bluuebunny/crossref_metadata_2025 huggingface dataset:
THE PRESIDENT'S PAGE
Authors: BEAVEN PAUL W.
Published: December 2021

"The object of the Academy shall be to foster and stimulate interest in pediatrics and correlate all aspects of the work for the welfare of children that properly come within the scope of pediatrics. The Academy shall endeavor to establish and maitain the highest possible standards for pediatric education in medical schools and hospitals, pediatric practice and research . . . to maintain the dignity and efficiency of pediatric practice in its relationship to public welfare."

The above quotation gives the real object of our organization as formulated by those who wrote our Constitution. The Executive Board believes this object to be the aim to which we are pledged. Details will be described in later columns, for we are organized to carry this out. The Academy will continue to correlate all pediatric aspects of the work for the welfare of children. As a society we will seek to maintain the highest possible standards for pediatric education. We will point out the relationship of pediatric practice to public welfare. By means of strong national committees dealing with child health and by reason of the survey and its subsequent interpretation and by working with other groups interested in child welfare, we have already gone a long way in blazing a trail to that goal our founders envisioned. We have no intention of losing what has been gained nor do we intend to lose our leadership in child welfare. Rather we propose to enhance it.

Our membership is composed in large measure of practitioners.
EFFECTS OF LARGE LOADS OF ELECTROLYTES
Authors: GAMBLE J. L. , WALLACE W. M. , ELIEL L. , HOLLIDAY M. A. , CUSHMAN MARGARET , APPLETON JANET , SHENBERG ANITA , PIOTTI JEAN
Published: December 2021

The effects of large electro'yte loads provided by adding various salts to a constant food intake were observed in two healthy infants on the basis of balance measurements found over a fore-period.

The salts used were NaCl, NaHCO3, KCl and K-acetate. The balances found over the periods of load were corrected for unmeasured loss by a value derived from the observed fore-period balances and an estimation of actual retention for growth based on expected body weight gain in relation to age. The measurements of balance thus obtained are regarded as rough approximations. It is believed, however, that they permit a description of the following main features of effects of load.

Adjustment of outgo to load was found to be a gradual process. Accumulation of surplus electrolyte in the body continued almost to the end of eight day periods of load and amounted to about 15% of initial body content.

With the large retentions of Na produced by NaCl or by NaHCO3, extensive depression of K retention below the fore-period level was found. The inverse effect, reduction of Na retention in the presence of large gain of K, was observed in the KCl and K-acetate periods.

Nitrogen retention was not disturbed by NaCl load and was found above the fore-period rate in the NaHCO3 and K-acetate periods but was extensively depressed by KCl.

Using the balance data and measurements of the concentration of Na and Cl in the blood plasma, estimations of sodium shift were obtained by the method of Darrow. A large transfer of Na to the intracellular compartment was found in the NaHCO3 period and in the KCl period Na was extensively removed. These transfers of Na closely preserved the usual concentration of bicarbonate in the plasma in the presence of widely unequal retentions of Na and Cl. A considerable gain of intracellular Na was observed under the NaCl load, but no removal was found in the K-acetate period.

Estimations of volume change of extracellular and of intracellular fluid are presented which illustrate the large effect of sodium shift in determining the distribution of body water accompanying electrolyte balance changes produced by load.
CIRCULATING EOSINOPHILS IN CHILDREN IN HEALTH AND DISEASE
Authors: HAIN KATHARINE
Published: December 2021

A total of 351 circulating eosinophil counts were done on 75 children.

The range of circulating eosinophils for 18 normal children was 109 to 359.

In 12 patients with nonfebrile miscellaneous diseases the circulating eosinophil counts ranged from 84 to 599, and in three patients with mild febrile illnesses, from 170 to 341. A possible explanation for the fact that these counts fell within the normal range was discussed.

In 29 patients with acute febrile illnesses the initial circulating eosinophil counts ranged from 0 to 97. Serial counts during convalescence on three of these patients are presented and the prognostic significance discussed.

In 10 patients with various allergic manifestations there was a range of 393 to 2665. Serial counts on one case of acute atopic eczema treated with ACTH are presented.

Serial counts on one patient before and after laparotomy are presented.

Results of the "ACTH test," the "epinephrine test" and the "insulin test" on a group of children with miscellaneous diseases are presented.
ELECTROENCEPHALOGRAM AND EYE DISORDERS
Authors: LEVINSON JULIAN D. , GIBBS ERNA L. , STILLERMAN MANUEL L. , PERLSTEIN MEYER A.
Published: December 2021

A preliminary report is presented of electroencephalographic studies, both awake and asleep, on 1281 children under 16 years of age with respect to the presence of eye abnormalities, particularly strabismus.

Thirty per cent of 36 children with strabismus but otherwise normal, and only 0.5% of 180 children entirely normal, had occipital abnormalities on their EEGs.

In children with organic brain disease causing cerebral palsy, electroencephalographic foci in the occipital region occurred almost twice as frequently in the presence of abnormal eye findings. This relationship prevailed regardless of the presence or absence of seizures.

