bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment of Theophylline Poisoning
Authors: STRAUSS ARTHUR , MODANL0U HOUCHANG D.
Published: December 2021

To the Editor.—

We were interested in the report by Shannon and co-workers1 in which they described the use of multiple exchange transfusions for the treatment of an accidental toxic serum theophylline level in an infant in the postoperative phase of an arterial switch procedure. Although we have no problem with the rationale used for an invasive procedure that has multiple complication risks, we would like to emphasize the option for the use of activated charcoal products in infants who are able to tolerate orally administered medications.
Role of the Pediatrician in Setting and Using Standards for Child Care
Authors: Aronson Susan S.
Published: December 2021

Standards for child care settings define expected performance. Other types of requirements applicable to operation of child care facilities include funding requirements, accreditation criteria, and regulations (legal requirements). During licensing inspections, program monitoring by funding agencies, evaluations by accrediting organizations, and self-evaluations, programs become aware of opportunities for improvement. The process of evaluation alone leads to improved program performance1; the majority of providers want to do a good job.

When requirements are used for systematic surveillance, the compliance data generated identify problems to be targeted for quality improvement. Training, technical assistance, linkage to existing resources, and development of new resources are common interventions that lead to improved performance in child care programs. These interventions may be applied at the level of an individual child care facility or at any level involved with child care services. Thus, training and technical assistance may be given to caregivers, to licensors, to policy makers, or to the public.

A surveillance system should continuously measure the impact of interventions and focus attention on problems that require further corrective action. When performance data from individual programs are aggregated, they provide powerful tools to assess the need for communitywide interventions. Some changes cannot be accomplished within the limited resources of an individual child care facility. Sometimes program improvement requires one or more types of intervention at the community, regional, state, and/or national level.

Updating requirements, conducting surveillance to measure compliance with requirements, and analyzing data to target interventions and measure the impact of actions on program performance are the basic elements of a systems model for improving quality in child care (see Figure).
Cocaine Use in Women From a Defined Population: Prevalence at Delivery and Effects on Growth in Infants
Authors: Weathers W. T. , Sauvain K. J. , Crane M. M. , Blackhurst D. W.
Published: December 2021

Adverse health effects associated with intrauterine cocaine exposure (prematurity and its associated morbidity, intrauterine growth retardation, possible risk of sudden infant death syndrome) are based on studies from large urban hospitals, but few data exist from other sources. The current study, set in a community hospital, was designed to (1) estimate the prevalence of maternal cocaine use at delivery, (2) describe neonatal outcomes, and (3) evaluate physiological growth in exposed children. The study was conducted over 30 months (total births were 14 074) at The Children's Hospital of Greenville Memorial Hospital, the major source of neonatal care for Greenville County, South Carolina (1990 population: 320 000). A child was considered exposed to cocaine if there was documented evidence of use in the mother's medical record or if one member of the pair had a positive urine drug screen. Growth data were abstracted from clinical records. Overall prevalence of exposure was 1.0%. Of the 137 subjects (89, positive urine drug screen; 48 self-reported exposure), 21 (15%, 95% confidence interval, 9% to 21%) were premature (gestational age <37 weeks) and 2 died of sudden infant death syndrome. Mean age- and sex-adjusted percentiles for weight, length, and head circumference increased from 23%, 29%, and 18%, respectively, at birth to 43%, 49%, and 54% in children followed for 12 months; however, 50% of the cohort were lost to follow-up, and these children were smaller at birth than those under active follow-up. Rates of prematurity and infant death were similar to those reported in urban hospitals. These data support the concept that cocaine-exposed children can achieve expected growth levels by 1 year of age.
Role of Local Anesthesia During Lumbar Puncture in Neonates
Authors: Pinheiro Joaquim M.B. , Furdon Sue , Ochoa Luis F.
Published: December 2021

Local anesthesia decreases physiologic responses to pain in neonates but has not been used routinely during lumbar punctures in newborns, as it might obscure anatomical landmarks. However, local anesthesia may decrease newborns' struggling during lumbar puncture, thus facilitating the procedure and increasing its success rate. The success rate of lumbar punctures was compared in neonates allocated prospectively to 0.2 to 0.5 mL of 1% lidocaine anesthesia (n = 48) or a control group (n = 52). Newborns were held in a modified lateral recumbent postion (neck not flexed) and their struggling response to the various steps in the lumbar puncture was scored by the holder. The newborns' struggling motion score increased in response to lidocaine injection, but response to the subsequent spinal needle insertion was significantly decreased. Despite this decreased motion, no differences were noted in the number of attempts per lumbar puncture (1.9 ± 0.2 [SEM] in lidocaine and 2.1 ± 0.2 in control groups), rate of lumbar puncture failure (15% in lidocaine and 19% in control groups), or the number of traumatic lumbar punctures (46% in both groups). The success rate of lumbar puncture was not dependent on level of training of physicians performing the procedure. No acute complications, cerebrospinal fluid contamination, or subsequent meningitis was noted in either group. It is concluded that local anesthesia with lidocaine decreases the degree of struggling but does not alter the success rate of lumbar puncture in neonates. The practice of withholding lidocaine anesthesia from neonates undergoing lumbar punctures cannot be justified by arguing that it makes the procedure more difficult to perform.
Serum Bactericidal Test as a Prognostic Indicator in Acute Pulmonary Exacerbations of Cystic Fibrosis
Authors: Cahen Pierre , Coustère Christine , Nicaise Pascale , Vèron Michel , Gaillard Jean-Louis , Le Bourgeois Muriel , Delacourt Christophe , de Blic Jacques , Scheinmann Pierre
Published: December 2021

