bluuebunny/crossref_metadata_2025 huggingface dataset:
Varicella Vaccine Reflux
Authors: WHITE C. J.
Published: December 2021

In Reply.—

Herpes zoster (shingles) is the dermatomal skin eruption resulting from the reactivation of varicella-zoster virus remaining latent in posterior sensory root ganglia following childhood chickenpox (the primary infection with varicella-zoster virus). Since the live attenuated varicella-zoster virus contained in the vaccine replicates in the vaccinee similar to the wild-type virus, establishment of latency is possible for the attenuated strain. Several publications have addressed latency of the attenuated virus following immunization.

Two studies have examined the incidence of zoster in children with acute lymphoblastic leukemia (ALL) following immunization with live attenuated varicella-zoster virus.
Risks with Translocation in "Typus Edinburgensis"
Authors: LAING IAN A. , HENDRY LYNN M. , LYALL E. G. HERMIONE , ELLIS PATRICIA M.
Published: December 2021

In Reply.—

We are grateful to the Drs Hecht for their stimulating comments on our paper and appreciate their criticisms. The purist approach of eliminating data because of `bias of ascertainment' is admired, but it is hard for clinicians to offer the suggestion of an 8% risk when the two confirmed carriers who have had offspring have a total of 10 pregnancies between them resulting in one healthy girl, two spontaneous abortions, one carrier status, and six cases of `Typus Edinburgensis.'
Very Low Birth Weight Outcomes
Authors: TARNOW-MORDI WILLIAM , WILKINSON ANDREW
Published: December 2021

To the Editor.—

In their valuable report1 Dr Hack and colleagues confirm large variations between centers in the perinatal histories, treatment, and outcomes of very low birth weight infants. Unfortunately, in contrast to earlier reports,2,3 they neglect to mention the need for measures of initial disease severity.

This is an important omission. In a survey of nine pediatric intensive care centers Pollack et al4 showed that hospital mortality varied from 3.6% to 17%. This large variation was explained completely by differences between hospital populations in initial severity of disease, calculated from routine indices of physiologic stability on the day of admission.
Early Expression of the Apolipoprotein (a) Gene: Relationships Between Infants' and Their Parents' Serum Apolipoprotein (a) Levels
Authors: Wang Xing L. , Wilcken David E. L. , Dudman Nicholas P. B.
Published: December 2021

The serum concentration of apo(a), the unique apolipoprotein of lipoprotein (a), reflects serum lipoprotein (a) levels. High concentrations are associated with increased cardiovascular risk. Inasmuch as atherogenesis may begin in childhood, the early expression of the apo(a) gene and relationships between serum levels in infants and their parents were explored. Serum apo(a) and lipid profiles were measured in 51 infants when aged 8.5 ± 2 months. They were from among 1032 consecutively born babies in whom apo(a) levels had been measured on day 2 to 5. Levels in 18 infants were in the top 5% of the neonatal apo(a) distribution and in 33 from below the 95th percentile. Parental values were also assessed. Infants' apo(a) levels (n = 51) at the ages of 2 to 5 days and 8.5 ± 2.3 months were highly correlated (r .73, P < .0001) and increased from an initial median value of 48 U/L (range 1 to 462 U/L) to 100 U/L (5 to 969 U/L) at 8.5 months, and they were then not different from parental levels. Measurements at both times were closely correlated with parental levels. Regression coefficients between 8.5-month levels, and the levels of fathers, of mothers, and the average level of both parents were 0.439, 0.521 and 0.93, respectively (P < .0001 for each). It is concluded that the gene for the regulation of apo(a) is fully expressed before the age of 1 year. The apo(a) levels in infants during this time track closely and are predictive of parental values. These results are consistent with apo(a) contributing to that part of coronary risk associated with a positive family history, with implications for both future childhood screening and family-based coronary prevention.
Health-Risk Behaviors and Health Concerns Among Young Adolescents
Authors: Millstein Susan G. , Irwin Charles E. , Adler Nancy E. , Cohn Laurence D. , Kegeles Susan M. , Dolcini M. Margaret
Published: December 2021

This study examined the health concerns and behaviors of 563 adolescents (aged 11 through 14) from a variety of social, racial, and ethnic backgrounds. Behaviors associated with adolescent morbidity and mortality were examined, including sexual behavior, substance use, and injury-related behaviors. Although young adolescents are often viewed as unlikely participants in these risk behaviors, the results of this study suggest that greater attention should be paid to this younger group and their health-risk behaviors. A majority of the sample had tried alcohol and tobacco, and almost a third had used marijuana. Twenty-one percent were sexually active. Prevalence rates varied by social class, race-ethnicity, gender, and age. More than 75% of the sample had visited a physician during the prior year, suggesting an important role physicians may serve as sources of information and positive role models for these young adolescents. The results suggest that we stop viewing young adolescents as naive children and begin to view them as observers of and participants in a changing social environment that has important implications for their current and future health status. Without a realistic appraisal of the young adolescent, we can expect to have little overall effect on the status of adolescent health in the United States.
Infant Health and Development Program for Low Birth Weight, Premature Infants: Program Elements, Family Participation, and Child Intelligence
Authors: Ramey Craig T. , Bryant Donna M. , Wasik Barbara H. , Sparling Joseph J. , Fendt Kaye H. , La Vange Lisa M.
Published: December 2021

