bluuebunny/crossref_metadata_2025 huggingface dataset:
Comprehensive Computerized Neonatal Intensive Care Unit Data System Including Real-Time, Computer-Generated Daily Progress Notes
Authors: Lowe William W. , Ciszek Thomas A. , Gallaher Keith J.
Published: December 2021

A neonatal intensive care unit patient data system, NeoData, which was developed using microcomputers connected by a local area network, is described. The system allows for real-time generation of daily progress notes, as well as admission and discharge summaries. It includes two databases: one for daily patient data and one for admission/discharge summary data. Both sets of data are easily accessible for later analysis and report generation. The daily patient data are entered directly into a computer by the neonatal intensive care unit medical and nurse practitioner staff; a progress note is printed immediately thereafter for inclusion in the patient's chart. Data from the previous day are selectively carried forward into the current day's note, minimizing data entry. Several benefits are derived from this progress note system, including legibility, tracking of laboratory and other data, tracking of management plans and procedures due at a later date, and significant time savings. The system has proved to be easy to learn, and the neonatal intensive care unit staff have found it to contribute to the efficient delivery of patient care.
Analysis of Facial Shape in Children Gestationally Exposed to Marijuana, Alcohol, and/or Cocaine
Authors: Astley Susan J. , Clarren Sterling K. , Little Ruth E. , Sampson Paul D. , Daling Janet R.
Published: December 2021

The association between fetal marijuana and/or alcohol exposure and facial features resembling fetal alcohol syndrome was investigated in a sample of 80 children. Standardized lateral and frontal facial photographs were taken of 40 children, 5 to 7 years of age, whose mothers reported frequent use of marijuana during the first trimester of pregnancy and 40 children whose mothers reported no use of marijuana during pregnancy. The marijuana-exposed and unexposed children were group-matched on alcohol exposure prior to and during pregnancy, sex, race, and age at the time of assessment. The photographs were assessed clinically by a study staff dysmorphologist and morphometrically by computerized landmark analysis. Fetal alcohol syndrome-like facial features were not associated with prenatal marijuana exposure in this study sample. No consistent patterns of facial features were identified among the marijuana-exposed group. Maternal consumption of two or more ounces of alcohol per day, on average, in early gestation was found to be associated with fetal alcohol syndrome-like facial features identified both clinically and morphometrically. Cocaine use reported by 13 of the 80 women was independently associated with mild facial dysmorphic features of hypertelorism and midfacial flattening. The results demonstrate the usefulness of this diagnostic technique for quantifying anomalies apparently unique to fetal alcohol syndrome and for targeting clusters of anomalies in new conditions for future evaluation.
Trends in Bicycle Helmet Use by Children: 1985 to 1990
Authors: Weiss Barry D.
Published: December 2021

Research has demonstrated that helmets protect against head injury during bicycle crashes. Several investigators have shown that large-scale, community-wide programs can increase the rate of helmet use by children. The objective of this research was to determine whether helmet use had changed over a 5-year period in a community with no formal programs designed to increase the use of helmets. In 1985 and again in 1990, project staff observed student bicyclists arriving at four elementary schools, three middle schools, three high schools, and one university campus. The same schools were used both years. There was no significant increase in the percentage of students who used helmets at the middle schools (0 both years), the high schools (1.85% vs 1.45%), or the university (10.0% vs 4.0%). At the four elementary schools, helmet use increased from 1.85% in 1985 to 17.1% in 1990. Much of this increase was attributable to one school at which helmet use increased from 4.4% to 21.4%. This school, and no others, had begun teaching about helmet use in the classroom. The results suggest that (1) helmet use will not increase at the middle school level or higher without specific interventions and (2) slmple, low-cost, classroom interventions can increase helmet use by elementary school children.
Intratracheal Suctioning, Systemic Infection, and the Meconium Aspiration Syndrome
Authors: Wiswell Thomas E. , Henley Mark A.
Published: December 2021

A retrospective analysis was performed to determine: (1) the proportion of neonates with the meconium aspiration syndrome (MAS) who were not depressed at birth; (2) to evaluate the clinical course of neonates with MAS, particularly relating to whether or not delivery room intubation and intratracheal suctioning had taken place; and (3) to examine the incidence of culture-proven bacteremia among meconium-stained neonates and those with MAS. The medical records of all meconium-stained neonates and those with MAS admitted to our facility from 1985 through 1989 were reviewed. Of 5697 liveborn neonates, 741 (13%) were meconium-stained, of whom 608 (82%) were intubated and suctioned in the delivery room. No complications of the intubation/suctioning procedure were noted in these neonates. Forty-five neonates had culture-proven bacteremia. Five bacteremic neonates had been meconiumstained (0.7% of all such neonates), while 40 were not stained (0.8% incidence). Of 36 neonates with MAS, 1 (2.8%) was bacteremic. Twenty (56%) of 36 newborns with MAS did not require positive pressure ventilation in the delivery room. Twelve (33%) of the babies with MAS had not been intubated and suctioned in the delivery room. Nine (75%) of 12 nonsuctioned neonates, as well as 6 (25%) of 24 suctioned neonates, required mechanical ventilation for more than 6 hours (P = .010). Pneumothoraces occurred in 6 (50%) of 12 nonsuctioned and 5 (21%) of 24 suctioned babies (P = .125). Four of 12 nonsuctioned newborns either died (n = 1) or required extracorporeal membrane oxygenation (n = 3), while only 1 of the suctioned newborns required extracorporeal membrane oxygenation (P = .034). It is concluded that (1) delivery room intubation of meconium-stained neonates appears to be a procedure with a low incidence of complications; (2) a substantial proportion of neonates in whom MAS subsequently develops do not require resuscitation at birth; (3) neonates who develop MAS after not having been suctioned may be at increased risk for adverse sequelae; and (4) there is no evidence for an increased incidence of bacteremia among meconium-stained neonates.
Cerebrospinal Fluid Isoniazid Concentrations in Children With Tuberculous Meningitis: The Influence of Dosage and Acetylation Status
Authors: Donald Peter R. , Gent William L. , Seifart Heiner I. , Lamprecht Johan H. , Parkin Donald P.
Published: December 2021

