bluuebunny/crossref_metadata_2025 huggingface dataset:
Neurologic History and Examination Results and Their Relationship to Human Immunodeficiency Virus Type 1 Serostatus in Hemophilic Subjects: Results From the Hemophilia Growth and Development Study
Authors: Bale James F. , Contant Charles F. , Garg Bhuwan , Tilton Ann , Kaufman David M. , Wasiewski Warren
Published: December 2021

In a prospective study of the growth and neuropsychologic function of hemophilic subjects, 333 boys, median age of 12.3 years, had baseline neurologic examinations. The study population included 207 individuals (62%) who were seropositive for human immunodeficiency virus type 1 (HIV-1). Overall results indicated that 11% had abnormalities of cranial nerve function, 17% had abnormal deep tendon reflexes, 23% had abnormal strength, 25% had abnormal coordination, and 31% had abnormal tone, bulk, or range of motion. By contrast, 2% or fewer displayed abnormal movements or had abnormal pain or vibratory sensation, or altered mental status. Abnormalities were more common in older hemophilic subjects (eg, 67 [38%] of 177 subjects ≥12 years of age had abnormal tone, bulk, or range of motion vs 36 [23%] of 156 subjects < 12 years of age). When compared with regard to HIV-1 status, HIV-seronegative and HIV-seropositive subjects did not differ with regard to head circumference or the frequency of abnormalities of cranial nerve function, sensation, muscle strength, or coordination. However, deep tendon reflexes and tone, bulk, or range of motion were more frequently abnormal in HIV-1-seropositive individuals. More HIV-1-positive subjects had at least one increased deep tendon reflex (13/207 [6.3%] vs 1/126 [0.8%] in seronegatives) and more had non-hemophilia-related decreases in muscle bulk (7/207 [3.4%] vs 0/126 in seronegatives). These results indicate that hemophilia causes substantial neurologic dysfunction and that certain findings, such as changes in muscle-stretch reflexes or muscle bulk, may also reflect the neurologic consequences of HIV infection.
Neutrophil Elastase and Acute Pulmonary Damage in Neonates With Severe Respiratory Distress Syndrome
Authors: Speer Christian P. , Ruess Dorothea , Harms Karsten , Herting Egbert , Gefeller Olaf
Published: December 2021

This study evaluated possible acute effects of neutrophil elastase on neonatal pulmonary morbidity. The activity of free elastase and α1-proteinase inhibitor as well as concentrations of elastase-α1-proteinase inhibitor in tracheal aspirate fluid of neonates with severe respiratory distress syndrome (fraction of inspired oxygen >0.6, mechanical ventilation) were analyzed between 6 and 36 hours after surfactant replacement therapy. One hundred forty neonates were included in this prospective study. Characteristics, disease severity, and ventilatory requirements were nearly identical in both groups. All patients were treated with natural porcine surfactant (Curosurf) at an age of 2 to 15 hours. In 42 neonates (30%) considerable activities of free elastase were detected (805 µg/L; 100 to 1850 [median, 25th to 75th percentile]); in 98 neonates (70%) who had protective levels of α1-proteinase inhibitor, no elastase activity was detected. The average concentrations of elastase-α1-proteinase inhibitor were significantly increased in patients with free elastase activity when compared with those of the nonelastase group. In logistic regression analyses, 28-day outcome data showed a pronounced increase in risk of pulmonary interstitial emphysema for patients with free elastase activity in tracheal aspirate fluid. The incidence of other pulmonary and nonpulmonary complications was very similar in both groups. It is concluded that elastolytic damage and barotrauma may both contribute to acute pulmonary injury in the early stages of respiratory distress syndrome.
Extremely Low Birth Weight Children and Their Peers: A Comparison of Preschool Performance
Authors: Halsey Carey L. , Anderson Craig L. , Collin Marc F.
Published: December 2021

Though not well studied, extremely low birth weight (ELBW; (1000 g) appears to be a major risk factor for developmental disability, with most affected children experiencing school problems (40% to 64%) rather than severe handicap (25%). This study marks the first published US attempt to document prospectively the developmental/educational progress of a cohort of predominantly white, middle-class ELBW children with randomly selected and matched heavier birth weight (1500 through 2500 g and >2500 g) peer comparison groups. Sixty ELBW children and 60 peers were administered a test battery at age 4 years, including the McCarthy Scales of Children's Abilities, Peabody Picture Vocabulary Test, and Beery Test of Visual-Motor Integration. The ELBW group mean scores were significantly lower than those of the peer groups on every measure, although generally still within 1 SD of the test mean. Twenty-three percent were clearly disabled; 26% had optimal development, having attained at least average scores on all measures; and 51% attained borderline scores globally or had an average cognitive score, but specifically poor performance in one or more areas. Comparison groups were 2½ times more likely to have optimal development and had mean cognitive scores 15 to 18 points higher than the ELBW group. In summary, weaker performance on all measures exists prior to school entry among nondisabled ELBW children compared with their peers. It is unclear whether these data portend emerging school-based disabilities or describe a continuing recovery process to be completed in middle childhood. Continued follow-up of this cohort at 7 and 10 years of age will address these questions.
Contralateral Renal Abnormalities in Patients With Renal Agenesis and Noncystic Renal Dysplasia
Authors: Atiyeh Bassam , Husmann Douglas , Baum Michel
Published: December 2021