The serum bactericidal test has been used for many years for optimal assessment of the efficacy of antibiotic therapy in patients with infective endocarditis and other bacterial infections. Its capacity to predict the bacteriological outcome of acute pulmonary exacerbations in patients with cystic fibrosis was evaluated. A total of 54 courses of intravenous antibiotic therapy were analyzed in 22 patients, whose ages ranged from 4 months to 24 years (mean age: 10 years). The serum bactericidal activity of blood samples, taken at expected peak and trough antibiotic levels on day 4 of therapy, were determined against the potentially pathogenic strains isolated in sputum at the time of admission. For 104 isolates (64 Pseudomonas aeruginosa, 28 Staphulococcus aureus, and 12 Haemophilus influenzae strains), the peak and trough bactericidal titers were compared to bacteriological outcome. Bacteriological success was defined as a decrease of 2 log10 units or more in the bacterial density in sputum between days 0 and 7 of therapy. At peak antibiotic levels, serum bactericidal titers of 1:128 or more were 96% (all isolates) and 89% (P aeruginosa isolates), predictive of cure, whereas serum bactericidal titers of less than 1:16 were 100% predictive of failure for all infecting bacteria. In patients aged less than 18 years, the best peak titer for predicting success was 1:64, with a predictive value of 96% for titers of 1:64 or greater The peak titer that best predicted success in patients aged 18 years or more was 1:128, with a predictive value of only 83% for titers of 1:128 or greater. No trough serum bactericidal titer achieved statistical significance as a predictor of bacteriological outcome in the two patient age groups. Peak serum bactericidal titers of 1:64 or more (patients aged less than 18 years) and of 1:128 or more (patients aged 18 years or more) are recommended to provide optimal treatment of acute pulmonary exacerbations of cystic fibrosis.
Early Lyme Disease: A Flu-Like Illness Without Erythema Migrans
Authors: Feder Henry M. , Gerber Michael A. , Krause Peter J. , Shapiro Eugene D. , Ryan Raymond
Published: December 2021

The existence of a form of early Lyme disease characterized by a flu-like illness without erythema migrans is controversial. To confirm the existence and define the clinical characteristics of the flu-like illness without erythema migrans of localized Lyme disease, the authors studied patients from a Lyme disease endemic area of Connecticut who visited their primary care physicians with an undefined flu-like illness. Patients kept a diary of their symptoms. Acute and convalescent sera were obtained. The diagnosis of Lyme disease was based on the appearance of IgM or IgG antibodies to Borrelia burgdorferi as demonstrated by both enzyme-linked immunosorbent assay and immunoblot assay. Twenty-four untreated patients were studied. In five patients acute serologic evidence of Lyme disease developed. The flulike illness in these five patients was characterized by fever and fatigue and resolved spontaneously in 5 to 21 days. Symptoms recurred in three of these five patients. The existence of a flu-like illness without erythema migrans of early Lyme disease has been clearly established. Prospective, controlled studies are needed to better define its incidence, characteristics, and prognosis so that appropriate diagnostic and therapeutic strategies can be developed.
Concerning the American Academy of Pediatrics Recommendation on Sleep Position for Infants
Authors: Orenstein Susan R. , Mitchell Allen A. , Ward Sally Davidson
Published: December 2021

In April 1992, the American Academy of Pediatrics (AAP) recommended a major change in the care of infants in the United States. Their statement recommending supine sleep position for infants was published in the June issue of Pediatrics.1 Many of us who have examined the evidence in detail, however, believe that the risks of such a recommendation may have been underestimated, and the benefits overestimated, for infants in this country. We therefore wish to present an alternative interpretation of the available evidence, so that practicing pediatricians may decide how to advise their patients on the basis of the broadest information, and with the knowledge that the evidence is inconclusive and that the AAP recommendation does not, as the Academy statement clearly acknowledges, serve as a standard of care.
Effects of Technologic and Sociocultural Changes on the Practice of Neonatal Medicine: A View From France
Authors: Relier J. P.
Published: December 2021

When one considers the changes that have occurred in trends of perinatal mortality or the proportion of severe handicap in infants or adults in most Western countries in the past 20 years, there has been a profound change in the prognosis for life and for long-term sequelae after perinatal distress. The technical reasons for this extraordinary progress are straightforward. But it is much more difficult to Understand the profound effects on the quality of the lives that have come into being as a result of these advances. Indeed, it is hard to assess the precise consequences directly related to the new technology, as opposed to effects related to the long separation of mother and child after an abnormal birth and in pathologic states of the newborn.
SIDS and Sleeping Position
Authors: GUNTHEROTH WARREN G. , SPIERS PHILIP S.
Published: December 2021

To the Editor.—

Hunt and Shannon1 decried the "precipitous action" of the task force of the American Academy of Pediatrics when the Academy recommended that "healthy infants, when being put down for sleep, be positioned on their side or back."2 Precipitous seems an inappropriate description of the Academy's conclusions which were based on 15 publications (dating back 14 years) with statistically significant increases in risk for sudden infant death syndrome (SIDS) in the prone position.

