bluuebunny/crossref_metadata_2025 huggingface dataset:
Head Trauma in Children
Authors: Goldstein Brahm , Powers Karen S.
Published: December 2021

Head injury, either alone or in association with multiple other injuries, is extremely common. The initial assessment and management of children who have a head injury is an important topic for all pediatricians.

Epidemiology

Table 1 lists definitions of minor, moderate, and severe head injuries as determined by the initial neurologic presentation. The most common method to assess a child's neurologic status initially is to assign a score based on the Glasgow Coma Scale (GCS). The GCS is determined by eye opening and best verbal and motor responses (Tables 2 and 3). Mild-to-moderate head injuries are far more common than severe injuries in the pediatric population. More than 90% of children requiring admission to a hospital following head injury have a GCS score of 13 to 15; severe head injury (GCS≤ 8) accounts for approximately 5% of admissions.

Motor vehicle accidents, bicycle accidents, falls, sporting accidents, assaults, and child abuse are the most common causes of pediatric head injury. Despite a significant reduction in the number of pediatric fatalities due to implementation of the 55 mile/hour speed limit, motor vehicle accidents still result in a large number of hospital admissions and deaths each year. Many of these accidents are associated with drug or alcohol abuse.
Hypothyroidism
Authors: Fisher Delbert A.
Published: December 2021

Thyroid Development

THYROID HORMONE SYNTHESIS AND CONTROL

Thyroid hormones (TH) are critical for normal growth, development, and metabolism during infancy and childhood. They are synthesized by the thyroid gland follicular cells, the function of which is to concentrate iodide from the blood and return it to peripheral tissues in a hormonally active form. The thyroid cell iodide-concentrating mechanism, often referred to as the iodide pump, confers on the gland its ability to concentrate iodide to many times its level in plasma. The steps involved in synthesis and release of TH include: 1) iodide trapping by the thyroid gland; 2) synthesis of thyroglobulin; 3) organification of trapped iodide as iodotyrosines (monoiodotyrosine, MIT, and diiodotyrosine, DIT); 4) coupling of the iodotyrosines to form the iodothyronines thyroxine (T4) and triiodothyronine (T3) and storage in follicular colloid; 5) endocytosis of colloid droplets and hydrolysis of thyroglobulin to release MIT, DIT, T4, and T3; and 6) deiodination of MIT and DIT with intrathyroidal recycling of the iodine.

The concentration of iodide in plasma under normal circumstances is less than 0.2 µg/dL. The iodide is removed from plasma almost entirely by the kidney and the thyroid gland. Transport of iodide across the thyroid cell membrane is the first and ratelimiting step in TH biosynthesis.
Hemangiomas
Authors: Wahrman Julie E. , Honig Paul
Published: December 2021

The lack of standardized terminology has been a significant obstacle to a clear understanding of vascular lesions. Although the classic hemangioma undergoes involution with time, the term hemangioma has been used generically to include various vascular lesions, such as port-wine stains or venous malformations. Hemangiomas differ significantly from these other vascular lesions with regard to their clinical and histologic characteristics as well as long-term prognosis.

In 1982, Mulliken and Glowacki published a classification scheme that simplified the nomenclature of vascular anomalies. It is based on the cellular biology and natural history of these lesions. The authors divide vascular birthmarks into two groups: hemangiomas and vascular malformations.

Definitions

HEMANGIOMAS

Hemangiomas are defined as benign neoplasms composed of proliferative and hyperplastic vascular endothelium. They are dynamic lesions that demonstrate rapid postnatal growth followed by slow involution. Resolution is associated with diminished cellularity and fibrosis.

Hemangiomas are subdivided into three types: superficial, deep, and mixed. Superficial hemangiomas, otherwise referred to as capillary or strawberry hemangiomas, lie in the papillary (upper) dermis. Deep lesions, also called cavernous, hypodermal, or subcutaneous hemangiomas, lie in the reticular (lower) dermis, fat, and muscle. Hemangiomas also may be mixed, having both superficial and deep components. Whether capillary hemangiomas differ histologically from cavernous lesions is controversial.
Atopic Dermatitis
Authors: Lapidus Candace S. , Honig Paul J.
Published: December 2021

Introduction

Atopic dermatitis, also referred to as atopic eczema, infantile eczema, allergic eczema, disseminated neurodermatitis, and prurigo Besnier, is a common and important cause of morbidity in children of all ages. A total of 22% of patients seen in pediatric dermatology clinics have atopic dermatitis. In 1969, Wingert et al reported that 4% of pediatric emergency room visits at the Los Angeles County General Hospital were due to atopic dermatitis, and this did not include patients seen for impetigo, a common complication of atopic dermatitis. The prevalence of atopic dermatitis in the pediatric population has increased over the past 3 decades from 3% to 10%, and it appears to be even higher in heavily populated urban areas. Pediatricians, therefore, must understand its pathogenesis and management.

