authors' point that oximetry alone is inadequate should be emphasized, their data demonstrates the difficulty in interpreting polysomnographic data in children, especially during active times such as feeding.

In Figure 2, the signal from the thoracic and abdominal strain gauges are of low amplitude and irregular, with no obvious relationship to airflow.
Very Low Birth Weight Outcomes of the National Institute of Child Health and Human Development Neonatal Network
Authors: Hack Maureen , Horbar Jeffrey D. , Malloy Michael H. , Wright Linda , Tyson Jon E. , Wright Elizabeth
Published: December 2021

This report describes the neonatal outcomes of 1765 very low birth weight (<1500 g) infants delivered from November 1987 through October 1988 at the seven participating centers of the National Institute of Child Health and Human Development Neonatal Intensive Care Network. Survival was 34% at <751 g birth weight (range between centers 20% to 55%), 66% at 751 through 1000 g (range 42% to 75%), 87% at 1001 through 1250 g (range 84% to 91%), and 93% at 1251 through 1500 g (range 89% to 98%). By obstetric measures of gestation, survival was 23% at 23 weeks (range 0% to 33%), 34% at 24 weeks (range 10% to 57%), and 54% at 25 weeks (range 30% to 72%). Neonatal morbidity included respiratory distress (67%), symptomatic patent ductus arteriosus (25%), necrotizing enterocolitis (6%), septicemia (17%), meningitis (2%), urinary tract infection (4%), and intraventricular hemorrhage (45%, 18% grade III and IV). Morbidity increased with decreasing birth weight. Oxygen was administered for ≥28 days to 79% of <751-g birth weight infants (range between centers 67% to 100%), 45% of 751-through 1000-g infants (range 20% to 68%), and 13% of 1001- through 1500-g infants (range 5% to 23%). Ventilator support for ≥28 days was given to 68% of infants at <751 g, 29% at 751 through 1000 g, and 4% at >1000 g. Hospital stay was 59 days for survivors vs 15 days for infants who died. Sixty-nine percent of survivors had subnormal (<10th percentile) weight at discharge. The data demonstrate important intercenter variation of current neonatal outcomes, as well as differences in philosophy of care and definition and prevalence of morbidity.
Carrying as Colic "Therapy": A Randomized Controlled Trial
Authors: Barr Ronald G. , McMullan Sara J. , Spiess Heinz , Leduc Denis G. , Yaremko John , Barfield Randy , Francoeur T. Emmett , Hunziker Urs A.
Published: December 2021

In healthy infants, crying behavior is reduced significantly by "supplemental" carrying; that is, increased carrying throughout the day in addition to that which occurs during feeding and in response to crying. To determine whether the recommendation to increase carrying would be effective as a therapy for colic, 66 mothers of infants 4 weeks of age or less who came to their pediatricians with complaints of crying problems ("colic") were randomized to receive standard pediatric advice (standard group) or standard advice plus the recommendation to increase supplemental carrying by 50% (supplemental group). Overall, the supplemental group carried their infants 6.1 hours/d throughout the intervention period, an increase of 2.2 hours/d (56%) more than that provided by the standard group. Despite this significant increase in carrying, there was no difference between groups in the duration or freguency of crying, fussing, or cry/fuss at any time throughout the intervention period. When the greatest treatment effect was expected at 6 weeks, the supplemental group infants cried only 3 minutes less per day (95% confidence interval: 37 minutes less to 32 minutes more per day). We conclude that, compared with standard pediatric advice to be "responsive," supplemental carrying does not reduce crying and fussing behavior further in infants who have colic. In marked contrast to healthy infants, this apparent resistance to increased carrying may indicate an important difference in state regulation and control in infants with colic.
Police Involvement in Pediatric Prehospital Care
Authors: Sinclair Lisa M. , Baker M. Douglas
Published: December 2021