The prevalence of contralateral renal abnormalities in noncystic-dysplastic kidney (NCDK) disease and renal agenesis is unknown. Twenty-four patients with NCDK disease and 16 patients with renal agenesis were studied in this 11-year retrospective study. In all patients the urinary system was evaluated by renal ultrasonography, and excretory urography or radionuclide scan. In addition, voiding cystourethrography was performed in 21 of 24 patients with NCDK disease and in 10 of 16 patients with renal agenesis. In those patients where voiding cystourethrography was performed, 14 (67%) patients with NCDK disease and 9 (90%) patients with renal agenesis had contralateral urologic abnormalities. Contralateral vesicoureteral reflux was the most common contralateral abnormality identified in 9 (43%) patients with NCDK disease and in 3 (30%) patients with renal agenesis. It is concluded that contralateral urologic abnormalities are common in patients with NCDK disease and in patients with renal agenesis and that vesicoureteral reflux is the most common contralateral abnormality noted.
Bulimic Behaviors Among Interscholastic Wrestlers: A Statewide Survey
Authors: Oppligen Robert A. , Landry Gregory L. , Foster Sharon W. , Lambrecht Ann C.
Published: December 2021

Wrestlers are known for their extreme weight-cutting practices including fasting, food and fluid restriction, and dehydration. Using a stratified statewide survey, this investigation elucidated weight loss practices, nutritional knowledge, and bulimic behaviors among 713 high school wrestlers in Wisconsin. Results showed that 1.7% of the wrestlers answered questions consistent with all five criteria for bulimia nervosa, a rate higher than expected for adolescent males. An additional 43% exhibited weight-cutting practices similar to those of the wrestlers who met all bulimia nervosa criteria. The average wrestler lost 3.2 kg to compete, cycled 1.8 kg weekly, and fasted 20 hours prior to weigh-in. More extreme behaviors occurred among the 45% who met two or more bulimia nervosa criteria on their questionnaire; 19% frequently fasted, 25% restricted fluids, 34% used rubber suits, and 8% vomited. These results are comparable with data published over the past 20 years. Efforts to curtail these behaviors through regulations restricting weight loss coupled with sound nutritional information are warranted. Physicians and health professionals should be alert to potential eating disorders within this population.
Hepatitis B Immunization: Premonitions and Perceptions of Pediatricians
Authors: HALL CAROLINE BREESE , MARGOLIS HAROLD S.
Published: December 2021

In this issue of Pediatrics, the article by Freed and colleagues1 emphasizes important issues in ensuring the implementation of our immunization programs. The effector arm of the program, those who administer the immunizations, must have not only the capability, but also the will. This comes only from understanding the need and rationale of the recommendations.

Freed et al surveyed pediatricians about their awareness and receptivity of the new recommendations for universal infant hepatitis B immunization; the survey was conducted during the 2- to 3-month period between publication of these recommendations from the Centers for Diseases Control and Prevention (CDC)2 and those of the American Academy of Pediatrics (AAP).3
It's Not Henoch-Schönlein Purpura (HSP)
Authors: MORGENSTERN BRUCE Z. , MILLINER DAWN S.
Published: December 2021

To the Editor.—

The cases reported by Olson et al1 of pulmonary hemorrhage in children with systemic vasculitis clearly highlight the fact that children are not "immune" to these conditions. We must take issue, however, with the diagnosis of Henoch-Schönlein purpura in the patients described. Because Henoch-Schönlein purpura is a subset of systemic vasculitis, the clinical manifestations may mimic or be mimicked by other vasculitis syndromes such as polyarteritis nodosa, Wegener's granulomatosis, and systemic lupus erythematosus.2
It's Not Henoch-Schönlein Purpura (HSP)
Authors: OLSON JUDYANN C. , KELLY KEVIN J. , PAN CYNTHIA G. , WORTMANN DOROTHY W.
Published: December 2021

In Reply.—

Classification criteria have been established by the American College of Rheumatology (ACR) for the diagnosis of Henoch-Schöenlein purpura (HSP). These criteria include palpable purpura, age ≤20 years, bowel angina, and wall granulocytes on biopsy. The presence of two of four criteria is required for classification with a reported 87.1 % sensitivity and 87.7% specificity. The authors of the criteria recognized that the diagnosis of HSP is primarily clinical and that biopsies are rarely necessary to diagnose HSP in children.1
Guidelines vs the Legal Standard of Care and Screening for Polycythemia
Authors: MERENSTEIN GERALD B.
Published: December 2021

To the Editor.—

Dr David Reynolds1 appropriately applauds policy of the American Academy of Pediatrics to accompany committee statements with a paragraph recognizing that alternative strategies may be appropriate and that the opinions expressed do not constitute standards of medical care. He states that he was unable to find a similar statement in the second edition of Guidelines for Perinatal Care.2 Both the second and third editions1 contain such a statement which says, in part, on page ii:
Screening for Treatable Disorders
Authors: CLAYTON ELLEN WRIGHT
Published: December 2021