Epidemiology

Sixty percent of children who have atopic dermatitis manifest their disease in the first year of life; 90% do so by age 5 years. A genetically prone individual may not manifest the disease until exposed to a particular environmental situation. Onset has been associated with relocation from a rural to an urban location or from a region of high to low humidity.

The course of adopic dermatitis is difficult to predict, although one 15-year longitudinal study revealed that the disease persisted in 60% of cases.
Consultation with the Specialist
Authors: Pakula Lawrence C.
Published: December 2021

A variety of children's behaviors are distressing to parents and often very difficult to manage. These can include biting, temper tantrums, breath-holding spells, and hitting.

Biting

Biting often is the first behavior that provokes major concern and a demand for solutions. The same child who might be excused for hitting may well end up isolated from peers and at risk of being barred from child care for biting. The situation is aggravated by increased parental fears of infection (acquired immunodeficiency syndrome, hepatitis, tetanus, rabies).

The initial biting episode often occurs when the child is teething, with parents being the first bitten; they mistakenly may think it is a cute game. A typical scenario is when one child wants the toy of another and bites in frustration. Many parents do not respond until the possibility of penalties that affect them arise. All adults must be encouraged to have a rule that interrupts the behavior with a strong "No, we never bite people because it hurts them," which can be extended to include pets and stuffed animals. With children in this age group, longer, more complex explanations only provide additional attention and reward behavior that you are trying to stop. Interruption and prevention before the biting occurs is important.
Conversion and Somatization in Pediatrics
Authors: Hodgman Christopher H.
Published: December 2021

Although conversion disorder rarely is diagnosed formally in ordinary pediatric practice, busy pediatricians often do encounter the phenomenon of conversion. Conversion is the experiencing of unacceptable emotional conflicts as symptoms, usually but not always physical, rather than as mental events. Conversion is commonplace, affecting almost all body systems. It must be recognized and managed appropriately early in its course, lest inappropriate evaluations and treatments occur; in addition to their other costs, such unnecessary procedures may introduce the child inadvertently to such symptomatization as a life-long pattern of behavior. More than a century ago, Briquet recognized that at least 50% of adult "professional patients" begin their symptomatic careers before puberty; thus, inappropriate care of the young patient who has conversion symptoms may have serious, long-lasting consequences.

Problems in Diagnosing Conversion

The traditional diagnostic elements of conversion often are difficult to demonstrate in pediatric practice. Almost all are either not specific to conversion or hard to confirm in young patients for reasons of developmental immaturity. These "standard" elements include the following:

• Stress or conflict preceding symptoms (true of many illnesses)

• Unconscious symptom production outside the patient's awareness (thus often inaccessible to the pediatrician)

• A model for the symptom (either unverifiable or prone to observer bias)

• Primary gain or relief of underlying conflict (again, difficult to confirm)
Therapeutic Uses of Intravenous Immunoglobulin (IVIG) in Children
Authors: Ramesh Sujatha , Schwartz Stanley A.
Published: December 2021

Introduction

HISTORY

Immunologists have been aware of the existence of protective humoral substances in the serum of patients after an infectious episode for a long time. Serum harvested from large animals after their immunization with specific pathogens was injected into humans for the prophylaxis and treatment of serious infections. The concept of immunoglobulin (also called gamma globulin) therapy originated from these early experiments. Subsequently, Paul Ehrlich produced antitoxin to diphtheria in 1897. To avoid complications such as serum sickness with the use of animal serums, attempts were made to concentrate the antibody-containing fractions of human serum. In 1936, placental immunoglobulin samples were used for prophylaxis of measles. In 1952, Bruton recognized that an 8-year-old child who had serious recurrent infections despite conventional therapy was incapable of making significant quantities of immunoglobulin. This was the first time primary immunodeficiency was diagnosed and treated successfully with intramuscular immunoglobulin. Since then, and until 1981, intramuscular gamma globulin or, alternatively, fresh frozen plasma has been the mainstay of treatment of hypogammaglobulinemia and other primary immune deficiencies. In 1981, intravenous immunoglobulin (IVIG) became available commercially in the United States.