One hundred fourteen emergency medical services agencies and 76 police chiefs throughout the United States were prospectively surveyed to ascertain the current utilization of police personnel within the prehospital care system. More than three fourths (77%) of the surveys mailed were completed. Respondents indicated the following: (1) a majority (92%) of police personnel were trained in cardiopulmonary resuscitation and basic first aid, (2) only half (57%) of police were trained in moving or transporting patients, and (3) few (36%) police were provided ongoing training in emergency pediatric medical skills. In spite of this, police were reportedly present at calls activating emergency medical services systems between 24% and 69% of the time, and the majority of these were trauma related. Police chiefs surveyed indicated that their officers played a large role in medical management prior to arrival of emergency medical services personnel; 87% would initiate cardiopulmonary resuscitation and 93% would begin basic first aid. Sixty-one percent of police chiefs indicated that officers would occasionally "scoop and run" with a critically ill child rather than await emergency medical services arrival. The data indicate that, right or wrong, police personnel are actively involved in their prehospital care system at present. In many instances, their help may be needed. Further thought should be given toward defining an exact emergency medical services role for police personnel and toward providing adequate initial and ongoing basic medical training for these individuals.
Cognitive Development of Children Following Early Repair of Transposition of the Great Arteries Using Deep Hypothermic Circulatory Arrest
Authors: Bellinger David C. , Wernovsky Gil , Newburger Jane W. , Rappaport Leonard A. , Mayer John E. , Castaneda Aldo R. , Jonas Richard A. , Farrell David M. , Wessel David L. , Lang Peter , Hickey Paul R.
Published: December 2021

Twenty-eight children who underwent corrective cardiac surgery in early infancy had developmental evaluations to explore whether cardiopulmonary bypass perfusion variables are associated with later cognitive function. All had transposition of the great arteries repaired by the arterial switch operation using deep hypothermic circulatory arrest. The mean duration of deep hypothermic circulatory arrest was 64 ± 10 minutes (mean ± SD). Median age at repair was 4 days (range 1 to 125 days). Tests of development were administered at age 7 to 53 months: Bayley Scales for children younger than 30 months of age (n = 18) and McCarthy Scales for older children (n = 10). Overall cognitive development score was 101.2 ± 11.1. Duration of deep hypothermic circulatory arrest was not associated with performance. However, for core cooling periods of less than 20 minutes' duration, shorter cooling periods were associated with lower scores (r = .85, n = 11, P < .001). These data suggest that patients undergoing relatively long periods of deep hypothermic circulatory arrest may require some minimum time of cardiopulmonary bypass cooling to avoid central nervous system injury.
Career Satisfaction in Pediatrics
Authors: STRAIN JAMES E.
Published: December 2021

In Reply.—

Dr Bosley cites the article by Schunk and Osterud on "Duration of Pediatric and Internal Medicine Practice in Oregon" (Pediatrics. 1989;83:28-432). A survey of Oregon pediatricians and internists older than 60 years of age showed close agreement between the two groups in their satisfaction with their career choices. Internists averaged 8.2 on a linear scale (with 0 representing low satisfaction and 10 representing high satisfaction), and pediatricians averaged 8.0.

Despite similar responses to career satisfaction, 76% of the internists indicated they would select internal medicine if they had it to do over again, but only 44% of the pediatricians said they would select the same specialty.
Diabetes Mellitus Associated With Cystic Fibrosis: Applying American Diabetes Association Standards
Authors: SHEEHAN JOHN P. , ULCHAKER MARGARET M.
Published: December 2021

To the Editor.—

The article of Reisman et al1 in the September 1990 issue of Pediatrics suggests that a diagnosis of diabetes mellitus does not impact survival negatively, in contradiction to an earlier study.2 It is therefore pertinent to look at the diagnostic and treatment criteria for Reisman et al's patients. First, the nondiabetic patients were not proven to be so based on glucose tolerance test. A recent study highlighted the fact that the glucose tolerance test may be required to diagnose accurately more than 60% of patients.3
Diabetes Mellitus Associated With Cystic Fibrosis: Applying American Diabetes Association Standards
Authors: REISMAN JOE
Published: December 2021