Cerebrospinal fluid (CSF) and plasma isoniazid (INFO concentrations were determined on 96 occasions in 38 children (median age 1.5 years) with tuberculous meningitis, and the effects of INH elimination status and test dosages of 10 mg/kg body weight and 20 mg/kg body weight was studied. Maximum cerebrospinal fluid INH concentrations were reached during the period 2 to 4 hours after dosing and cerebrospinal fluid and plasma INH concentrations did not differ significantly during this period. Cerebrospinal fluid INH concentrations following a dosage of 10 mg/kg (4.6 ± 2.4 µg/mL) were, however, significantly lower than those following a dosage of 20 mg/kg (11.6 ± 2.7 µg/mL). Cerebrospinal fluid INH concentrations in faster acetylators at a dosage of 10 mg/kg (3.2 ± 1.1 µg/mL) were significantly lower than in slower acetylators (7.7 ± 1.3 µg/mL), as was the case with a dosage of 20 mg/kg, where faster acetylators had cerebrospinal fluid INH concentrations of 10.5 ± 2.5 µg/mL compared with 14.1 ± 1.4 µg/mL in slower acetylators. Following dosages of both 10 mg/kg and 20 mg/kg, INH concentrations in excess of the minimal inhibitory concentration for Mycobacterium tuberculosis persisted in the CSF 12 to 14 hours later. Despite the patients' being young and frequently malnourished, suffering from advanced forms of tuberculous meningitis, and receiving high dosages of INH, rifampicin, and pyrazinamide, none developed any clinical signs of hepatotoxicity and in only one child did the serum bilirubin level rise to 19 µg/mL.
Increased Familial Cardiovascular Mortality in Obese Schoolchildren: The Muscatine Ponderosity Family Study
Authors: Burns Trudy L. , Moll Patricia P. , Lauer Ronald M.
Published: December 2021

Total and cause-specific mortality was investigated in 387 first- and second-degree deceased adult relatives of three groups of children selected from those who participated in three biennial school surveys in Muscatine, Iowa: the lean group (students in the first quintile of relative weight on all three surveys); the random group (a random sample of all eligible students); and the heavy group (students in the fifth quintile of relative weight on all three surveys). A greater proportion of death certificates for heavy group relatives listed a cardiovascular cause of death (60%) compared with lean (48%) and random (43%) group relatives. The relative risk of dying of cardiovascular disease for heavy group vs random group relatives was 1.41 (95% confidence interval 1.01, 1.98). In a subset of heavy group families identified by children with elevated systolic blood pressure, the proportion of death certificates listing a cardiovascular cause was even higher (76%) and the estimate of relative risk vs random group relatives was 2.20 (95% confidence interval 1.43, 3.37). These results indicate that persistent obesity in children, particularly when accompanied by persistent blood pressure elevation, identifies families whose members are at increased risk of dying of cardiovascular disease.
Parasitology Screening of Latin American Children in a Primary Care Clinic
Authors: Bass Joel L. , Mehta Kishor A. , Eppes Bonnie
Published: December 2021

A screening program based in a Massachusetts community hospital primary care clinic, which included 124 children from 12 different Latin American countries, demonstrated that nearly 35% were carriers of pathogenic parasites. The large majority (83.7%) of these children were asymptomatic at the time of the examination. Although there may be considerable variation based on country of origin, the present results, as well as a review of the literature, suggest this is likely to be a common finding among children born in most regions of Latin America. Compliance with the screening process was significantly higher in groups with higher infection rates and the successive yield in those patients who submitted two or more stool samples revealed that most pathogens were identified in the first sample. Schoolage children were found to have the highest risk for both roundworm infections and multiple parasitic infections. For those children with identified pathogens, nearly 90% received treatment. Current trends in immigration, international adoptions, and special circumstances including day care, family shelters, and increasing numbers of human immunodeficiency virus-infected children have made an appreciation of the extent of parasitosis, and awareness of possible management approaches, an important consideration for primary care physicians in the United States.
Intraventricular Hemorrhage in the Full-Term Neonate Associated With Abdominal Compression
Authors: WEHBERG KURT , VINCENT MARTIN , GARRISON BOBBY , DILUSTRO JOSEPH F. , FRANK L. MATTHEW
Published: December 2021

Intraventricular hemorrhage (IVH) in the full-term neonate usually is associated with birth trauma and/or perinatal asphyxia. A cause can be found in approximately 75% of cases; however, the remainder have no identifiable risk factors.1 This report describes a 13-day-old full-term neonate who sustained an IVH following moderate abdominal trauma.