Hunt and Shannon complained that the data are "preliminary" and might lead to "iatrogenic disasters," as though the use of the prone position was novel and had unknown consequences, ignoring centuries of experience with the supine position in Asian cultures, which have extraordinarily low rates of SIDS.3
The Changing Role and Responsibilities of a Chairman—Letters
Authors: EISENBERG LEON
Published: December 2021

To the Editor.—

I enjoyed the splendid article on "The Changing Role and Responsibilites of Chairmen in Clinical Academic Departments: The Transition from Autocracy" which was published in Pediatrics (1992;90:50-57).
Garlic Burns
Authors: GARTY BEN-ZION
Published: December 2021

Five things have been said about garlic: it assauges hunger, warms the body, brings joy, increases virility and destroys intestinal lice. There are those who say that it engenders love and dispels envy.

—Babylonian Talmud: Baba Kama (first gate) page 82

Garlic (Liliaceae Allium sativum) has been used for centuries by many cultures as a remedy for a variety of illnesses. Herodotus spoke about the medical use of garlic in Egypt, 3000 years BC. Hippocrates, in the fifth century BC, used garlic to treat a variety of infections, including leprosy, intestinal disorders, and chest pain. In the Middle Ages garlic was used for protection against the plague.
Long-term Psychosocial Sequelae of Chronic Physical Disorders in Childhood
Authors: Pless Ivan B. , Power Christine , Peckham Catherine S.
Published: December 2021

Objective. This study was designed to examine the long-term psychosocial sequelae of chronic physical disorders that begin during childhood.

Design. We analyzed data from a national birth cohort. 12 537 children were followed until age 23 years—76% of all born in Britain during one week in 1958. Of these, 1667 had a chronic disorder before age 16 and 1279 were included in the 23-year follow-up.

Measures. Outcome measures included self-reported psychological disturbances between ages 16 and 23, scores on the Malaise Inventory, social class, educational qualifications, unemployment, and social activities.

Results. The total cumulative incidence rate before 16 years was 109.5 per 1000. Demographic comparisons showed that the group with chronic physical disorders was similar to those free of chronic disorders in all respects except the sex ratio. Men with chronic physical disorders had significantly higher relative risks for abnormal scores on the Malaise Inventory (1.52, confidence interval [C]]1.13, 2.05); specialist psychological care (1.43, CI 1.00, 2.03); poor educational qualifications (1.26, CI 1.08, 1.47); periods of unemployment (1.20, CI 1.03, 1.41); and less social drinking (1.36, CI 1.15, 1.60). In contrast, women only had a significantly elevated risk for having seen a mental health specialist (1.32, CI 1.02, 1.71). Among the men some of the risks were further elevated for those in specific diagnostic groups. These findings are examined in the light of postulates about the impact of chronic physical disorders as a whole and in an attempt to explain the striking sex differences. For clinicians they provide further reason to justify concern about the psychosocial aspects of care for children with chronic disorders.
Helicobacter pylori in Children With Acquired Immunodeficiency Syndrome
Authors: BLECKER U. , KEYMOLEN K. , SOUAYAH H. , LEVY J. , VANDENPLAS Y.
Published: December 2021

To the Editor.—

It has been demonstrated that the presence of Helicobacter pylori-associated gastritis is rare in adults with acquired immunodeficiency syndrome (AIDS).1 To investigate the prevalence of H pylori infection in pediatric AIDS patients, we examined 19 children, aged 1 to 14 years (mean age 5 years 11 months), of mainly central African ethnic origin. They were compared to an asymptomatic control population of comparable age (n = 52; mean age = 5 years, 10 months) and ethnic origin.
Risk Factors for Acute Wheezing in Infants and Children: Viruses, Passive Smoke, and IgE Antibodies to Inhalant Allergens
Authors: Duff Angela L. , Pomeranz Elaine S. , Gelber Lawrence E. , Price G. Weyman , Farris Holly , Hayden Frederick G. , Platts-Mills Thomas A.E. , Heymann Peter W.
Published: December 2021

Objective. To examine the prevalence of viral infection, passive smoke exposure, and IgE antibody to inhaled allergens in infants and children treated for acute wheezing.

Design. Case-control study of actively wheezing children who were compared with children without respiratory tract symptoms.

Setting. University of Virginia Pediatric Emergency Room.

Patients. Convenience sample of 99 wheezing patients (2 months to 16 years of age) and 57 control patients (6 months to 16 years of age).