The advantages of IVIG over intramuscular gamma globulin are: 1) administration is relatively painless; 2) higher doses can be given, resulting in rapid achievement of therapeutic levels, because volume is not a limitation: 3) its absorption is good: 4) it does not undergo local degradation during infusion; and 5) it does not aggregate and activate complement.
Cleft Palate
Authors: Bogdanow Anna , Menasse-Palmer Lisa , Marion Robert W. , Shanske Alan L.
Published: December 2021

Cleft palate (CP) is one of the most common congenital malformations in children. Isolated CP occurs in approximately 1 in 2500 newborns: cleft lip with or without CP occurs in about 1 in 700 live births. Caused by failure of the embryonic palatine shelves to fuse in the midline between the sixth and tenth weeks of gestation. CP actually represents a complex of problems involving not only a defect in the palate, but dysfunction of the eustachian tubes and middle ears as well. Thus, the newborn who has a cleft may have difficulty sucking and feeding and may go on to develop hypernasal speech, a condition that leads to problems with clarity of speech.
Family-focused Behavioral Pediatrics: Clinical Techniques for Primary Care
Authors: Coleman William L. , Howard Barbara J.
Published: December 2021

Whenever a behavioral or psychosocial problem presents in a child, all members of the family are affected. Conversely, when the problem lies within the family, the child is affected and often presents as the symptomatic patient. The goals of family-focused pediatrics are to: 1) determine the need for a family intervention; 2) conduct a family interview-assessment; 3) clarify the issues; 4) teach healthy communication skills and interactions; and 5) facilitate generation of family goals and solutions. Family-focused strategies provide an effective, brief, and timely approach that can aid the pediatrician in helping children and their families function in more healthy and satisfying ways.
Consultation with the Specialist
Authors: Lovejoy Frederick H. , Woolf Alan D.
Published: December 2021

Two particularly relevant questions frequently asked by pediatricians about caustic ingestions by children are: 1) What signs and symptoms are common with a caustic ingestion, and can esophageal injury occur in the absence of mouth burns? and 2) When should the patient be referred to the surgeon for endoscopy to confirm a corrosive ingestion?

Signs and Symptoms

Approximately 53 000 corrosive exposures occur yearly in the United States. The Federal Hazardous Substances Act and the Poison Prevention Packaging Act of 1970 requires that corrosive agents that have concentrations of active ingredients greater than 10% be sold in child-resistant containers. This has done much to reduce the frequency and severity of signs and symptoms of corrosive ingestions. The child may lick or take only several swallows of a corrosive liquid compared with an adolescent purposefully ingesting a corrosive, who may consume a larger amount. The lips, oral mucosa, tongue, pharynx, esophagus, and stomach all may be affected. Other areas, such as the eyes, larynx, and/or respiratory tract, also may be exposed to the corrosive agent.

Many infants and children who have a history of ingesting a corrosive recently are without signs and symptoms. However, others have clear signs of injury, including pain on swallowing, drooling, excessive salivation, and inability or refusal to drink. Examination of the mouth shows edema, inflammation, or whitish areas.
Erythema Infectiosum (Fifth Disease)
Authors: Stiefel Laurence
Published: December 2021

Erythema infectiosum (EI), also known as fifth disease, is one of the most common childhood exanthems. The condition first was described by Tschamer in 1889 and initially was thought to be a manifestation of rubella. It is seen most often in children ages 4 to 15 years and has peak incidences in winter and spring. It can present in focal outbreaks or in community-wide epidemics, which can last from 3 to 6 months. Infection rates of 20% to 50% have been noted in families and classrooms.

The condition was termed fifth disease because of the numerical designation it originally was given (following measles, scarlet fever, rubella, and Filatov-Dukes disease, now regarded as a mild atypical form of scarlet fever).
Autism and the Pervasive Developmental Disorders: Part 1
Authors: Bauer Stephen
Published: December 2021

Introduction

It has been just 50 years since the syndrome of autism was named and described by Leo Kanner. In 1943, he wrote about a small group of children in his child psychiatric practice who shared clinical characteristics of extreme social isolation, severe language abnormalities, and unusual responses to their environment. Since that time, many earlier concepts have given way to a newer, biologically based understanding of autism as a developmental disability that has an underlying neurologic basis. An expanding body of research has revealed insights into the broad clinical range of autism, the possible nature of the underlying defects, and useful approaches to helping children who have the disorder.

Autism also has become part of the public consciousness. Television talk shows frequently feature autism-related topics, and autobiographies by adults who have autism have become best sellers (see Grandin and Williams on the Resources list). Perhaps the event that most solidified autism as a subject of popular interest was Dustin Hoffman's portrayal of Raymond Babbitt, a young adult who had high functioning autism, in Barry Levinson's 1988 film Rain Man.

Once considered to be encountered only rarely in practice, autism now is thought to be part of a spectrum of related conditions that are much more common than previously thought.
Quality Improvement: An ACQIP Exercise on the Management of Acute Asthma—Part 1
Authors: Smith-Ross Shannon , Honigfeld Lisa
Published: December 2021