In patients with eye disorders, electroencephalographic foci involving the occipital region were six times more common than all other foci combined.

On the basis of this study, it would seem that children who show some neuro-ocular disorder should have a careful study of their EEGs for the detection of a possible central basis for their pathology. Conversely, patients who show an occipital focus on EEG should have a thorough ophthalmologic examination to rule out eye abnormalities.
THE PRESIDENT'S PAGE
Authors: BEAVEN PAUL W.
Published: December 2021

OFTEN officers or members of the Board are asked questions concerning the Academy meetings. This letter is written to answer these questions.

The Academy now holds one areal meeting and one general meeting a year. For a time an attempt was made to have two areal meetings a year. Since it is difficult to interest commercial firms in that many meetings, it resulted in a deficit, which the Board felt we could not afford. Occasionally now the areal meetings do lose money, but the Board has felt that one such meeting is indispensable. The annual meeting results in a profit. The areal meeting this year is in Cincinnati; the annual meeting will be in Toronto. Next year the areal meeting will be in Washington, and the annual meeting in Chicago.

The Board has debated whether to hold most, if not all, the general meetings in Chicago. There are three advantages in this: it is centrally located, facilities are available, and the central office is located there. They would like your opinion as to the wisdom of doing this.

Each year the areal meeting is held in a different part of the country and its program is arranged completely by the men in the locality in which it is held. It has speakers, symposia, and panels; and most often they are outstanding. Sometimes comparisons are made between the excellence of the areal meeting and the annual meeting. They are not really comparable, for their composition is significantly different.

When it was first held, the composition of the annual general meeting was like the areal meeting, except that the annual business meeting was held at this session.
GALACTOSEMIA
Authors: DONNELL GEORGE N. , LANN STANLEY H.
Published: December 2021

Four cases of galactosemia are presented; three occurred in one family. Autopsy findings on one case revealed portal cirrhosis and fatty infiltration of the liver.

The etiology of hepatomegaly and the genetic aspects of the disease are discussed. The importance of identifying the reducing substance in patients with glycosuria is emphasized by the cases reported here.
HYPERPOTASSEMIA AND BODY WATER DISTRIBUTION IN AN ANURIC CHILD
Authors: SCHWARTZ ROBERT , TOMSOVIC EDWARD J. , SCHWARTZ IRVING L.
Published: December 2021

A patient with anuria in whom a rising plasma potassium concentration was associated with progressive signs of potassium intoxication exhibited a decrease in the intracellular compartment and increase of the extracellular compartment without significant change in plasma volume, while total body water remained essentially normal.
TRENDS
Authors: BAIN KATHERINE
Published: December 2021

PERHAPS instead of saying "The Children's Bureau looks ahead," one might more correctly say that the Children's Bureau looks around at what is happening and peers ahead into the fog. For though one can identify many problems arising out of the emergency, their outline, bulk and duration are still indistinct. Many of the words we are using today are those we learned to use 10 years ago—day care, civil defense, evacuation. But the emergency of 1951 is far different from that of 1941. Then we were faced with a clearcut objective which could be mastered by rapid, all-out effort. We had before us something to be done quickly and finished. Today no such well-defined goal is visible. All one can say is that it looks like a long pull— not five years, but perhaps 15 or 20. In a quick dire emergency there is justification for abandoning some basic services. In view of the long pull ahead of us now, it would be suicidal to fail to meet basic needs of children. This country cannot afford to sacrifice one generation. In World War II our potential allies far outnumbered our enemies. Today our potential enemies far outnumber our friends. Each individual American is an asset which needs to be conserved.
CHYLOUS ASCITES IN INFANCY
Authors: GRIBETZ DONALD , KANOF ABRAM
Published: December 2021

A description of a case of chylous ascites with chylocele unassociated with chylous fluid in any other of the body cavities is described. The literature is reviewed and a summary of four similar cases is presented. The 25 cases in the literature are analyzed in terms of etiology, association of chylocele, roentgenographic findings, treatment and prognosis.

It is suggested that all such cases, particularly when they occur in the newborn infant, should be treated with conservative measures, i.e., paracentesis and supportive management, before resort to laparotomy.

Studies concerning the absorption of vitamin A are presented which indicate that where defects in fat absorption through lymphatic pathways exist, the use of aqueous dispersions of fat soluble vitamins ensures their absorption into the general circulation.
PREVALENCE OF HEART DISEASE IN TORONTO CHILDREN
Authors: GARDINER J. H. , KEITH JOHN D.
Published: December 2021

The prevalence of heart disease in school children in this study was found to be .37%. This agrees rather closely with the recent findings of Rauh in Cincinnati and Robinson and Aggeler in San Francisco, but is a distinct drop from the findings of investigators 20 and 30 years ago, when 1 to 2% was the prevalence commonly reported.

From birth to 5 years of age heart disease in children is almost always congenital in origin. In the school age group 55% had congenital heart disease and 44% had rheumatic heart disease. Thus in the school age group, congenital heart disease occurred in just over half the heart cases, whereas if one takes the whole age group from birth to 15 years, congenital heart disease is found twice as commonly as rheumatic heart disease.