The Infant Health and Development Program was an eight-site randomized controlled trial testing the efficacy of early intervention to enhance the cognitive, behavioral, and health status of low birth weight, premature infants. The 377 intervention families received for the first 3 years of life: (1) pediatric follow-up, (2) home visits, (3) parent support groups, and (4) a systematic educational program provided in specialized child development centers. The control group (n = 608) received the same pediatric follow-up and referral services only. This paper describes the delivery of the intervention and its outcomes. A Family Participation Index that was the sum of participation frequencies in each of the program modalities unique to the intervention revealed that program implementation was not different across the eight sites. Index scores did not vary systematically with mother's ethnicity, age, or education or with child's birth weight, gender, or neonatal health status; but they were positively related to children's IQ scores at age 3. Only 1.9% of children of families in the highest tercile of participation scored in the mentally retarded range (IQ ≤70), whereas 3.5% and 13% of children in the middle and lowest participation terciles, respectively, scored in the retarded range. Similar findings were obtained for borderline intellectual functioning. These findings are consistent with previous research linking intensity of intervention services with degree of positive cognitive outcomes for high-risk infants. The determinants of variations in individual family participation remain unknown.
Identification and Management of Psychosocial and Developmental Problems in Community-Based, Primary Care Pediatric Practices
Authors: Horwitz Sarah McCue , Leaf Philip J. , Leventhal John M. , Forsyth Brian , Speechley Kathy Nixon
Published: December 2021

The importance of psychological and social issues for children's well-being has long been recognized and their importance in the practice of pediatrics is well documented. However, many of the studies looking at this issue have emphasized psychiatric problems rather than issues commonly referred to as the new morbidity. The goal of this research was to refocus interest on the problems of the new morbidity. This study examined the rates and predictors of psychological problems in 19 of 23 randomly chosen pediatric practices in the greater New Haven area. Families of all 4- to 8-year-old children were invited to participate and to complete the Child Behavior Checklist prior to seeing a clinician. Clinicians completed a 13-category checklist of psychosocial and developmental problems based on a World Health Organization-sponsored primary care, child-oriented classification system. Of the 2006 eligible families, 1886 (94%) participated. Clinicians identified at least one psychosocial or developmental problem in 515 children (27.3%). Thirty-one percent of the children with problems received no active intervention, 40% received intervention by the clinician, and 16% were referred to specialty services. Not surprisingly, children whose problems were rated as moderate or severe were twice as likely to be referred compared with children with mild problems. Recognition of a problem was related to four characteristics: if the visit was for well child rather than acute care; if the clinician felt he or she knew a child well; if the child was male; and if the child had unmarried parents (all P ≤ .05). The data suggest that, when asked to use a taxonomy appropriate for primary care, clinicians recognize problems in many 4- to 8-year-old children (515/1886; 27.3%). This rate is considerably higher than the rates previously reported. Further, many children with identified problems (56%) were reported by their clinicians to receive some form of active intervention. Characteristics of the visit (type of visit, clinician's knowledge of a child) that influence the recognition of problems were also identified. These results suggest that investigators must define what types of problems they are interested in and under what circumstances to determine accurately what pediatric practitioners know about psychosocial and developmental problems in their young patients and families.
Diagnosis-Related Criteria in the Consideration of Extracorporeal Membrane Oxygenation in Neonates Previously Treated With High-Frequency Jet Ventilation
Authors: Baumgart Stephen , Hirschl Ronald B. , Butler Sharon Z. , Coburn Christine E. , Spitzer Alan R.
Published: December 2021

High-frequency jet ventilation (HFJV) is one of several high-frequency techniques that are particularly valuable for treating the neonate with lung disease refractory to conventional ventilation or with pulmonary air leak. Extracorporeal membrane oxygenation (ECMO) has also emerged as a valuable rescue therapy for neonates of more than 2000 g birth weight and 34 weeks's gestation with intractable respiratory failure. With the concurrent introduction of HFJV and ECMO, the authors sought to evaluate the role of HFJV prior to the institution of ECMO therapy. The data base for 2856 neonates receiving mechanical ventilation in one unit was used to identify 73 (of 298 total) neonates treated with HFJV, who were eligible by age and weight criteria for ECMO. Patients were grouped by diagnosis, and the oxygenation index (OI) was calculated during therapy. Outcome was evaluated for mortality, and the sensitivity of the OI for predicting mortality was calculated. Neonates who survived with HFJV alone presented with an OI of 0.30 ± 0.03 (SEM), significantly less than nonsurvivors (0.42 ± 0.04, P = .016). Survivors responded to HFJV with a rapid decrease in OI at 1 hour (0.19 ± 0.02, P < .001) and 6 hours (0.15 ± 0.01, P < .001). Nonsurvivors did not respond significantly at 1 hour (OI = 0.33 ± 0.04, P = not significant [NS]) or at 6 hours (OI = 0.40 ± 0.06, P = NS). By diagnosis, neonates with respiratory distress syndrome survived more often with HFJV (28/34, 82%) than neonates with meconium aspiration (10/26, 38%) or diaphragmatic hernia (3/9, 33%). Neonates with respiratory distress syndrome seldom presented with high OI values, but the majority of those who did survived (5/7 survived with initial OI ≥ 0.40). Neonates with meconium aspiration and a single OI ≥ 0.40 on presentation fared much worse: 13 (87%) of 15 died. From these results, it appears that neonates with severe intractable respiratory distress syndrome and/or air leak are most likely to respond favorably within 6 hours of starting HFJV. In contrast, neonates with meconium aspiration respond far less well and may require early ECMO intervention, particularly with a single OI ≥ 0.40.
Cholesterol Screening by Primary Care Pediatricians: A Study of Attitudes and Practices in the Minneapolis-St Paul Metropolitan Area
Authors: Arneson Thomas , Luepker Russell , Pirie Phyllis , Sinaiko Alan
Published: December 2021