As part of Pediatrics in Review's ongoing focus on quality improvement, we present a self-assessment exercise taken from the American Academy of Pediatrics' Ambulatory Care Quality Improvement Program (ACQIP). A previous exercise and a description of the program were published last year.1 Tabulated responses of pediatricians who completed this exercise as part of the ACQIP program will be published next month, allowing readers to see how their own answers compare and providing material for thought and discussion.
INDEX OF SUSPICION
Authors: Dover Arthur S. , Love Barry A. , Khanfar Nasha't M.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 7-year-old girl is admitted to the hospital because of 9 days of gastrointestinal illness with fever. Her illness began with watery green diarrhea that has persisted. She has had several stools each day: no pus, blood, or mucus has appeared in the stool. She has been vomiting up to six times a day, with bile noted in the vomitus at times. Abdominal pain has been present almost constantly from the onset. The pain has been generalized except for intermittent periods of right-sided lower abdominal, groin, and leg discomfort. Fever in a daily spiking pattern and chills have occurred since shortly after her illness began. She has complained of a frontal headache and has had a mild cough.
Pneumococcal Vaccine
Authors: Peter Georges , Klein Jerome O.
Published: December 2021

Streptococcus pneumoniae, commonly termed the pneumococcus, is a major pediatric pathogen both in developed and developing countries. Despite the availability of multiple antimicrobials to which this organism is susceptible, it continues to cause significant morbidity and mortality. Recognition of the limitations of antimicrobial therapy in controlling the consequences of infection, particularly among high-risk persons such as those who have underlying pulmonary or cardiovascular disease and the elderly, led to the introduction in the 1970s of a polyvalent, polysaccharide pneumococcal vaccine. As a result, the current indications for vaccination of both children and adults are based on risk factors for severe, potentially life-threatening pneumococcal infections and, in the case of children, the age-related immunogenicity of the polysaccharide antigens of this vaccine. Appropriate use of this vaccine is facilitated by knowledge of the pathogenicity of S pneumoniae, epidemiology of the infections it causes, and the immunogenicity and efficacy of the vaccine.

The limitations of the current pneumococcal vaccine not only affect management of vaccinated patients but also have prompted development of investigational vaccines for use among infants and young children. Polysaccharide-protein conjugate pneumococcal vaccines that have increased immunogenicity in infants are in clinical trials and will be discussed only briefly in this review.
Consultation with the Specialist
Authors: Warner Brad W.
Published: December 2021

Wilms tumor is an important solid neoplasm in children that occurs with a frequency of 400 to 500 cases annually in the United States. It is important, therefore, for primary care physicians to be aware of the clinical presentation and associated symptoms and signs of Wilms tumor. Progress in management of this neoplasm has been outstanding, primarily because of cooperative efforts of the National Wilms Tumor Study Group. The significantly improved survival that has resulted from the Group's cooperative efforts serves as a paradigm for the management of all tumors.

Presentation

Wilms tumor most commonly presents as an asymptomatic abdominal mass. The average age of presentation is 3 to 4 years. This mass, which usually is located in the region of the flank, may be detected during a well-child routine physical examination. It also is not unusual for the mass to expand acutely due to hemorrhage within the tumor. This may account for discovery of the mass by the parents shortly after a recent thorough physical examination. The child also may present with abdominal pain associated with the mass due either to acute hemorrhage or to rupture of the tumor into the peritoneal cavity. Up to one third of children who have Wilms tumor may have microscopic hematuria, and in male patients, obstruction of the left spermatic vein can produce a left-sided varicocele.
Chronic Nonspecific Diarrhea
Authors: Judd Robert H.
Published: December 2021

Case Presentation

A toddler is seen for his 2-year well child examination. His parents are concerned and have received complaints from his child care provider that he has three to four loose, watery bowel movements daily; each bowel movement requires a clean-up and change of clothes. This diarrhea has been present intermittently for at least 6 months. He has a very good appetite, no other abdominal symptoms, and no blood in his stools. His development appears normal. Physical examination is entirely normal, including a weight of 13 kg and height of 90 cm, both at the 75th percentile for age. What additional history is useful, what laboratory evaluation would you perform, and how would you advise his parents?

Introduction

Gastrointestinal disorders account for approximately 5% of pediatric office visits. Many of these visits are for acute diarrhea that usually is infectious in origin and resolves in fewer than 7 days. Diarrhea in the young child that persists for longer than 3 weeks is termed chronic and can be frustrating and anxiety provoking for both physicians and parents. Through careful clinical assessment, the clinician can separate the majority of patients who require only observation from those who require a limited number of simple tests or those who require extensive testing.

Definition
BACK TO BASICS
Authors: Jospe Nicholas , Forbes Gilbert
Published: December 2021

Changes in volume and composition of body fluids due to disorders of fluid and electrolyte balance cause various common clinical illnesses. The rationale for reviewing the diagnosis and management of fluid and electrolyte disorders was eloquently denoted by Dr Altemeier, when he suggested that this knowledge belongs among the core concepts needed by the "keepers of the gates," that is, primary care pediatricians.1 In the body, homeostasis is maintained by the coordinated action of behavioral, hormonal, renal, and vascular adaptations to volume and osmotic changes. These core issues have been outlined in a previous article in this journal by Dr Hellerstein, and the current article proceeds from that discussion.2 Following introductory comments about body fluid volume and composition, we provide an overview of some of the etiologies of the disorders of volume, tonicity, and composition of body fluids and of the therapy to correct these disorders.