Deaths from congenital heart disease are roughly six times as common as rheumatic heart disease in the birth to 15 years age group. During one year there were 29 deaths from congenital heart disease and five from rheumatic heart disease.

It is of interest that by far the most common congenital defect of the heart is the ventricular septal defect. The patent ductus arteriosus is second with a third as many cases, tetralogy of Fallot is fourth, auricular septal defect is fifth, and so on. This is important to the paediatrician but it is of interest and importance to both the surgeon and the paediatrician to note the frequency according to the cause of death. Here tetralogy of Fallot is first, transposition of the great vessels second, anomalies of the aortic valve and ascending aorta third, ventricular septal defect fourth and coarctation of the aorta fifth. Thus efforts might well be directed to evolving satisfactory methods of treating transposition of the great vessels, the second most common cause of death from congenital heart anomalies.
Effectiveness of a Regional Poison Center in Reducing Excess Emergency Room Visits for Children's Poisonings
Authors: Chafee-Bahamon Claire , Lovejoy Frederick H.
Published: December 2021

A study was done to assess the necessity of hospital care for poisoning episodes in children less than 5 years old and to evaluate the impact of a regional poison center on the use of emergency rooms for pediatric poisonings. Of the pediatric patients seen in emergency rooms for acute poisonings, 63% did not require the services of a hospital; 95% did not contact the regional poison center before going to the hospital. When all poisoning episodes were considered, the regional poison center was found to reduce significantly pediatric visits to emergency rooms. Of parents who did not call the poison center, 44% went to an emergency room whereas less than 1% of parents who called the poison center went to a hospital (P < .001). Moreover, 28% of those who did not call made unnecessary visits to the hospital compared with only 0.5% of parents who called the poison center (P < .001). A regional poison center was found to be an effective means of decreasing unnecessary hospital visits for pediatric poisonings. Regional poison centers, however, need to further their impact by addressing outreach efforts to parents who do not call poison centers, emergency rooms, and pediatricians.
‘Reactive Gliosis’ in the Medulla Oblongata of Victims of the Sudden Infant Death Syndrome
Authors: Kinney Hannah C. , Burger Peter C. , Harrell Frank E. , Hudson R. Page
Published: December 2021

A current hypothesis that the sudden infant death syndrome (SIDS) is a sleep apnea syndrome precipitated by defective control of involuntary respiration prompted the present study in which "reactive gliosis" in sections of the medulla oblongata of 45 SIDS victims was quantitated and compared with that in 20 control infants. Six anatomic regions were studied; five are related and one is unrelated to neural control of involuntary respiration. Increased numbers of "reactive" astrocytes were found in the SIDS group when the counts for all regions were combined (P = .04). Counts were also significantly higher in the SIDS victims for each of three regions alone: (1) the hilum of the inferior olivary nucleus (P = .01); (2) a lateral region (P = .02); and (3) the nucleus of the tractus solitarius (P = .03). The region with the greatest statistical difference, the inferior olivary hilum, has no recognized role in the control of involuntary respiration. There were no consistent associations between reactive astrocyte counts and specific clinical, socioeconomic, and pathologic variables. Characterization of the SIDS group whose counts exceeded that of the highest control infant also did not uncover distinguishing features. This study reinforces previous observations that, at least statistically, an abnormality of the brainstem occurs in a group of SIDS victims in contrast to a group of control infants, but also discloses considerable overlap in the numbers of such cells between these two groups.
Medical Cure of Apparent Brain Abscesses
Authors: Rennels Margaret B. , Woodward Celeste L. , Robinson Walker L. , Gumbinas Maria T. , Brenner Joel I.
Published: December 2021

Two children with apparent brain abscesses were cured with antibiotic therapy. Review of the literature reveals clinical and experimental evidence that both cerebritis and an encapsulated abscess may appear as an enhancing ring lesion on cranial computed tomography. Patients reported to have had brain abscesses cured without surgery actually may have had cerebritis. There are only preliminary hints as to how to differentiate patients with cerebritis from those with an abscess. More experience is necessary to develop criteria to determine which patients may be appropriately treated with antibiotic therapy alone.
Assessment of Antifungal Therapy in an 800-Gram Infant with Candidal Arthritis and Osteomyelitis
Authors: Ward Robert M. , Sattler Fred R. , Dalton A. Stanley
Published: December 2021

A 720-g premature newborn developed disseminated candidiasis during treatment with systemic antibiotics and total parenteral nutrition through an umbilical arterial catheter. Clinical features were typical for candidal skeletal infection at this age and included warmth and fusiform swelling of the lower extremities together with radiographic evidence of osteolysis and cortical bone erosion. Candida albicans was cultured from blood, urine, joint fluid, and a bone aspirate. The infection was cured with a 44-day course of amphotericin B and flucytosine (5-fluorocytosine). Antifungal therapy was monitored closely with serum drug levels and laboratory tests for bone marrow toxicity and renal dysfunction. Serum levels of both drugs were comparable to those achieved in older patients treated with similar doses. Significant concentrations of amphotericin B were detected in serum four and 17 days after completion of therapy, indicating a slow rate of elimination similar to that which occurs in adults. There was no evidence of drug-induced toxicity other than transient elevation in the fractional urinary excretion of sodium. This suggests that antifungal therapy may be effectively and safely administered to infants in dose schedules similar to those used for older patients.
Effect of Psychosocial Stimulation on Mental Development of Severely Malnourished Children: An Interim Report
Authors: Grantham-McGregor Sally , Schofield William , Harris Linda
Published: December 2021