In Reply.—

I appreciate the opportunity to respond to Dr Arnold's thoughtful letter because she raises a frequently made argument that failure to consent to newborn screening constitutes actionable neglect.1-3 The problem with this argument, however, is that it tends to combine inappropriately the risks of failing to screen with the risks of failing to treat a child with the disease being sought.4 For example, the actual risk that any particular child who is not screened will develop mental retardation that could have been avoided is very low simply because the incidence of phenylketouria (PKU), congenital hypothyroidism, and the other metabolic disorders sought is very low, even in the aggregate.
Lead and IQ
Authors: BELLINGER DAVID
Published: December 2021

In Reply.—

Dr Needles raises several important points about our study. He questions the presence of a dose-effect relationship between blood lead level at age 24 months and intellectual functioning at age 10, as well as our assertion that a threshold for this relationship was not apparent. His skepticism is understandable. Our conclusions were based on three observations, not all of which we were able to include in our paper. 1) Examination of the partial regression residual plot (IQ adjusted for all covariates and blood lead level adjusted for all covariates) indicated symmetrical distribution of residuals about the regression line and similarity in the residual variances over the blood lead range.
Stewart Smiled
Authors: KIBELBEK MICHAEL J. , SCHWARTZ JAN A. , TENEDIOS GEORGE
Published: December 2021

To the Editor.—

Dr Tobias' study dramatically demonstrates the efficacy of orally administered ketamine.1 When given in a controlled manner to properly prepared oncology patients, ketamine can be a very useful drug. Tobias suggests that although many institutions restrict the use of ketamine to anesthesiologists, "...we believe that other physicians should be allowed to use this valuable agent as an oral premedicant." We believe he is wrong. Except for scheduled oncologic procedures, there are relatively few areas where profound central nervous system depression is desirable.
A Conference on Culture and Chronic Illness in Childhood: Conference Summary
Authors: Patterson Joan M. , Blum Robert Wm
Published: December 2021

A focus on disability and chronic illness within the disciplines of health, education, and social services has usually assumed a dominant cultural ethos grounded in European-American values. Indicators of social and psychological competence, normative behavior, response to stress and to illness, and even adaptation to life have been assumed to comprise a relatively homogeneous pattern. "Abnormal" has usually been defined as deviation from this pattern. For the most part, there has been a failure to take into account the reality that there may be many different processes of adaptation utilized by different cultural and ethnic groups. Such adaptation patterns should not be viewed as deviant, but rather as different and comprising strengths, resources, and advantages, as well as potential problems and disadvantages. Unfortunately, the continuing prevalence of racism in our society has contributed to equating different with deviant.

Just as children from different cultural, ethnic, and racial groups are too often marginalized by society and experience restricted access or denial to important resources needed for optimal physical, psychological, and social development, so too, children who experience disability and chronic illness are too often marginalized by the attitudes and behaviors of others. The parallels between these two sources of exclusion—minority status and disability status—as well as the interaction of the two factors has received very little attention in research, service delivery, or policy formation.

Even though pluralism is inherent in the history of the United States, our orientation has been homogenization—"the great melting pot." This is changing. With awareness of the growing proportion of ethnic minorities comprising tht US population and with a new positive value and emphasis being placed on ethnic diversity, there is renewed interest in cultural variation.
Prevention of Progression to Severe Obesity in a Group of Obese Schoolchildren Treated With Family Therapy
Authors: Flodmark Carl-Erik , Ohlsson Torsten , Rydén Olof , Sveger Tomas
Published: December 2021

Study objective. To evaluate the effect of family therapy on childhood obesity.

Design. Clinical trial. One year follow-up.

Setting. Referral from school after screening.

Participants. Of 1774 children (aged 10 to 11), screened for obesity, 44 obese children were divided into two treatment groups. In an untreated control group of 50 obese children, screened in the same manner, body mass index (BMI) values were recorded twice, at 10 to 11 and at 14 years of age.

Intervention. Both treatment groups received comparable dietary counseling and medical checkups for a period of 14 to 18 months, while one of the groups also received family therapy.

Results. At the 1-year follow-up, when the children were 14 years of age, intention-to-treat analyses were made of the weight and height data for 39 of 44 children in the two treatment groups and for 48 of the 50 control children. The increase of BMI in the family therapy group was less than in the conventional treatment group at the end of treatment, and less than in the control group (P = .04 and P = .02, respectively). Moreover, mean BMI was significantly lower in the family therapy group than in the control group (P < .05), and the family therapy group also had fewer children with BMI > 30 than the control group (P = .02). The reduction of triceps, subscapular, and suprailiac skinfold thicknesses, expressed as percentages of the initial values, was significantly greater in the family therapy group than in the conventional treatment group (P = .03, P = .005 and P = .002, respectively), and their physical fitness was significantly better (P < .05).

