bluuebunny/crossref_metadata_2025 huggingface dataset:
Survey: Methods of Feeding Low-Birth-Weight Infants
Authors: Churella Helen R. , Bachhuber Wendy L. , MacLean William C.
Published: December 2021

The directors of 269 neonatal intensive care units were surveyed to determine how low-birth-weight infants are being fed. Feeding practices were based on birth weight, with the smallest infants receiving parenteral nutrition for the longest time after birth. First enteral feedings usually were given by the nasogastric route in infants with birth weight of 1,500 g or less, but transpyloric feedings were used in 15% of neonatal intensive care units for infants with birth weight less than 1,000 g. The initial enteral feeding was sterile water in 56% to 58% of the neonatal intensive care units, but was glucose water or milk in the others. Once enteral feeding was established, both human milk from the infant's own mother and commercial formula were used. Whether human milk was mixed or alternated with infant formula, or whether some infants in the nursery were fed human milk while others were fed formula, was not determined. The type of infant formula fed to low-birth-weight infants depended on the infant's birth weight and clinical status. Both human milk and formula were supplemented with energy (fat or carbohydrates) and vitamins, but not with calcium and phosphorus, in most neonatal intensive care units. Some vitamins, such as vitamins A and D, may be oversupplemented, while others, such as folic acid, may be undersupplemented.
Developmental Pediatrics: Not Just the Care of Children with Developmental Disabilities
Authors: PARMELEE ARTHUR H.
Published: December 2021

To the Editor.—

I am concerned about the article by Bennett et al,1 on a training program in developmental pediatrics. Although I am in agreement with all of the contents of the training program, I am concerned about the narrow definition of developmental pediatrics as only the identification and care of children with developmental disabilities. They state that a major goal was ". . . to differentiate developmental and behavioral pediatrics despite their obvious overlaps and shared expertise" and that the primary focus of behavioral pediatrics is on the behavioral or psycho-social aspects of pediatric practice.
Effectiveness of Moped Legislation
Authors: WESTMAN JUDITH A.
Published: December 2021

To the Editor.—

In a previous report studying moped-related injuries in children,1 we urged pediatricians to support and promote legislation encouraging the legal, safe use of mopeds. Since the time of the initial study, the state of Ohio passed legislation requiring that moped drivers be aged 14 years or older, wear an approved safety helmet, carry no passengers, ride within 3 ft (0.9 m) of the right side of the road when possible, have a rearview mirror, and have turning signals on the moped.
Subcutaneous Versus Intramuscular Growth Hormone Therapy: Growth and Acute Somatomedin Response
Authors: Wilson Darrell M. , Baker Bonita , Hintz Raymond L. , Rosenfeld Ron G.
Published: December 2021

To determine the optimal route of growth hormone administration, a comparison was made of the acute somatomedin response and chronic growth response to either intramuscular or subcutaneous growth hormone in 20 children with growth hormone deficiency. None of the children had received growth hormone for at least 2 weeks prior to their random selection to receive growth hormone by either the subcutaneous (N = 11) or intramuscular (N = 9) route. Plasma samples for determination of levels of insulin-like growth factors I and II (IGF-I and IGF-II) were obtained prior to therapy and 20 hours after the first and fourth of four daily injections of growth hormone. Growth rate and growth hormone antibody levels were determined before and after 6 months of therapy. IGF-I levels tripled in both treatment groups after four days of growth hormone injections, whereas IGF-II levels nearly doubled, with no significant difference between the intramuscular or subcutaneous group. After 6 months of therapy, there was no significant difference in growth rate and only two patients had developed growth hormone antibodies. Both patients and parents expressed a preference for the subcutaneous method. The identical rises in the IGF-I and IGF-II levels following a brief course of either subcutaneous or intramuscular injections of growth hormone, the similar growth rates, the low incidence of antibody development, and the preference for the subcutaneous route all suggest that the subcutaneous route is the method of choice for chronic growth hormone therapy.
Developmental Pattern of Splenic Dysfunction in Sickle Cell Disorders
Authors: Pearson Howard A. , Gallagher Diane , Chilcote Robert , Sullivan Edmund , Wilimas Judith , Espeland Mark , Ritchey A. Kim ,   The Cooperative Study of Sickle Cell Disease
Published: December 2021

Splenic function in sickle hemoglobinopathy syndromes was assessed to determine the developmental pattern of splenic dysfunction. Nonvisualization of the spleen using technetium-99 metastable (99mTc) spleen scans correlated strongly with pocked (vesiculated) RBCs ≥3.5%. Cross-sectional analysis of pocked RBC data from 2,086 patients showed differences in the developmental pattern of splenic dysfunction between several disorders. In hemoglobin SS disease (sickle cell anemia) and hemoglobin Sβ° thalassemia, splenic dysfunction (≥3.5% pocked RBCs) often occurred in the first 6 to 12 months of life. In hemoglobin Sβ+ thalassemia, splenic dysfunction occurred less frequently and later. Splenic dysfunction in hemoglobin SC disease (sickle cell-hemoglobin C) was intermediate. The level of pocked RBCs was inversely associated with fetal hemoglobin (P < .007) and directly associated with age (P ≤ .001). These patterns of splenic dysfunction reflect the known severity of hemolysis and intravascular sickling and are consistent with the epidemiology of severe bacterial meningitis and sepsis in these diseases. Serial measurement of pocked RBCs permits determination of the onset of splenic dysfunction and the time of increased susceptibility to severe bacterial infections.
Effect of Donor-Specific Transfusions on Renal Transplantation in Children
Authors: Potter Donald , Garovoy Marvin , Hopper Susan , Terasaki Paul , Salvatierra Oscar
Published: December 2021