The effect of adding psychosocial stimulation to the treatment of severely malnourished children was studied. The study period covered children from the time they left the hospital to 24 months later. The children's developmental levels (DQs) were compared with those of two other groups who were in the hospital—an adequately nourished group with diseases other than malnutrition, and a severely malnourished group who received standard hospital care only. The children receiving intervention had structured play sessions in the hospital and were visited weekly for 2 years after returning home. During the visits paraprofessionals showed mothers how to continue structured play with their children. The malnourished children who did not receive intervention showed a marked deficit in developmental level compared with that of control children throughout the study. The control children showed a decline in developmental level with age, which is characteristic of disadvantaged children. The children receiving intervention showed marked improvements and by 24 months were ahead of the children who did not receive intervention in every subscale and were ahead of the adequately nourished children in two subscales. Both groups of malnourished children remained behind the control children in nutritional status and locomotor development.
Too Few Cases
Authors: Stickler G. B.
Published: December 2021

After reading the article by Jakobsson and Lindberg "Cow's Milk Proteins Cause Infantile Colic in Breast-Fed Infants: A Double-Blind Crossover Study" (Pediatrics 1983;71:268-271), I am wondering a little bit what is happening to the review process. The study supposedly shows experience with 66 breast-fed infants. However, the critical double-blind crossover trial was completed successfully only with ten. It is not clear why the article was published including 50 children who were not studied objectively. I do believe a paper of this sort will cause a great deal of alarm on data based on much to small a sample.
Early Management and Decision Making for the Treatment of Myelomeningocele
Authors: Gross Richard H. , Cox Alan , Tatyrek Ruth , Pollay Michael , Barnes William A.
Published: December 2021

A program for early selection and treatment of the infant with myelomeningocele was developed at the University of Oklahoma Health Sciences Center in 1977. Over a 5-year period, 69 babies were evaluated, 36 babies were recommended for early vigorous treatment. Of the 33 babies for whom only supportive care was recommended, five were initially treated at the parents' request, two underwent delayed vigorous treatment, one was subsequently treated by "crisis management," one moved and did not return for follow-up, and 24 received only supportive care. All 24 babies died between 1 to 189 days of age (mean 37 days). The involvement of several physicians and paramedical support personnel is considered essential for this approach of early selection and treatment. Continued support and regular follow-up is necessary for any baby who receives only supportive care. Parents retain legal custody. Although ethical concerns make any approach difficult, the method presented is considered to be the best alternative available at this time.
Treatment of Critically III Newborns
Authors:   Committee on Bioethics
Published: December 2021

No more devastating event can befall parents than the birth of an abnormal or seriously ill child. A very prematurely born infant must be included in this category; in fact, 10% of newborns weighing 2,000 to 2,500 g will die despite the most heroic treatment. Moreover, the spectrum of congenital illness is vast and includes birth defects resulting from a complex interaction of genetic and environmental factors.

The American Academy of Pediatrics agrees with the Department of Health and Human Services of the federal government that the decision to treat or not treat seriously ill newborns should not be based on concomitant handicapping conditions, such as Down's syndrome or other congenital anomalies. However, we strongly oppose the remedy proposed by the DHHS. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research also strongly opposes the federal government's proposal. The pediatric research societies, the American Hospital Association, the National Association for Children's Hospitals and Related Institutions, and many other organizations and individuals including, we believe, the vast majority of the AAP membership, are opposed to these regulations. A better remedy, we believe, is the establishment in each hospital of an internal review procedure whenever the decision to forgo life-sustaming therapy is being considered.

The Academy's official policy with regard to the treatment or nontreatment of critically ill newborns has been developed by our Committee on Bioethics in consultation with the Committees on Fetus and Newborn, Hospital Care, and Children with Handicaps. It is published below.

Pediatrics, although the official journal of the American Academy of Pediatrics, publishes many commentaries that do not represent official AAP policy.
Neonatal Hyperviscosity
Authors: HATHAWAY WILLIAM E.
Published: December 2021

Increased viscosity of the blood in newborn infants has been known to be associated with significant morbidity for more than a decade.1-4 A recent review of neonatal polycythemia and hyperviscosity by Black and Lubchenco5 summarizes the available literature and emphasizes the diagnostic and management problems that pediatricians currently face. This commentary will attempt to highlight some of these problems. During this discussion, measurements of hematocrit refer to venous microhematocrits and viscosity refers to measurements by the Wells-Brookfield microviscometer on heparinized whole blood samples, unless otherwise specified.

