bluuebunny/crossref_metadata_2025 huggingface dataset:
PMA SURVEY IDENTIFIES 114 DRUGS, VACCINES IN DEVELOPMENT FOR CHILDREN
Authors: L. J. F.
Published: December 2021

WASHINGTON, D. C.—The first-ever survey to identify pediatric medicines in development has found that 114 drugs and vaccines are in testing for use in children. The survey, conducted by Pharmaceutical Manufacturers Association, revealed that these medicines are involved in 127 research projects, because some are being tested for more than one use.

"The results of this survey are remarkable considering the difficulties of testing drugs in children," said PMA President Gerald J. Mossinghoff. "Although researchers are faced with problems of recruitment, safety and costs for pediatric clinical trials, the medical community has expressed an increasing need for child-specific testing, and America's pharmaceutical research companies are making an enormous commitment to fulfilling that need."
Child Abuse or Osteogenesis Imperfecta: How Can We Tell?
Authors: Gahagan Sheila , Rimsza Mary Ellen
Published: December 2021

Osteogenesis imperfecta may be difficult to differentiate from nonaccidental trauma. Social history may prejudice the physician in favor of or against considering the diagnosis of child abuse. Three cases of osteogenesis imperfecta that were initially diagnosed as nonaccidental trauma are presented. The availability of biochemical analysis of type I collagen was instrumental in confirming the diagnosis of osteogenesis imperfecta in all three cases.
Nasal Continuous Positive Airway Pressure Facilitates Extubation of Very Low Birth Weight Neonates
Authors: Higgins Rosemary D. , Richter Susan E. , Davis Jonathan M.
Published: December 2021

A prospective randomized trial was performed in 58 neonates comparing nasal continuous positive airway pressure (NCPAP) vs oxyhood following extubation of neonates weighing less than 1 kg. All neonates had been ventilated for the treatment of respiratory distress syndrome for at least 24 hours and weighed less than 1 kg at the time of extubation. Clinical criteria for elective extubation included improving pulmonary status, fraction of inspired oxygen (FIO2) ≤ 0.35, mean airway pressure ≤ 7 cm H2O, ventilator rate ≤ 20 breaths per minute, and weight at least 80% of birth weight. Informed consent was obtained and neonates were randomized to NCPAP or oxyhood following extubation. Success was defined as remaining free of additional ventilatory support for at least 5 days. Failure criteria included FIO2≥ 0.60 to maintain pulse oximetry ≥ 93%, PaCO2 ≥60 mm Hg, pH ≤ 7.23, or moderate to severe apnea. Results demonstrate that 22 (76%) of 29 neonates were successfully extubated to NCPAP while only 6 (21%) of 29 were successfully extubated to oxyhood (P < .0001). There were no differences in baseline characteristics between the two groups. Of the 23 neonates who failed oxyhood, 21 were then given a trial of NCPAP and 58% (12/21) remained extubated. Data indicate that using selected clinical criteria for elective extubation of neonates weighing less than 1 kg, NCPAP facilitates successful extubation.
Parental Reports of Apnea and Bradycardia: Temporal Characteristics and Accuracy
Authors: Steinschneider Alfred , Santos Vicki
Published: December 2021

A prospective examination was made of the temporal course of parental observations in response to a monitor alarm of apnea (apnea setting of 20 seconds) or bradycardia (bradycardia setting of 80 beats per minute). Data were obtained from 155 subsequent sudden infant death syndrome siblings followed up at home, during the first 20 weeks of life, on an apnea/bradycardia monitor with an attached event recorder. In addition, parental reports were compared to an objective recording of the pattern of cardiorespiratory activity surrounding each monitor alarm. Only those parental observations were considered which reported the infant to be asleep with no apparent equipment malfunction following an apnea alarm (with or without pallor, cyanosis, or the provision of external stimulation) or a low heart rate alarm associated with pallor, cyanosis, or stimulation. Observations were analyzed within each of five age periods (<29, 29 through 56, 57 through 84, 85 through 112, 113 through 140 days). The percentage of infants reported to have prolonged apnea, prolonged apnea with stimulation, or bradycardia with stimulation was found to decrease with age. An examination of the linked event recordings failed to document an episode of apnea as long as 15 seconds for any of the reported episodes of apnea. Furthermore, bradycardia as long as 5 seconds in duration could be documented in only 3 of 422 reported episodes of bradycardia. These results indicate the potential for considerable error when total reliance is placed on parental observations and point to the necessity for objective event recordings when using home monitors in the clinical management of at-risk infants.
Educational Status and School-Related Abilities of Very Low Birth Weight Premature Children
Authors: Ross Gail , Lipper Evelyn G. , Auld Peter A.M.
Published: December 2021

Eighty-eight premature children with birth weights ≤1500 g were evaluated at ages between 7 and 8 years old to determine their academic status in comparison with those of a matched full-term group. Results showed that a much higher proportion of the premature children required special educational interventions (48%) than either the full-term children (15%) or the New York State public elementary school population (10%). More than half of the premature children who received educational intervention were neurologically impaired or had below normal intelligence. The entire group of premature children differed significantly from the matched full-term group on IQ score and on tests of verbal ability, school achievement, and auditory memory. Lower socioeconomic status children performed significantly less well on each type of these measures and on a measure of attention than children of the higher socioeconomic status group. There was an interaction of prematurity and social class on Full Scale IQ, verbal tests, academic achievement, and attention, with lower socioeconomic status premature children scoring lowest on these measures. The subset of premature children normal in both IQ and neurologic status did not differ significantly from a matched normal full-term group on any cognitive measures other than arithmetic ability, but they continued to have significantly lower academic achievement scores.
Estimation of Mortality Risk in Chronically Ventilated Infants With Bronchopulmonary Dysplasia
Authors: Overstreet Debora W. , Jackson J. Craig , van Belle Gerald , Truog William E.
Published: December 2021