Most family members who are evaluated as kidney donors for children have high reactivity in a mixed lymphocyte culture test and are thus excluded from donation. Fifty children, most of whom had highly reactive mixed lymphocyte cultures with their donors, were challenged with three blood transfusions from their donors before transplantation and were tested for the development of lymphocytotoxic antibodies. Ten children (20%) became sensitized and had a positive T-cell or B-cell crossmatch. Sensitization occurred less frequently in children treated with azathioprine during donor-specific transfusions (11%) than in those not treated (26%), but the difference was not significant. Thirty-seven children received renal transplants from their blood donors after the donor-specific transfusions. There were no deaths, and only two patients had kidney failure. Actuarial kidney survival was 93% after 6 years. The use of donor-specific transfusion has increased the number of related-donor transplants performed and the results have been highly successful.
Antenatal Sonographic Diagnosis of Fetal Gastrointestinal Malformations
Authors: Barss Vanessa A. , Benacerraf Beryl R. , Frigoletto Fredric D.
Published: December 2021

Fetal gastrointestinal abnormalities are readily detected by ultrasonography. The presentation, management, and outcome of 17 cases of fetal gastrointestinal and associated anomalies are presented. Antenatal knowledge of these abnormalities can potentially decrease neonatal morbidity and mortality because the appropriate preparations can be made in advance of delivery.
Aicardi Syndrome in One Dizygotic Twin
Authors: Constad William H. , Wagner Rudolph S. , Caputo Anthony R.
Published: December 2021

The Aicardi syndrome consists of infantile spasms, defects of the corpus callosum, dorsal vertebral anomalies, and chorioretinal lacunar defects. The etiology is, as yet, unknown. The most likely cause, however, is an χ-linked mutational event that is lethal in males. The first case of the Aicardi syndrome known to occur in one twin is reported. The patient was female and her unaffected sibling was male. This provides strong evidence to support the theory of an χ-linked mutational event as the cause of this condition. The typical chorioretinal defects, often difficult to document because these children die at an early age, are clearly illustrated in this report.
Child Life Programs for Hospitalized Children
Authors:   Committee on Hospital Care
Published: December 2021

There is increasing emphasis on the finances involved in the care of children in hospitals. In times of financial difficulty, biosocial programs may be curtailed. One of the most progressive, useful, and humane programs to be initiated in recent years is the child life concept. These programs are essential to quality care, and the Committee on Hospital Care (COHC) of the American Academy of Pediatrics (AAP) is concerned that existing child life programs may be endangered and plans for new programs abandoned, because of fiscal restraints. The purpose of this statement is to describe the concept of child life, its nature, function, and inherent worth. Information is provided for physicians, hospital administrators, government officials, and others who make decisions affecting the sponsorship of child life programs in children's hospital units.

CHILD LIFE PROGRAMS

A unique activity in pediatric departments is the child life program. Originally developed in children's hospitals and in hospitals affiliated with medical schools, child life programs now are found in other children's units. The COHC believes that such programs are an essential component of quality care for hospitalized children.

Child life specialists meet developmental, emotional, recreational, and educational needs of hospitalized children and their families. They use play and other forms of communication to help children cope with health care experiences more positively. The child who uses a place devoted to play in the hospital commonly changes his perception of himself and his abilities. Hence, playrooms must be large enough to accommodate wheelchairs, traction beds, stretchers, and accompanying apparatus—such as that used for suction and intravenous administrations—so that most patients can come and enjoy activities in these rooms.
Pesticide Residues in Food
Authors: JACKSON RICHARD J. , GOLDMAN LYNN
Published: December 2021

To the Editor.—

The Environmental Health Committee of the Northern California Chapter of the American Academy of Pediatrics is concerned about the finding of pesticide residues in food, particularly the fumigant ethylene dibromide (EDB), which is a known carcinogen in animals and a mutagen in many testing systems, including mammals.1,2 Recently, Gerber Products published a statement, "Ethylene Dibromide Background Information," in their widely disseminated journal Pediatric Basics.3

Gerber rightly states that analytical testing ability has improved during the past 30 years.
Divergent Paths for Children and the Elderly
Authors: PRESTON SAMUEL H.
Published: December 2021

In the past two decades we have witnessed a sharp reversal of fortunes for the two large groups of age-related dependents in the United States. Conditions among the elderly have improved markedly, whereas those among children have deteriorated. These changes reflect alterations in family structures, in public policy, and in the size of the two dependent groups.