In Reply.—

John Sheehan and Margaret Ulchaker make several interesting points in their letter. They were critical of the fact that nondiabetic patients were not proven to be so by glucose tolerance testing. To test more than 530 patients regularly with such testing is not felt to be indicated or practical in our clinic. Although such testing may identify individuals with abnormal glucose metabolism, this manuscript was concerned with survival of insulin-dependent diabetics.1 Such patients when untreated will spill sugar in their urine, and/or exhibit other clinical symptoms, and thus be identified at their regular clinic visits.
Neuroanatomic Imaging in Autism
Authors: Courchesne Eric
Published: December 2021

In the last decade, neuroimaging research has established that neuroanatomical abnormalities often occur in autistic individuals, but no single type of reported abnormality is ubiquitous in autism. Abnormalities in cerebral cortex, thalamus, basal ganglia, and brainstem have been inconsistently found or infrequently reported, but definitive studies remain to be done. Enlargement of cerebrospinal fluid spaces is present in some autistic people.1-10 One of the most frequently found abnormalities in autism with and without mental retardation is a reduction of cerebellar tissue.1,2,4,5,11-22 The reduction in cerebellar tissue appears to be greatest in neocerebellar regions within the vermis and hemispheres.4,11,12,15,16,18-22 The reduction appears to be the result of developmental hypoplasia rather than damage following full development, and so it may serve as a temporal marker to identify the events that damage the developing brain in autism, including other neural structures that may be concomitantly damaged.11

CEREBRAL HEMISPHERES, THALMUS, BASAL GANGLIA, AND LATERAL AND THIRD VENTRICLES

Quantitative Imaging Studies

Early quantitative computed tomography (CT) studies reported unusual parietooccipital and frontal asymmetries in autistic patients.23 Fourteen recent CT and magnetic resonance (MR) studies involving 283 autistic subjects have quantitated the size, volume, night-left asymmetry, and radio density on signal intensity of either the cerebral hemispheres, thalamus, basal ganglia, limbic structures, lateral ventricles, or third ventricle (Tables 1 and 2). In addition, these structures have been microscopically examined at autopsy in several cases of autism (Table 1).

As seen in Tables 1 and 2, in quantitative neuroimaging studies there is no substantial evidence of abnormality in the cerebral hemispheres, corpus callosum, thalamus, basal ganglia, brain volume, lateral ventricles, and third ventricles.
Microscopic Neuroanatomic Abnormalities in Autism
Authors: Bauman Margaret L.
Published: December 2021

Since its initial description in 1943,1 autism has been primarily conceptualized as a behavioral disorder, and for many years it was believed to be the result of parental and environmental influences. With heightened clinical interest in the disorder, coincident with advances in medical technology, however, evidence for an underlying neurologic basis for autism has become increasingly apparent.

HISTORICAL NEUROPATHOLOGIC PERSPECTIVE

Based largely on the constellation of symptoms that characterize the disorder, various anatomical sites within the brain have been suggested as a possible primary source of pathology in autism. Suspected regions have included the medial temporal lobe,2-5 the thalamic nuclei,6 the basal ganglia,7 and the vestibular system.8 Computed tomographic imaging studies have shown inconsistent findings.9-14 More recently, however, magnetic resonance imaging studies have described abnormalities in portions of the cerebellum and posterior fossa.15-17

Direct microscopic examination of the autistic brain has, until recently, yielded little information. Aarkrog18 reported "slight thickening of the arterioles, slight connective tissue increase in the leptomeninges, and some cell increase" in a frontal lobe biopsy performed on an autistic patient. Later, in 1976, 33 cases of childhood psychosis were reviewed by Darby.19 Although he suggested a possible correlation between limbic system lesions and the affective symptomatology of autism, no consistent neuropathologic findings were found. In 1980, Williams et al20 studied sections of brain from four patients with autistic-like behavior; looking primarily for cell loss and gliosis, they failed to find any consistent abnormalities.