Bronchopulmonary dysplasia is a chronic, sometimes fatal lung disease, which primarily affects premature infants and often leads to a dependence on mechanical ventilation lasting many months. To identify prognostic factors of mortality at 1 and 2 months of age, the authors reviewed the medical records of the 144 neonates admitted to two neonatal intensive care units in Seattle from January 1, 1986, through December 31, 1988, who required mechanical ventilation throughout the first month of life. Likely predictors of mortality were tested by logistic regression analysis. The calculated mean airway pressure at 30 days of age (MAP30) and the diagnosis of bacterial sepsis at any time during the first month of life (Bact0-30) were statistically significant predictors of mortality (P < .001 and P = .018, respectively) and had the lowest deviance in the regression model. The probability of mortality was estimated by 1/(1 + e-x, where x = -6.510 + 0.4588 (MAP30) + 1.475 (Bact0-30), and where MAP30 is expressed as centimeters of water pressure (1 cm H2O = 0.0978 kPa) and the presence or absence of bacteremia is 1 and 0, respectively. The records of the 57 infants who still required mechanical ventilation at 60 days of age were reanalyzed with clinical data available during the first 2 months of life. Mean airway pressure (MAP60) and the fraction of inspired oxygen (F60) at 60 days of age combined to form the best predictors of mortality, where x = -7.668 + 0.2940 (MAP60) + 5.935 (F60). The occurrence of bacterial sepsis during the first 2 months of life, the degree of hypochloremia, and the duration of chronic sedative use were also significant predictors of survival, even controlling of MAP60 and F60. These regression equations allow more accurate estimation of the likelihood of survival for chronically ventilated infants and may facilitate decisions regarding withdrawal or continuation of life support.
The Attitude-Practice Gap Revisited: Risk Reduction Beliefs and Behaviors Among Owners of Residential Swimming Pools
Authors: Wintemute Garen J. , Wright Mona A.
Published: December 2021

Complete pool fencing and effective by-stander resuscitation are both believed to reduce the risk of childhood drowning. The relationship between support for, and prevalence of, a complete pool barrier and current cardiopulmonary resuscitation certification was investigated among an equal probability sample of 795 owners of residential swimming pools in Sacramento County, California. Only 50% (95% confidence interval [CI] 44%, 56%) of respondents who favored a cardiopulmonary resuscitation certification requirement for pool owners represented a household with any members so certified. Only 35% (95% CI 26%, 44%) of respondents who endorsed a complete barrier requirement for all pools had a fence surrounding their own pool. Support for a cardiopulmonary resuscitation requirement was associated with a modestly higher prevalence of current cardiopulmonary resuscitation certification (46% vs 33%, difference = 13%, 95% CI for difference 2%, 24%). Endorsement of a pool barrier requirement was associated with a substantially higher prevalence of complete pool fencing (35% vs 7%, difference = 28%, 95% CI for difference 19%, 37%). The proportion of the pool-owning population endorsing these risk reduction behaviors is much larger than the proportion actually adopting them. The results suggest that an effective pool drowning-prevention program will rely primarily on legislative approaches, with health education serving as a useful adjunct.
Cardiotoxicity During Treatment of Severe Childhood Asthma
Authors: Maguire James F. , O'Rourke P. Pearl , Colan Steven D. , Geha Raif S. , Crone Robert
Published: December 2021

We prospectively evaluated 20 patient admissions for severe exacerbation of childhood asthma at The Children's Hospital, Boston, to detect evidence of cardiotoxicity. Evidence of cardiotoxicity was found in all six patient admissions for which isoproterenol infusion was utilized. This included marked elevation of serum creatine phosphokinase isoenzyme (CPK-MB) levels and electrocardiogram abnormalities consistent with transient myocardial ischemia. Peak serum CPK-MB levels were significantly lower and electrocardiogram abnormalities were significantly less frequent during 14 patient admissions for which isoproterenol infusion was not utilized. Risk factors associated with cardiotoxicity included tachycardia, hypercapnia, acidosis, and intravenous isoproterenol therapy. We conclude that cardiotoxicity is not infrequent during therapy for severe exacerbations of childhood asthma. Electrocardiograms and measurement of serum CPK-MB levels are sensitive, useful, and readily obtained indicators of cardiotoxicity. Abnormalities of these studies may detect cardiotoxicity prior to the occurrence of more blatant or catastrophic manifestations of cardiotoxicity. We therefore recommend serial monitoring of serum CPK-MB levels and electrocardiograms for all children requiring an admission to the intensive care unit for management of severe asthmatic exacerbation.
Acquired Structural Genitourinary Abnormalities Contributing to Deterioration of Renal Function in Older Patients with Nephropathic Cystinosis
Authors: Strife C. Frederic , Strife Janet L. , Wacksman Jeffrey
Published: December 2021