One of the most straightforward ways to compare children with the elderly is to measure the fraction of the two groups that live in poverty. Because children generally do not have independent incomes, one cannot directly compare personal income. One can, however, measure the incomes of the families in which the children live and compare the incomes to a minimum standard of need.
Nutrition Study Design Questioned
Authors: JANAS LYNN MARIE , PICCIANO MARY FRANCES , HATCH TERRY F.
Published: December 2021

In Reply.—

We welcome the interest in our study1 and are pleased to have the opportunity to respond to Dr Wilson's letter. At the initiation of our study, there were two equivocal reports on indices of protein metabolism in full-term infants fed human milk, whey-predominant formula, or cow's milk formula.2-4 Therefore, our objective was to assess whether specific parameters of protein metabolism responded quantitatively to dietary intakes of protein, nitrogen, and amino acids. Our results did confirm that plasma aminograms are elevated with feeding either a whey-predominant or a cow's milk formula3; however, we are the first to report that total protein (total nitrogen) intake is as important as protein quality in determining plasma amino acid response in infants.
Controversies in Screening for Middle Ear Disease and Hearing Loss in Children
Authors: Bluestone Charles D. , Fria Thomas J. , Arjona Sandra K. , Casselbrant Margaretha L. , Schwartz Daniel M. , Ruben Robert J. , Gates George A. , Downs Marion P. , Northern Jerry L , Jerger James F. , Paradise Jack L. , Bess Fred H. , Kenworthy O. T. , Rogers Kenneth D.
Published: December 2021

GOALS

—Charles D. Bluestone, MD, and Thomas J. Fria, PhD

The goal of this Workshop was to assemble experts in pediatrics, infectious disease, otolaryngology, epidemiology, audiology, and biostatistics to assess the current status of screening for otitis media in infants and children. The need for such a Workshop has become increasingly apparent with the advent of the widespread use of tympanometry as a case-finding method and the controversies that have surrounded these proliferating screening programs. Specifically, the objectives of the Workshop were to (1) review the state of our knowledge of middle ear disease in children in terms of its epidemiology, diagnosis, management, complications, and sequelae, all of which pertain to the justification for screening; (2) review the epidemiologic basis of screening and relate these to otitis media; (3) review current viewpoints on screening for middle ear disease from professionals in the field; (4) review the current status of screening programs in the United States; (5) attempt to reach concensus as to the target population to be identified by screening and the most appropriate and reasonable method for screening and referral; and, (6) make recommendations as to the best manner in which to resolve the remaining controversial issues. In addition to the above named specialists, representatives from federal funding agencies and from screening instrument companies were present in an ex officio capacity. A summary of the discussions is presented here.

INCIDENCE, PREVALENCE, AND NATURAL HISTORY OF OTITIS MEDIA

—Margaretha L. Casselbrant, MD

Otitis media is one of the most common diseases of childhood and, thus, has important economic and health care implications in society.
Slow-Acting Antirheumatic Drug Use in Systemic Onset Juvenile Chronic Arthritis
Authors: Manners P. J. , Ansell B. M.
Published: December 2021

The records of patients with systemic onset juvenile chronic arthritis were reviewed to study the effects of slow-acting antirheumatic drugs on systemic features of the disease and joint manifestations. Frequency and severity of side effects were also evaluated. The following conclusions resulted from this study. Most children could be treated with an alternate-day corticosteroid regimen. Gold and D-penicillamine treatment was not effective or tolerated during the systemic phase. However, after that phase, joint disease was controlled in 42% and 60% of children, respectively. Chlorambucil treatment was helpful in patients with amyloidosis and in those patients in whom all other drugs had failed. The incidence of side effects of chlorambucil are high, however. Antimalarial drug treatment was well tolerated but ineffective during the systemic phase. It was effective on joint disease alone in 44% of a small number of patients. Azathioprine treatment was well tolerated and effective in 50% of patients.
Serum Immunoreactive Pancreatic Lipase and Cationic Trypsinogen for the Assessment of Exocrine Pancreatic Function in Older Patients With Cystic Fibrosis
Authors: Cleghorn Geoffrey , Benjamin Lynne , Corey Mary , Forstner Gordon , Dati Francesco , Durie Peter
Published: December 2021

Indirect and qualitative tests of pancreatic function are commonly used to screen patients with cystic fibrosis for pancreatic insufficiency. In an attempt to develop a more quantitative assessment, we compared the usefulness of measuring serum pancreatic lipase using a newly developed enzyme-linked immunosorbent immunoassay with that of cationic trypsinogen using a radioimmunoassay in the assessment of exocrine pancreatic function in patients with cystic fibrosis. Previously, we have shown neither lipase nor trypsinogen to be of use in assessing pancreatic function prior to 5 years of age because the majority of patients with cystic fibrosis in early infancy have elevated serum levels regardless of pancreatic function. Therefore, we studied 77 patients with cystic fibrosis older than 5 years of age, 41 with steatorrhea and 36 without steatorrhea. In addition, 28 of 77 patients consented to undergo a quantitative pancreatic stimulation test. There was a significant difference between the steatorrheic and nonsteatorrheic patients with the steatorrheic group having lower lipase and trypsinogen values than the nonsteatorrheic group (P <.001). Sensitivities and specificities in detecting steatorrhea were 95% and 86%, respectively, for lipase and 93% and 92%, respectively, for trypsinogen. No correlations were found between the serum levels of lipase and trypsinogen and their respective duodenal concentrations because of abnormally high serum levels of both enzymes found in some nonsteatorrheic patients. We conclude from this study that both serum lipase and trypsinogen levels accurately detect steatorrhea in patients with cystic fibrosis who are older than 5 years but are imprecise indicators of specific pancreatic exocrine function above the level needed for normal fat absorption.
Migraine in Children: Association With Primary and Familial Dyslipoproteinemias
Authors: Glueck Charles J. , Bates Stephen R.
Published: December 2021