The syndrome of neonatal hyperviscosity may be defined as alterations in flow properties of blood associated with symptoms and signs of organ dysfunction.
Number Crunching
Authors: DAVIS HARRY C. , ROBERTSON ALEX
Published: December 2021

To the Editor.—

A recent letter1 suggested that a "gaffe" and "blunder" was committed by the author of an earlier article.2 The letter is signed, "Student," reminding us of W. S. Gossett, the original "Student" of "Student's t-distribution" fame. Gossett was employed by Guinness Brewery which had forbidden him from publishing under his own name. Perhaps the letter writer was imbibing Gossett's product and not his wisdom.

Specifically, the letter writer suggests that Apgar scores are "semiquantitative," are ordinal and that "the arithmetic mean and standard deviation of Apgar scores are meaningless expressions."
Intralesional Corticosteroid Injections for Infantile Hemangiomas of the Eyelid
Authors: Nelson Leonard B. , Melick Judith E. , Harley Robison D.
Published: December 2021

Infants with capillary hemangiomas of the eyelid are at risk for amblyopia and strabismus. Several methods of treating these tumors have been associated with complications and limitations. The use of intralesional corticosteroid injections has been demonstrated to be a simple, safe, and effective method of treating capillary hemangiomas of the eyelid.
Effect of Breast-Feeding on Morbidity in Rotavirus Gastroenteritis
Authors: Weinberg Robert J. , Tipton Gary , Klish William J. , Brown Marilyn R.
Published: December 2021

Fifty infants less than 1 year of age with rotavirus gastroenteritis were studied with regard to the protective effect of breast-feeding. The initial incidence of breast-feeding was 64% in the patients infected with rotavirus and 70% in a matched control population. Seven patients were breast-fed at the time of infection, 25 patients had stopped breast-feeding prior to infection, and 18 patients were exclusively formula-fed. There were no significant differences between groups in the average age of infection, mean duration of diarrhea, mean number of bowel movements in 24 hours, or in the frequency of fever or irritability. The only apparent difference between groups was that the frequency of vomiting was significantly decreased in the breast-fed children. The results of this study suggest that breast-feeding offers little protection against rotavirus gastroenteritis.
Feeding of Infants with Cleft Palate
Authors: MARTIN LESTER W.
Published: December 2021

In Reply.—

Perhaps, we should not have called the nipple "gravity flow," because, as described in the manuscript, the formula is expressed through the nipple by means of a compressible plastic feeding bottle. The bottle is compressed manually in order to deliver the formula.

What we introduced was a standard nipple that does not require puncturing with extra holes, cutting with a razor blade, or altering in some other manner.
W.A.S.T.E
Authors: GREENSHER JOSEPH
Published: December 2021

In Reply.—

TIPP-The Injury Prevention Program, inaugurated by the American Academy of Pediatrics in April 1983, is gaining acceptance by pediatricians as an essential aspect of the care they provide their patients.

The major aim of TIPP is to give parents the impetus to acquire for their children the protection afforded by: (1) child car restraints, (2) smoke detectors, (3) safe hot water temperatures at the tap, (4) window and stairway guards/gates, and (5) a 1-oz bottle of Syrup of Ipecac.
A Randomized Trial of A.C.T. (Asthma Care Training) for Kids
Authors: Lewis Charles E. , Rachelefsky Gary , Lewis Mary Ann , de la Sota Ann , Kaplan Michael
Published: December 2021

A randomized control trial of a curriculum, A.C.T. (Asthma Care Training) for Kids, was conducted. Seventy-six children between the ages of 8 and 12 years, whose asthma required treatment with medications at least 25% of the days per month, were randomly assigned to control and experimental groups. The control group received 4½ hours of lecture presentations on asthma and its management. The experimental groups (consisting of four to seven children and their parents) received five 1-hour sessions comprising "the treatment." Children and their parents were interviewed before the sessions and 3, 6, and 12 months after the completion of the experimental treatment. Use of emergency rooms and hospitals was determined by reviewing the records of these patients (all members of the Los Angeles Kaiser Permanente health care system) for the period of 1 year before and 1 year after the treatment. Results include (1) equivalent increases in knowledge and changes in beliefs in both groups, (2) significant changes in the self-reported compliance behaviors of the experimental group only, and (3) significant reductions in emergency room visits and days of hospitalization among those receiving the experimental treatment, compared with the control group. These changes represent an estimated savings of approximately $180 per child per year for those in the experimental group.
Using Conventional Infant Ventilators at Unconventional Rates
Authors: Boros Stephen J. , Bing Dennis R. , Mammel Mark C. , Hagen Erik , Gordon Margaret J.
Published: December 2021