The natural progression of nephropathic cystinosis to end stage renal disease can be delayed, sometimes by many years, by the reducing agent, cysteamine. which lowers intracellular cystine content to near normal. We report on two patients with nephropathic cystinosis who were treated with cysteamine and developed structural genitourinary abnormalities which may have contributed to an increase in the rate of decline of renal function. One patient, aged 11 years, was found to have massive megacystis and hydroureteronephrosis but no anatomic bladder outlet obstruction. His abnormality was presumed to be related to chronic high urine volumes leading to megacystis and physiologic ureteral obstruction. Vesicostomy stabilized renal function. The second patient, aged 11½years, was found to have bilateral renal cystic disease which presumably was acquired and may have been related to long-standing hypokalemia. Minor renal abnormalities were found by ultrasound in five additional cystinotic children. We concluded that older children with nephropathic cystinosis may be prone to acquire structural abnormalities of their kidneys or urinary tract.
A Prospective Study of Infants of Human Immunodeficiency Virus Seropositive and Seronegative Women with a History of Intravenous Drug Use or of Intravenous Drug-Using Sex Partners, in the Bronx, New York City
Authors: Mayers Marguerite M. , Davenny Katherine , Schoenbaum Ellie E. , Feingold Anat R. , Selwyn Peter A. , Robertson Verna , Ou Chin-Yih , Rogers Martha F. , Naccarato Marcella
Published: December 2021

A prospective study was conducted in the Bronx, New York, of 70 infants of human immunodeficiency virus (HIV)-infected (n = 33) and uninfected (n = 37) mothers who had a history of intravenous drug use or of intravenous drug-using sex partners. Infants were observed from birth to a median age of 23 months (range 3 to 54 months).

HIV infection was confirmed in seven infants (21%) of seropositive mothers; six developed HIV disease, with symptoms observed in the first year. Of these, three died (3, 9, and 36 months) of HIV-related causes; 3 of 4 survivors were >25 months of age. HIV symptoms preceded or were concurrent with abnormalities in T-lymphocyte subsets; postneonatal polymerase chain reaction confirmed HIV infection in five infants with symptoms and one without symptoms.

Among infants of seropositive mothers, seven without laboratory evidence of HIV (including polymerase chain reaction) had findings suggestive of HIV infection, including persistent generalized lymphadenopathy, hepatosplenomegaly, oral candidiasis, parotitis, and inverted T-lymphocyte ratios. These findings were not observed in infants of seronegative mothers.

Although the presence of HIV proviral sequences was associated with HIV disease, the observation of indeterminate symptoms in at-risk infants indicates the importance of long-term clinical follow-up to exclude HIV infection. Disease manifestations in comparable infants of seronegative mothers are important for assessment of the impact of maternal drug use, development of specific clinical criteria for early diagnosis of HIV and eligibility for antiretroviral therapy.
Terminal Care and the Pregnant Woman: Ethical Reflections on In Re: A.C.
Authors: Tuohey John F.
Published: December 2021

In June 1987, a Washington, DC, court, stating that it had an interest in protecting viable fetal life, ordered a 27-year-old woman dying of cancer to undergo a cesarean section to deliver a 26½-week fetus. The child died within hours, and the woman within days, of the surgery. The ruling was appealed. In April 1990, the court vacated its order, stating that because the court had not first determined the woman's wishes, either as expressed by herself or through a substituted judgment, it was not possible to find a state interest in protecting fetal life which outweighed her own. Beyond this legal issue lie the ethical questions of appropriate care for the pregnant, terminally ill woman. This article argues that it is important to distinguish a decision not to deliver at this time from a decision to terminate a pregnancy. Further, because a cesarean section, unless there is a threat to her life, is not of any clear benefit to the woman, it is wrong to insist that a dying woman must always endure burdensome treatment for the sake of a viable fetus. Should the mother decide to take on such burdens, it is important also to recognize that a cesarean section is not always in the interest of the fetus simply because it is viable. Given the ambiguity of the prognosis for survival and the risks of significant handicaps for the preterm or low birth weight fetus, it may be ethically appropriate to omit an act on behalf of the fetus. Finally, the fact that the fetus' only chance of survival is a preterm delivery does not make the delivery ethically mandatory. The issue is not whether a preterm delivery is the fetus' only hope, but whether a preterm delivery is in the interest of the fetus.
Cimetidine and Breast-Feeding
Authors: BERNSHAW NICOLE
Published: December 2021

To the Editor.—

In the September 1983 report from the AAP Committee on Drugs1 cimetidine (Tagamet) is classified with the "Drugs That Are Contraindicated During Breast-Feeding" and refers to a 1979 publication in the British Journal of Clinical Pharmacology2 by Somogyi and Gugler. Reported signs or symptoms are "May suppress gastric acidity in infant, inhibit drug metabolism, and cause CNS stimulation." In the November 1989 report from the AAP Committee on Drugs,3 this same drug is listed under "Maternal Medication Usually Compatible With Breast-Feeding" while referring to the same 1979 British publication and adding no other reference.
Cimetidine and Breast-Feeding
Authors: BERLIN CHESTON M.
Published: December 2021