We studied lipids and lipoprotein cholesterols in 39 children (26 boys, 13 girls) with severe migraine, to examine the hypothesis that primary and familial lipoprotein abnormalities might be associated with or predispose children to the migraine syndrome. Each of the children, 4 to 20 years of age, had severe migraine, leading to pediatric neurologic referral and therapy. Twenty-five of the 39 probands (64%) had a first degree relative with severe migraine, and 18% had a second degree relative with severe migraine. In 11 of the 39 kindreds (28%), there was a family history of premature myocardial infarction and/or cerebral vascular accident (<age 55 years), involving one grandparent from each of ten kindreds and one parent in the 11th kindred. In nine of the 26 boys, low-density lipoprotein cholesterol (LDL-C) levels were greater than or equal to the age-, sex-, race-specific 90th percentile, and in three of these nine children, there was at least one additional first degree relative also having a primary top decile LDL-C level, consistent with the presumptive diagnosis of familial hypercholesterolemia. The finding of more than three times as many boys with migraine headache having top decile LDL-C than expected (9 v 2.6) was significant (x2 = 17.5, P <.01). Also, there were six boys having bottom decile levels of high-density lipoprotein cholesterol (HDL-C); all six came from kindreds with at least one first degree relative also having bottom decile HDL-C. The finding of more than two times as many boys with migraine having bottom decile HDL-C than expected (6 v 2.6) was significant (x2 = 4.94, P < .05). Of the 13 female pediatric probands, two had top decile LDL-C and two had bottom decile HDL-C and came from families with at least one additional first degree family relative also having a primary and similar dyslipoproteinemia. Our observations suggest that the clinical diagnosis of severe migraine in childhood should lead to measurement of lipids and lipoprotein cholesterols, particularly in boys, because they represent a cohort with a disproportionate number of hyper-β- and hypo-α-lipoproteinemic subjects. We speculate that primary and familial lipoprotein abnormalities, particularly those involving high levels of LDL-C and/or low levels of HDL-C, may be etiologically related to migraine, perhaps related to platelet hyperaggregability, and/or increased likelihood of cerebral vascular instability.
Follow-up Study of Physical Growth of Monozygous Twins With Discordant Within-Pair Birth Weights
Authors: Keet Marie P. , Jaroszewicz Alina M. , Lombard Carl J.
Published: December 2021

In an attempt to determine the future growth of intrauterine growth-retarded babies, 14 pairs of monozygous twins, showing within-pair birth weight differences of 11% to 48% (median 28%), were followed prospectively for 3 to 9 years. Weight, length, and head circumference were measured biannually for the first 3 years of life and thereafter annually. At birth, the median within-pair percentage differences of weight (28%), length (6.2%), and head circumference (5.2%) were all significant (P < .01). At 12, 24, and 30 months of age, these median within-pair percentage differences became insignificant for head circumference, length, and weight, respectively. The most rapid catch-up growth of the lighter twins occurred during the first 2 years of life. Analysis of individual pairs, however, showed suboptimal growth in both members of two pairs, although growth became concordant. In four other pairs, the lighter birth weight member remained growth retarded in comparison with the cotwin and showed within-pair differences in weight varying between 8% and 19%, in height between 1% and 6%, and in head circumference between 1.9% and 7%. All children with birth weights above the tenth percentile grew up normally, regardless of the extent of within-pair birth weight differences, with one exception. This exception was a pair in whom there were withinpair differences in child rearing. In the six pairs in which the smaller twin's birth weight was below the tenth percentile, only three pairs showed normal growth. In these six pairs a normal ponderal index in the lighter twin members was associated with poorer growth than a low ponderal index. It is concluded that monozygous twins will grow up normally, despite large within-pair birth weight differences, provided that both twins' birth weights are above the tenth percentile. Should the birth weight of the smaller member be below the tenth percentile, the prognosis has to be guarded, but the ponderal index may prove to be a valuable indicator of future growth.
Nemaline Myopathy as a Cause of Sleep Hypoventilation
Authors: Maayan Ch. , Springer C. , Armon Y. , Bar-Yishay E. , Shapira V. , Godfrey S.
Published: December 2021

Two siblings, a 14.5-year-old boy and his 11.5-year-old sister, with congenital nemaline myopathy presented with severe respiratory failure and, in the case of the older patient, with cor pulmonale and systemic hypertension. The children were treated initially by continuous mechanical ventilation, but after a few weeks they only required ventilation at night. At the start of treatment, both were found to have a decreased ventilatory response to CO2 which apparently improved during 4 to 5 years of follow-up treatment. It has not been possible to wean them from nocturnal mechanical ventilation, but during the daytime they attend school and function almost normally. It is postulated that respiratory failure in nemaline myopathy may not be related to the severity of the muscle weakness but may result from a disturbance of the feedback required for normal control of breathing.
School Attendance of Children and Adolescents With Human T Lymphotropic Virus Ill/Lymphadenopathy-Associated Virus Infection
Authors:   COMMITTEE ON SCHOOL HEALTH,   COMMITTEE ON INFECTIOUS DISEASES
Published: December 2021