Measurements and results. Serum IgE antibody to inhalant allergens, measured by radioallergosorbent test (RAST), was uncommon in wheezing and control patients under age 2. After 2 years of age, the percentage of RAST-positive patients increased markedly and was significantly higher in wheezing patients than controls after age 4 (72%, n = 54, and 30%, n = 40, respectively, P < .001). Total IgE levels and nasal eosinophilia were strongly correlated with a positive RAST after age 2. Viral pathogens, predominantly respiratory syncytial virus, were identified in nasal washes from 70% (n = 20) of wheezing patients younger than 2 years of age compared with 20% of controls (n = 10), P < .05. After age 2, viruses, particularly rhinovirus, were isolated in washes from 31% (n = 70) of wheezing patients, 64% of whom were also RAST-positive. Levels of cotinine, a nicotine metabolite, were elevated (≥10 ng/mL) in saliva from a large percentage of smoke-exposed, wheezing patients under 2 (74%, n = 19) compared with those over 2 (14%, n = 51), P < .001. Odds ratios for wheezing were significant for virus (8.2, confidence interval [CI] = 1.3 to 5.0), and cotinine (4.7, CI = 1.0 to 21.3) in children under 2, and IgE antibody by RAST (4.5, CI = 2.0 to 10.2), virus (3.7, CI = 1.3 to 10.6), and the combination of IgE antibody and virus (10.8, CI = 1.9 to 59.0) were significant risk factors after age 2.

Conclusion. Wheezing children younger than 2 years of age had a high rate of viral infection and a low rate of IgE antibody to inhalant allergens. When these children were exposed to passive smoke, salivary cotinine levels were elevated suggesting heavy exposure. After 2 years of age, sensitization to inhaled allergens became increasingly important and viruses remained a significant risk factor for wheezing. These data support recommendations to reduce tobacco smoke exposure at home, especially for young patients, and to consider sensitization to inhaled allergens and allergen avoidance in wheezing children at an early age, particularly after age 2 years.
Advertising in Pediatrics
Authors: ALDEN ERROL R. , DOW JEAN
Published: December 2021

The practice of publishing advertising in the journal is occasionally questioned by our readers, as is the process by which ads are screened prior to publication. Some believe that the presence of any advertising somehow contaminates the objectivity of a professional journal; others take issue with particular advertisements. The purpose of this commentary is to make readers aware of the Academy's policies and procedures as they relate to this practice.

The most frequent question is, why does Pediatrics carry advertising at all? The simple answer is that journal advertising provides a significant source of revenue for Pediatrics and provides a source of financial support for other Academy programs. Indeed, many worthwhile programs and projects designed for the benefit of children and AAP members could not be undertaken without this and other sources of income.
Different Views on Adolescent Abortion
Authors: LEE JUNE PATRICIA
Published: December 2021

The article, "Adolescent Abortion: Views of the Membership of the American Academy of Pediatrics" was interesting but contained some false implications. The authors imply that it is natural for pediatricians to support abortion because, in part, it is safer than childbirth. This implies that childbirth is dangerous for adolescents, but the facts show that maternal mortality is lower for adolescents than for any other age, and in fact, there were no reported deaths related to childbirth between 1980 and 1985 in the 19 states reporting to the Maternal Mortality Collaborative and the Centers for Disease Control for women younger than 15 years of age. The risk for all ages combined was less than 1 in 10 000, and less than that for adolescents. Is a 1 in 10 000 risk a rational reason to kill one of our patients?
Different Views on Adolescent Abortion
Authors: MALLORY GEORGE B. , MALLORY SUSAN B.
Published: December 2021

We are writing to express strong disagreement with the perspective expressed in the recent article by Fleming and O'Connor (Pediatrics. 1993;91:561-565) with reference to adolescent abortion. Although there is virtue in using clinical scientific language in analysis of controversial issues, the seemingly objective approach used by the authors can obfuscate the real issues when issues of morality are involved. We do not quibble with the survey or its analysis in the results section, but we disagree with several points in the discussion.

The discussion begins with the statement that "there is general agreement in the literature that abortion is one of the safest medical procedures with no clear evidence of long-term negative effects."
A LESS COSTLY REGIMEN OF ALGLUCERASE TO TREAT GAUCHER'S DISEASE
Authors: Figueroa Michael L. , Rosenbloom Barry E. , Kay Andrea C. , L. J. F.
Published: December 2021

Alglucerase (Ceredase) provides effective enzyme-replacement treatment for patients with Gaucher's disease, but at the usually recommended dose of 60 U per kilogram of body weight every two weeks (130 U per kilogram per month), it costs $382,200 per year for a 70-kg patient. Theoretical considerations suggest that more frequent administration would be more efficient...

The treatment of Gaucher's disease with smaller total doses of alglucerase given more frequently yields satisfactory results. A dose of 2.3 U per kilogram three times weekly yields major financial benefits with no sacrifice of therapeutic effect. Even taking into account the ancillary costs of more frequent administration, this method of administering alglucerase reduces the annual cost of the drug for a 70-kg patient to about $100,000. (N Engl J Med. 1992;327:1632-1636.)
SUING YOUR PARENTS
Authors: H. B.
Published: December 2021

In a court battle beginning today, a judge will be asked for what is believed to be the first time to determine whether children have the right to take legal action on their own behalf.

At the heart of the dispute in a Lake County, Fla., courtroom is a small, bespectacled boy who claims his childhood has been destroyed and who is doing battle with two formidable adversaries: his parents and the U.S. legal system.