Conclusions. Family therapy seems to be effective in preventing progression to severe obesity during adolescence if the treatment starts at 10 to 11 years of age.
Smoking and the Sudden Infant Death Syndrome
Authors: Mitchell E. A. , Ford R. P. K. , Stewart A. W. , Taylor B. J. , Becroft D. M. O. , Thompson J. M. D. , Scragg R. , Hassall I. B. , Barry D. M. J. , Allen E. M. , Roberts A. P.
Published: December 2021

Objective. Maternal smoking has been shown to be a risk factor for sudden infant death syndrome (SIDS). The effect of smoking by the father and other household members has not previously been examined.

Methods. A large nationwide case-control study. Four hundred eighty-five SIDS deaths in the postneonatal age group were compared with 1800 control infants.

Results. Infants of mothers who smoked during pregnancy had a 4.09 (95% confidence interval [CI] = 3.28, 5.11) greater risk of death than infants of mothers who did not smoke. Infants of mothers who smoked postnatally also had an increased risk of SIDS compared with infants of nonsmokers and, furthermore, the risk increased with increasing levels of maternal smoking. Smoking by the father and other household members increased the risk (odds ratio [OR] = 2.41, 95% CI = 1.92, 3.02 and OR = 1.54, 95% CI = 1.20, 1.99, respectively). Smoking by the father increased the risk of SIDS if the mother smoked, but had no effect if she did not smoke. In analyses controlled for a wide range of potential confounders, smoking by the mother and father was still significantly associated with an increased risk of SIDS.

Conclusion. Passive tobacco smoking is causally related to SIDS.
Increases in Crash Involvement and Fatalities Among Motor Vehicle Occupants Younger Than 5 Years Old
Authors: Chorba Terence L. , Klein Terry M.
Published: December 2021

Objective. To determine whether increased exposure as car occupants could be a major contributor to increases observed in deaths of young children in car crashes.

Design and setting. Crash data from police reports for Maryland, Michigan, Pennsylvania, and Washington for various years from 1982 through 1990 were examined to compare annual age mix of injured and uninjured occupants in crashes involving at least two passenger vehicls. Aggregate national data from the Fatal Accident Reporting System were also examined over the same time period and compared to population estimates for children younger than 5 years old to assess temporal trends in number of occupants in this age group who were involved in motor vehicle crashes in which a fatality occurred in fatal crashes and the number of them killed in passenger vehicles.

Results. In regression analyses for each state, the number of car occupants younger than 5 involved in crashes increased during the years studied; their percentage among nondriver occupants involved also increased. At a national level, similar analyses showed increases in the number of occupants younger than 5 involved in crashes in which a fatality occurred.

Conclusions. Despite overall increases in the use of restraint devices (ie, both child safety seats and adult restraints), fatalities among restrained children have increased. Given that exposures to crash environments are increasing, clinicians need be aware of the importance of child restraints as a means of reducing the likelihood of injury.
Clinical and Biochemical Phenotype in 11 Patients With Mevalonic Aciduria
Authors: Hoffmann Georg F. , Charpentier Christiane , Mayatepek Ertan , Mancini Josette , Leichsenring Michael , Gibson K. Michael , Divry Priscille , Hrebicek Martin , Lehnert Willy , Sartor Klaus , Trefz Friedrich K. , Rating Dietz , Bremer Hans J. , Nyhan William L.
Published: December 2021

Objective. Mevalonic aciduria is a consequence of the deficiency of mevalonate kinase, the first enzyme after 3-hydroxy-3-methylglutaryl-coenzyme A reductase in the biosynthesis of cholesterol and nonsterol isoprenes. To establish the clinical and biochemical phenotype of mevalonic aciduria, the authors assembled their experience with 11 patients including attempts at therapeutic interventions.

Methods. Mevalonic acid in body fluids was determined by stable isotope dilution gas chromatography/mass spectroscopy with selected ion monitoring, ubiquinone-10 concentrations by reversed-phase high-pressure liquid chromatography.

Results. Varying degrees of severity of clinical illness were observed despite uniform, virtual absence of residual activity of the enzyme. The most severely affected patients have had profound developmental delay, dysmorphic features, cataracts, hepatosplenomegaly, lymphadenopathy, and anemia, as well as diarrhea and malabsorption, and have died in infancy. Less severely affected patients have had psychomotor retardation, hypotonia, myopathy, and ataxia. All patients have had recurrent crises in which there was fever, lymphadenopathy, increase in size of liver and spleen, arthralgia, edema, and a morbilliform rash. Neuroimaging studies revealed selective and progressive atrophy of the cerebellum. Mevalonic acid concentrations were found to be grossly elevated in body fluids of all patients. Concentrations of plasma cholesterol were normal or only slightly reduced. Concentrations of ubiquinone-10 in plasma were found to be decreased in most patients. Abnormalities such as hypoglycemia, metabolic acidosis, or lactic acidemia, the usual concomitants of disorders of organic acid metabolism, were conspicuously absent.