The effect of progressive increases in ventilator rate on delivered tidal and minute volumes, and the effect of changing peak inspiratory pressure (Pmax), positive end-expiratory pressure (PEEP), and inspiration to expiration (I:E) ratio at different ventilator rates were examined. Five different continuous-flow, time-cycled, pressure-preset infant ventilators were studied using a pneumotachograph, an airway pressure monitor, and a lung simulator. As rates increased from 10 to 150 breaths per minute, tidal volume stayed constant until 25 to 30 breaths per minute; then progessively decreased. In all, tidal volume began to decrease when proximal airway pressure waves lost inspiratory pressure plateaus. As rates increased, minute volume increased until 75 breaths per minute, then leveled off, then decreased. Substituting helium for O2 increased the ventilator rate at which this minute volume plateau effect occurred. Increasing peak inspiratory pressure consistently increased tidal volume. Increasing positive end-expiratory pressure decreased tidal volume. At rates less than 75 breaths per minute, inspiratory time (inspiration to expiration ratio) had little effect on delivered volume. At rates greater than 75 breaths per minute, inspiratory time became an important determinant of minute volume. For any given combination of lung compliance and airway resistance: (1) there is a maximum ventilator rate beyond which tidal volume progressively decreases and another maximum ventilator rate beyond which minute volume progressively decreases; (2) at slower rates, delivered volumes are determined primarily by changes in proximal airway pressures; (3) at very rapid rates, inspiratory time becomes a key determinant of delivered volume.
Vitamin E Toxicity
Authors: SOKOL RONALD J.
Published: December 2021

To the Editor.—

The article by Hittner et al1 extended some of their previous observations concerning the relationship between the retinopathy of prematurity and pharmacologic vitamin E therapy. The authors, however, reach what we consider are incorrect conclusions concerning the relationship between vitamin E status, patient survival, and vitamin E toxicity, and they provide the reader with recommendations that are not substantiated by the data presented.

The major concern is the error in the comparison of the two groups of infants in their table 4 (page 243), the "control" infants (oral vitamin E therapy alone) and the "treated infants" (combination of intramuscular and oral vitamin E therapy).
Factors Associated with the Choice and Duration of Infant-Feeding Practice
Authors: Simopoulos Artemis P. , Grave Gilman D.
Published: December 2021

Breast-feeding makes a unique, fundamental contribution to the health and nutrition of infants. The World Health Organization International Code of Marketing of Breastmilk Substitutes is designed to encourage, promote, and protect breast-feeding in all WHO member states. The Code acknowledges that a number of social and economic factors affect the decisions of women to breast-feed and that breast-feeding has declined. Member states have been urged, therefore, to develop appropriate social support systems to overcome and adjust for factors associated with breastmilk substitutes. Although the Code does not so state, these factors are not fully understood.

The reasons for unsuccessful breast-feeding and early termination are important concerns. So far only vague and rudimentary answers have been identified, eg, "the milk dried up"49 or "lack of satisfaction."7 The decision-making process involved in early weaning has yet to be carefully analyzed. Certainly, biologic variables are involved, such as maternal nutritional status, maternal nutrient intake, and volume and quality of milk produced. These factors have not been well studied, and they are presumably influenced by psychological, social, cultural, and economic factors.

Vahlquist,55 writing in the introduction to the WHO Collaborative Study on Breast-Feeding, noted, "Whereas, up to the 1960's it had been widely held that the decline in breast-feeding was a `fact of modern life,' this premise began to be increasingly questioned, and it was wondered whether the trend was really irreversible." The stakes in reversing the trend are great, as breast-feeding is the safest, most economical way to promote infant health and sound nutrition. Since then, the literature on the determinants of infant-feeding choice has grown rapidly.
Review of the Epidemiologic Evidence for an Association Between Infant Feeding and Infant Health
Authors: Kovar Mary Grace , Serdula Mary K. , Marks James S. , Fraser David W.
Published: December 2021

The approach in this paper is to investigate the health impact of feeding infants breast milk or its substitutes in the United States and other industrialized countries today. This report is limited to an evaluation of epidemiologic and clinical studies of human populations conducted in the United States and other industrialized countries and published since 1970.

QUESTIONS ADDRESSED

This review addresses five questions on breast-feeding:

1. Is breast-feeding associated with lower post-neonatal mortality than alternative forms of feeding?

2. Is breast-feeding associated with lower infectious disease-specific morbidity than alternative forms of feeding?

3. Is breast-feeding associated with lower rates of allergic disease-specific morbidity than alternative forms of feeding?

4. Is breast-feeding associated with malnutrition as indicated by either unusually rapid growth or faltering growth?

5. Is breast-feeding associated with bonding or with better psychological and intellectual development?

QUESTIONS NOT ADDRESSED

The decision to focus on specific questions meant that several issues could not be addressed. For example, the relationship between breast-feeding and fertility, the possible impact of breast-feeding on the mother's health, and the possible impact of a mother's health condition or her use of drugs on infant feeding are not discussed, nor are medical characteristics of the infant that might make breast-feeding difficult or inadvisable. Thus, several factors that should be taken into consideration in evaluating whether breast-feeding should be encouraged or discouraged in specific circumstances are not discussed in this section.