Gregory K., age 11, (his name is being withheld by the court) has taken the unprecedented step of filing a petition to divorce himself from his parents ...

Judge C. Richard Singeltary is being asked to decide whether Gregory has the right to divorce his parents. The court is also being asked to allow Gregory's foster parents—with whom the boy has been living for nine month—to adopt him.
Safety of Continuous Nebulized Albuterol for Bronchospasm in Infants and Children
Authors: Katz Robert W. , Kelly H. William , Crowley Mark R. , Grad Roni , McWilliams Bennie C. , Murphy Shirley J.
Published: December 2021

Objective. To determine the incidence of cardiotoxicity in infants and children who receive continuous nebulized albuterol (CNA) for bronchospasm.

Design. Prospective, case series.

Setting. A university pediatric intensive care and pediatric subacute units.

Patients. Nineteen infants and children who received CNA for at least 24 hours.

Interventions. None.

Measurements. Creatinine phosphokinase (CK) was measured at the time of admission and then at 12,24,48, and 72 hours while the patient received CNA. Isoenzyme CK-MB fractions were measured if CK concentration was ≥250 IU/L. One electrocardiogram was obtained for each patient during CNA treatment. All patients had continuous cardiac monitoring during continuous nebulization therapy.

Main results. Creatinine phosphokinase levels remained within normal limits for 16 patients during CNA treatment. Three patients had elevated CK and in two CK-MB fractions were elevated at one measurement. None of the electrocardiograms showed evidence of ischemia and no arrhythmias were noted during CNA therapy, even in the patients with elevated CK-MB fractions.

Conclusions. Continuous albuterol therapy appears to be safe in our patient population as there was no significant evidence of cardiotoxicity. The significance of the transient elevation of CK-MB without other evidence of cardiotoxicity remains to be determined.
Glucocorticoid-Responsive Hypotension in Extremely Low Birth Weight Newborns
Authors: HELBOCK HAROLD J. , INSOFT ROBERT M. , CONTE FELIX A.
Published: December 2021

The maintenance of normal basal secretion and the ability to produce a stress-induced rise in cortisol secretion are critical to homeostasis. Glucocorticoids have a multiplicity of effects, among which are maintenance of glucose homeostasis, facilitation of free water clearance, and maintenance of vascular tone. Patients with glucocorticoid deficiency manifest hypotension which is resistant to the effects of volume expansion and vasopressors. This form of hypotension has been attributed to (1) renin substrate deficiency, (2) a direct effect of glucocorticoids, and/or (3) the lack of cortisol inhibition of nitric oxide and/or prostaglandin I2 synthesis, both potent vasodilators.1,2

At birth, complex changes occur in both the secretion and metabolism of steroids; these result in maintenance of appropriate postnatal cortisol production.3
Prevention of Fetal Alcohol Syndrome
Authors: SCHYDLOWER MANUEL , PERRIN JAMES
Published: December 2021

In Reply.—

Doctors Shoemaker, Alpert, and Zuckerman's comments on abstinence from alcohol during pregnancy and alcohol effect on intrauterine growth are appreciated. The statement developed by the American Academy of Pediatrics (AAP) Committees on Substance Abuse and Children with Disabilities did in fact note that evidence for harm to the fetus is much stronger with large amounts of maternal alcohol consumption, and there is controversy about the association between maternal consumption of smaller amounts of alcohol and possible damage to the fetus.1
School Bus Transportation of Children With Special Needs
Authors:   Committee on Injury and Poison Prevention
Published: December 2021

Many school-aged children with handicaps are transported in school buses. A recent amendment to the Individuals with Disabilities Education Act has established requirements for infants and toddlers to have access to developmental and rehabilitation facilities. This amendment, to Part H of the Individuals with Disabilities Education Act (enacted as part of Public Law 102-119), however, does not specify how these children are to be transported to these facilities, a responsibility that will be faced by many school systems.

FMVSS 222 (School Bus Passenger Seating and Crash Protection) established safety requirements for school bus interiors, but to date it only applied to able-bodied children. However, an amendment to FMVSS 222 becomes effective in January 1994 that applies to the securement of wheelchairs and their occupants in school buses. National recommended standards for special education school buses were revised in May 1990 by the Eleventh National Standards Conference on School Transportation.1

Wheelchairs are the primary mode of transport on the school bus for many children with special needs. They have not been developed as safety restraint devices, however, and are not currently subjected to any crash-testing requirements. Research,2-5 nevertheless, has provided a basis for recommendations concerning occupant securement for a wheelchair-dependent child and a child with special needs who is transported on a school bus:

1. Any child who can assist with transfer or be "reasonably" moved from a wheelchair, stroller, or special seating device to the original manufacturer's forward-facing vehicle seat equipped with dynamically tested occupant restraints or be "reasonably" moved to a child car seat complying with FMVSS 213 requirement should be so transferred for transportation to and from school.
Letter to the Editor
Authors: Hall Caroline Breese , Margolis Harold S.
Published: December 2021

We appreciate the concerned letter of Dr Jacobs and his thoughtful questions arising both from his knowledge of the recommendations and public health issues, as well as those of private practice.