Sodium, Osmolality, and the Volume of Body Fluids

Total body water, which is 55% to 72% of body mass, varies with sex, age, and fat content and is distributed between the intracellular and extracellular spaces. The extracellular fluid (ECF), which comprises about one third of total body water, includes the intravascular plasma fluid and the extravascular interstitial fluid.
INDEX OF SUSPICION
Authors: Block Janice L. , Daisy Selina , Mostaque A K , Waler James A.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

An 11-month-old boy is brought to the emergency department because of 3 days of fever, "crossed eyes," and a discharge of bloody pus from his left ear. His mother also has noticed that he is less steady on his feet. His left ear has been infected for 6 months despite therapy with amoxicillin/clavulanate, cefpodoxime, clarithromycin, ceftriaxone, cefaclor, and antibiotic drops with hydrocortisone. The mother states that she has been fully compliant with the drug regimens.

On physical examination, the child's height and weight are in the 50th percentile. He tugs frequently at both ears but is afebrile and does not look ill. He is unable to move his left eye laterally past midline, giving him a cross-eyed appearance on left lateral gaze.
Separation or Synthesis: A Holistic Approach to Therapeutics
Authors: Kemper Kathi J.
Published: December 2021

Over the past 50 years, health care has grown more complex and specialized. Health-care institutions now are staffed with an array of specialist physicians, social workers, psychologists, therapists, and nutritionists as well as general practitioners and nurses. The types of providers outside of the hospital are even more numerous and diverse: physicians; nurses; nurse practitioners; chiropractors; counselors; acupuncturists; herbalists; spiritual healers; and purveyors of nutritional supplements, aromatherapy, crystals, and more.

Intent on distinguishing their "products," providers focus on differences, polarizing into distinct camps such as "mainstream or traditional" versus "alternative or unconventional." Although these dichotomies are simple, they also can mislead. The definition of "alternative" is very dependent on the definition "mainstream"; acupuncture may be an alternative in one setting, but it clearly is traditional within Asian communities. Therapies that once were considered unconventional, such as hypnosis and meditation, have moved into many mainstream medical settings. (See Sugarman article "Hypnosis: Teaching Children Self-regulation" in the January 1996 issue of Pediatrics in Review.)

The public wants health care that is low-cost, safe, effective, and personalized. Practitioners of "natural" therapies often are viewed as more humanistic and less technological than busy physicians. According to one study, in 1990, alternative medical therapies were used by nearly one third of Americans.1
INDEX OF SUSPICION
Authors: Colson Eve R. , Herendeen Neil , Szilagyi Peter , Bush William , Pandit Sharad
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 9-month-old African-American boy is brought to you in early April for a well child visit. Born after an uncomplicated pregnancy and delivery, he has been healthy at all previous visits and was noted to have normal growth and development when last seen at 6 months of age.

At this visit, the baby's length has dropped from the 50th to the 5th percentile, while his weight and head circumference remain at the 50th. He is breastfed and eats small amounts of chopped fruits and vegetables. His parents give him no foods that contain artificial ingredients, and he receives no supplemental vitamins. The baby's stools are normal in pattern and consistency, and he has had no recent illnesses.
Delivering Nebulized Medication to Infants and Toddlers
Authors: Seidel James
Published: December 2021

Several aerosolized drugs are available for the management of reactive airway disease. Nebulized drugs are given directly into the airway, which minimizes the systemic effects of musculoskeletal tremor, anxiety, and cardiovascular stimulation in most patients. Although infants and young children can be given medication via a metered dose inhaler that has a spacer, these children may not generate enough inspiratory pressure to open the oneway valve on the spacer fully.
Preventing Drug and Alcohol Abuse
Authors: Faigel Harris C.
Published: December 2021

We know that some societies and some cultures have less alcoholism and drug abuse than others. Their experience suggests that children do best when they grow up in a community that uses alcohol, tobacco, and drugs responsibly, with parents who have equally responsible attitudes about these chemicals and expectations that their children will follow suit, and with low peer pressure for abuse. If we can develop a common goal of responsible use of these chemicals within our polymorphous society, we may be able to reduce, and even prevent, some alcohol and drug abuse in America.
Incest
Authors: Sarles Richard M.
Published: December 2021

Incest, one facet of sexual abuse of children and adolescents, refers to sexual relations between persons too closely related to marry. These relations mean an overt action by one partner with a sexual intent ranging from physical fondling to genital contact and/or intercourse. Many legal codes extend the incest restrictions to adopted and/or stepchildren. This definition technically includes prepubertal sex play between siblings. However, curiosity appears to be the motivating factor in the prepubertal age group and clear evidence of the intent for sexual exploitation inappropriate for the children's age is usually lacking.