Conclusions. These observations establish the broad range of clinical symptoms and biochemical findings in mevalonic aciduria. It is concluded that although patients with mevalonic aciduria have a recognizable phenotype of serious clinical manifestations, some patients are likely to remain undiagnosed and may be found in a variety of subspeciality clinics, including neurology, troenterology, cardiology, and genetics.
Families on the Move and Children's Health Care
Authors: Fowler Mary Glenn , Simpson Gloria A. , Schoendorf Kenneth C.
Published: December 2021

Objective. To evaluate the relationship of family moves to children's health care use.

Design. Analyses of data from the 1988 National Health Interview Survey of Child Health (NHIS-CH). This survey uses a multisite probability cluster technique to achieve nationally representative estimates of health and demographic characteristics of the US civilian population.

Participants. 17 110 US children and their families who took part in the 1988 NHIS-CH.

Measurements. The 1988 NHIS-CH collected health and demographic data including family mobility information on 17 110 US children and their families. This study analyzed the relationship of number of family moves to reporting a regular site for preventive pediatric health care services, a regular site for pediatric sick care, and routine use of emergency departments when a child was sick.

Results. Overall, 8% of US children were reported to lack a regular site for preventive care services, 7% a site for sick care, and 3% routinely used an emergency department for sick care. However, 14% of children who had moved three or more times lacked a regular site for preventive care and 10% lacked a regular site for sick care, compared to only 3% of children who had never moved. Children who had moved more than twice were three times as likely to lack a regular site for preventive or sick care and 1.6 times as likely to use an emergency department for sick care, as were children who had never moved.

Conclusions. Families with increased mobility are more likely to lack a regular site for both preventive and sick care and to use emergency departments when their children become ill.
Dietary Approaches for Reducing Fat Intake of Preschool-Age Children
Authors: Sigman-Grant Madeleine , Zimmerman Sally , Kris-Etherton P. M.
Published: December 2021

Study objective. The present study was conducted to determine the effects of applying different fat reduction strategies to the overall nutrient profile of diets for preschool-age children.

Design. Computer modeling techniques were used to modify the diets of children (ages 2 through 3 and 4 through 5 years old) to meet contemporary dietary recommendations (<30% of calories from total fat, <10% from saturated fatty acids, and <300 mg of cholesterol daily). Fat reduction strategies were applied to a 1-week menu that included preschoolers' favorite foods. Strategies applied were replacing high-fat meat exchanges with lean meat exchanges (± three high-fat meat exchanges per week), replacing higher fat milks with skim milk, replacing high-fat meat exchanges with medium-fat meat exchanges, using fat-modified products, using low-fat preparation techniques, and added fat. All diets were made isocaloric after modifications were applied.

Results. It is more difficult to meet all recommendations for the 2- and 3-year-old children. Use of skim milk is the simplest strategy to use for the 4- and 5-year-old children, although other single strategies are effective.

Conclusions. When multiple strategies are effected. some diets are very low in fat (<20% of calories) and potentially inadequate in energy and nutrients. It is important that caregivers know the appropriate foods to choose when modifying fat in children's diets to ensure meeting energy and nutrient requirements.
Leber's Hereditary Optic Neuropathy as a Cause of Severe Visual Loss in Childhood
Authors: MOORMAN C. M. , ELSTON J. S. , MATTHEWS P.
Published: December 2021

Leber's hereditary optic neuropathy (LHON) is a rare, maternally transmitted disease that most commonly causes acute or subacute visual loss in young men, typically between the ages of 17 and 24 years (although perhaps 14% of affected individuals are women), which may be associated with systemic disorders, eg, cardiac dysrhythmias and neurologic problems.1 Onset is usually asymmetric, but intervals between involvement of the two eyes are usually less than a few months. A definitive diagnosis rested on a family history, age of onset, and the characteristic circumpapillary microangiopathy of the optic disc in the acute phase. However, recent demonstration of point mutations of mitochondrial DNA in affected individuals means that confirmation of the diagnosis can now be obtained in atypical or sporadic cases.2
Inhalational Nitric Oxide Therapy for Persistent Pulmonary Hypertension of the Newborn
Authors: KINSELLA JOHN P. , ABMAN STEVEN H.
Published: December 2021

Persistent pulmonary hypertension of the newborn (PPHN) is a clinical syndrome associated with various neonatal cardiopulmonary diseases, including meconium aspiration, group B streptococcal sepsis, congenital diaphragmatic hernia, and undetermined causes (idiopathic).12 Despite the diversity of clinical settings of PPHN, marked pulmonary hypertension and altered pulmonary vasoreactivity are its central pathophysiologic features. High pulmonary vascular resistance (PVR) results in right-to-left shunting of blood across the patent ductus arteriosus and foramen ovale, often causing critical hypoxemia. Current therapy to reduce pulmonary hypertension includes mechanical hyperventilation, alkalosis, hyperoxia, and cardiotonic and vasodilator drug therapy.3 Attempts at reducing PVR with hyperventilation and hyperoxia may cause severe lung injury, contributing to further morbidity and mortality of PPHN.
INTRODUCTORY COMMENTS
Authors: DAVILA ROBERT R.
Published: December 2021

This conference comes at an appropriate time in our nation's history. As we move toward the close of the 20th century the full participation of individuals with disabilities in all aspects of daily life is gaining in importance. Never before have the needs, capabilites, and potential of people with disabilities received so much attention at all levels of government and in the private sector.