MICROSCOPIC NEUROANATOMIC OBSERVATIONS

In 1984, anatomic abnormalities were reported in the brain of a 29-year-old man with well-documented autism; the technique of whole brain serial section was used, and the patient was studied in comparison with an identically processed age- and sex-matched control subject.21,22
Maternal Versus Infant Factors Related to Breast Milk Intake and Residual Milk Volume: The DARLING Study
Authors: Dewey Kathryn G. , Heinig M. Jane , Nommsen Laurie A. , Lonnerdal Bo
Published: December 2021

Factors related to milk volume and sources of variance in intake were examined using data at 3 months from the longitudinal Davis Area Research on Lactation, Infant Nutrition and Growth study. Milk intake of 73 exclusively breast-fed infants was measured by 4-day test-weighing, correcting for insensible water loss. Total volume extracted was assessed by a combination of test-weighing and expression of breast contents during a subsequent 24-hour period. Residual milk volume was calculated as volume extracted minus intake. Intake, volume extracted, and residual milk volume averaged 818, 914, and 109 g/d, respectively. The interindividual coefficient of variation in intake (16.3%) was greater than within-individual day-to-day variation (8.9%). In comparing those with low (<650 g/d) vs average intake, there was no significant difference in residual milk volume between groups (85 vs 111 g/d), indicating that infants with low intakes left as much milk unconsumed as those with higher intakes. There were no differences between groups in maternal age, parity, or anthropometric indices. Infants with low intakes were smaller and spent less time nursing, even though their mothers reportedly nursed on demand. In linear regressions, none of the maternal variables was significantly correlated with intake, volume extracted, or residual milk volume. Infant birth weight, weight at 3 months, and total time nursing were positively associated with intake. The results suggest that infant demand is the main determinant of lactation performance in populations such as this.
Early Vaginal Bleeding, Late Prenatal Care, and Misdating in Adolescent Pregnancies
Authors: Stevens-Simon Catherine , Roghmann Klaus J. , McAnarney Elizabeth R.
Published: December 2021

Vaginal bleeding early in pregnancy may be mistaken for menstrual bleeding and delay entry into prenatal care by delaying the diagnosis of pregnancy. This study tests the hypotheses that (1) more adolescents report early first-trimester vaginal bleeding than do adults and (2) a history of vaginal bleeding is associated with later entry into prenatal care, particularly among adolescents. Reports of early vaginal bleeding were prospectively obtained from black, predominantly primiparous, unmarried poor women (136 adolescents and 53 adults). As hypothesized, more adolescents reported early first-trimester vaginal bleeding than did adults (16.9% vs 5.7%; P < .01). Adolescents who reported early vaginal bleeding also entered prenatal care later (16.2 weeks) than did adolescents who reported no bleeding (12.7 weeks) (P < .03); this was not true for adults. If dating of the gestation is based solely on last menstrual period history, inflation of the incidence of preterm births to adolescents and the mean birth weights of those preterm neonates may occur. The findings suggest that new strategies focusing on the recognition of menstrual irregularities as a symptom of pregnancy may be needed to promote early prenatal care among adolescents. Additionally, adolescent pregnancies should be dated by both ultrasound and Dubowitz examinations.
School-age Mothers: Predictors of Long-term Educational and Economic Outcomes
Authors: Horwitz Sarah McCue , Klerman Lorraine V. , Kuo H. Sung , Jekel James F.
Published: December 2021