CASE REPORT

History

A full-term male newborn was delivered via an uncomplicated spontaneous vaginal delivery to a 35-year-old biparous mother with third trimester diet-controlled gestational diabetes mellitus. Apgar scores were 8 at 1 minute and 9 at 5 minutes. Birth weight was 3660 g, and the results of the neurologic examination were normal with a fronto-occipital head circumference of 35.0 cm.
Publish or Perish
Authors: SAHLER OLLE JANE Z.
Published: December 2021

To the Editor.—

In a recent issue of Pediatrics,1 the editors of several pediatric journals express disgruntlement with the practices of submitting articles reporting the same data to more than one journal, or "self-plagiarism," and of dividing studies into numerous short reports or "least publishable units." To combat these practices, they infarmally" inform one another about suspected duplication.

All well and good, I suppose, and occasionally authors probably have had their hands slapped. But, the crux of the matter, really, is contained in paragraph 1, sentence 5: "We suspect that these practices are based on the desire to expand one's list of publications so as to enhance one's reputation and the chances of achieving promotion and academic tenure."
More on Dog-Bite Injuries
Authors: AVNER JEFFREY R. , BAKER M. DOUGLAS
Published: December 2021

In Reply.—

The experience of Lackmann and Tollner confirms many of our clinical findings concerning dog-bite-related injuries in children; namely, young children are more likely to be bitten at home by a familiar dog. Although they report a lower incidence of provoked attacks than we found, it is unclear how they defined "provoked." We defined provoked as any child-initiated interaction with the dog, including playing with the dog. Clearly, these data support the recommendation that families with young children should be the target of pet safety education.
Prophylactic Oral Acyclovir in Outbreaks of Primary Herpes Simplex Virus Type 1 Infection in a Closed Community
Authors: Kuzushima Kiyotaka , Kudo Toyoichiro , Kimura Hiroshi , Kido Shinji , Hanada Naoki , Shibata Motohiro , Nishikawa Kazuo , Morishima Tsuneo
Published: December 2021

Oral acyclovir was given prophylactically to 37 children in the early stages of three outbreaks of herpes simplex virus type 1 (HSV-1) infection and the results were compared with those in untreated control subjects in two other outbreaks. The rates of seroconversion to HSV were significantly reduced in children treated with acyclovir compared with control subjects (91% vs 27%, P < .001). The incidence of symptomatic disease was also significantly reduced (82% vs 0%, P < .001). In some children receiving prophylactic acyclovir, anti-HSV antibody titers did not rise despite the presence of replicative HSV on throat swabs just before the start of treatment. Restriction endonuclease analysis of isolated HSV-DNA confirmed that one strain was responsible for the five outbreaks. No resistance to acyclovir was detected during the study, and no adverse effects of treatment were noted. In conclusion, short-term prophylactic acyclovir may limit the spread and reduce clinical manifestations of HSV infections in closed communities, although this use should be restricted to communities where severe symptoms are observed.
Acute Prolactin and Oxytocin Responses and Milk Yield to Infant Suckling and Artificial Methods of Expression in Lactating Women
Authors: Zinaman Michael J. , Queenan John T. , Labbok Miriam H. , Albertson Barry , Hughes Vergie
Published: December 2021

Breast-feeding is today the major form of infant nutrition in the immediate postpartum period. Despite this, recent trends in modern life-styles have raised obstacles to successful lactation. These include infant illness and maternal responsibilities outside the home, both requiring separation from the mother. While the hormonal dynamics of infant suckling are understood, little is known about the effects of artificial methods of milk expression. A variety of breast pumps exist in the current US market which vary considerably in price and effectiveness. To understand better the ability of these pumps to assist women in the maintenance of lactation, the current study was undertaken to evaluate their effects on milk yield and prolactin and oxytocin release when compared to natural infant suckling. Twenty-three women who were exclusively breast-feeding their infants were randomly assigned to serially use several pumping methods, as well as infant suckling, with blood being taken at 10-minute intervals to determine the hormonal responses. The results reveal variability in the prolactin responses to the artificial pumping methods, with the greatest responses found with an electric pulsatile pump; these responses compare favorably with those of natural infant suckling. Other methods were less successful in causing prolactin elevations. No differences were seen among the methods in the oxytocin response. The results of this study demonstrate striking differences in the ability of breast-pumping methods to produce an acute and sustained prolactin rise in breast-feeding mothers. The large discrepancies found suggest the need for further studies to enable women and health care providers to choose the most appropriate method for milk expression.
Persistent Antinuclear Antibodies in Children Without Identifiable Inflammatory Rheumatic or Autoimmune Disease
Authors: Cabral David A. , Petty Ross E. , Fung Marinda , Malleson Peter N.
Published: December 2021