This increase in awareness and activity has brought with it the recogintion that the disability community, like society in general, is a diverse community, made up of people from many different backgrounds and walks of life. The needs of this community are as complex as the community itself; they are influenced by such factors as age, gender, disability, and of course, cultural background.

If we are to reach our goal of full participation for individuals with disabilities, our first task is to try to understand the various forces that shape the lives of individuals with disabilities in our society.

The Office of Special Education and Rehabilitative services (OSERS) supports the goal of full community integration for all persons with disabilities and their families. In our efforts to pursue this goal, we must consider the strengths and needs of children and their families from a variety of backgrounds. We must be aware of the unique ethnic and cultural values of children with disabilities and their families. These values give meaning to a particular illness or disability and affect current functioning and future developmental outcomes.

It is especially important for policy-makers and service providers to understand the differences that exist among people in a culturally divergent society.
Monitoring Premature Infants in Car Seats: Implementing the American Academy of Pediatrics Policy in a Community Hospital
Authors: Bass Joel L. , Mehta Kishor A. , Camara Jeanne
Published: December 2021

Objectives. In 1990, the American Academy of Pediatrics (AAP) Committeee on Injury and Poison Prevention issued a policy statement which recommended that all infants born at less than 37 weeks gestational age be monitored in their car seat before discharge to identify infants at risk for apnea associated with car seat use. The objective of this report is to summarize the experience of a community hospital in implementing this recommendation, including: education of health professionals about the problem and its management, development of an effective hospital policy and procedure for testing at-risk infants, overcoming logistical difficulties for nursing staff who implement the policy, overcoming liability concerns, and summarizing the clinical results which we observed during a 15-month period.

Methods. MetroWest Medical Center, Framingham Union Campus is a community hospital with a Level II Neonatal Unit with approximately 2200 deliveries annually. Hospital procedures and policies were developed to implement the AAP policy for safe transportation of premature infants. Consequently, infants less than 37 weeks gestation at birth were monitored for a 90-minute observation period for oxygen saturation, apnea, or bradycardia in the car seat that they would be going home in from the nursery.

Results. Policies and procedures for car seat monitoring were instituted successfully during 15-month period. Sixteen of 87 (18.4%) monitored infants 26 to 36 weeks gestation had abnormal results. In addition, one 37-week gestational newborn who was monitored because of duskiness during feeds also became apneic and bradycardic in the car seat.

Conclusions. A car seat monitoring program can be incorporated effectively into a Level II community hospital nursery discharge plan provided that appropriate medical staff policies, nursing procedures, and administrative support to deal with the logistics of the program is established. Our monitoring results are consistent with previous reports that premature infants are at risk of desaturation in a car seat. In addition, we have demonstrated that a full-term neonate may also be at risk if other evidence of desaturation (eg, duskiness during feedings) is observed.
Efficacy of Albumin and Diuretic Therapy in Children With Nephrotic Syndrome
Authors: Haws Robert M. , Baum Michel
Published: December 2021

Objective. To examine the efficacy and complications of albumin and diuretic therapy in the treatment of edema due to the nephrotic syndrome.

Methods. The clinical and biochemical effects of 35 treatment courses of albumin and diuretics administered to 21 children with nephrotic syndrome were retrospectively examined. Treatment consisted of intravenous infusion of 25% albumin and furosemide. A second diuretic was administered in addition to furosemide during 10 treatment courses. There was an average of 5 infusions per hospitalization.

Results. Albumin and furosemide therapy resulted in a 1.2 ± 0.2% (SEM) body weight loss per infusion. The administration of albumin with two diuretics did not result in improved weight loss compared to albumin and furosemide alone. Patients whose nephrotic syndrome was in remission at the time of posthospitalization follow-up (n = 8) had a sustained weight loss both during and after albumin and diuretic treatment. Patients with persistent proteinuria (n = 27) transiently lost weight during therapy, but returned to a weight similar to their pretreatment weight at 2-week follow-up. Albumin infusion resulted in hypertension, requiring acute antihypertensive therapy in 16 treatment courses (46%) and increased maintenance antihypertensive therapy in 12 treatment courses (34%). In addition, hypokalemia, hypernatremia, and hyperbicarbonatemia developed in 40%, 17%, and 11% of treatment courses, respectively. Albumin and diuretic therapy resulted in the development of respiratory distress during four treatment courses, including one patient who developed respiratory failure and one patient who developed congestive heart failure.