Biochemical and immunologic laboratory studies and animal studies have also not been reviewed. Such studies are potentially valuable, and the decision to exclude them should in no way be interpreted as failure to recognize their importance.
Heterogeneous Growth and Mental Development of Intrauterine Growth-Retarded Infants During the First 3 Years of Life
Authors: Villar J. , Smeriglio V. , Martorell R. , Brown C. H. , Klein R. E.
Published: December 2021

Postnatal growth and development were studied in two groups of term infants with intrauterine growth retardation (IUGR) and one group of infants with normal birth weight up to 3 years of age (total sample, 205 infants). Infants with IUGR were classified as having low ponderal index (IUGR-LPI) or adequate ponderal index (IUGR-API). At birth, the two groups of infants with IUGR had similar birth weight, but length and head circumference measurements were significantly different. Overall, the IUGR-API infants remained lighter and shorter and had smaller head circumferences up to 30 months of age. The IUGR-LPI infants experienced catch-up growth in weight during the first months, because of greater fat deposition. At 24 months of age, the IUGR-API infants scored below the others on mental items. At 3 years of age the IUGR-API infants had the lowest values on seven of eight developmental measures and on the composite score; at these two time periods, the group with normal birth weight scored the highest, and the IUGR-LPI infants obtained intermediate values. It is concluded that infanst with IUGR tend to follow postnatal growth and developmental patterns that are associated with their physical characteristics at birth.
Moped Injuries in Children
Authors: Westman Judith A. , Morrow Grant
Published: December 2021

Moped injuries are an important cause of traffic-related injuries in children. An attempt was made to define the epidemiology as well as the nature and severity of injuries sustained in 88 moped-related accidents. Bicycle injuries among children (579) were used as a control. The patients with moped injuries were younger than expected (mean 12.8 years with a minimum legal driving age of 14 years in the study area). Among 26 hospital admissions due to moped accidents, there were 11 admissions to the intensive care unit, demonstrating the severe nature of the injuries. Fifty percent of the patients had orthopaedic injuries and 46% had neurologic injuries. These injuries resulted in an average length of hospitalization of 8.5 days (intensive care unit admissions lasted an average of 14.6 days). Recommendations are made to aid pediatricians in the counseling of patients and parents.
Toward a New Understanding of Vascular Proliferative Disease in Children
Authors: Folkman Judah
Published: December 2021

These studies provide the following evidence:(1) Angiogenesis is a multistep process. (2) The steps necessary to construct a capillary must occur in correct sequence, a motif that seems to be expressed entirely by vascular endothelial cells. (3) Primary tumors and their metastases are angiogenesis dependent, and angiogenesis may be a critical control point in tumor growth. (4) Heparin potentiates angiogenesis. (5) Heparin or its nonanticoagulant fragments, administered with cortisone, inhibit angiogenesis. (6) Heparin is degraded in the gastrointestinal tract and yields low molecular weight fragments, some of which are absorbed into the circulation. (7) There is a group of corticosteroids that inhibit angiogenesis in the presence of a heparin fragment, but have no glucocorticoid or mineralocorticoid activity. The compounds to which this new biologic activity has been assigned have been named "angiotropic" steroids. (8) There is a potential future role for angiogenesis inhibitors as a new class of pharmacologic agents.
Zinc and Low Birth Weight: Relationship Questioned
Authors: KUMAR SAVITRI P. , ANDAY ENDLA K.
Published: December 2021

We appreciate the concerns raised by Carpentieri et al. Unfortunately, there is no reliable method currently available for determining the body's zinc status in routine clinical practice. Although erythrocyte and leukocyte zinc determination may be more reliable than plasma levels, it has been noted that erythrocyte zinc content rises progressively during the first 12 years of life and this may limit its applicability in children.1 Moreover, to our knowledge, there is no published study of leukocyte or erythrocyte zinc levels in premature infants of different gestational and postnatal ages.
Administration of Thyroxine to Very Low-Birth-Weight, Premature Infants
Authors: CHOWDHRY PARVEEN , ScANLON JOHN W. , AUERBACH RICHARD , ABBASSI VAL
Published: December 2021

Schwartz et al have questioned the advisability of administering thyroxine (T4) to premature infants with respiratory distress syndrome and low levels of T4 as reported in our study.1 We have not advocated routine administration of T4, however, in premature babies who fail to increase their T4 concentration for several weeks. The question of possible consequences of prolonged hypothyroxinemia in a critical period remains unresolved. Our study demonstrated that hypothyroxinemia was of no immediate consequence.

The study by Hadeed et al2 on the prevalence of hypothyroxinemia of less than 6.5 µg/dL is on cord blood and does not apply to the postnatal period.
Fever Therapy Failure
Authors: SWEET LAWRENCE
Published: December 2021

To the Editor.—

Drug efficacy depends, in part, upon adequate dosage. It has been recognized in our outpatient pediatric clinic that parents have sometimes unwittingly given to their febrile child amounts of liquid acetaminophen inadequate for fever control.

Based on available clinical and pharmacokinetic data, oral acetaminophen should be administered in single doses in the range of 10 to 15 mg/kg at four-hour intervals.1 To achieve this dosage range in infants, only small volumes of concentrated acetaminophen "drops" (80 mg/0.8 mL) are necessary.
Marijuana in Urine
Authors: SCHWARTZ RICHARD H.
Published: December 2021

Silber underscores the importance of urine toxicology for detection of recent cannabinoid use by adolescent patients.