One Hundred eight children with musculoskeletal pain considered not to be due to an autoimmune or inflammatory disease had an antinuclear antibody (ANA) test performed. Twenty-four of these children were ANA positive on HEp-2 cell substrate at a screening serum dilution of 1:20. A positive ANA test persisted in 21 of 24 of the patients over a mean time period of 38 months (range 1 to 103 months). No sera from any patient at initial evaluation had anti-DNA antibodies by radioimmunoassay or by indirect immunofluorescence on Crithidia luciliae. One patient recently developed elevated anti-DNA (radioimmunoassay) antibodies but still has a negative assay on C luciliae. Four patients had antibodies to core histones by immunoblotting. None had antibodies to Sm, RNP, Ro (SS-A), or La (SS-B) by counterimmunoelectrophoresis. No patient developed an overt inflammatory or autoimmune disease during a mean follow-up period of 61 months (range 13 to 138 months). A child with musculoskeletal pain and a positive test for ANA, but with no clinical evidence at presentation of inflammatory or autoimmune disease, is at low risk of imminently developing such a disease.
Physical Examination of Patients With Cerebrospinal Fluid Shunts: Is There Useful Information in Pumping the Shunt?
Authors: Piatt Joseph H.
Published: December 2021

To assess the value of the information derived from pumping the shunt valve in hydrocephalic patients with cerebrospinal fluid shunts, the findings on examination of 200 consecutive patients were recorded prospectively. The status of each shunt was determined on the basis of all available clinical data, and the results of the shunt pumping test were compared to the final status of each shunt for various subsets of the study group. In the most clinically pertinent subsets, the sensitivity of the shunt pumping test in the detection of shunt obstruction was 18% to 20%, and the predictive value of a negative shunt pumping test, indicating shunt patency, was only 65% to 81%. For the hydrocephalic patient with symptoms of shunt malfunction, definitive imaging studies must not be deferred because of reassuring findings on examination of the shunt valve.
The Child as a Witness
Authors:   Committee on Psychosocial Aspects of Child and Family Health
Published: December 2021

In the last two decades, there has been a dramatic increase in the recognition and reporting of child physical and sexual abuse. This, coupled with the current 50% divorce rate and the fact that many of these separations involve child custody decisions, has led to an increasing need for children to appear in court.

Custody decisions usually involve family or civil courts; however, allegations involving sexual abuse may require a child to appear as a witness in criminal court. Although the procedures and potential consequences of these legal processes are quite distinct, all situations in which children offer testimony can be quite stressful and merit the awareness and support of pediatricians.

Pediatricians can become involved with children who are to be witnesses at several levels, including: 1) supporting patients in the pediatric office; 2) participating in legal proceedings; and 3) advocating for legal reform.

SUPPORT IN THE PEDIATRIC OFFICE

The pediatrician is an important source of support for the child who is to be a witness, from the initial contact through preparation for court appearance, and after the court proceedings. A pediatrician should attempt to keep the legal process in the child's best interest and should help the child maintain a healthy adaptation to a stressful experience. The pediatrician should also address the psychological impact of the event responsible for the child's court appearance.

When parents plan to separate, pediatricians may help the family by discussing living arrangements and visitation during an office visit. If custody is disputed, which is the case in 10% of divorces, and a child is asked to appear in family court, the pediatrician can provide counseling to help prepare the child for the court appearance.
Role of the Pediatrician in the Multidisciplinary Team
Authors: BRONFIN DANIEL R. , GELLIS SYDNEY S.
Published: December 2021

To the Editor.—

We would like to commend Dr Lowe and the remainder of the Task Force on the recent Report on the Future Role of the Pediatrician in the Delivery of Health Care.1 The distinction between "primary care" and "level of care" is of major importance. It is correctly stated that "the essential nature of primary care services includes first contact, continuity, comprehensiveness, and coordination of needed services"; however, "level of care describes intensity of treatment, the need for technologic support, and specially trained support personnel."
Gay Teens and Suicide
Authors: FIKAR CHARLES R.
Published: December 2021

To the Editor.—

I would like to comment upon the excellent article concerning adolescent suicide attempters by Drs Swedo et al.1 The authors correctly state that suicide is the third leading cause of death among American youth. Obviously, health care providers have an imperative obligation to become involved in the early recognition of suicidal risk factors in adolescents.

Dr Swedo's report cites many of the risk factors associated with adolescent suicide attempts, including poor self-image, depressed mood, feelings of hopelessness, and social stress.
Weight and Menstrual Function in Patients with Eating Disorders and Cystic Fibrosis
Authors: JAFFE ARTHUR C.
Published: December 2021

In Reply.—

We appreciate Dr Hergenroeder's thoughtful comments, and have no major disagreements with any of them. His point about the difficulty of estimating ideal body weight from the height tables of Hamill et al is well taken. Our study was meant to be only a limited, "first pass" effort to evaluate the nutritional contributions to menstrual abnormalities in eating disorders, and we felt a rough approximation of ideal weight was acceptable.

We agree entirely that assessment of body composition to elucidate a possible relationship between percentage of body fat and normal menstruation would have been helpful.
Disposable Diapers vs the Environment
Authors: SUTTON MARIANNE B.
Published: December 2021

In Reply.—

We appreciate the August 1991 Consumer Reports price figures on diapers that Dr Seitz provides. She correctly points out that the prices quoted in our article are from a 1987 Consumer Reports article. When our manuscript was accepted for publication (December 6, 1990), the more recent figures had not yet been published.