The long-term effects of school-age pregnancy were investigated in a 20-year follow-up of a cohort of women who were pregnant adolescents in the late 1960s. Of the 149 living young black primiparas in the original cohort, 121 (81%) were located and interviewed. At follow-up the study population ranged in age from 32 to 38 years, 68% were unmarried, 71% had finished high school, 82% were completely self-supporting, and 27% reported living in public housing. Long-term success, defined as currently employed or supported by a spouse and a high school education (62%) or its equivalent, was associated with six features: having completed more school prior to becoming pregnant (odds ratio [OR] = 18; 95% confidence interval [CI] 2.3, 139.5); participating more actively in a program intervention offered to these pregnant teenagers 20 years ago (OR = 11.11; 95% CI 1.54, 79.87); being in school with no subsequent pregnancy at 26 months postpartum (OR = 10.1; 95% CI 1.64, 62.07); feeling in control of one's life (OR = 5.4; 95% CI 1.36, 21.54) and little social isolation (OR = 8.24; 95% CI 1.56, 43.50) at 26 months postpartum; and lifetime fertility control defined as one or two children after the index child (OR = 14.19; 95% CI 3.28, 61.29). It is concluded that most former teenage mothers complete a reasonable amount of education and are economically self-sufficient. Further, a comprehensive program that served these women 20 years ago when they were pregnant was related to long-term success. This result supports the idea that short-term targeted spending can produce long-term social benefits.
Risk Factors for Attempted Suicide in Gay and Bisexual Youth
Authors: Remafedi Gary , Farrow James A. , Deisher Robert W.
Published: December 2021

Studies of human sexuality have noted high rates of suicidality among homosexual youth, but the problem has not been systematically examined. This work was undertaken to identify risk factors for suicide attempts among bisexual and homosexual male youth. Subjects were 137 gay and bisexual males, 14 through 21 years of age, from the upper Midwest and Pacific Northwest. Forty-one subjects (41/137) reported a suicide attempt; and almost half of them described multiple attempts. Twenty-one percent of all attempts resulted in medical or psychiatric admissions. Compared with nonattempters, attempters had more feminine gender roles and adopted a bisexual or homosexual identity at younger ages. Attempters were more likely than peers to report sexual abuse, drug abuse, and arrests for misconduct. The findings parallel previous studies' results and also introduce novel suicide risk factors related to gender nonconformity and sexual milestones.
Linea Vestibularis: A Previously Undescribed Normal Genital Structure in Female Neonates
Authors: KELLOGG NANCY D. , PARRA JUAN M.
Published: December 2021

The increasing number of evidentiary examinations conducted for sexual abuse has accentuated the importance of defining normal genital anatomy, particularly within the vestibule of female children. In female newborns, normal anatomical variations of the hymen have been described1,2 but anatomical variations of the posterior vestibule underlying the hymen have not been reported. In children evaluated for sexual abuse a vestibular structure of varying description and location has been reported. A "midline avascular streak," "scar," and "a white area" have been noted in the posterior vestibule, posterior fourchette, and hymen.1,3,4 Whether these descriptions all pertain to a single entity or are multiple lesions is not known.
Summary of Major Changes in the 1991 Red Book
Authors:   Committee on Infectious Diseases
Published: December 2021

In 1991, the new edition of the Report on the Committee on Infectious Diseases (the Red Book) has been published by the American Academy of Pediatrics (AAP), providing the most recent recommendations and guidelines for control and management of infectious diseases in infants and children.1 These recommendations and guidelines are based on information available through October, 1990 and replace those given in the 1988 Red Book. To aid physicians and other health care professionals in assimulating new recommendations and information into their practices, a summary of major changes is given in the Red Book. This summary is reprinted here (with minor changes). Subsequent recommendations of the American Academy of Pediatrics are published as committee statements in AAP News and Pediatrics. In keeping with the 2-to 3-year intervals between the editions of the Red Book, the next edition is anticipated in late 1993 or 1994.

Major changes in recommendations and related information in the 1991 Red Book are summarized as follows:

1. Immunization Recommendations. The schedules for routine immunization incorporate the changes in recommendations for Haemophilus b, as of October, 1990 (See "Note.") and measles vaccines. In view of the increased complexity of immunization schedules, particular attention should be given to the footnotes in the immunization schedules. The schedule recommended by the World Health Organization Expanded Programme on Immunization (EPI) is also included.

2. Reporting of Adverse Events. The new procedure for reporting adverse events following administration of vaccines (VAERS) is described.