Because Δ9-THC, the major psychoactive component of cannabis, is lipophilic, it is stored in adipose tissue and released slowly and unevenly back into the bloodstream during the 21 days or more after use. 9-Carboxy-tetrahydrocannabinol (THC), a stable nonpsychoactive metabolite of cannabis, is excreted in relatively large amounts in feces (70%) and urine (30%) and can be detected by urine toxicology for several days after last use of marijuana or hashish.
What Do Patients and Parents Want to Know? What Do They Need to Know?
Authors: Korsch Barbara M.
Published: December 2021

Health, or patient, education is important in enhancing patient cooperation and compliance with medical regimens. When communication flows in only one direction (from the physician to the patient), education is relatively ineffective. The process of patient education should be viewed as a joint venture, in which the patient helps to determine what information should be provided. The physician must consider not only what the patient needs to know, but also what he or she wants to know. The physician should find out specifically what a patient on a particular occasion would like to have explained. If necessary, the physician can effect a bridge between the information that is deemed to be appropriate and the patient's perceived needs. Anxiety may block the patient's receptiveness to health care information. The physician can alleviate these fears by creating a "therapeutic alliance." A helpful tactic is to speak in language the patient can understand, keeping the message simple and specific. Timing is also crucial; the physician must be able to judge when a patient is ready to receive certain information. The degree of detail offered will depend on the patient's needs and preferences. The hallmark of a pediatric practice is an open mind and continued readiness to assess the patient's knowledge, receptiveness to additional health information, and current needs.
Fever in Childhood
Authors: Schmitt Barton D.
Published: December 2021

Fever is one of the commonest reasons for seeking pediatric care. Many parents have unrealistic fears regarding fever. Many physicians treat fevers vigorously to relieve these concerns. Parent education in the following areas may be helpful: a definition of fever, including diurnal variation; a demonstration of how to take axilary, rectal, and oral temperatures; guidelines for retaking the temperature in febrile children; a reminder that fevers can be helpful in fighting infections; clarification that fever by itself is rarely harmful below 41.7°C; recommendations for when to use antipyretics, including clarification of appropriate dosages; recommendations for sponging; and guidelines for when to call the child's physician, with an emphasis on observation of the child rather than the level of fever. If parents are instructed about fever, inappropriate telephone calls, unnecessary office visits, and the giving of antipyretics to afebrile children can be reduced.
Impact of the WIC Program on the Iron Status of Infants
Authors: Miller Virginia , Swaney Sheldon , Deinard Amos
Published: December 2021

The WIC Program (Special Supplemental Food Program for Women, Infants and Children) was initiated in the early 1970s to improve the nutritional status of pregnant women, lactating women, and children from birth to 5 years of age who were at risk for nutritionally related health problems. Better hematologic status of a group of preschool-aged infants who were enrolled in the WIC Program from birth, as compared with another group of similar age and socioeconomic status from the pre-WIC Program era, suggests that participation in the WIC Program will help limit the development of iron depletion or iron deficiency anemia in young children, an important consideration in view of the deleterious hematologic and nonhematologic effects that have been attributed to those conditions.
Group C Streptococcal Endocarditis
Authors: GOLDBERG PAUL , SHULMAN STANFORD T. , YOGEV RAM
Published: December 2021

Although endocarditis is often caused by α-hemolytic streptococci, endocarditis due to β-hemolytic streptococci is rare. Most cases of β-streptococcal endocarditis are due to Lancefield groups B or G, whereas group C streptococci rarely cause endocarditis.1 Only 15 cases of endocarditis caused by group C streptococci, all in adults, have been reported.2-13 The rarity of this association is emphasized by the fact that Mohr et al13 reported one patient with group C streptococcal endocarditis from a series of 150,000 blood cultures. In addition, Cherubin and Neu14 found no cases of group C streptococcal endocarditis while reviewing 656 cases of infective endocarditis.
Clinical Estimation of Liver Size in Newborn Infants
Authors: ASHKENAZI SHAI , MIMOUNI FRANCIS , MERLOB PAUL , REISNER SALOMON H.
Published: December 2021

In Reply.—

Brion and Avni have compared the clinical estimation of liver size by the liver span and the size of its edge below the right costal margin.

Some of their results are in accordance with ours, such as the lack of differences between the measurements immediately after birth and a few days later, and the reduced size of liver edge found in our preliminary measurements in infants who were small for gestational age (Table).

It seems to us that the practical approach to the clinical estimation of liver size in the newborn should include routine measurement of liver edge in every healthy newborn infant.
Zinc Deficiency: Cause of Hypoproteinemia or Its Result?
Authors: KUMAR SAVITRI P. , ANDAY ENDLA K.
Published: December 2021

In Reply.—

We agree with Weizman that quantification of enteric protein loss is best carried out by the use of51 Cr-albumin. Although this test has been used in adults and older children, there is no published study on the use of this method in neonates or low-birth-weight infants. The use of radioactive isotopes and the necessity of obtaining fecal samples without urinary contamination makes this an undesirable test in infants. Although the fecal clearance of α1-antitrypsin overcomes all the drawbacks of the 51Cr-albumin method, there are again no studies to date, on its use in neonates.