In Reply.—

When the Committee on Drugs revised the statement on the transfer of drugs and other chemicals into human milk, the decision was made to include only drugs for which there were published data on the measurement of the compound in milk, maternal serum, and/or infant urine and serum. This resulted in the reclassification of a number of drugs other than cimetidine. The publication that is cited in the 1983 and the 1989 publication for cimetidine in human milk1 is a Letter to the Editor describing an experience with a single mother and nursing infant and the measurement of cimetidine in the milk.
Lomotil Overdose
Authors: WASSERMAN GARY S.
Published: December 2021

To the Editor.—

I read with disappointment the Lomotil overdose article by McCarron et al.1 The title states "an update" and yet 6 of the 8 new cases are from the 1970s with the most recent case from 1986. The last part of the title claims a "review of the literature," yet two thirds of the published acute pediatric overdoses are not included. My case series of 45 exposures with 13 hospitalized acute intoxications is cited as an early reference yet excluded from "Table 2: Diphenoxylate/Atropine (DPX/ATR) Intoxication in Children: 28 Cases From the Literature."
Drug Screening of Newborns by Meconium Analysis: A Large-Scale, Prospective, Epidemiologic Study
Authors: Ostrea Enrique M. , Brady Mark , Gause Sybil , Raymundo Anna Lisa , Stevens Maria
Published: December 2021

A large-scale, prospective drug screening of newborns by meconium analysis was done to determine more accurately the prevalence and epidemiologic characteristics of drug use in a high-risk urban, obstetric population. Every other neonate delivered in a perinatal center from November 1988 to September 1989 was prospectively enrolled and their meconium was analyzed by radioimmunoassay for the metabolites of three commonly abused drugs—cocaine, morphine (opiates), and cannabinoid. In 3010 subjects studied, 44% were positive for cocaine, morphine, or cannabinoid; 31% were positive for cocaine, 21% for morphine, and 12% for cannabinoid. In contrast, only 335 (11%) mothers admitted to illicit drug use: 52% of their newborns had a positive urine drug screen and 88% had a positive meconium drug screen. Prevalence of drug use among the pregnant women varied per month. A profile of the pregnant addict in the population studied was noted (P < .001): service patient, single, multigravid (>3), and little or no prenatal care. The major problems associated with drug use during pregnancy were principally noted in the group that was exposed to cocaine and opiates and in the group where the mothers admitted to the use of illicit drugs. On the other hand, a large number of neonates who have been exposed to drugs in utero, particularly those whose mothers denied the use of drugs, appear normal at birth and may not be recognized. Improved detection of these newborns at risk can be achieved with a high index of suspicion and meconium drug analysis.
Viremic Phase in a Leukemic Child After Live Varicella Vaccination
Authors: IHARA TOSHIAKI , KAMIYA HITOSHI , TORIGOE SADAYOSHI , SAKURAI MINORU , TAKAHASHI MICHIAKI
Published: December 2021

Live varicella vaccine has been shown to be efficacious for prevention of varicella even in immunocompromised children.1-4 Although the site and extent of viral replication in vaccinated hosts have not been fully defined, vaccinees have developed humoral and cellular immunity.1-5 A viremic phase has been demonstrated in immunocompromised and normal children with natural varicella.6,7 However, a viremic phase has not been reported in vaccinated children.

We report our observation of viremia in a leukemic child in whom vesicles and hepatitis developed after live varicella vaccination.

MATERIALS AND METHODS

Human embryonic lung fibroblasts (HEFs) were used for virus isolation. The cells were grown in 25-cm2 plastic tissue culture flasks containing Eagle's minimal essential medium with 7.5% fetal bovine serum.
Repeated, Childhood Vaginal Bleeding Is Not Always Precocious Puberty
Authors: YANOVSKI JACK A. , NELSON LAWRENCE M. , WILLIS ENGLISH D. , CUTLER GORDON B.
Published: December 2021

Vaginal bleeding is an uncommon problem in childhood. In infants and children, vaginal bleeding may result from the hormonal fluctuations of precocious puberty.1-4 However, many cases are related to local vaginal problems. We report a case of recurrent vaginal bleeding caused by infection with Shigella flexneri that was difficult to diagnose and treat. This patient was considered by her general pediatrician possibly to have precocious puberty because of her repeated episodes of bleeding.

CASE REPORT

The patient was a 2-year-old Peruvian girl who was suffering from severe nonbloody, nonpurulent diarrhea when she met her adoptive parents in July 1989. The diarrhea persisted for almost 2 months, and although stool cultures in Peru were unrevealing, she was treated with 10-day courses of both trimethoprim-sulfamethoxazole and metronidazole.
Influence of Portagen and Pregestimil on Essential Fatty Acid Status in Infantile Liver Disease
Authors: KAUFMAN S. S. , SCRIVNER D. J. , MURRAY N. D. , VANDERHOOF J. A. , HART M. H. , ANTONSON D. L.
Published: December 2021

Nutritional support of the pediatric patient with chronic liver disease continues to pose a challenge to physicians. These patients frequently are profoundly anorexic, have reduced assimilation of dietary fats from intestinal bile acid deficiency and have increased caloric requirements because of hypermetabolism.1 Provision of formula by nasogastric tube may effectively circumvent anorexia while providing additional calories.2 Traditionally, supplying a substantial portion of lipid intake as medium-chain triglyceride (MCT) has also been advocated.3 Rationale for use of MCT in place of usual dietary lipid, ie, long-chain triglyceride (LCT), has included the former's partial hydrolysis and absorption within the stomach, more rapid hydrolysis by pancreatic lipase in the intestinal lumen, and reduced requirement for bile salts to effect aqueous dispersion of free medium-chain fatty acids prior to absorption by intestinal epithelium.4
Academically Talented Children: The Case for Early Identification and Nurturance
Authors: Mills Carol J.
Published: December 2021