Father-daughter incest, including stepfather-stepdaughter incest, constitutes approximately 75% to 85% of the cases reported. Although brother-sister incest is thought to be the most common form of incestuous behavior, only 15% of the cases reported to the authorities are of this type. Most brother-sister incest represents exploitative sexual behavior rather than age-appropriate mutual curiosity and experimentation. Such sibling incestuous behavior does not cross generational lines and seems, therefore, to be less influenced by the guilt of the incest taboo. In mother-son incest, which is the most uncommon type, the taboo appears to be so strong that one or both of the partners are usually severely emotionally disturbed or psychotic.
Risk Factors for Coronary Artery Disease in Children: Recognition, Evaluation, and Therapy
Authors: Glueck C. J. , Mellies M. J. , Tsang R. C. , Morrison J. A.
Published: December 2021

PEDIATRIC GENESIS OF ATHEROSCLEROSIS

Atherosclerosis results from a variety of pathophysiologic disturbances, some currently recognized, and many undoubtedly not yet recognized, which in aggregate are identified as risk factors. Genetic and environmental influences conjointly affect the incidence and the severity of these risk factors and, thus, coronary heart disease (CHD) risk. Prophylaxis should be designed to prevent or retard the development of arterial plaques. This suggests that diagnostic and preventive efforts should begin in childhood. Eating habits are also probably established in childhood, allowing their early modification.

The atherosclerotic plaque appears to have its genesis in childhood. The data from wartime autopsies confirm the presence of mature atherosclerotic lesions by the end of the second decade and emphasize the importance of primary atherosclerosis prevention beginning in the first and second decades.

While there are clearly genetic factors in CHD, variation in rates in differing geographic areas appears less likely to be related to genetic than to environmental differences. Marked differences in plasma cholesterol levels are found in children in different geographic areas, generally paralleling pediatric cholesterol and saturated fat intake and the incidence of adult coronary heart disease. The relationships of elevated total plasma cholesterol levels to the incidence of coronary heart disease are clearly established in adults.
Juvenile Rheumatoid Arthritis
Authors: Schaller Jane G.
Published: December 2021

Juvenile rheumatoid arthritis is the condition of chronic synovitis in children. This Condition was first well described in the English literature by George Frederick Still,1 an English pediatrician and pathologist, who in 1897 described 22 children with chronic arthritis who had come to his attention while he was still in training at the Hospital for Sick Children, Great Ormond Street. Still postulated that several distinct conditions were responsible for chronic arthritis in children. After Still, unfortunately, little work was done in the field of pediatric rheumatology until recent years. Most modern observers have come to agree with Still that chronic arthritis in children encompasses several distinct disease subgroups.2-5 The relationship of juvenile rheumatoid arthritis to adult rheumatoid arthritis remains uncertain; some of the subgroups described in children are not recognized in adults, whereas classic adult-type rheumatoid arthritis occurs in children, but accounts for only a small percentage of total patients.4 The nomenclature for chronic childhood arthritis is quite confusing at the present time (Table 1). The term juvenile rheumatoid arthritis (JRA) has been retained in the United States to describe all children with chronic arthritis, whereas the term juvenile chronic arthritis is becoming more widely used in Europe. The term Still disease, although according due honor to an important person, is confusing and should probably be discarded.
Inborn Errors of Metabolism
Authors: Komrower George M.
Published: December 2021

Around the turn of the century Garrard established the concept of an inborn error of metabolism using his study on alcaptonuria to exemplify his hypothesis that a considerable number of metabolic disorders with clearly defined clinical, pathologic, and biochemical abnormalities arise because an enzyme governing a single metabolic step is either reduced in activity or missing altogether. He pointed out the familial distribution of alcaptonuria and later showed that the inheritance could be explained on mendelian principles, ie, the affected individual was homozygous for the abnormal gene and that the inheritance was recessive, both parents being heterozygous for the disorder. He suggested that the accumulation of homogentisic acid in alcaptonuria was evidence that this substance is a normal metabolite in the degradation of tyrosine and attributed this accumulation to a failure of oxidation of homogentisic acid. In addition to alcaptonuria he described cystinunia, pentosuria, and albinism. This work was the forerunner of the classic studies of Beadle and Tatum on mutants of Neurospora crassa which led to the one gene-one enzyme concept.

DETECTION

Different groups require special attention: the family at risk because of previously affected individuals, those with unusual features suggestive of metabolic disorders, and sick newborns. Screening of normal newborns requires a different approach.
Editorial: Those Educational Objectives
Authors: H. R. J.
Published: December 2021

The material Covered in PEDIATRICS IN REVIEW is, for the most part, based upon Educational Objectives developed by two Task Forces and accepted by the Coordinating Committee on Continuing Education and Recertification. Both Task Forces are made up of practicing pediatricians (at least 50%) and academicians, and are appointed by the American Academy of Pediatrics and the American Board of Pediatrics. The organization and respective responsibilities of the Task Forces are shown in the diagram. The activities of The Academy (PREP) and The Board are based upon these objectives.

The Topics Task Force develops some 25 to 35 Educational Objectives dealing with the Topics selected for review each year.
Febrile Seizures: Long-Term Management of Children with Fever-Associated Seizures
Authors:   Consensus Development Panel
Published: December 2021

A Consensus Development Conference on Febrile Seizures was held at the National Institutes of Health on May 19-21, 1980. The purpose of the Conference was to bring together practicing physicians, research scientists, consumers, and others in an effort to reach general agreement on the risks of sequelae in children with febrile seizures and to compare them with the potential risks and benefits of prophylaxis with anticonvulsants. This summary is the result of these deliberations.

1. What is a febrile seizure?

A febrile seizure (an abnormal, sudden, excessive electrical discharge of neurons (gray matter) which propagates down the neuronal processes [white matter] to affect an end organ in a clinically measurable fashion) is an event in infancy or childhood, usually occurring between 3 months and 5 years of age, associated with fever but without evidence of intracranial infection or defined cause. Seizures with fever in children who have suffered a previous nonfebrile seizure are excluded. Febrile seizures are to be distinguished from epilepsy, which is characterized by recurrent nonfebrile seizures.

2. What are the risks facing the child who has a febrile seizure?

Children who suffer a febrile seizure generally enjoy normal health after the episode. They are, however, at some risk in several respects. Thirty percent to 40% of children who have one febrile seizure and who do not receive prophylactic therapy will experience a second.
Ankle Injuries in Children and Adolescents
Authors: Harvey Jack
Published: December 2021

Every general pediatric practice has its share of minor orthopedic trauma, comprising approximately 5% of the average practice. In practices slanted toward the care of adolescents or athletes the percentage is higher. The vast majority of these injuries occur to the ankle and knee, however; this article will discuss ankle injuries exclusively. Whether you are dealing with athletes or with active children and adolescents, the proper diagnosis, treatment, and rehabilitation of common ankle injuries is an important aspect of general pediatric practice. Failure to treat a specific injury properly may not only prolong the discomfort and disability produced by the injury but may produce the end result of a chronically unstable ankle and possible degenerative joint disease.

ANATOMY AND BIOMECHANICS

Proper diagnosis of ankle injuries requires a knowledge of the anatomy of the bones and ligaments that make up the ankle joint (Fig 1). The distal ends of the fibula and tibia are held in close approximation by ligamentous structures to produce an ankle mortise lined with articular cartilage. This surface articulates with the cartilaginous surface of the dome of the talus. The anterior and posterior tibiofibular ligaments (syndesmosis) are responsible for holding the distal tibia and fibula together. The joint proper is stabilized medialy and laterally by the distal processus of these bones as well as attached ligaments.
Crohn's Disease in Children
Authors: Gryboski Joyce D.
Published: December 2021

Once considered rare in children, Crohn's disease (CD) is being recognized with increasing frequency.1-3 This is due not only to physical awareness but to an alarming increase in the incidence of the disease in young people. Although early descriptions of CD localized the site of involvement to the terminal ileum, it is now recognized that all organs of the alimentary tract may be affected, and in some unfortunate patients involvement extends proximally as far as the stomach, esophagus, or oropharynx and distally, to involve even perianal tissue.

Unlike ulcerative colitis which is rather clear-cut in its presentation, CD is often insidious with solitary symptoms of anorexia, weight loss, short stature, or fever of unknown origin being its only manifestation. The presenting symptoms and longterm course vary with the site of disease, and although each patient must be evaluated and treated individually, some overall predictions may be offered as to the victim's future quality of life.4-6

Significant advances have been made during the last decade in understanding the pathophysiology of the disease and in methods of its treatment, although as yet the etiology remains to be defined. Although CD has many features in common with ulcerative colitis and the two are often combined in the terminology, "inflammatory bowel disease," the pathologic findings, course, and complications are distinctive enough that they should be considered as two distinct diseases.
Herpes Simplex Virus Encephalitis in Pediatrics
Authors: Nahmias André J. , Whitley Richard J.
Published: December 2021

It is disturbing to note that since the advent of national reporting of acute encephalitis, no etiology has been established for the majority of cases diagnosed in the United States every year.1 This complacent approach to diagnosis probably stems from the apparent lack of specific therapy. Nevertheless, correct diagnosis has always been important for several reasons: for epidemiologic control of such entities as mosquito-borne encephalitis, for prognostic considerations, and so as not to miss known treatable conditions that may mimic encephalitis. In pediatrics particularly, we can illafford not to attempt to establish the specific diagnosis of encephalitis which is so prone to affect the quality of life of newborns and older children. There is even more reason today to improve our diagnostic acumen as newer methods are becoming available for the prevention and/or therapy of the second most devastating of the viral encephalitides—that due to herpes simplex viruses (HSV).