Conclusions. Albumin and diuretic therapy results in fluid removal and weight loss in children with the nephrotic syndrome; however, this effect is transient unless remission of proteinuria occurs. While this is a retrospective study, the findings suggest that albumin and diuretic therapy can be associated with frequent and potentially serious complications.
Severe Reactions Associated With Diphtheria-Tetanus-Pertussis Vaccine: Detailed Study of Children With Seizures, Hypotonic-Hyporesponsive Episodes, High Fevers, and Persistent Crying
Authors: Blumberg Dean A. , Chatfield Patricia , Cherry James D. , Mink ChrisAnna M. , Lewis Karen , Christenson Peter D.
Published: December 2021

Objective. The pathophysiology of severe reactions to diphtheria-tetanus-pertussis (DTP) vaccine is not well understood. Active pertussis toxin in DTP vaccine has been proposed to cause severe DTP vaccine reactions. Large doses of pertussis toxin cause hyperinsulinemia and hypoglycemia as well as leukocytosis with a predominant lymphocytosis in animal models. To learn more about the causes of and risk factors for severe DTP vaccine reactions, children experiencing severe DTP vaccine reactions were studied.

Design. Prospective, referral-based surveillance.

Setting. Los Angeles, CA.

Subjects. Children experiencing severe reactions within 48 hours of DTP immunization and evaluated within 24 hours of the reaction. Severe reactions included encephalopathy, persistent crying ≥3 hours, hypotonic-hyporesponsive episodes (collapse episodes), fever ≥40.5°C, or seizures. Some comparisons were made between children with DTP vaccine-associated seizures and a comparison group of children experiencing febrile seizures unrelated to immunization.

Outcome measures. A history and physical examination were performed. Follow-up examinations were performed 1 month later. Blood was collected for complete blood cell count with leukocyte differential count, serum chemistry measurements, and insulin and glucose values. Serum was assayed for active pertussis toxin, both in free and immune-complex masked states.

Results. Sixty children experienced severe reactions within 48 hours of DTP immunization: 32 children had seizures only, 14 subjects had hypotonic-hyporesponsive episodes, 2 subjects had fever ≥40.5°C only, 4 subjects had persistent crying ≥3 hours, 6 children had seizures and fever ≥40.5°C, and 2 children had persistent crying and seizures. The children with seizures had a high rate of personal and family histories of seizures, and 90% had documented fevers (≥38°C). Persistent crying was associated with painful local reactions. Effects that may have been due to vaccine pertussis toxin were not found. Lymphocytosis did not occur, nor did hypoglycemia. Some relatively elevated insulin values were noted; however, this finding was also noted in the comparison group of children experiencing febrile seizures unrelated to immunization. No biologically active pertussis toxin was found in the acute sera of children experiencing severe DTP vaccine reactions.

Conclusions. Seizures associated with DTP vaccine have similar clinical characteristics as febrile seizures, and persistent crying is initiated by painful local reactions. Vaccine endotoxin is a cause of febrile DTP vaccine reactions. We found no evidence that DTP vaccine pertussis toxin plays a role in severe DTP vaccine reactions.
Self-medication in Childhood: Observations at a Residential Summer Camp
Authors: Rudolf Mary C.J. , Alario Anthony J. , Youth Brian , Riggs Suzanne
Published: December 2021

Since the 1930s our society has experienced a marked increase in the consumption of medicines. Expenditure for medications has amounted to 10% to 15% of health care costs in both the United States and Europe, equivalent to 1% of the American Gross National Product.1 Per capita drug consumption in the United States is among the highest in the Western World and twice that in the British Isles.1,2 A large proportion of drugs consumed are self-prescribed, nonprescription medications accounting for 40% of the national expenditure on medicines.1 Surveys of large populations confirm the high rate of drug consumption; 30% of people questioned have used one or more nonprescription medications in the previous 48 hours.2,3

The use of nonprescription medications is not limited to adults. In surveys of large populations it has been shown that 30% to 50% of children have received medicines during a 48-hour recall period,4,5 and 75% received medicines during a 4-week period.5-7 Furthermore, 50% of mothers stock seven or more medicines for home use, and 30% report giving their children seven or more types of medicines during the course of a year.6,7

In the face of this extensive consumption of medicines little is known about the age at which children are given or assume responsibility for taking medications. A review of medical history forms for enrollment at a summer camp in 1990 revealed that 30% of campers aged 9 to 16 years intended to bring their own nonprescription medications to camp.8 This led us to suspect that American children may be given responsibility for self-medicating at an early age.
Establishment of Primary Care Continuity Experiences in Community Pediatricians' Offices: Nuts and Bolts
Authors: Sargent Janice R. , Osborn Lucy M. , Roberts Kenneth B. , DeWitt Thomas G.
Published: December 2021

During the past 30 years, there has been an increasing awareness of the importance of ambulatory care training in medical education. The discrepancy between education and practice was pointed out in the General Professional Education Panel report that indicated training was based largely in hospital settings even though the vast majority of doctor-patient encounters do not result in hospitalization.1 Perkoff,2 noting changes in hospital care such as shorter lengths of stay, increased outpatient care, and the need for well-trained primary care physicians, stated that programs need to make a major effort to emphasize clinical teaching in outpatient settings. Recognizing the need for these changes, the Accreditation Council on Graduate Medical Education (ACGME) has increased dramatically the requirement in primary care specialties for clinical ambulatory training.3 For pediatrics, these requirements have progressed from the suggestion that clinical training should be obtained in outpatient clinics (1961) to requiring clinical training in primary care clinics weekly for 3 years (1985).