Almost without exception, experts in the field of education of the intellectually gifted agree that early identification of such talented students is important. There is a good deal of evidence to show that many gifted students who are not identified and whose needs are not met adequately at an early age become frustrated and disillusioned with school, falling into a pattern of low achievement and/or behavioral problems.1,2 At the very least, we know that if educational intervention does not take place at an early age, the child is missing out on valuable years of exciting learning. Interest in learning may diminish and important study skills may not develop because the child is never challenged to think and work hard.
Do You Remember E-Ferol? The Penalty for Selling Untested Drugs in Neonatology: Fines and a Jail Sentence
Authors: Lucey Jerold F.
Published: December 2021

The most recent therapeutic disaster in neonatology occurred in 1984 when E-Ferol killed at least 38 newborns.1 It's not the first time that this kind of thing has happened. Let's hope it will be the last.

Previous iatrogenic disasters have been caused primarily by well-intentioned physicians using logical therapies which turned out to have unexpected, lethal side effects. The E-Ferol chapter was a different story. A poorly managed, avaricious company, O'Neil, Jones and Feldman, Inc, a subsidiary of Carter-Glogau, decided to get the jump on the market and sell an untested preparation of intravenous vitamin E. The physicians assumed it had been tested and approved for use.
Time for a Change
Authors: Harvey Birt
Published: December 2021

This edition of Pediatrics ushers in a number of changes. You will have noticed the new cover design, the first in more than 20 years. We hope that you will welcome this change, but other changes are of more importance.

We have been concerned for a long time about our inability to publish more than 20% of the over 1200 articles that we receive each year; many worthy articles have been rejected for reasons of space. We could not expand the size of each issue because of postal regulations and other limiting factors. We have decided on a new page format and a new size of type that, while approximating those of other leading medical journals, should permit us to publish about 40 more articles each year.
Micropremies
Authors: GINSBERG HARLEY G.
Published: December 2021

To the Editor.—

We read with great interest the editorial submitted by Drs Moro and Minoli describing the neurodevelopmental outcome of an infant who was delivered at 27 weeks gestation with a birth weight of 450 g.1 We were disappointed, however, that they overlooked our recent report of a 380-g female infant who was delivered at 25 3/7 weeks gestation.2 Our infant, Monica, is developing normally after a 122-day hospitalization. Her 20-month Bayley developmental assessment revealed a mental development index of 69 (102 when corrected for prematurity), and psychomotor developmental index of 97 (122 when corrected for prematurity).
Pediatric Telephone Advice in the Emergency Department: Results of a Mock Scenario
Authors: Isaacman Daniel J. , Verdile Vincent P. , Kohen Francine P. , Verdile Louise A.
Published: December 2021

To assess the appropriateness of pediatric telephone advice given by emergency departments (EDs), a mock scenario simulating a 5-week-old with fever of 102°F and signs compatible with meningitis was used to evaluate the responses of 61 randomly selected EDs, of which half were affiliated with pediatric residency training programs. All EDs were given the identical chief complaint: "My baby has been having a fever all day, and I can't seem to get it down." Calls were made by research technicians and monitored by one or more of the investigators by speakerphone. Fifty-three (87%) programs gave advice by telephone; in 42 (79%) of the 53 respondents the individual giving advice was a nurse. Fourteen programs (26%) gave advice without asking either the age of the child or height of the fever. Few of the respondents took historical information assessing irritability (4 programs), fluid intake (11 programs), urine output (8 programs), or breathing pattern (6 programs). Thirty-eight (71.7%) EDs advised the patient to see a physician, while only 32 (60.4%) suggested same-day evaluation. In several instances the caller was not advised to seek medical attention despite having given a history documenting the infant's fever, irritability, and lethargy. These findings show variability and inadequades in pediatric telephone advice currently offered by the EDs that were studied.
Barriers to Pediatric Referral in Managed Care Systems
Authors: Cartland Jenifer D. C. , Yudkowsky Beth K.
Published: December 2021

Anecdotal evidence suggests that children's access to pediatric subspecialty and inpatient care is hampered by referral barriers imposed by managed care systems. To identify such barriers and determine how they affect the referral process, a sample of American Academy of Pediatrics Fellows (n = 1598) was surveyed. The response rate was 79.1% (n = 1264). Of those pediatricians in direct patient care (n = 956), 71.4% participated in a managed care plan. Pediatricians referred patients in managed care systems somewhat less frequently than in traditional pay systems: 8.7% and 6.9% referred managed care patients to subspecialists and inpatient care, respectively, less often. More than 20% and 10% of pediatricians with patients in managed care systems had at least one referral to subspecialist care and inpatient care, respectively, denied in the previous year. Pediatricians experienced more barriers in preferred provider organizations than in health maintenance organizations. These data suggest that utilization management programs, such as those used in managed care systems, may limit necessary access to pediatric subspecialty and inpatient care.
Cost-Effectiveness of Erythromycin Versus Mupirocin for the Treatment of Impetigo in Children
Authors: Rice Teresa Duryea , Duggan Anne K. , DeAngelis Catherine
Published: December 2021