As of October 15, 1985, there have been 204 cases of acquired immunodeficiency syndrome (AIDS) (or 1% of the total number of cases) reported in American children. Serologic testing has detected additional high-risk children (eg, hemophiliacs) who are human T lymphotropic virus type Ill/ lymphadenopathy-associated virus (HTLV-III/ LAV) antibody positive and are apparently well. Some of these children are of school age; thus, a policy on school attendance of children with HTLV-III infection is required.

The present AAP recommendations are based on (1) a review of available data related to potential transmission of HTLV-III by school-aged children and (2) the Centers for Disease Control (CDC) statement of August 30, 1985.

BACKGROUND

These recommendations apply to all children known to be infected with HTLV-III/LAV including (1) children with AIDS as defined for reporting purposes (see Table); (2) children determined to have an illness due to infection with HTLV-III/ LAV but who do not meet the case definition, which has been called AIDS-related complex (ARC; symptoms may include chronic lymphadenopathy, weight loss, fever, chronic diarrhea, anemia, thrombocytopenia, and mild signs of opportunistic infections); (3) children who are asymptomatic but have virologic or serologic evidence of HTLV-III/LAV infection.

It is important that the serologic screening test for HTLV-III be confirmed by specific tests to eliminate false-positive results. True seropositive individuals have a high probability of being infected with HTLV-III and, therefore, are potentially Capable of transmitting the virus to others.

The adult and adolescent cases, which constitute about 99% of all cases, are transmitted primarily through sexual contact (homosexual and heterosexual) and by intravenous injection of infected blood or blood products.
Discontinuing the PKU Diet
Authors: BARABAS GABOR , MATTHEWS WENDY S.
Published: December 2021

In response to the article by Seashore et al, "Loss of Intellectual Function in Children With Phenylketonuria After Relaxation of Dietary Phenylalanine Restriction" (Pediatrics 1985;75:266-232): we have had a similar experience at the PKU Outpatient Clinic at the Bancroft School in Haddonfield, NJ. In a retrospective study of the effects of diet termination on the intellectual and social functioning of children with phenylketonuria (PKU), we found that a significant number of the children's IQ scores declined five or more points following termination of the restricted diet.
In Reply: Discontinuing the PKU Diet
Authors: SEASHORE MARGRETTA R.
Published: December 2021

The similarity of Drs Barabas and Matthews' findings to ours is striking and enhances our concern about discontinuation of the phenylalanine-restricted diet in children with classical PKU. Their additional finding of a decline in the Vineland Score raises the question of whether such a decline, if it had been measured in our patients, would relate to decline in school function. Our experience in attempting to reinstitute dietary restriction has been most discouraging. We have been unable to establish satisfactory control for any significant period of time in any of our patients. The improvement reported by Drs Barabas and Matthews in compliant patients gives evidence for the need to continue those efforts.
In Reply: Metronidazole Use
Authors: HAMMERSCHLAG MARGARET R.
Published: December 2021

We appreciate the thoughtful comments included in this letter about the possible toxicity of metronidazole and the efficacy of ampicillin for the treatment of nonspecific vaginitis. The concern about carcinogenicity is real, but metronidazole is still believed to be the drug of choice for the treatment of nonspecific vaginitis (NSV) with consistent cure rates of 80% to more than 90%. The data concerning carcinogenesis are not uniform. Studies in mice and rats fed the drug (as 0.05% to 0.06% of the bulk diet) have shown an increase in tumors, however, studies in hamsters have been negative.
In Reply: CSF Cell Counts
Authors: PORTNOY JAY M. , OLSON LLOYD C.
Published: December 2021

We appreciate Dr Stern's interest in our article and would like to address his criticisms. He is correct in stating that we have not completely eliminated the possibility that a patient with viral or pretreated bacterial meningitis was included in our study. The only way to do so would be to examine only well children, as has been previously done. We chose not to do so because that is not the group of patients on whom septic workups are done.
GUILTY! DON'T WORRY
Authors: Girone Joseph A. C.
Published: December 2021

It's amazing. The lawyers make the malpractice laws, witch hunt until a case is found, and then take a large portion of any award given. They are not satisfied with that. Robert V. Wills, JD, writing in Surgical Rounds gives we physicians three maxims on how to react when slapped with a malpractice suit.

The lawyers don't want the physicians to get upset or overreact when accused of negligence, carelessness, or reckless behavior. Wills reminds us there is better than a 50/50 chance of resolution of the claim in the doctor's favor. These cases should be treated as an economic nuisance and you may not be the primary defendant. He further suggests physicians regard a malpractice claim as a "cost of doing business."