A telephone survey of the 197 board-certified pediatricians actively engaged in primary care in the Minneapolis-St Paul metropolitan area was conducted to assess their cholesterol screening practices and hypercholesterolemia management. The response rate was 95%. Nearly all the pediatricians (90%) do some cholesterol screening, with the majority (58%) screening only children with a strong family history of coronary heart disease. Though only 33% screen all their patients, 66% advocate universal pediatric screening. Most of the pediatricians indicated they would manage hypercholesterolemia patients themselves, nearly always with dietary means. Despite their strong support for screening, the pediatricians expressed skepticism about the significance of childhood cholesterol level as a predictor of adult cardiovascular disease and doubted their effectiveness in getting patients to adopt a cholesterol-reducing diet. Their definition of elevated total cholesterol level in childhood was consistent with published recommendations, but only 29% could define elevated low-density lipoprotein cholesterol level. The pediatricians expressed strong opposition to pediatric cholesterol screening in schools or in any setting other than clinics and hospitals.
Infimary-Style Sick Child Day Care
Authors: FURMAN LYDIA
Published: December 2021

In Reply.—

I appreciate the opportunity to respond to Dr Auerback's letter.

I find the community hospital versus university hospital distinction that Dr Auerback raises neither compelling nor helpful. Community hospital patients are also susceptible to rotavirus and respiratory syncytial virus, for example, with their attendant morbidities, even though the illnesses may not be life-threatening as they can be for the tertiary care hospital patients with leukemia or bronchopulmonary dysplasia. Anecdotal evidence regarding the two-way spread of illness between sick care attendees and hospitalized patients is superficially reassuring, but does not provide the information we need to evaluate what the risks really are for either population.
Curmudgeon Strikes
Authors: LUCEY JEROLD F.
Published: December 2021

In Reply.—

I envy Dr Silverman because he, of course, is right! Editors, reviewers, and copy editors are losing the battle against abbreviations. We try but it's hard to save space and not use abbreviations. Language changes; have you tried reading Beowulf? We may be destined to communicate via hated abbreviations.

As for fillers, which we use to fill up empty space in the Journal, some of these are chosen to reflect current social problems. I'm sorry he didn't enjoy the irony of the items I chose; others did.
Blood Lead Levels in Children With Foreign Bodies
Authors: Wiley James F. , Henretig Fred M. , Selbst Steven M.
Published: December 2021

To determine the risk of increased blood lead levels in children with aural, nasal, or gastrointestinal foreign bodies, the authors prospectively obtained venous blood lead and erythrocyte protoporphyrin levels from 40 study patients and two control groups without foreign bodies (65 patients presenting to a medical clinic and 40 patients presenting to an emergency department). A questionnaire was used to assess environmental and behavioral risk factors for lead poisoning in the three groups. Mean blood lead level was higher in children with foreign bodies (P < .001), and they were more likely to have a venous blood lead value of more than 1.2 μmol/L (25 μg/dL, P < .01) than patients in either control group. Seventy-eight percent of study patients had no prior lead screening by parent's report vs 64% of emergency department control subjects and 55% of medical clinc control subjects. Control patients in the emergency department had the same incidence of elevated blood lead values as patients enrolled from the medical clinic(6%). No differences in environmental risk factors were found among the three groups. Study patients more often had a history of pica or ingestion of a poison than control patients from the medical clinic. Inner-city children with foreign bodies have increased lead exposure and may have an increased risk for lead poisoning. In areas of high prevalence of lead poisoning, children with foreign bodies should be screened for lead poisoning in the emergency department. General lead screening in the emergency department may be justified for high-risk, inner-city populations.
Psychosocial Problems During Child Health Supervision Visits: Eliciting,Then What?
Authors: Sharp Lee , Pantell Robert H. , Murphy Lisa O. , Lewis Catherine C.
Published: December 2021