We did not intend to "nonchalantly discard the demonstrated benefit of disposable diapers in preventing diaper rash." We did provide the reader with ten references documenting this benefit.
Definition of Bronchopulmonary Dysplasia
Authors: KAPLAN MICHAEL
Published: December 2021

To the Editor.—

Once again, a study of bronchopulmonary dysplasia (BPD), this time assessing the effect of antenatal steroid therapy, has timed the criteria for diagnosis (oxygen requirement and radiographic changes) at 28 postnatal days.1 Unfortunately, oxygen requirement, with or without radiographic changes, at this age, is being accepted widely as the clinical definition of this condition (alternatively termed chronic lung disease).2,3 Frequently, clinical studies relate minimally, if at all, to the later outcome of infants with BPD.
Definition of Bronchopulmonary Dysplasia
Authors: VAN MARTER LINDA J. , LEVITON ALAN , ALLRED ELIZABETH N. , PAGANO MARCELLO , KUBAN KARL C. K.
Published: December 2021

In Reply.—

Dr Kaplan raises an interesting and intriguing point. He proposes that the diagnosis of BPD be reserved for infants who are oxygen-dependent with radiographic changes characteristic of the condition at 40 weeks postconceptional age. This approach, advocated by Sinkin et al1 and Merritt et al,2 has intuitive appeal to individuals interested in gestational variation in pulmonary development as well as the pathophysiology and short-term outcome of BPD. A potential problem with the new standard proposed by Dr Kaplan is that gestational age is often uncertain and is not readily established by pediatric examination in very low birth weight infants.
Do Pediatricians Like Childish Ads?
Authors: FISCHER HOWARD
Published: December 2021

To the Editor.—

I have long thought that much of the advertising in pediatric journals is "childish": It uses cartoon-type drawings or comic strip characters. To evaluate this impression I counted the number of illustrated advertisements in one year's issues of three pediatric and two internal medicine journals and determined the proportion of "childish" advertisements found. Illustrated advertisements were those which contained any form of image (photograph, drawing, graph); "childish" advertising is defined above. Results may be seen in the Table.
Progress Against Childhood Cancer: The Pediatric Oncology Group Experience
Authors:   Pediatric Oncology Group
Published: December 2021

The sequential outcome was evaluated for all childhood cancers in which the Pediatric Oncology Group has conducted a series of clinical trials, with constant eligibility, on patients with newly diagnosed cancer. The analysis was applied to more than 7000 patients with cancer diagnosed between 1976 and 1989. These include acute leukemia (4 subgroups), non-Hodgkins lymphoma (4 subgroups), osteogenic sarcoma, and advanced neuroblastoma. In 8 of these 10 disease areas, significant improvement in outcome has occurred. In rare diseases such as pediatric cancer, collaborative studies may be the only way to conduct therapeutic trials of sufficient statistical power. A cooperative group has distinct advantages over a series of ad hoc collaborative studies in that it can maintain a unified data base, study its history with minimal confounding effects of changing institutional participants, and develop long-term research relationships among its participants.
Hospitalizations for Traumatic Injuries Among Children in Maryland:Trends in Incidence and Severity: 1979 Through 1988
Authors: Marganitt Baruch , MacKenzie Ellen J. , Deshpande Jayant K. , Ramzy Ameen I. , Haller J. Alex
Published: December 2021

Trends in incidence and severity of hospitalized injury among children aged 0 through 13 years in the state of Maryland from 1979 through 1988 (n = 35 746) were examined using routinely reported hospital discharge data. Hospital discharge rates declined over the study period from 509 per 100 000 population in 1979 to 320 in 1988. There was a decline in incidence trends for both races. However, the decrease in the nonwhite population was smaller than in whites. Analysis of incidence rates for specific Injury Severity Score groups revealed a declining trend in all Injury Severity Score groups, although the mildest group (Injury Severity Score 1 through 4) had the most notable decline of 44% compared with an average decline of 20% in the other severity groups. These data suggest a change in admission practices of mildly injured children as a major cause for the observed overall decline in hospitalization rates. The smaller decrease in the hospitalization rates of non-white children compared with white children requires further study to determine the cause.
Management of Childhood Lead Poisoning: A Survey
Authors: Glotzer Deborah E. , Bauchner Howard
Published: December 2021