Are we going to accept this advice so kindly offered by the legal councilors? After all, they don't give free advice often. The medical profession is special in many ways. Therefore, any allegation of wrongdoing or mistreatment of a patient must be addressed by that profession the best way available. The medical profession should never approach the malpractice crisis in this country with an attitude of "economic nuisance" or percent chances of resolution in the doctor's favor.

The physician's attitude and feelings toward a malpractice action are more accurately described by a fellow physician, Dave Ellison, MD, in the piece "Not Guilty." These cases are a direct attack on the competence and integrity of the victim—physician. Let's take the advice of Dr. Ellison and show our colleagues who are sued, respect, compassion, and concern. Unknowingly, he put in prospective the lawyer's maxims when he wrote "[it's] no more useful than advising a depressed patient to "cheer up!" We need not look outside of our profession to advise us on our behavior in this difficult situation.
TRUTH
Authors: Long Kenvin Jay
Published: December 2021

Hunches and intuitive impressions are essential for getting the work started, but it is only through the quality of the numbers at the end that the truth can be told.
Human Rights Consultation: A 12-Year Experience of a Pediatric Bioethics Committee
Authors: Michaels Richard H. , Oliver Thomas K.
Published: December 2021

For many years there has been a committee at the Children's Hospital of Pittsburgh to review research proposals to assure that the rights of children are protected. In 1974, its composition was changed and its mission broadened to include consultation and discussion of ethical issues in clinical care. The committee is called the Human Rights Committee to reflect this mission. Medical ethical consultations are performed by rotating on-call teams consisting of a physician and a nonphysician who are members of the committee. Selected cases from 48 consultations are presented to demonstrate the process and to illustrate some of the questions that were addressed. The clinical diagnoses were varied, but the commonest were congenital malformations. The most frequent reason for consultation was to question the advisability of assisted ventilation (27 cases), but other reasons concerned definitive surgery, intravenous hyper-alimentation, cardiopulmonary resuscitation, and tracheostomy. Consultations are always optional and advisory. The recommendations of the consultation team are subsequently reviewed by the entire Human Rights Committee. The service has been well received by the medical staff. This method has some of the advantages of both the hospital ethics committee and the single consultant. Therefore, it should be considered when planning how to deal with these important problems.
Palpable Lymph Nodes in Healthy Newborns and Infants
Authors: Bamji Mahrukh , Stone R. K. , Kaul A. , Usmani G. , Schachter F. F. , Wasserman E.
Published: December 2021

We examined 548 healthy neonates and infants to document the frequency, size, and location of palpable lymph nodes. The subjects consisted of 214 neonates from birth to 4 weeks of age and 334 infants from 4 weeks to 1 year of age. All of the infants were asymptomatic and had been free of major or minor systemic or cutaneous infections in the past. Of the 214 neonates, 73 (34%) had palpable nodes at one or more sites. Of the 334 infants, 190 (57%) had palpable lymph nodes. Inguinal, cervical, and axillary lymph nodes can be palpable in neonates and infants. Supraclavicular nodes are not generally palpable. The commonest site of palpable nodes is the inguinal area in neonates and the cervical area in older infants. It would appear that the palpable nodes noted in the neonatal period do not disappear but persist. This knowledge is useful in determining when adenopathy may be abnormal.
Splenic Trauma in the Pediatric Patient: The Integrated Roles of Ultrasound and Computed Tomography
Authors: Adler Dorit D. , Blane Caroline E. , Coran Arnold G. , Silver Terry M.
Published: December 2021

Seven children who sustained splenic trauma were scanned by ultrasound and computed tomography (CT) or ultrasound and nuclear liver/spleen scan. All patients were managed conservatively and did not need abdominal surgery. On the initial sonogram, the majority of children had multiple areas of both increased and decreased echogenicity. Hematomas were followed to resolution in five of seven children and were usually multiple and hypoechoic prior to complete disappearance. On contrast-enhanced CT scans, areas of splenic hemorrhage appeared as low attenuation. Our small patient population demonstrates that, following an initial CT scan, sonography is helpful for sequential splenic imaging to show when the appearance of the spleen returns to normal. When correlated with the clinical information, such data are helpful to the clinician in determining when a child who has sustained splenic trauma may resume normal activity.
Interactions of Adolescent Mothers and Their 1-Year-Old Children
Authors: McAnarney Elizabeth R. , Lawrence Ruth A. , Ricciuti Henry N. , Polley Jennifer , Szilagyi Moira
Published: December 2021

It is unclear why the school-aged children of adolescent mothers have more cognitive and behavioral problems than those of adult mothers. To clarify why these children have problems and when during their lives they develop, the relationship between adolescent maternal age and the nature of the behavioral interaction between mothers and their children was studied in the laboratory. Thirty lower socioeconomic status mothers who were 15.5 years to 20 years of age and their 9- to 12-month-old children were videotaped for 20 minutes. Rating scales were developed to score the videotapes. There were significant correlations indicating that younger mothers tended to show less acceptance (r = .63; P < .001), less cooperation (r = .57; P < .001), less accessibility (r = .51; P < .003), less sensitivity (r = .46; P < .006), and more negative verbal communication (r = .32; P < .047) than older adolescent mothers. Younger maternal age was also associated with more overall negative interaction between mother and child (r = .35; P < .032) and with less child-initiated social contact with the mother (r = .32; P < .050). We conclude that over the relatively narrow age range younger adolescent maternal age is related to less favorable mothering behaviors in the laboratory when the children are 9 to 12 months of age.
Munchausen Syndrome by Proxy Simulating Cystic Fibrosis
Authors: Orenstein David M. , Wasserman Abby L.
Published: December 2021