An explicit goal of child health supervision visits is to gather information and provide guidance about the psychosocial problems of children and families. The purpose of this study was to determine the extent to which parents had opportunities to express psychosocial concerns and the nature of physicians' responses to these concerns during health supervision visits. The authors analyzed videotapes of child health supervision visits by 34 children aged 5-12 years to 34 pediatric and family medicine residents. Coding systems with acceptable interobserver reliability were developed to assess (1) the nature of opportunities provided to express concerns, (2) categories of psychosocial problems expressed by parents and children, and (3) the nature of physicians' responses. In 88% of the child health supervision visits,opportunities were created by the physician to discuss psychosocial concerns or were spontaneously raised by the parent or child. In half of the visits,parents or children expressed a total of 30 psychosocial concerns. Psychosocial problems raised included conduct/behavior problems (47%),insecurity (13%), family, sibling, or social problems (13%), learning difficulties (10%), somatization (7%), and other (10%). Physicians' responses to these psychosocial concerns were as follows: 17% ignored the concern; 43%asked further exploratory questions but provided no information, reassurance,or guidance; 3% reassured the parent; 27% responded with psychosocial information and/or action; 3% responded with medical information and/or action; and 7% responded with a combination of these latter two modes of actions. Pediatric residents were more likely to respond to more disruptive behavioral concerns (r = .60, P < .05). This study has documented that parents and children are given and take the opportunity to express psychosocial concerns to their physicians. Unfortunately, in only 40%of cases did physicians respond with information, reassurance, guidance, or referral. This study suggests the importance of further efforts focusing on the ability of physicians to respond effectively to patients' psychosocial concerns.
Severe Respiratory Failure After Elective Repeat Cesarean Delivery: A Potentially Preventable Condition Leading to Extracorporeal Membrane Oxygenation
Authors: KESZLER MARTIN , CARBONE MARY TERESE , COX CYNTHIA , SCHUMACHER ROBERT E.
Published: December 2021

Significant respiratory morbidity following elective cesarean delivery has been widely reported.1-4 More recently, it has been recognized that this morbidity is not always the result of inadvertent delivery of a premature neonate,5 but, instead, may be due to a predilection of these neonates for developing persistent pulmonary hypertension of the newborn(PPHN).6-8 Despite Heritage and Cunningham's report6 of 25% mortality in patients with persistent pulmonary hypertension following elective repeat cesarean section, the potential severity of respiratory distress associated with this method of delivery does not appear to be generally recognized. Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat newborns
Cholesterol Screening
Authors: FEEMAN W. E.
Published: December 2021

To the Editor.—

The commentary by Neil A. Holtzman, MD (Pediatrics. 1991;87:943-945)1 is a swing of the pendulum diametrically away from the overly aggressive recommendations of the National Cholesterol Education Program. Whenever there exist diametrically opposed points of view,the truth can usually be found somewhere in between.

The comments that I am about to make are based on my own study of the primary and secondary prevention of atherosclerotic disease (ASD). From November 1,
T.A.C.
Authors: DEAN ROGER
Published: December 2021

To the Editor.—

As a pharmacist at a pediatric hospital which uses tetracaineadrenaline-cocaine (TAC), I was interested in the article by Bonadio and Wagner.1 I have often wondered about the relative anesthetic contribution of tetracaine in this arbitrarily developed extemporaneous product.2

The use of TAC in our emergency department has increased greatly during the last year, and the physicians have accepted it as a safe and effective anesthetic alternative to injections of lidocaine. As in
HIV and Day Care
Authors: FENSTER DIANE LIND
Published: December 2021

To the Editor.—

I read with interest the article in Pediatrics by Morrow et al on children with HIV in day care centers.1 The tone of the article is patronizing: the authors suggest that if parents were better educated, they would accept the presence of HIV-infected children in their day care centers.

I agree that increased education of parents and day care providers is highly desirable. In keeping with the decline of paternalism in medicine,
Battery Ingestions
Authors: RUMACK CAROL M. , RUMACK BARRY H.
Published: December 2021

The proliferation of battery-operated devices has provided a new source of hazards for children. "Button batteries" are small cells used in hearing aids, cameras, watches, and a wide variety of miniaturized electronic marvels. They are ingested by children who either remove them from the device by themselves or find them left in their environment.

The article by Litovitz and Schmitz in this issue represents the culmination of 7 years' worth of tenacious research.1 Though it was made clear by an earlier report from this study that an initial roentgenogram is required following ingestion,2 they found 13.4% of patients never had a diagnostic roentgenogram.
Firearms and Adolescents
Authors:   Committee on Adolescence
Published: December 2021

Firearms play a major role in childhood morbidity and mortality in the United States, especially among adolescents. The American Academy of Pediatrics is committed to reducing firearm death and injury of children and youth and has published policy statements on handgun control (1985),1 "toy" firearms (1987),2 and "Firearm Injuries Affecting the Pediatric Population" (1992).3 The purpose of this statement is to identify major firearm issues that specifically address adolescents.

Reducing injuries and deaths from firearms is an essential priority for adolescent health. Of all firearm deaths among children from birth to age 19 years, 80% occur in older youths aged 10 to 19 years. Firearms are involved in 70% of teen homicide and 63% of teen suicide. Firearms are the second beading cause of death (after motor vehicle accidents) among all teenagers aged 15 to 19 years.4,5 Risk factors for firearm death seem particularly related to age, as rates of firearm violence peak in bate adolescence (ages 15 to 24 years) and decrease in young adulthood (ages 25 to 34 years).6 Therefore, special characteristics of adolescent development must be considered in designing effective countermeasures to prevent injury and death.