3. Contraindications to Vaccines. The recommendation concerning a minor illness as a possible contraindication to diphtheria-tetanus-pertussis (DTP) immunization has been modified.
Evaluation of Heart Murmurs
Authors: SMYTHE JOHN F. , TEIXEIRA OTTO H. P. , VLAD PETER , DEMERS PIERRE PAUL , FELDMAN WILLIAM
Published: December 2021

In Reply.—

We find that when the patient has not been diagnosed as having organic heart disease, the authority of the cardiologist is challenged rarely, because most people accept the concept that those who dedicate full time to a specific activity (the cardiologist) have a higher level of confidence than those who do not (family physician). Obviously, the problem is more complicated when there is need to delabel a child previously diagnosed incorrectly. We find then that laboratory studies are helpful to alleviate unnecessary but persistent parental concerns.
Newborn Screening for Cystic Fibrosis
Authors: LYON IAN C. T. , WEBSTER DIANNE R.
Published: December 2021

To the Editor.—

The report on newborn screening for cystic fibrosis1 illustrates the need for continued evaluation of such programs. The authors state that the identification of cases of cystic fibrosis (CF) by an elevated level of immunoreactive trypsinogen (IRT) in second (follow-up) samples from infants with positive initial screening tests could result in false negatives in 27% of cases of cystic fibrosis without meconium ileus (MI).

We have screened 401 122 infants using the method originally reported.2
Obstructive Sleep Apnea in Children With Down Syndrome
Authors: Marcus Carole L. , Keens Thomas G. , Bautista Daisy B. , von Pechmann Walter S. , Ward Sally L. Davidson
Published: December 2021

Children with Down syndrome have many predisposing factors for the obstructive sleep apnea syndrome (OSAS), yet the type and severity of OSAS in this population has not been characterized. Fifty-three subjects with Down syndrome (mean age 7.4 ± 1.2 [SE] years; range 2 weeks to 51 years) were studied. Chest wall movement, heart rate, electrooculogram, end-tidal Po2 and Pco2, transcutaneous Po2 and Pco2, and arterial oxygen saturation were measured during a daytime nap polysomnogram. Sixteen of these children also underwent overnight polysomnography. Nap polysomnograms were abnormal in 77% of children; 45% had obstructive sleep apnea (OSA), 4% had central apnea, and 6% had mixed apneas; 66% had hypoventilation (end-tidal Pco2, >45 mm Hg) and 32% desaturation (arterial oxygen saturation <90%). Overnight studies were abnormal in 100% of children, with OSA in 63%, hypoventilation in 81%, and desaturation in 56%. Nap studies significantly underestimated the presence of abnormalities when compared to overnight polysomnograms. Seventeen (32%) of the children were referred for testing because OSAS was clinically suspected, but there was no clinical suspicion of OSAS in 36 (68%) children. Neither age, obesity, nor the presence of congenital heart disease affected the incidence of OSA, desaturation, or hypoventilation. Polysomnograms improved in all 8 children who underwent tonsilletomy and adenoidectomy, but they normalized in only 3. It is concluded that children with Down syndrome frequently have OSAS, with OSA, hypoxemia, and hypoventilation. Obstructive sleep apnea syndrome is seen frequently in those children in whom it is not clinically suspected. It is speculated that OSAS may contribute to the unexplained pulmonary hypertension seen in children with Down syndrome.
Foreign Body Pulmonary Granulomas in an Abuser of Nasally Inhaled Drugs
Authors: JOHNSON DANIEL COREY , PETRU ANN , AZIMI PARVIN H.
Published: December 2021

Development of pulmonary granulomas from injected foreign substances is a known complication of intravenous drug abuse.1 We observed the development of foreign body granulomas in the lungs of a patient who abused methamphetamines solely by nasal inhalation.

CASE REPORT

J.R. was a 15-year-old white boy who presented with a 1-month history of intermittent fever, night sweats, pleuritic chest pain on inspiration, and cough. He specifically denied anorexia, weight loss, intravenous drug abuse, homosexuality, known exposure to asbestos or silicone, or contact with birds or hay. He admitted to a severalmonth history of snorting "crank," a powdered form of methamphetamines. He had smoked one pack of cigarettes per day for the previous year.