Published recommendations (1985) for the management of childhood lead poisoning suggest the use of ethylenediaminetetraacetic acid (EDTA)provocation testing and chelation as the mainstay of treatment for blood lead levels between 25 and 55 μg/dL. Since 1985 evidence has accumulated indicating that (1) levels of blood lead less than 25 μg/dL are detrimental to cognitive development, (2) EDTA provocation testing may result in potentially harmful shifts in the body lead burden, and (3) oral agents such as penicillamine and 2,3-dimercaptosuccinic acid are effective in reducing elevated lead levels. To determine how this evidence impacts on the management of childhood lead poisoning, the authors surveyed the lead poisoning clinics of pediatric departments in the cities estimated by the United States Public Health Service to have the largest number of children affected by lead poisoning. Thirty (70%) of 43 surveys were completed. Respondents indicated that the lowest blood lead level for which they would use a chelating agent to reduce the lead burden was as follows: 50 μg/dL (3%), 45 μg/dL (3%), 40μg/dL (13%) 35 μg/dL (3%), 30 μg/dL (27%), 25 μg/dL (47%) and 20μg/dL (3%). For all blood lead levels from 20 through 55 μg/dL, EDTA was the most frequently recommended chelating agent (chelation and provocation testing). Fifteen percent of responding lead clinics do not use the provocation test under any circumstances. For a child with a negative EDTA provocation test, the percentage of respondents recommending the use of any chelation therapy ranged from 16% for blood lead levels of 25 through 29μg/dL to 66% for levels of 50 through 55 μg/dL. Orally active chelating agents are used by fewer than one third of the responding lead clinics and were selected as the chelating agent of choice at all blood lead levels from 25 through 55 μg/dL by at least one respondent. The results of this survey indicate the following: (1) There is a wide range of blood lead levels for which chelation therapy is recommended. (2) The majority of children with elevated lead burdens are managed using EDTA. (3) The EDTA provocation test continues to be widely used. (4) The majority of children with blood lead levels of 25 through 44 μg/dL with negative provocation tests do not receive chelation therapy. (5) Orally active chelating agents are used in the minority of lead clinics. (6) No common approach for the treatment of lead toxicity appears to exist. (7) In the majority of pediatric centers, current management of blood lead elevation does not appear to reflect new information regarding the effects and treatment of lead poisoning.
No Increased Risk For Invasive Bacterial Infection Found Following Diphtheria-Tetanus-Pertussis Immunization
Authors: Griffin Marie R. , Taylor Jo A. , Daugherty James R. , Ray Wayne A.
Published: December 2021

During the acellular pertussis vaccine trial in Sweden, 4 children who were randomly assigned to receive the vaccine died of suspected or confirmed bacterial infections compared to 1 expected. There were no deaths in the placebo arm. This raised concern about the role of pertussis immunization in the development of serious infections. Through linking computerized immunization records with an active surveillance system for serious bacterial infections in children, the authors studied a cohort of 64 591 children immunized through Tennessee county health clinics who had a total of 158 episodes of invasive bacterial infections after a diphtheria and tetanus toxoids and pertussis (DTP) immunization. There were 8 invasive bacterial infections that occurred within the first 7 days following DTP immunization,yielding an age-adjusted relative risk (95% confidence interval) of 1.0 (0.5 to 2.0), compared to the interval 29 or more days following immunization. There were 7 and 20 infections in the 8- through 14- and 15-through 28-day intervals following DTP immunization, giving relative risks of 0.8 (0.4 to 1.7) and 1.2 (0.7 to 1.9), respectively. These data provide reassurance that the use of DTP vaccine is not followed by a large increased risk of serious bacterial infections.
Crystalluria Following Cephalexin Overdose
Authors: CLARK RICHARD F.
Published: December 2021

Crystalline forms of certain drugs can appear in the urine, especially when the specimen is concentrated. Most often they are of little clinical significance,1 but the unexpected finding of crystals of an unknown etiology can be disconcerting. This is a case of a child with hematuria and crystalluria following a cephalexin overdose.

CASE REPORT

A 3-year-old boy weighing 24 kg was brought to the emergency department by his mother; the chief complaint was hematuria. His mother stated that the child had been asymptomatic and his urine had been normal prior to the day of presentation. Five hours earlier, she had
Use of Acyclovir in the Treatment of Chickenpox
Authors: LASSITER HERBERT A.
Published: December 2021

To the Editor.—

In a recently reported well-designed study, oral acyclovir significantly reduced the severity and duration of symptoms of chickenpox in otherwise healthy children.1 The study was randomized, double-blind, and placebo-controlled. Of the 724 children who were enrolled and evaluated, 367 received acyclovir and 357 received placebo. Clearly, the severity of itching and the duration of vesicles and fever were diminished in the acyclovir recipients. The incidence of important complications did not differ significantly
Bicycle Helmet Promotion
Authors: BROWN JEFFREY
Published: December 2021

To the Editor.—

In two recent articles by Dr Robert Cushman and his colleagues in Ottawa,Canada,1,2 including a publication in the July 1991 issue of Pediatrics, they conclude “physicians interested in [bicycle]helmet promotion would do better to participate in the design and implementation of multidisciplinary community campaigns.”

I find this conclusion, which is identical in both articles, to be enlightening but, at the same time, disturbing. In their two articles Dr Cushman's group
Bicycle Helmet Promotion
Authors: CUSHMAN ROBERT
Published: December 2021

In Reply.—

Dr Jeffrey Brown raises concerns about the quality of the intervention as well as the conclusion in our recent articles about bike helmet promotion.1,2

It appears that the term “cue card” gave the false impression that clinicians read the material in front of patients. Our apologies for the confusion! At the orientation sessions, in addition to the study information package, we gave participants a plasticized card so that they could review the material
Cholesterol Screening
Authors: CHRISTOFFEL KATHERINE KAUFER , GRIFFIN TIMOTHY C. , BINNS HELEN J. , STOCKMAN JAMES A.
Published: December 2021

To the Editor.—

We are writing to correct erroneous assertions about our published article“Family History Evaluation as a Predictive Screen for Childhood Hypercholesterolemia,”1 which appeared in a recent Commentary in Pediatrics.2

1. Our study, which was conducted 4 years ago, was designed to describe the efficacy of then-prevalent cholesterol screening practices in achieving their goal: the identification of children with elevated low-density lipoprotein(LDL)-cholesterol. (Once so identified, such children generally underwent further evaluation to
T.A.C.
Authors: BONADIO WILLIAM A. , WAGNER VIRGINIA
Published: December 2021

In Reply.—

Regrettably, there was a typographical error in our manuscript.1The actual formula used for making the adrenaline-cocaine (AC) solution involved mixing 28 g of cocaine with 120 mL of 1:1000 (not 1:100) epinephrine and adding enough normal saline to bring the total solution volume of 240 mL(not 480 mL). This formula makes the “full-strength” AC preparation, which contains a cocaine concentration of 11.8%.

With regard to the necessity of the adrenaline component,
Therapeutic Orphans
Authors: YASTER MYRON
Published: December 2021

In Reply.—

We agree with Drs Darling and Lambert that children are “therapeutic orphans” and that precious little data exist concerning the safety and efficacy of many of the drugs used in pediatric practice. Although Drs Darling and Lambert believe that we, in “academia,” have a“responsibility” to study these drugs, they have not offered any suggestions of how to do this. These are very difficult studies to design,with soft end points, that must
Adolescent Health: Is It Now on the Nation's Agenda?
Authors: HAGGERTY ROBERT J. , COHEN MICHAEL I.
Published: December 2021

The Office of Technology Assessment has a deserved reputation for issuing high-quality, if hard-nosed and critical reports. Pediatricians reacted somewhat skeptically to their earlier report on child health,1 which stated that there was little evidence for the efficacy of the number of health supervision visits that are recommended by the American Academy of Pediatrics. We urge you not to let that report scare you off from a new report on adolescents.2 It is very comprehensive, and should go far to put adolescents on the national agenda. It is passionate, yet based on careful analysis of data. It documents the increase in risk-taking behaviors, with a concomitant decrease in healthy life-styles, among many adolescents over the past two decades.
Firearm Injuries Affecting the Pediatric Population
Authors:   Committee on Injury and Poison Prevention
Published: December 2021

In the United States approximately 30 000 people die from firearm injuries each year. Many more are wounded. In the mid 1980s, more than 3000 of the dead were children and adolescents aged 1 to 19 years.1 In 1989 nearly 4000 firearm deaths were among children 1 to 19 years of age, accounting for 12% of all deaths in that age group.2 All of these deaths or injuries affect other children because the victims who are killed or wounded are frequently relatives, neighbors, or friends.

Comparison data for childhood age groups demonstrate that in 1987, 203 children aged 1 to 9 years, 484 children aged 10 to 14 years, and 2705 adolescents aged 15 to 19 years died as a result of firearm injuries.1 Firearm deaths include unintentional injuries, homicides, and suicides. Among the 1- to 9-year-olds, half of the deaths were homicides and half were unintentional. Among the 10- to 14-year-olds, one third of the deaths were homicides, one third were suicides, and one third were unintentional. Among the 15- to 19-year-olds, 48% were homicides, 42% were suicides, and 8% were unintentional.1

Firearm homicides are the leading cause of death for some US subpopulations, such as urban black male adolescents and young adults.3 Table 1 indicates how firearms contributed to the deaths of children and adolescents (homicides, suicides, and all causes) in 1987. Table 2 illustrates the unusual scale of firearm violence affecting young people in the United States compared with other developed nations.4 Firearm injuries are the fourth leading cause of unintentional injury deaths to children younger than 15 years of age in the US.5
Chronic Fatigue Immune Dysfunction Syndrome: An Epidemic?
Authors: VAN AERDE J.
Published: December 2021

To the Editor.—

Chronic Fatigue Immune Dysfunction Syndrome (CFIDS) or Myalgic Encephalomyelitis (M.E.) is a debilitating neuroimmune disorder which is taking on epidemic proportions. Some estimates indicate that 5% of the North American population might become affected this decade.

Smith et al1 confuse the symptom of "chronic fatigue" with the disease "chronic fatigue syndrome" The terminology is mixed up throughout the entire paper, but the authors clearly report on the symptom only. According to the Centers for Disease Control (CDC), the patient has to meet two major and eight minor criteria to be diagnosed with CFIDS.
Acute Diarrhea Therapy—Suboptimal?
Authors: SNYDER JOHN D.
Published: December 2021

In Reply.—

The findings of Ms Simpson and Drs McIntyre and Ste-Marie are very interesting and raise some intriguing questions. What was the outcome of therapy in these children? Were there differences in outcome related to the therapy used? Their findings also raise the question of whether more optimal therapy would reduce admissions from their Emergency Room or return visits from children sent home. Such data would make an even stronger case for the need to improve case management practices.
In Search of a `Gold Standard' for Bilirubin Toxicity
Authors: POLAND RONALD L.
Published: December 2021

In this issue of Pediatrics, Newman and Maisels1 have given us a thorough and thoughtful review of current knowledge about the toxicity of bilirubin in term, otherwise healthy, newborn infants and have concluded that there is little evidence that bilirubin toxicity can be predicted from the concentration of bilirubin in the serum. They propose that we worry about bilirubin less in this population and treat hyperbilirubinemia only if it reaches much higher concentrations than the traditional 20 mg/dL. Their conclusions and recommendations are very reasonable given that the serum bilirubin concentration is the primary predictive measure for bilirubin neurotoxicity available to us.
Hyperbilirubinemia: Should We Adopt a New Standard of Care?
Authors: CASHORE WILLIAM J.
Published: December 2021

The review and recommendations by Newman and Maisels1 in this issue of Pediatrics constitute a provocative critique of our current state of knowledge concerning the risks of hyperbilirubinemia in term infants and should begin a dialogue about the recommended standard of care for jaundiced newborns.

For several decades, the use of exchange transfusions to prevent kernicterus and phototherapy to prevent exchange transfusions, the puzzling emergence of low-bilirubin kernicterus, the "discovery" of breast milk jaundice, and concern over the possible contribution of bilirubin to neurologic handicap have combined to encourage preemptive intervention for moderate jaundice in asymptomatic newborns. But has this strategy of anticipatory management become hardened into an overly aggressive pattern of testing and treatment? Newman and Maisels conclude that it has.
Jaundice in Healthy, Term Neonates: Do We Need New Action Levels or New Approaches?
Authors: BROWN AUDREY K. , SEIDMAN DANIEL S. , STEVENSON DAVID K.
Published: December 2021

All seems infected that th' infected spy,

As all looks yellow to the jaundiced eye.

—Alexander Pope

An Essay on Criticism, 1711

We take note of Alexander Pope's admonition, and we are reminded by others that, from their perspective, the evidence is unconvincing that moderate neonatal hyperbilirubinemia adversely affects the neurodevelopmental outcome of healthy, term infants. Moreover, although there is ample evidence that high levels of bilirubin may be associated with neurologic injury, a linear relationship between neonatal serum bilirubin levels and long-term neurodevelopmental impairment does not seem to exist.1 Such observations have been recognized for some time2,3 and have encouraged some of our colleagues to propose new guidelines for the treatment of jaundice in well, term infants.4,5
Hypoxic Arousal Responses in Normal Infants
Authors: Ward Sally L. Davidson , Bautista Daisy B. , Keens Thomas C.
Published: December 2021

Failure to arouse in response to hypoxia has been described in infants at increased risk for sudden infant death syndrome (SIDS) and has been suggested as a possible mechanism for SIDS. However, most SIDS victims are not in a high-risk group before death. Thus, if a hypoxic arousal disorder is an important contributor to SIDS, normal infants might fail to arouse from sleep in response to hypoxia. To test this hypothesis, the authors studied hypoxic arousal responses in 18 healthy term infants younger than 7 months of age (age 12.1 ± 1.7 [SEM] weeks; 56% girls). Hypoxic arousal challenges were performed during quiet sleep by rapidly decreasing inspired oxygen tension (Pio2) to 80 mm Hg for 3 minutes or until arousal (eye opening, agitation, and crying) occurred. Tests were performed in duplicate when possible. Only 8 infants (44%) aroused in response to one or more hypoxic challenges; arousal occurred during 8 (32%) of 25 trials. There were no significant differences in lowest Pio2 or arterial oxygen saturation during hypoxia between those infants who aroused and those who failed to arouse. All 18 infants had a fall in their end-tidal carbon dioxide tension during hypoxia, suggesting that each had a hypoxic ventilatory response despite failure to arouse in the majority. Periodic breathing occurred following hypoxia in only 1 (13%) of the 8 trials that resulted in arousal, compared with 16 (94%) of 17 trials without arousal (P < .005). It is concluded that the majority of normal infants younger than 7 months of age fail to arouse from quiet sleep in response to hypoxia, despite the apparent presence of a hypoxic ventilatory response.
Sleep State Organization in Normal Infants and Victims of the Sudden Infant Death Syndrome
Authors: Schechtman Vicki L. , Harper Ronald M. , Wilson Arian J. , Southall David P.
Published: December 2021

Infants at increased risk of the sudden infant death syndrome (SIDS) show abnormal patterning of sleep-waking states. It was hypothesized that infants who were to die of SIDS would show abnormalities of sleep state distribution prior to their deaths. Twenty-two 12-hour recordings were obtained from infants who subsequently died of SIDS, and sleep state patterns were compared in these records and 66 records of age-matched control infants. Each 1-minute epoch was classified as quiet sleep, rapid eye movement (REM) sleep, waking, indeterminate state, or artifact-contaminated. Victims of SIDS showed less waking and more sleep than control infants during the early-morning hours. Victims of SIDS younger than 1 month of age showed significantly more epochs classified as REM sleep across the night and significantly fewer epochs contaminated by artifacts relative to control infants. Further analysis indicated that the increased number of REM epochs resulted from fewer artifact-contaminated epochs, suggesting reduced motility during REM sleep in the SIDS victims compared with the control infants. The finding of decreased waking time during the early morning is of particular importance since most SIDS deaths occur during this portion of the day. The findings of altered sleep patterns in SIDS victims suggest that central neural changes are associated with SIDS risk.