ADOLESCENT MORTALITY AND MORBIDITY

The statistics on firearm death and injury in adolescents emphasize the severity of the problem.

Mortality

Firearms account for 20% of deaths among all older youth, with almost 3200 US youths aged 15 to 19 years fatally shot each year.4 In the last 20 years, the rate of firearm deaths among teenagers has increased 75%, from 10.1/100 000 to 17.7/100 000.4
Does the Commercial Type of IVIG Used Make a Difference?
Authors: HAQUE KHALID H.
Published: December 2021

To the Editor.—

I read with interest the article "Intravenous Immunoglobulin Therapy for Prevention of Infection in High-Risk Premature Infants: Report of a Multicenter, Double-Blind Study."1 I would agree with the authors that to date none of the published studies2-10 have shown "absolute and unquestionable efficacy" in the prevention of neonatal infections in all preterm babies, but like others I feel there does seem to be a beneficial trend for the under 1500 g baby.2,3,5,8,10 What worries me about this paper is that contrary to all the previous studies, Magny et al found greater incidence of proven or suspected infection 54% vs 41% in the intravenously administered Ig (IVIG)-treated group.
Does the Commercial Type of IVIG Used Make a Difference?
Authors: BREMARD-OURY CLOTHILDE , MAGNY JEAN-FRANÇOIS
Published: December 2021

In Reply.—

We agree with Dr Haque that our paper has shown a nonsignificant greater incidence of proven or suspected infections and weakly higher mortality in the IVIG-treated group. However, the results of various studies hardly can be compared because different treatment protocols were used by different investigators. Moreover the clinical features of newborns were not the same in all the series (gestational age, birth weight, risk factors ...), and the IVIG preparations used are different in their characteristics.
Stun Gun Injury: A New Presentation of the Battered Child Syndrome
Authors: Frechette Alan , Rimsza Mary Ellen
Published: December 2021

Stun guns are self-protection devices that are increasingly available with few restrictions on their use and sale. We present a case of child abuse with a stun gun. The signs of such abuse are often subtle, and they may be underrecognized currently. The skin lesions that are often seen are hypopigmented circular macules, measuring approximately 0.5 cm in diameter. They may be raised slightly and erythematous if inflicted recently. Most characteristic of stun gun assault is pairing of lesions approximately 5 cm apart. We discuss the design, operation, and effects of stun guns, and give an extensive differential of abusive and nonabusive circular lesions.
Firearm Injury Prevention Counseling: A Study of Pediatricians' Beliefs and Practices
Authors: Webster Daniel W. , Wilson Modena E. H. , Duggan Anne K. , Pakula Lawrence C.
Published: December 2021

Members of the Maryland Chapter of the American Academy of Pediatrics completed a mail survey on their beliefs and counseling practices related to firearm injury prevention. Respondents were skeptical of the protective value of firearms in the home and most were supportive of gun control measures. Only a fifth believed that most families with handguns keep them inaccessible to children; however, many seemed to believe that the children at risk were in practices other than their own. Among those providing direct ambulatory care, 40% had had a patient who had been shot. Seventy-four percent believed pediatricians have a responsibility to counsel families about firearms. Only 13% believed parents would be offended if guns were included in anticipatory guidance discussions. Even so, only 30% had ever provided such counseling. Just half of the respondents agreed that they knew what to tell families about firearms. Ninety percent were very likely to counsel parents to store guns unloaded and locked up, whereas 54% were very likely to advise parents to remove guns from the home. More than two thirds believed parents would heed their advice about storing firearms, and 30% believed parents would follow advice about having guns. Results suggest pediatricians are ready to counsel about firearm injury prevention, but are not yet doing so.
Parents' Beliefs About Preventing Gun Injuries to Children
Authors: Webster Daniel W. , Wilson Modena E. H. , Duggan Anne K. , Pakula Lawrence C.
Published: December 2021

Data were collected from parents bringing children to selected pediatric practices in Maryland using questionnaires and focus group discussions. Gun ownership ranged from 27% in the suburban practice to 53% in the rural practice. Unrealistic perceptions of children's capabilities and behavioral tendencies with regard to guns were common among gun owners. Half of all gunowning parents believed that active strategies (eg, education, supervision) were the best method of preventing gun injuries to children older than 12 years of age. Nearly all gun owners indicated a willingness to follow their pediatrician's advice about gun storage, but only 19% of the mothers and 10% of the fathers said they would follow advice to remove guns from the home. Among parents who did not have a gun in the home, 40% said they would consider obtaining one if they felt threatened; however, 73% of these parents indicated they would be dissuaded from doing so by a pediatrician's advice about the risks of keeping guns in the home. Results suggested that pediatricians will be most effective if they recommend passive strategies (eg, removing guns from the home or storing guns unloaded and locked) on the basis of children's developmental capabilities and behavioral tendencies and make their recommendations part of general counseling about child safety.
Velo-Cardio-Facial Syndrome Associated With Ventricular Septal Defect, Pulmonary Atresia, and Hypoplastic Pulmonary Arteries
Authors: Jedele Kerry B. , Michels Virginia V. , Puga Francisco J. , Feldt Robert H.
Published: December 2021

We report on 15 patients with velo-cardio-facial syndrome who had a severe form of tetralogy of Fallot (pulmonary atresia, ventricular septal defect, and hypoplastic pulmonary arteries). Noncardiac anomalies in these patients included typical facial and ear anomalies in 15, nasal speech in 13, palate anomalies in 10, and developmental delay in 10. Seven patients had significant bronchospasm, which has not been reported in association with the velo-cardio-facial syndrome.

All 15 patients had severe abnormalities of the arborization of the pulmonary arterial tree, which also has not been reported in velo-cardio-facial syndrome. All patients underwent staging operations to prepare the true pulmonary vascular tree for complete repair of the defect (five underwent complete repair and three survived). Of the remaining 10 patients, 6 are awaiting further operation, 3 are not candidates for complete repair, and 1 has died.
Resuscitation and Withdrawal of Therapy in Pediatric Intensive Care
Authors: MINK RICHARD B. , POLLACK MURRAY M.
Published: December 2021

Although issues concerning withdrawal and limitation of life support are commonly discussed,1-6 actual practices in pediatrics are largely unknown and are limited to neonatal intensive care unit (ICU) studies. In the neonatal ICUs at Yale-New Haven Hospital and at Hammersmith Hospital, 14% and 30%, respectively, of all deaths followed withdrawal of care.7,8 In adult ICUs, limitation and/or withdrawal of therapy is common,9 and in one investigation, resuscitation was not attempted immediately before ICU death in nearly two-thirds of cases.10 Nonetheless, many physicians believe that most hospital deaths occur only after all resuscitative attempts have failed,6,11,12 and others believe that resuscitative efforts neither are indicated nor desirable in many cases.1,13
Collaborative Research in Pediatric Practice
Authors: Haggerty Robert J.
Published: December 2021

Research in practice has a long and distinguished history. Pickles,1 a general practitioner in Yorkshire, deduced the difference between infectious and serum hepatitis through careful clinical observation of hundreds of patients in his own practice. In recent years, pediatricians such as Breese2,3 and his colleagues in Rochester, New York, outlined effective methods for the diagnosis and treatment of streptococcal disease in children as a result of studies in their practice, and Carey4 in his suburban Philadelphia practice developed a widely used scale for assessing temperament in children.

In the 1970s, Charney and his colleagues in Rochester, New York, developed a more systematic approach to collaborative research in practice, enlisting a large number of the practicing pediatricians who kept registries of their patients with data on visits, laboratory studies, and diagnoses in easily retrievable form.
Hepatitis B Immunization
Authors: FARBER JON MATITHEW
Published: December 2021

To the Editor.—

As a practicing pediatrician, I have two major reservations with the current recommendations of the Committee on Infectious Diseases for universal Hepatitis B virus (HBV) immunization. The first reservation is practical, and the second is theoretical.

The Committee realized that administering three injections of different vaccines at the same time is something most parents and pediatricians would wish to avoid, and also that requiring an extra office visit for HBV vaccination was not attractive.
Perinatal Manifestations of Maternal Yellow Nail Syndrome
Authors: Govaert Paul , Leroy Jules G. , Pauwels Romain , Vanhaesebrouck Piet , De Praeter Claudine , Van Kets Henri , Goeteyn Marleen
Published: December 2021

A term female firstborn infant had unexplained nonimmune fetal hydrops and recurrent left chylothorax at 4 weeks of age. A few months before conception, her mother had had acute dystrophic nail changes and is being treated for recurrent sinusitis, bronchiectasis, and a deficiency of serum IgG2. We suggest that they both suffer from a dominantly inherited congenital lymphedema syndrome known as `yellow nail dystrophy.' Prenatal manifestation of this disorder has not been reported previously. The child's anthropometric and neurological development was normal at 1 year of age, whereas mild ankle edema and marbling of the skin of the limbs were salient clinical findings. Inherited lymphedema leading to nonimmune fetal hydrops also has been recognized in chromosomal disorders, Noonan's syndrome, multiple pterygium syndrome, pulmonary lymphangiectasis, and mixed-vessel lymphatic dysfunction. Indicators of parental lymphedema are not on record in those instances.
Effect of Recipient's Race on Pediatric Renal Allograft Survival: A Single-Center Study
Authors: Schulman Seth L. , Palmer JoAnn , Dunn Stephen , Kaiser Bruce A. , Polinsky Martin S. , Baluarte H. Jorge
Published: December 2021

One hundred twenty-seven children (83 males, 44 females, 86 white, 41 nonwhite; mean age 12.1 years) who received 160 renal transplants between 1980 and 1989 were retrospectively studied. Variables such as age, sex, primary diagnosis, type, HLA-DR mismatching, and repeated transplants were compared between races and found not to be significant. However, HLA-A and -B cadaveric-graft mismatching, which was equivalent between whites and nonwhites prior to 1985 (pre-cyclosporine A era), has significantly favored whites (49% with 0 to 2 HLA-A and -B mismatch vs 16% in nonwhites) since 1985 (P < .05), and a significantly higher proportion of nonwhite patients (59%) were receiving medical assistance (P < .0001). Graft survival was evaluated with significantly poorer results in nonwhites as compared to whites (P < .05). Although no difference was found between white and nonwhite cadaveric-graft survival before 1985, nonwhites had significantly worse graft survival since 1985 (72% vs 59% for 1 year and 61% vs 24% for 3 years in whites and nonwhites, respectively; P < .05). Subpopulations such as nonwhite adolescents, nonwhite females, nonwhites with repeated transplants, and all low socioeconomic patients were identified as high-risk children with poor long-term survival. It is concluded that secondary to poorer matching since 1985 there has been decreased graft survival in nonwhites despite cyclosporine A. Attempts to improve matching and attention to high-risk groups are needed for equivalent survival.
Standards for Selected Anthropometric Measurements in Males With the Fragile X Syndrome
Authors: Butler Merlin G. , Brunschwig Ari , Miller Lora K. , Hagerman Randi J.
Published: December 2021

Standards (95th, 50th, and 5th percentiles) in fragile X syndrome for weight, height, head circumference, ear length, and testicular volume are reported. For comparison with fragile X syndrome standardized curves, normal control data from the literature were similarly plotted and curves produced. These standards reflect the physical parameters that are frequently abnormal in males with the fragile X syndrome and should be useful in the medical management of patients with this syndrome. The standards may also be used to help identify those individuals, particularly the younger males, for chromosome studies to confirm the clinical impression of the fragile X sydrome.
Bucket-Related Drownings in the United States, 1984 Through 1990
Authors: Mann N. Clay , Weller Susan C. , Rauchschwalbe Renae
Published: December 2021

The purpose of the study is to document the incidence of bucket-related drowning in the United States and to identify factors associated with this type of submersion injury. Analysis of Consumer Product Safety Commission data revealed 160 bucket-related drownings for the years 1984 through 1989, representing a mortality rate of 0.367 per 100 000 persons (younger than 2 years old) per year in the United States. Eighty-eight percent of bucket drownings occurred in toddlers aged 7 to 15 months old. Black children were six times more likely to drown in a bucket than white children of similar age (P < .0001). Male toddlers were at significantly greater risk than females (P < .01). A seasonal trend present in the data indicated that infants are more likely to drown in warmer than in colder months (P < .01). States with the highest rates of bucket drowning were Vermont (2.1/100 000), Arizona (1.5/100 000), and Illinois (1.0/100 000). Through passive and active educational strategies, perhaps this fatal home injury can be prevented.
Cognitive-Behavioral Pain Management in Children With Juvenile Rheumatoid Arthritis
Authors: Walco Gary A. , Varni James W. , Ilowite Norman T.
Published: December 2021

Decreasing chronic joint pain is a major goal in the management of juvenile rheumatoid arthritis. Cognitive-behavioral self-regulatory techniques were taught to children with juvenile rheumatoid arthritis to reduce musculoskeletal pain intensity and to facilitate better adaptive functioning. Subjects were 13 children between the ages of 4.5 and 16.9 years who had pauciarticular or systemic onset juvenile rheumatoid arthritis. Baseline data included an initial comprehensive assessment of pain, disease activity, and level of functional disability, as well as pain intensity ratings gathered over a 4-week period. Subjects were seen for eight individual sessions in which self-regulatory techniques (progressive muscle relaxation, guided imagery, meditative breathing) were taught, and parents were seen for two sessions in which key aspects of behavioral pain management techniques were reviewed. Results indicated that these techniques led to substantial reduction of pain intensity, which generalized to outside the clinic setting. Six- and 12-month follow-up data showed consistent decreases in pain as well as improved adaptive functioning. The data suggest that cognitive-behavioral interventions for pain are an effective adjunct to standard pharmacologic interventions for pain in patients with juvenile rheumatoid arthritis.
Injury Illiteracy
Authors: WIDOME MARK D.
Published: December 2021

If you already find talking with parents about injury prevention a frustrating exercise, you may not want to read the article on bucket-related drowning published in this issues of Pediatrics.1 However, for readers, the article will strike a familiar chord. Bucket drownings are reminiscent of other serious or fatal injuries occurring in superficially benign circumstances: children becoming entrapped in household appliances and picnic coolers,2 children and adults suffering serious and fatal injuries from toothpicks,3 and teenagers being crushed to death beneath commercial soda-vending machines.4

Now, add to this list reports of injury associated with more hostile-appearing fixtures and products: entrapment by electrically operated garage doors,5 piercing skull injuries due to law darts,6 and esophageal burns caused by caustic pipeline cleaner used on dairy farms.7
Exposure to Toxoplasma gondii and Cat Ownership in Nova Scotia
Authors: Pereira Linda H. , Staudt Miriam , Tanner Charles E. , Embil Juan A.
Published: December 2021

In this survey, 998 children and adolescents between 7 months and 17 years of age who attended a hospital diagnostic center in the city of Halifax, Nova Scotia, for routine evaluation were tested for Toxoplasma gondii antibody. The 5.2% prevalence rate of antibody for children living in the outlying rural areas was significantly higher than the 1.1% rate among the urban children (P = .0006). Seroprevalence increased with age for both rural and urban children. Cat ownership was associated with antibodies to Toxoplasma among rural children but not urban children. Rural children who lived in a house with more than one cat were two times more likely to be infected than children who had one cat and three times more likely to be infected than children with no cats. The geometric mean titer was also significantly higher among the rural children with more than one cat, 1:152, than rural children with one or no cats, 1:63 (P = .02). In light of these findings for children and adolescents, the association of Toxoplasma infection with cat ownership needs to be thoroughly evaluated among pregnant women in rural areas.
Pulmonary Disease with Hemorrhage in Henoch-Schöenlein Purpura
Authors: Olson Judyann C. , Kelly Kevin J. , Pan Cynthia C. , Wortmann Dorothy W.
Published: December 2021

Henoch-Schönlein purpura is a common vasculitic syndrome of childhood. Pulmonary hemorrhage is a rare complication, which resulted in death in three of four previously reported cases. We report concerning four additional patients with Henoch-Schönlein purpura and pulmonary hemorrhage. Three survived the episode. Aggressive and supportive care may improve survival.
Mental Health Service Utilization by Children in Foster Care in California
Authors: Halfon Neal , Berkowitz Gale , Klee Linnea
Published: December 2021

An examination of Medi-Cal-paid claims was undertaken to assess the utilization of mental health services by children in California's foster care system. Using unduplicate counts of service use and diagnoses, it was determined that children in foster care account for 41% of all users of mental health services even though they represent less than 4% of Medi-Cal-eligible children. When partitioned into specific service categories, children in foster care account for 53% of all psychologist visits, 47% of psychiatry visits, 43% of Short Doyle/Medi-Cal inpatient hospitalization in public hospitals, and 27% of inpatient psychiatric hospitals. Expenditure for services paralleled utilization frequency. When compared to the non-foster care Medi-Cal-eligible child population, children in foster care have 10 to 20 times the rate of utilization per eligible child for selected services. For children in foster care, 75% of all diagnoses for billed service were accounted for by four diagnoses: adjustment disorders (28.6%), conduct disorders (20.5%), anxiety disorders (13.8%), and emotional disorders (11.9%), with clear age-related differences in the distribution of diagnoses.
Bicycle Helmet Law for Children: A Case Study of Activism in Injury Control
Authors: Scheidt Peter C. , Wilson Modena H. , Stern Melvin S.
Published: December 2021

In 1990, the first regulation requiring the use of helmets for bicyclists younger than 16 years of age was passed in Howard County, Maryland. This unexpected injury control measure resulted from the convergence of multiple factors and efforts: the bicycle-related deaths of two children from the same middle school, creative students and teachers motivated by these deaths, a responsive legislator to introduce the legislation, available surveillance and research statistics supporting the need and efficacy for helmet use, increased national awareness of the importance of helmet use to prevent bicycle-related head injuries, and organized national and local public health groups to support the legislation. This case study of activism in injury control illustrates the importance of supporting research, of well-organized public health coalitions and groups, and of creative community activists motivated by local circumstances.
Management of the Febrile Infant
Authors: MCCARTHY PAUL
Published: December 2021

In the past 15 years, there has been a geometric increase in the number of studies and commentaries that have focused on the management of the febrile infant. This fact is nicely highlighted by the 48 references in Lieu and coworkers' article in this issue of Pediatrics. Only 5 of the articles appeared prior to 1976, and several of those report on hospitalized infants in nurseries and not those seen in an outpatient setting. Forty of the references were published in the past 10 years and 15 since 1990. Of interest, two of the largest studies, both of which examined the issues of the efficacy of clinical judgment and screening laboratory tests and challenged, through careful study protocols, the traditional "admit for intravenous antibiotics" dictum which has been applied to most infants with fever, are now completed and recently published1 or being prepared for publication.2
Liposomal Amphotericin-B (AmBisome) for Treatment of Disseminated Fungal Infections in Two Infants of Very Low Birth Weight
Authors: LACKNER H. , SCHWINGER W. , URBAN C. , MÜLLER W. , RITSCHL E. , REITERER F. , KUTTNIG-HAIM M. , URLESBERGER B. , HAUER C.
Published: December 2021

Systemic fungal infections represent an increasing problem among low birth weight neonates.1-4 The necessity of many invasive procedures such as endotracheal intubation, central venous catheterization, prolonged antibiotic therapy, and hyperalimentation including intravenous fat emulsions increases the risk of nosocomial infections.4,5 Amphotericin-B (Amph-B) combined with 5-fluorocytosine is reported to be the treatment of choice for disseminated fungal infections. However conventional Amph-B medication is often limited due to severe side effects. Fever, chills, bronchospastic reactions, nephrotoxicity, and hepatic necrosis have been reported frequently.2,6 Previous experiences with immunocompromised patients indicate that the liposomal encapsulation of amphotericin-B decreases its toxicity while maintaining its effectiveness as an antifungal agent.7-12
Poisoning by Pickup Truck
Authors: WIDOME MARK D.
Published: December 2021

In Reply.—

The risks to children riding in other than the standard seating positions of motor vehicles are multiple. In a vehicle crash, the unrestrained child in the cargo bed of a truck can become an "unguided missile," crashing into the sides of the cargo bed. Alternately, cargo in the cargo bed can become the "missile," and the child then becomes the target. Worse, there is a high probability in a crash that the child will be ejected from the cargo bed onto the highway.1