The cost of vaccines is an issue with which we must all be concerned. By highlighting the importance of childhood immunization the Clinton administration has engendered interest and, thus, optimism that efforts toward reducing the cost will be successful. However, we should remember that the many excellent studies that have analyzed the reasons why children are not being vaccinated have shown that cost is not the major factor, but access, difficulties, and obstacles, real and perceived, to obtaining immunizations are.
SEEDS OF MURDER EPIDEMIC: TEEN-AGE BOYS WITH GUNS
Authors: L. J. F.
Published: December 2021

BOSTON, Oct. 18—A new study has found that while the number of adults arrested for murder has declined since 1985, there has been a stunning increase in the number of boys under 18 charged with homicide.

"Murder is plunging to a much younger age group," said James Alan Fox, dean of Northeastern University's College of Criminal Justice and a co-author of the report. "What is so dangerous about this is that a 15-year-old with a gun in his hand is a much more volatile individual than a 40-year-old or even an 18-year-old," Mr. Fox said.

The study, by the National Crime Analysis Project at Northeastern University, found that the number of 17-year-olds arrested for murder climbed 121 percent from 1985 through 1991, and the number of 16-year-olds arrested rose 158 percent. But the biggest increase—217 percent—was in the arrest of 15-year-olds. Even the number of arrests of boys 12 and under soared 100 percent in that time.

These figures are the clearest statistical confirmation of what had been just anecdotal evidence...
SUPERMAN TO BE KILLED
Authors: L. J. F.
Published: December 2021

The news that Superman is about to die has provoked anger and surprise, much of it from people who haven't read his comic book adventures in decades. Closer readers may have suspected for quite some time that death was in the cards. It's a logical outgrowth of a humanizing process that started in the 1980's.

For 50 years, the Man of Steel moved planets without breaking a sweat and survived Armageddon-like battles with nary a scratch and every hair in place. But invulnerability became a bore. It bored the writers and editors at D.C. Comics. It bored the readers who'd become accustomed to more mortal heroes, like Spiderman, who risk their lives in every adventure. In other comic books, heroes had become morally ambiguous, at times even a little shady. But Superman had remamed very much a boy scout, in style and temperament.

Then, six years ago, D.C. Comics began to revise him. Now he gets insomnia, forgets to shave, even weeps at times of emotional distress. Gone is that super self-reliance: Clark Kent leans on his parents when there's a wrenching decision to make.

Superman is more physically vulnerable, too. That suit, previously impervious to rips and tears, goes to tatters when he fights...

Superman will die next month at the hands of Doomsday, an escapee from what seems to be a prison. The battle rages through seven episodes and wrecks the better part of America.
Children With Chronic Illness and Medicaid Managed Care
Authors: Newacheck Paul W. , Hughes Dana C. , Stoddard Jeffrey J. , Halfon Neal
Published: December 2021

Incorporating these suggestions would necessitate a significant commitment of funds and other resources on the part of federal and state governments. This level of commitment is necessary if children with chronic conditions from low-income families are to receive appropriate care and their sponsors receive fair value. However, attending to the suggestions made in this commentary—while necessary—will not automatically assure that chronically ill children receive the services they need. All too often the emphasis of Medicaid managed care is on managing costs rather than managing care. It is only through a more enlightened perspective—one that places a greater emphasis on what is best for children and a lesser emphasis on what is best for budgets—that chronically ill children will receive the care they deserve.
Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media
Authors: Heery Lee B.
Published: December 2021

It is exciting to see such a large, well-controlled study1 showing the protective effects of exclusive breast-feeding against otitis media. The study has given breast-feeding some positive attention in the lay press as well. The study overcame problems seen in other studies of the benefits of breast-feeding in that it was large (>1000 infants), data were collected prospectively, and breast-feeding was well-defined.

My main concerns with this study regard statistical significance and the discussion of the results.
SYPHILIS CASES AMONG NEWBORNS CLIMB WITH THE RISE IN CRACK USE
Authors: L. J. F.
Published: December 2021

According to the Federal Centers for Disease Control and Prevention, medical authorities reported the births of 4,322 babies with syphilis last year, 3,272 in 1990, and 1,807 in 1989. In the early 1980's, there were fewer than 200 cases recorded annually nationwide...

"The overriding issue is that although every obstetrician is required to take blood to check whether the pregnant woman has syphilis, 60 percent of the mothers who have babies with syphilis have had no prenatal care," said Steven Rubin, acting director of the New York City Health Department's bureau of sexually transmitted disease control. "That's what we need to change."
Letter to the Editor
Authors: Shepard Arthur J. , Doron Mia W.
Published: December 2021

We read with interest William A. Silverman's commentary regarding the ratio of neonatologists per 10 000 live births in the United States compared with other similarly developed nations of the world.1 The tone and title of the commentary imply that the United States unwisely spends a disproportionate amount of gross domestic product on physician care of the sick neonate. Silverman postulates rhetorically that perhaps other similarly developed nations have set realistic limits on the number and compensation of neonatologists, or that perhaps America's "laissez-faire" capitalism allows market-driven expansion of the specialty.
GANG THAT COULDN'T GIVE SHOTS STRAIGHT
Authors: L. J. F.
Published: December 2021

There has not been a social program in recent history so badly flawed as Vaccine for Children. The administration's initiative is based on misleading information about immunization levels in the US. It is determined to create an entitlement even though immunization rates are at record levels. At a time when local health officials have more free vaccine than they can use, it is spending money to set up a government-run delivery service of unknown cost and questionable utility. Ignoring calls to delay the program, the administration has arrogantly dug in its heels to carry out a campaign pledge.