Less than a decade ago it was widely believed that HSV encephalitis in newborns and older children was an extremely rare occurrence, being a disease primarily of adults. This erroneous impression is again most likely a result of inadequate diagnosis, as well as the lack of adequate information. However, there have been many recent advances at all levels in this area.
Increased Intracranial Pressure
Authors: Griffith John F. , Brasfield Jimmy C.
Published: December 2021

The infant or child with increasing pressure within the cranial cavity must be identified early and treated promptly in order to prevent serious complications or death. When the pressure elevation is gradual it is frequently well tolerated, and the patient may seem deceptively well. There is a critical point, however, beyond which any further increase in pressure leads to a catastrophic deterioration in the patient's condition.1 When this occurs, the outlook for quality survival is poor despite the best therapy. Unfortunately, this can occur when the underlying process is benign and would have been reversible if recognized and treated promptly. For prompt recognition and treatment, the physician must be familiar with the pathophysiology of raised intracranial pressure.

PATHOPHYSIOLOGY

The intracranial compartment contains blood vessels, cerebrospinal fluid (CSF), brain, and leptomeninges which include the rigid dural membranes forming the falx and tentorium. Whenever there is an increase in the volume of any one of these intracranial components (brain, CSF, blood) there must be a corresponding reduction in the size of the others in order for the intracranial pressure to remain normal. This type of compensation or buffering capacity is particularly important in the early stages of intracranial disease. As the pressure mounts from any type of mass lesion, the CSF is displaced caudally into the spinal subarachnoid space and there is a corresponding increase in the rate of absorption of CSF.2
Eczematous Eruptions in Childhood
Authors: Hurwitz Sidney
Published: December 2021

Atopic dermatitis, one of the most common skin disorders seen in infants and children, is frequently a source of frustration to parents and presents a challenge to immunologists, pediatricians, and dermatologists alike. Affecting approximately 3% of the childhood population, atopic dermatitis frequently causes confusion because the terms eczema and dermatitis are often used synonymously and interchangeably.1 Eczema is a generic term that identifies an acute inflammatory cutaneous eruption characterized by itching, redness, papules, vesicles, edema, serous discharge, and crusting (Fig 1). Dermatitis without a qualifying adjective is less definitive and merely refers to an inflammation of the skin which may result in a spectrum of lesions varying from acute necrosis and ulceration to simple erythema.2 A modifying adjective therefore is frequently added to the general term in an effort to identify the specific eruption under consideration, hence the terms contact dermatitis, seborrheic dermatitis, nummular dermatitis, and atopic dermatitis.

PATHOGENESIS

Atopic dermatitis is the most common cause of eczema in children. Although its cause remains unknown, the disorder represents an eczematous disorder of characteristic distribution, a hereditary symptom complex in individuals with paradoxical physiologic responses to pharmacologic stimuli, a constitutional predisposition to develop dry skin and pruritus, and a personal or family history of allergy.
Role of the General Pediatrician in Neonatology: Relevance of Recent Advances
Authors: Stark Ann R.
Published: December 2021

The general pediatrician plays important roles even as neonatology becomes more specialized: first in the evaluation of the newborn infant and in the organization of resources for care; and second as a major influence in the education of the parents. Awareness of significant advances will allow appropriate counseling of parents and obstetricians. Inasmuch as perinatal centers can provide care for mothers and babies that other hospitals cannot, pediatricians must ensure that the regionalization network and transport mechanism are established so that life-saving advances are available for their patients. Then, the pediatrician and the obstetrician, as members of a team, can provide the best possible care to mother and infant.
Learning Disabilities in Children
Authors: Wender Esther H.
Published: December 2021

Of the many factors that may combine to produce school problems, learning disabilities constitute the most prevalent underlying cause. This article is devoted to a better understanding of this complex disorder. Following a brief discussion of diagnosis, etiology, and prevalence, the focus will be on controversies surrounding therapy arising from recent outcome studies and the attention given to dietary treatment. Objectives of this report include reviewing the evidence that suggests limitations of medication as the only treatment for this disorder, some of the possible harmful effects of medication, and the efficacy of diet as a mode of therapy. The discussion will also acquaint the clinician with major aims of therapy and suggest multiple approaches to treatment.

DEFINITION AND TERMINOLOGY

Learning disabilities can be broadly defined as a cluster of biologically based disturbances in development that significantly impair school performance. These developmental problems fall into two broad categories that differ in the kind of symptoms that predominate, the manner in which school performance is affected, the regions of the central nervous system most likely involved, and the types of therapy needed. The first category affects primarily the acquisition of specific academic skills (such as reading individual words, spelling, handwriting, and mathematic computation) information remains intact.