The problems in providing good training in ambulatory settings have been well described.2-4 In comparison inpatient teaching, training students and residents in an outpatient clinic is inefficient and costly. One of the methods suggested to address these problems has been to move ambulatory training out of tertiary care centers to community sites.5-9 Many pediatric programs are now using community sites for at least a portion of resident education.10 Alpert et al10 and Greenberg et al,11 although encouraging the use of these sites to reduce the gap between pediatric education and the service delivery system, pointed out that there are no standards for use of community sites.
Blue Sclerae: A Sign of Iron Deficiency Anemia in Children?
Authors: BEGHETTI MAURICE , MERMILLOD BERNADETTE , HALPERIN DANIEL S.
Published: December 2021

An association between blue sclerae and iron deficiency anemia (IDA) was described in 1908 by W. Osler1 and confirmed recently in adults.2 In these studies, blue sclerae appeared more sensitive and equally specific as an indicator of IDA than mucosal pallor.4 Because IDA is common in young children even in industrialized countries, and since infants with IDA may be at risk for long-lasting developmental impairment,9-11 we carried out a survey to verify the validity of this association and to assess the value of this clinical sign in a pediatric population.

SUBJECTS AND METHODS

One hundred hospitalized children (median age 3.3 years, range 2 months to 17 years) were prospectively studied in accordance with the ethics committee of our institution.
Self-regulation of Energy Intake in Children, Questioned
Authors: GOLDMAN HERBERT I.
Published: December 2021

To the Editor.—

The paper by Shea et al1 is misleading. The observed coefficients of variability of the caloric intakes of children at individual meals and snacks were much larger than the variability of the total daily intakes, 46.5 to 165.8 vs 30.3. However, the main reason for this is statistical. The variability of the sum of a total of such items is less than that of the individual items. For example, if you time your daily mile run, the variability of each day's run will be substantially less than the variability of the total weekly times.
On the Association of Unilateral Thalamic Hemorrhage and Urinary Tract Infection
Authors: ROLAND ELKE H. , FLODMARK OLOF , HILL ALAN
Published: December 2021

In Reply.—

Rooman et al report on an infant who developed thalamic hemorrhage associated with a urinary tract infection caused by Escherichia coli. They speculate that E coli endotoxin may enhance clotting potential via the extrinsic cascade and decrease endothelial thrombomodulin expression, thus shifting the hemostatic balance and increasing the risk of cerebral venous infarction.

In our article,1 we suggest that the most probable mechanism causing thalamic/intraventricular hemorrhage in the full-term newborn is thrombosis of the deep cerebral veins resulting in infarction and secondary hemorrhage in the thalamic region.
The Lead Debate Goes On
Authors: MARCUS STEVEN M.
Published: December 2021

To the Editor.—

I had to pinch myself to realize that I was not dreaming after reading the Letters to the Editor in the January 1992 issue of Pediatrics. I thought this was 1993, and I thought that we were scientists and that we were adaptable to change. After reading the letters by Drs Banner et al and Ernhardt et al, I seriously question our stances. No other than Benjamin Franklin, in the late 1700s, commented on how long it is between the time that a certain thing is "known" and that we begin to act on it.
The Avianca Plane Crash: An Emergency Medical System's Response to Pediatric Survivors of the Disaster
Authors: van Amerongen Robert H. , Fine Jeffrey S. , Tunik Michael G. , Young Grace M. , Foltin George L.
Published: December 2021

Objective. On January 25, 1990, a jetliner crashed on Long Island, New York. Twenty-two children survived the crash. The purpose of this study was to evaluate the emergency medical system's response to these pediatric survivors.

Methods. A questionnaire was sent to all local, acute care hospitals to determine their specific pediatric capabilities and to rank them as level I, II, or III pediatric centers; level I centers are tertiary care facilities. A second questionnaire was sent to all hospitals that received pediatric survivors to collect specific clinical information for each patient. Based on this clinical information a Pediatric Trauma Score (PTS) was assigned to each patient. Children with a PTS ≤8 are considered to be at increased risk of trauma-related mortality. The assigned PTS was compared to the level of the pediatric center to which each patient was transported.

Results. Of 25 children on board the plane, 22 (88%) survived the crash; of 135 adults on board, 70 (52%) survived (χ2 = 9.9, P = .002). Seven children had a PTS ≤8; only 1 of these high-risk patients was transported directly to a level I pediatric center, and only 2 of the 5 high-risk children initially transported to level III facilities were transferred to higher level pediatric centers.

Conclusions. Pediatric survivors were neither adequately triaged nor transported to appropriate facilities which could optimize their care. Possible explanations for this include (1) unique features of the rescue operation, (2) limited pediatric training of prehospital personnel, and (3) deficiencies of the regional disaster plan. Emergency medical services systems and disaster plans can be made more responsive to children's needs by (1) acknowledging that children have special needs requiring referral, (2) improving the training of prehospital personnel in pediatric emergency care, (3) classifying ill and injured children according to appropriate triage criteria, (4) recognizing existing tertiary care pediatric centers as the optimal location for the treatment of critically ill and injured children, and (5) designating these centers as the appropriate transport destination for critically ill and injured children.