Congress assumed and the administration said that private vaccine companies would distribute the government-supplied vaccine. But the price controls the government imposed on vaccines to meet the [Congressional Budget Office] estimate left no margin for paying delivery costs. Therefore, the Department of Health and Human Services decided to set up its own distribution system. The rush to fulfill a campaign pledge now threatens to compromise the nation's vaccine supply.

First, HHS wanted the Veterans Administration and the Defense Department to operate a vaccine depot system for the program. The offer was rejected: Both agencies were getting out of the vaccine and medical distribution business; two government studies showed that private companies distributed health care products more cheaply and efficiently.

Worst of all, the administration is diverting funds to the warehousing scheme at a time when public health officials insist they have plenty of free vaccine. State and local health officials such as F. E. Thompson of the Mississippi State Department of Health note: "We have enough vaccine... What we do not have enough of is nurses to give it, clerical staff to track the children, and outreach workers to bring them."
Assessment of Telephone Survey Data
Authors: Ikeda Robin M. , Sacks Jeffrey J. , Briss Peter A. , Addiss David G
Published: December 2021

The article by Briss et al1 describes injuries at child care centers using information collected through a telephone survey of center directors. Telephone surveys have been used to collect information about child care centers regarding injuries,2 safety practices,3 and infectious diseases.4-8 To evaluate the quality of the data obtained during telephone interviews, we compared the telephone responses of day care center directors with written responses to the same questions from care givers working in those centers.
NURSES LOOK TO HEALTH-CARE REFORMS TO FLEX MUSCLE. DOCTORS FIGHT BACK
Authors: L. J. F.
Published: December 2021

Nurses press the White House for a bigger role in primary care, including diagnosing patients and determining treatment, a move they say would save money. Due to the shortage of primary-care doctors, "a person who would see a nurse as a first-line provider would get better care," argues Virginia Trotter Betts, president of the American Nurses Association.

But the American Medical Association wants to keep nurses in supporting roles. "This is a quality of care issue," says AMA Chairman Raymond Scalettar. "We're not looking down on nurses at all, but this push is wrong and could be harmful to the public." Instead, the doctors' group wants to assure that all Americans have a primary-care physician.
Apolipoprotein E Phenotypes and Serum Lipids in Newborns and 3-Year-Old Children: The Cardiovascular Risk in Young Finns Study
Authors: Lehtimäki Terho , Nikkari Tapio , Porkka Kimmo , Viikari Jorma , Ehnholm Christian , Åkerblom Hans K.
Published: December 2021

Background. Apolipoprotein E (apoE) phenotype is a genetic determinant of plasma total cholesterol and low density lipoprotein (LDL) cholesterol concentrations, that are classical coronary heart disease risk factors. ApoE appears in three major isoforms E2, E3, and E4, coded by corresponding alleles ∈2, ∈3, and ∈4. These give rise to six different phenotypes.

Objective. To study the associations of apoE phenotype with cord serum lipids (during minimal enteral nutrition), and with serum lipids of 3-year-old children.

Subjects and methods. We determined serum lipid levels and apoE phenotypes in 206 newborns and 259 3-year-old children in connection with a larger follow-up study of atherosclerosis precursors in children and young adults. ApoE phenotyping was done directly from plasma by isoelectric focusing followed by immunoblotting.

Results. The effect of apoE phenotype on serum total and LDL cholesterol was significantly different in newborns and 3-year-old children (two-way ANOVA, interaction between apoE phenotype and age group: P < .001 for both). In 3-year-old children, the concentrations of serum total cholesterol and LDL cholesterol increased with apoE phenotype in the order of E3/2, E3/3, E4/3, and E4/4, in both males and females (P < .0001). On the contrary, in neonates total cholesterol and LDL cholesterol concentrations were low and did not differ significantly between apoE phenotypes (P > .05) either in males or in females. The mean serum levels of triglycerides and high density lipoprotein cholesterol did not differ between apoE phenotypes either in 3-year-old children or newborns.

Conclusions. The results show that the differences in serum total and LDL cholesterol levels between apoE phenotypes are formed after birth by the influence of environmental factors and suggest that both genetic and external factors influence the levels of serum cholesterol concentrations during the first years of life.
"Flat Heads" and the American Academy of Pediatrics' (AAP) Sleep Position Statements
Authors: BRAKELEY JOHANA KASHIWA
Published: December 2021

Just over I year ago, the AAP recognized research studies that showed an increased incidence of sudden infant death syndrome associated with the prone sleeping position. In response to this information, the AAP changed its recommendation for infant sleeping position. Instead of the prone position for sleep, the AAP is now recommending that infants be placed on their side or back for sleep.