A new topical antibiotic, mupirocin, has been found to be as effective as erythromycin for the treatment of impetigo, but concerns about its expense have been raised. This controlled clinical trial sought to compare the cost-effectiveness of erythromycin (E) and mupirocin (M). Ninety-three children, aged 3 months to 16 years, were randomly assigned to receive 10 days of oral erythromycin (n = 46) or topical mupirocin (n = 47). Costs and effects were measured through structured interviews. Cost per case differed significantly by group (E = $56.85; M = $62.30; P < .05) due chiefly to extra visits and medication changes needed by those treated with mupirocin. Erythromycin and mupirocin were equally effective. The likelihood of side effects (E = 43%, M = 22%) approached significance (P < .07); those treated with erythromycin were willing to pay more for a different medicine to avoid the side effects experienced (P < .05). Working parents and school-age children were more likely to alter their daily activities when the patient was taking erythromycin (P < .04). Compliance and parental satisfaction did not differ by treatment group; however, parents of children treated with erythromycin were more likely to prefer the alternate drug regimen. It is concluded that the type of medication prescribed can be based on parental preference because the increased cost of mupirocin is offset by increased side effects and number of schooldays and workdays lost with erythromycin.
Adaptation of Feeding to a Low Fat Yield in Breast Milk
Authors: Tyson Jon , Burchfield Jeannette , Sentance Felicity , Mize Charles , Uauy Ricardo , Eastburn Judy
Published: December 2021

The effect of a low milk fat yield was assessed in a blinded prospective study of healthy term infants and mothers encouraged to breast-feed. Fat yield index was calculated as milk volume collected by Egnell pump multiplied by the "creamatocrit." Two weeks after delivery mothers who had a relatively low fat yield index (≤30th percentile) were matched with mothers with a higher fat yield index and with formula-feeding mothers. Between 2 and 6 weeks the low fat yield group had a marginally lower weight gain but similar growth in length and head circumference to that of the higher fat yield group. The low fat yield group spent more time per feeding and had more complete breast emptying, resulting in a fat yield index comparable with the higher fat yield group for the mean milk volume ingested by the infant at 6 weeks. A low fat yield had no adverse effect on maternal satisfaction or maternal-infant interaction during feeding. Formula feeders spent the least time in feeding and en face gazing. Adaptation of breast-feeding to a low fat yield sustains infant intake and growth, maternal-infant interaction, and maternal satisfaction. However, there is little reserve if milk production diminishes. Further study is needed to define the limits of adaptation and effective interventions if fat yield is inadequate.
Rapid Improvement in the Renal Tubular Dysfunction Associated With Tyrosinemia Following Hepatic Replacement
Authors: Shoemaker Lawrence R. , Strife C. Frederic , Balistreri William F. , Ryckman Frederick C.
Published: December 2021

The postoperative management of patients with hereditary tyrosinemia type I (McKusick 27670) following liver transplantation is often complicated by the renal tubular dysfunction associated with this disease. To characterize better the temporal course of the improvement in renal excretory activity following hepatic replacement, renal tubular function and metabolite excretion were studied in a 4-year-old girl with hereditary tyrosinemia during the immediate post-transplantation course. Tubular reabsorption of bicarbonate and phosphate were normal 5 days following transplantation, in contrast to glucosuria, hyperaminoaciduria, and tyrosyluria, which persisted for approximately 3 weeks. After hepatic replacement, serum amino acid concentrations returned to normal and succinylacetone was no longer detected in the urine. This is the third tyrosinemia patient reported to achieve complete resolution of urinary abnormalities following transplantation, and the only patient in whom renal tubular function was formally assessed within the first postoperative week.
Horizontal Transmission of Hepatitis B Virus Infection to United States-Born Children of Hmong Refugees
Authors: Hurie Marjorie B. , Mast Eric E. , Davis Jeffrey P.
Published: December 2021

There is evidence that hepatitis B virus (HBV) transmission continues among Southeast Asian refugees after resettlement. To determine the prevalence of HBV infection (hepatitis B surface antigen [HBsAg] positive or core antibody positive) and modes of transmission in Hmong refugee households in Wisconsin, results of serologic tests were reviewed for 429 US-born children not previously vaccinated with hepatitis B vaccine and 754 of their Asian-born household members. The prevalence of HBV infection was 14% (62/429) among all US-born children, 30% (21/69) among children whose mothers were HBsAg-positive, and 11% (41/360) among children whose mothers were HBsAg-negative. Among children whose mothers were HBsAg-negative, the prevalence of HBV infection increased with increasing age (χ2 test for trend = 5.6, P .02) and was related to the household presence of HBsAg-positive sibling(s) (relative risk 4.0; 95% confidence interval = 1.5, 9.3; P < .001). Of the 62 infected children, 13 (21%) lived in households with no HBsAg-positive household members. US-born children of Hmong refugees apparently acquire HBV infection through both horizontal and perinatal transmission. These findings emphasize the importance of routinely integrating hepatitis B vaccine doses into the childhood vaccination schedule for all infants whose parents are from areas where HBV infection is highly endemic. In addition, the findings support the need for pediatricians to consider vaccinating older children (up to age 7 years) whose parents are from HBV-endemic areas.
Markers for Occult Liver Injury in Cases of Physical Abuse in Children
Authors: Coant Pierre N. , Kornberg Allan E. , Brody Alan S. , Edwards-Holmes Karen
Published: December 2021

Children suffering physical abuse are at risk for abdominal trauma. When the abdominal trauma is not evident clinically and remains occult, the child's condition can rapidly deteriorate before the diagnosis is made, and delay may occur in the activation of child protective services. The use of markers for abdominal trauma in the evaluation of cases of child physical abuse was examined. Children younger than 12 years presenting to the Emergency Department at the Children's Hospital of Buffalo from August 1989 through April 1990 for the evaluation of suspected physical abuse were prospectively entered in the project. All patients had a complete history and physical examination performed. Those patients who did not show any signs of abdominal injury had the following laboratory tests done: (1) levels of liver transaminases, lactate dehydrogenase, and alkaline phosphatase; (2) amylase level; and (3) uranlysis. Of 49 patients without clinical signs of abdominal trauma, 4 children had elevated transaminase levels. Three of these 4 patients had liver lacerations documented by subsequent abdominal computed tomographic scans. A new finding of transaminase levels as markers of occult liver injury in children suffering physical abuse is reported.
Estimating Infant Mortality From Human Immunodeficiency Virus and Other Causes in Breast-Feeding and Bottle-Feeding Populations
Authors: Lederman Sally Ann
Published: December 2021

This paper discusses the literature dealing with breast-feeding in women with human immunodeficiency virus (HIV) infection. This review is used to develop a background for a quantitative assessment of factors determining whether breast-feeding or bottle-feeding will result in a lower overall mortality in areas of different HIV prevalence. An algebraic formula is presented that enables calculation of the mortality that would result in any population if the following variables are known or capable of estimation: portion of child-bearing women infected with HIV, portion of newborns infected with HIV at birth, relative mortality of breast-fed and bottle-fed infants that are not HIV infected, and transmissibility of HIV during breast-feeding. The information available for estimating these variables is incomplete. Nevertheless, boundaries can be set for each variable, based on information obtained locally or from the literature, to aid in objective evaluation of the risks of promoting bottle-feeding or breast-feeding in populations with different risk characteristics. Consideration of these factors indicates that the benefits of breast-feeding over bottle-feeding can substantially outweigh any putative risk of HIV transmission during breast-feeding unless the prevalence of HIV infection is quite high or the difference in mortality of breast-fed and bottle-fed infants is very low.
Thymic Abnormalities in Fetuses Aborted From Human Immunodeficiency Virus Type 1 Seropositive Women
Authors: Papiernik Martine , Brossard Yves , Mulliez Nicole , Roume Joelle , Brechot Christian , Barin Francis , Goudeau Alain , Bach Jean-François , Griscelli Claude , Henrion Roger , Vazeux Rosemay
Published: December 2021

Pathological abnormalities of the thymus were found in 3 of 37 fetuses aborted from human immunodeficiency virus (HIV)-infected mothers. These lesions were located predominantly in the thymic cortex, which contains mostly immature lymphocytes. Areas of focal lymphocyte depletion were infiltrated with CD4+ macrophages and were associated with abnormalities of the epithelial stromal network. No evidence of extensive HIV infection in any of the 37 thymuses was detected by either immunofluorescence or in situ hybridization techniques, although rare cells that expressed HIV antigens were found in 3 fetuses. Although less extensive, this thymic fetopathy was similar to that described in postnatal acquired immunodeficiency syndrome thymuses, strongly suggesting that the lesions were related to HIV infection. Thymic fetopathy might represent the initial injury to the lymphoid system in HIV-infected infants in whom early and severe immunosuppression develops.
Prospective Randomized Double-Blind Study Comparing l-Epinephrine and Racemic Epinephrine Aerosols in the Treatment of Laryngotracheitis (Croup)
Authors: Waisman Yeheskel , Klein Bruce L. , Boenning Douglas A. , Young Grace M. , Chamberlain James M. , O'Donnell Regina , Ochsenschlager Daniel W.
Published: December 2021

Aerosolized racemic epinephrine, but not l-epinephrine, is commonly used in treating croup. The efficacy and adverse effects of nebulized racemic and l-epinephrine in the treatment of laryngotracheitis were compared. Children 6 months to 6 years of age with a croup score of 6 or above were assigned in a randomized double-blind fashion to receive either racemic (n = 16) or l-epinephrine (n = 15) aerosols. Croup score, heart rate, blood pressure, respiratory rate, fraction of inspired oxygen, and oxygen saturation were recorded before treatment and at 5, 15, 30, 60, 90, and 120 minutes after the aerosol. Patients in both groups showed significant transient reduction of the croup score and respiratory rate following the aerosol (P < .001), but there were no differences between treatment groups when croup score, heart rate, blood pressure, and respiratory rate were assessed over time. It is concluded that l-epinephrine is at least as effective as racemic epinephrine in the treatment of laryngotracheitis and does not carry the risk of additional adverse effects. l-Epinephrine is also more readily available worldwide, is less expensive, and can be recommended for this purpose.
Idiopathic Neonatal Hepatitis in One DNA Fingerprint Identical Twin
Authors: VAJRO PIETRO , FONTANELLA ANGIOLA , VUTTARIELLO EMILIA , DE VINCENZO ANNA , FORTUNATO GIULIANA
Published: December 2021

For the practicing pediatrician, the most commonly encountered causes of neonatal cholestasis are idiopathic neonatal hepatitis (INH) and extrahepatic biliary atresia (EHBA). However, despite extensive research, little improvement in our understanding of the etiology of INH and EHBA has occurred.1 It has been proposed that both of them may be part of a continuum of hepatobiliary disease caused by a common insult with a different predominant injury site.2 In this respect, it is interesting that, up to the present, several cases of discordance for EHBA in twins of various zygosity have been reported,3-8 whereas no data are available about either concordance or discordance for INH both in monozygotic and dizygotic twins.
Not All Severe Hyperglycemia Is Diabetes
Authors: BOULWARE SUSAN D. , TAMBORLANE WILLIAM V.
Published: December 2021

Severe hyperglycemia without ketosis at the clinical onset of insulin-dependent diabetes mellitus (IDDM) has been reported in children and adolescents.1 Non-diabetic children can develop modest hyperglycemia (usually in the range of 11 to 14 mmol/L (200 to 250 mg/dL)) without ketosis in response to physiologic stress such as trauma, burns, or sepsis,2,3 but severe hyperglycemia is seen rarely in this setting. We recently encountered the case of a 22-month-old infant with severe nonketotic hyperglycemic hyperosmolar syndrome due to gastroenteritis and dehydration who rapidly recovered and has had no subsequent evidence of diabetes mellitus.

CASE REPORT

A 22-month-old Hispanic male infant was brought to the Yale-New Haven Hospital Pediatric Emergency Room with a 48-hour history of fever, diarrhea (8 to 10 stools/day), and vomiting (approximately hourly for the previous 24 hours).
Magnetic Resonance Imaging Evaluation of Neonates With Retinal Hemorrhages
Authors: SMITH WILBUR L. , ALEXANDER RANDELL C. , JUDISCH G. FRANK , SATO YUTAKA , KAO SIMON C. S.
Published: December 2021

Retinal hemorrhages occur frequently in association with abusive head trauma.1 The injuries are venous

[See table in the PDF]

in origin and, as such, are similar to the retinal hemorrhages which frequently occur in full-term neonates after vaginal delivery. Because retinal hemorrhages in child abuse frequently are associated with intracranial bleeding, we questioned the possibility of a relationship between parturitional retinal hemorrhages and concurrent intracranial injuries.

To answer this question we designed a prospective study in which we performed magnetic resonance imaging on 10 randomly selected full-term neonates in whom the presence of retinal hemorrhages was confirmed on fundascopic examination by a pediatric ophthalmologist.
Pediatrician's Role in the Development and Implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP)
Authors:   Committee on Children With Disabilities
Published: December 2021

Approximately 10% of young persons between the ages of 6 and 17 years receive special education and related services.1 An additional 750 000 neonates each year may have or be at risk for having developmental disabilities.2 Therefore, pediatricians have many patients who have disabling conditions or are at risk for them.

Federal legislation requires each child identified as having a disability to have a written plan of service: an Individual Education Plan (IEP) for children aged 3 through 21 years or an Individual Family Service Plan (IFSP) for children aged birth through 2 years. The pediatrician is in a unique position to be involved in planning and providing care for both groups of children.

BACKGROUND

The Individual Education Plan

In 1975 Congress passed Public Law 94-142, the Education for All Handicapped Children Act, as an educational bill of rights to guarantee handicapped children a free and appropriate education. The law required that identification, diagnosis, education, and related services be provided for children 5 to 18 years of age. In 1977, the age range was extended to include children aged 3 to 21 years, with services for children aged 3 to 5 years remaining optional. Not only were these services to be provided, but states also were encouraged to seek out children who had not been served previously.

Conditions eligible under Public Law 94-142 include mental retardation, hearing deficiencies, speech and language impairments, specific learning disabilities, visual handicaps, emotional disturbances, orthopedic impairments, and a variety of other medical conditions categorized as "other health impaired."
Mental Retardation and ADHD!
Authors: VOIGT ROBERT G. , JOHNSON GRAEME H. , BROWN FRANK R.
Published: December 2021

To the Editor.—

This letter cautions the general practitioner about prescribing methylphenidate to children with mental retardation, despite the reported utility in nine patients.1 Methylphenidate is understood to be an effective medication for treatment of children who have attention-deficit hyperactivity disorder (ADHD), characterized by a developmentally inappropriate attention span, level of impulsiveness, and motor activity. For the general practitioner, ADHD typically is identified in children with normal neurodevelopment. Because children with mental retardation may have attention spans, impulse control, and activity levels inappropriate for their chronologic age, albeit appropriate for their underlying level of cognitive function, we are concerned about the general practitioner's ability to identify ADHD in children with mental retardation.
Varicella Vaccine Reflux
Authors: MANGANO MARK F.
Published: December 2021

To the Editor.—

I have just completed reading the article published in Pediatrics on the live, attenuated varicella vaccine (Varivax), written by the groups from Merck Sharp & Dohme and Biogen Incorporated.1 I was quite impressed with their clinical data concerning the relatively small number of acute side effects and the apparent immunogenicity of the vaccine. Although I'm sure that more studies are in progress, on the basis of the above data, one would think that United States licensure should be right around the corner.