The case of a child with apparent cystic fibrosis whose many signs, symptoms, and laboratory results were convincingly portrayed by his mother is presented. The mother falsified the history, and cunningly altered sweat tests and stool fat analyses, and stole sputum from patients with cystic fibrosis to make her child appear to have cystic fibrosis. This case of Munchausen syndrome by proxy highlights the extent to which the diagnosis of cystic fibrosis rests on reliable history and laboratory data and emphasizes the extremes to which perpetrators of this form of child abuse may go to make their case. Medical personnel must educate civil authorities about this syndrome and the dangers it represents to the child.
Varicella Vaccine: A Point of Decision
Authors: Plotkin Stanley A.
Published: December 2021

The governmental authorities on biologics soon will be asked to decide on the licensure of a live varicella vaccine. Pediatricians may then have to decide whether and how to use it. This commentary summarizes the data and provides a viewpoint in favor of licensure and use in normal children and adults. Additional articles are published in the accompanying supplement to this issue of Pediatrics.

The goals of a varicella vaccine are three: (1) to protect normal children against the complications of varicella, (2) to protect normal adults against the complications of varicella, and (3) to protect immunosuppressed children (particularly those with leukemia) against disseminated varicella.
Changing Spectrum of Serious Child Abuse
Authors: BERGMAN ABRAHAM B.
Published: December 2021

In Reply.—

Dr Hanson seems to be so upset with our article that she appears not to have read it. I thought we packed our paper with disclaimers of our imperfect data system and our fallibility in identifying perpetrators. In epidem research on clinical problems, one must play with the cards that are dealt.

The diagnosis of physical abuse is a medical one and was made by the pediatrician attached to the child abuse teams or by the King County medical examiner.
Prospective Pricing System for Tertiary Neonatal Intensive Care
Authors: Resnick Michael B. , Ariet Mario , Carter Randy L. , Fletcher James W. , Evans Janet H. , Furlough Robert R. , Ausbon William W. , Curran John S.
Published: December 2021

This study assessed the potential impact of the federal neonatal diagnosis-related group (DRG) pricing system upon reimbursement to a state neonatal intensive care program. Data for length of intensive care unit stay, procedures, hospital charges, and audited cost reports from the state of Florida's ten regional neonatal intensive care centers were analyzed for 8,492 neonates whose charges totaled $118 million. Mean lengths of stay in these tertiary care centers were substantially longer than those reported for the federal DRGs, which were based on community hospital data. If federal DRG-based reimbursement to hospitals were implemented in Florida's perinatal intensive care program, compensation would range from 9% to 56% of actual hospital care charges. Federal DRG price rates were not predictive of hospital charges. Only 16% of the total variation in hospital charges was explained by differences among federal DRG rates (R2 = .16). Analysis of data by major determinants of resource consumption provided groups more homogeneous with respect to hospital charges and, hence, cost. Therefore, we developed a prospective pricing system that used modifications of federal newborn DRG system. These modifications resulted in a threefold increase in R2 (.52). Our proposed system permits prediction of cost and reimbursement for infants by three criteria: (1) birth weight, (2) need for mechanical ventilation and/or major surgery, and (3) survival status and length of survival for those who die.
Renal Ultrasound Evaluation of Urinary Tract Infections in Children
Authors: Johnson Candice E. , DeBaz Baz P. , Shurin Paul A. , DeBartolomeo Rose
Published: December 2021

Ultrasonography of the kidney may replace the intravenous pyelogram as the study of choice in identifying treatable abnormalities in children with urinary tract infection. In a series of 64 consecutive children with urinary tract infection in whom an intravenous pyelogram, renal ultrasound, and voiding cystogram were performed, only one treatable abnormality (calyceal dilation) was identified by intravenous pyelogram, and it was not detected by ultrasound. Eleven children showed vesicoureteral reflux on the cystogram. In an additional 43 children in whom intravenous pyelogram was done only if the ultrasound or cystogram were abnormal, there were five abnormal cystograms. Four treatable abnormalities were identified by ultrasound, and three were confirmed by the intravenous pyelogram. Ultrasound should replace the intravenous pyelogram in children with a normal cystogram because of its accuracy, safety, and high patient acceptance. We have also documented a significant volume increase with acute infection in one or both kidney(s) of those children having upper urinary tract infection. Fifteen of 18 children with upper urinary tract infection had volume increases of 30% on more in at least one kidney; whereas only four of 21 children with lower urinary tract infection had increases of greater than 30% (P < .005). Ultrasound volume measurements provide a new, noninvasive method for identifying the probable site of urinary tract infection.
Prenatal Diagnosis of Urinary Tract Abnormalities by Ultrasound
Authors: Helin Ingemar , Persson Per-Håkan
Published: December 2021

The capacity of a general ultrasound screening program to detect fetal malformations affecting the urinary tract was evaluated in an epidemiologic study. A total of 11,986 pregnant women, representing 97% of the pregnant population in Malmö, Sweden, from April 1978 through August 1983 were examined. On routine examinations performed by midwives in the 17th and 33rd gestational weeks, the fetal anatomy was carefully surveyed. The overall frequency of fetal malformations was 0.5%, with urinary tract abnormalities representing approximately 50% of the total number. In 20 of 33 cases, the ultrasound findings were those of hydronephrosis or hydroureter. In ten cases, a cystic renal malformation was found, and the remaining three cases represented double renal pelvis, Potter syndrome, and posterior urethral valve. A total of 28 abnormalities were unilateral and five bilateral. No case of unilateral absence of renal tissue was noted prenatally. Prenatal diagnosis of urinary tract abnormalities known to precipitate neonatal urosepsis and subsequent renal scarring and other complications makes it possible to start an early antibiotic prophylaxis regimen. A complete workup of the infants can be started early and before life-threatening complications occur.
Lactational Capacity of Marginally Nourished Mothers: Infants' Milk Nutrient Consumption and Patterns of Growth
Authors: Brown Kenneth H. , Robertson Alastair D. , Akhtar Naheed Ahmed
Published: December 2021

The consumption of human milk by 58 Bangladeshi infants of marginally nourished mothers was measured during longitudinal studies. Daily milk consumption, as estimated by test weighing, and intakes of energy and protein, as calculated from the measured concentrations of macronutrients in the milk, were related to infant body weight, to internationally recommended intakes of these nutrients, and to the infants' patterns of physical growth. Each of the milk variables, when related to infant body weight, declined significantly with increasing (log) infant age (P < .001). The average consumption of energy and protein was less than current recommendations at all ages. Nevertheless, the average growth of the Bangladeshi infants approximated the fifth centile of the US National Center for Health Statistics during the first 4 months of life. By the fourth month, however, the weight increments of more than half the infants (79%) were less than the reference data. The intakes of energy and protein by individual infants less than 90 days of age were related to their patterns of growth. There were significant positive relationships between the change in Z score weight-for-age and weight-for-length and the consumption of breast milk energy (kilocalories per kilogram of body weight per day) and protein (grams per kilogram per day). Consumptions of 86.5 kcal/kg/d and protein 1.48 g/kg/d were associated with a nonchanging Z score weight-for-age. Thus, intake of these amounts of nutrients permitted weight gain comparable to the reference population but did not permit recovery from the existing relative weight deficits.
Cranial Bruising and Intraventricular Hemorrhage
Authors: ACS HEDDA , KILCHEVSKY EITAN
Published: December 2021

To the Editor.—

We read with interest the article by Kuban et al1 that concluded that phenobarbital might be associated with an increased risk of subependymal-intraventricular-in-traparenchymal hemorrhage in premature infants. The authors compared the incidence of cranial bruising and found it to be 17.2% in the phenobarbital-treated group and 9.6% in the placebo-treated group. Szymonowitz et al2 found that, of all the obstetric data obtained from premature infants in whom intracranial hemorrhage developed, birth trauma, as evidenced by severe bruising, was the only significant factor.
Dyslipoproteinemia and Migraine
Authors: LEVITON ALAN
Published: December 2021

To the Editor.—

Glueck and Bates1 describe a greater than expected incidence of dyslipoproteinemias in boys who were brought to the Children's Hospital of Cincinnati for evaluation of disabling migraine. They will have made an important contribution if their findings are replicated, and treatment of the lipid disorders in these children and their families does indeed reduce their risk of cardiovascular disorders.

Two implications of their work were not considered in the article. First, who should be screened for dysilipoproteinemias?
Parental Genetic Contribution to Mode of Presentation in Pompe Disease
Authors: Cottrill Carol M. , Johnson Gregory L. , Noonan Jacqueline A.
Published: December 2021

Echocardiograms were performed on parents of five infants with Pompe disease (glycogen storage disease, type II). Three of the infants had presented with congestive cardiomyopathy and two with dynamic muscular subaortic stenosis. No heart murmurs were audible in any of the parents of the five infants. The parents of the three infants without left ventricular outflow tract obstruction had normal echocardiographic results, whereas one parent of each of the infants with left ventricular outflow obstruction had asymmetric septal hypertrophy. The association between left ventricular outflow obstruction and parental asymmetric septal hypertrophy suggests that both septal hypertrophy and glycogen storage disease were inherited by these two infants.
Rooster Attacks on Children
Authors: PREISER GARY , LAVELL THOMAS E.
Published: December 2021

No doubt minor rooster assaults go unreported. Indeed, I have solicited reports of rooster peckings, clawings, and spurrings from many local farmers. Today, in parts of the world where people live closer to their animals, I assume such attacks are more common and the risk to small children well appreciated. Avian attacks provoke badinage in the literature1-3 as well as serious reports of this recreational hazzard to joggers who violate the attacker's territory. The spectrum from large scalp lacerations inflicted by European buzzards4 to annoying pecks by red-winged blackbirds has been reported. In rural Delaware County in upper New York State, we treated two children seriously injured by roosters in the summer of 1985.