Since that time, I have noticed more and more babies with head asymmetry. Most often the right side of the back of the head is flattened.
MAKING NECESSITY OUT OF A VIRTUE
Authors: Student
Published: December 2021

Maybe the fact that no one has gone to the trouble of [doing controlled trials of intravascular ultrasound] reflects our past experience that it is not necessary to go to all that trouble. Maybe now we are living in a new era where if we feel strongly enough about something like this we have to do it.
Salmonella Infection Presenting as Hematochezia on the First Day of Life
Authors: Chhabra Rakesh S. , Glaser Joy H.
Published: December 2021

Salmonella infections are common in young infants. The incidence in the first month of life is estimated by the Centers for Disease Control and Prevention to be approximately 75 per 100 000 liveborn infants.1 Symptomatic neonatal Salmonella infections generally develop during or after the first week of life. We recently cared for two otherwise healthy newborns who developed bloody stools within 24 hours of birth as the clinical manifestation of a Salmonella infection. These two cases and a review of the literature describing six similar patients are presented to highlight the infectious etiology for hematochezia on the first day of life.
Recognition, Investigation, and Control of Communicable-Disease Outbreaks in Child Day-Care Settings
Authors: Davis Jeffrey P. , Mac Kenzie William R. , Addiss David G.
Published: December 2021

The importance of disease surveillance and outbreak-control activities in child day-care settings has been detailed as part of the American Public Health Association/American Academy of Pediatrics guidelines for out-of-home day-care programs.14 Aggressive assessment of outbreaks will continue to provide critical information needed to prevent and control diseases and other adverse health events in day-care facilities.
Care of Mildly Ill Children in the Day-Care Setting
Authors: Giebink G. Scott , Chang Albert , Koch Pauline D. , Murray Dennis L. , Gonzalez Gail D.
Published: December 2021

Out-of-home day-care programs for mildly ill children exist in a majority of states, and 32 states currently license these programs. A small sample of these programs suggests sensitivity to child development, infection control, and financing concerns. Implementation of the new national standards will lead to questions necessitating periodic review and updating of the standards. The care of mildly ill children remains a highly sensitive form of early care and education that requires specialized regulatory attention for the adequate protection of young children. The level of regulatory attention and the method of regulation vary considerably among states with varying degrees of consensus on critical issues. Regulations need to be written to permit some flexibility within a safety zone of acceptable care and infection control. From a child-development perspective, "get-well care" within the child's regular care environment might be optimal. Before this is a reality, however, additional studies are needed to investigate mechanisms that limit the spread of infectious agents, enhance the child's recovery, and assure safe but affordable care. American society must also reflect on their child-care priorities and create more options for parents to care for their ill children at home.
Training To Ensure Healthy Child Day-Care Programs
Authors: Kendrick Abby Shapiro
Published: December 2021

Training in child care assumes a number of forms. There is pre-service training (needed before entering the field); orientation training (received when first on the job, highlighting the most essential skills, tasks and knowledge needed to begin the job); and ongoing training (required by regulation or recommended periodically for current staff).

Despite the fact that training is known to have a positive effect on the field of early care and education, the current training system is fraught with problems. A 1991 national survey conducted by the Wheelock College Center for Career Development in Early Care and Education found that at least one of three key informants in 59% of states said "training is fragmented, random, scattershot, and not based on the needs of the field."1

The licensing system requires minimal training and experience. For teachers in child-care centers, five states require no training, four states require pre-service training, 29 states require only ongoing training, and 14 states require both pre-service and ongoing training. Few states require more than 10 hours of annual ongoing training for any child-care professionals. For family child-care providers, the numbers are even lower: 24 states require no training and only 12 states require annual ongoing training.1 If first aid and cardiaopulmonary resuscitation (CPR) certification are required, there is little time for any other training.

In addition to limited funds to support training and limited incentives for providers, administrators, on funders to invest in training, other well-known barriers to implementing systematic and coordinated training efforts include the following items:
PEDIATRIC CRITICAL CARE FELLOWSHIP MATCH PROGRAM
Authors:   Pediatric Critical Care Fellowship Match Program
Published: December 2021

The Critical Care Section of the American Academy of Pediatrics, in conjunction with the Pediatric Section of the Society of Critical Care Medicine, is again sponsoring an informal fellowship match program for Pediatric Critical Care. This program is designed to be of service to fellowship applicants who have not yet secured a position for the academic year 1995-96, as well as to program directors who still have vacant positions available. For further information, applicants and program directors should contact Dr Greg Stidham by phone (901/572-3132) or in writing at the following address:
ANNOUNCEMENT
Authors: Haggerty Robert J.
Published: December 2021

The Executive Committee of the International Pediatric Association (IPA) has established an "Ihsan Dogramaci" IPA Medal and Prize, to be awarded triennially during the IPA International Congresses. This will consist of a medal and a US $10 000 prize. The award will be made to someone who has made a significant contribution to pediatric education at the national or international level. A selection committee will screen the candidates and make a proposal to the IPA Executive Committee for a final decision.

The Member Societies of IPA are invited to propose candidates, with their CVs and a description of their contribution to pediatric education, to reach the office of the Executive Director no later than December 31, 1994: