bluuebunny/crossref_metadata_2025 huggingface dataset:
Play and Imitation Skills in the Diagnosis of Autism in Young Children
Authors: Stone Wendy L. , Lemanek Kathleen L. , Fishel Pamela T. , Fernandez Maria C. , Altemeier William A.
Published: December 2021

Play behaviors and motor imitation skills of 91 children between the ages of 3 and 6 years were investigated to determine their utility in distinguishing autism from mental retardation and other communication disorders. The performance of 22 autistic children was compared with that of 15 mentally retarded, 15 hearing-impaired, 19 language-impaired, and 20 nonhandicapped children. Play behaviors were assessed using structured observations of free-play activities, and imitation skills were measured using a set of 12 individually administered tasks. The autistic group spent less total time interacting with toys and using toys appropriately, engaged in fewer functional play acts, and obtained lower imitation scores compared with all other groups. Discriminant function analysis revealed that the latter three variables discriminated the autistic children from the nonautistic handicapped children, with motor imitation emerging as the most important differentiating measure. These results suggest that measuring play and imitation skills may be useful in the clinical diagnosis of autism.
Pediatric Cardiopulmonary Arrests in Rural Populations
Authors: Thompson Jeffrey E. , Bonner Bethann , Lower Gerald M.
Published: December 2021

We reviewed emergency department records that spanned a period of 5 years at seven rural hospitals to provide more specific data concerning pediatric resuscitation. The purpose was to plan better for preventive programs and to help rural health care providers prepare better for these difficult patients. Patients entered in the study had either cardiorespiratory arrest or respiratory arrest. Although the distribution by age was similar to studies from other areas, the outcome for cardiorespiratory arrests was as bad or worse (70 arrests with 3 survivors), and the outcome of respiratory arrests was as good or better (25 arrests with 21 survivors) as reported previously. Survival of arrest from trauma and accidents was markedly worse (16%) than survival from nontraumatic arrests (44%). The etiologies of the arrests were dominated by sudden infant death syndrome and pulmonary disease but with very few drownings or farmrelated fatalities. This study should encourage rural health care providers to increase efforts in specific areas of trauma and accident prevention. Also, respiratory illness needs to be monitored aggressively and respiratory arrests treated more effectively to avoid the much more consistently lethal cardiac arrests. In addition, more careful prospective study of these patients may be able to identify care patterns that can be improved to increase survival in these groups.
Escherichia coli Sepsis and Prolonged Hypophosphatemia Following Exertional Heat Stroke
Authors: KAY MARK A. , MCCABE EDWARD D. B.
Published: December 2021

Because of the increasing emphasis on physical activity, sports medicine represents a growing proportion of medical care. Climatic heat stress, including heat stroke, is of sufficient concern that its preventability has been addressed by the American Academy of Pediatrics.1 Although heat stroke is defined by the triad of hyperpyrexia, anhydrosis, and altered mental status, the clinical course of these patients may include multiple complications.2-8 In this article we describe a previously unrecognized etiologic relationship between two of these complications, which may permit early identification and prevention of life-threatening consequences to heat stroke.

Two cases of Gram-negative sepsis have been described in previously healthy young adults suffering from fatal exertional heat stroke.7,8
Diagnosis and Management of Psychogenic Stridor Caused by a Conversion Disorder
Authors: GEIST ROSE , TALLETT SUSAN E.
Published: December 2021

Psychogenic stridor, a recently reported cause of acute upper-airway obstruction, is also known as paradoxical vocal cord motion.1-3 Although reported to occur predominantly among young women,1,2 it has been recognized in both male adolescents and adults,3 as well as in older women.4,5 Several authors1,3,4,6 have associated psychogenic stridor with conversion disorder, but few have included a discussion of the diagnostic criteria or elaborated on the underlying mechanisms of the conversion process.

In the case of a female adolescent with a diagnosis of paradoxical vocal cord motion presented here, we have included a discussion of the diagnostic psychological criteria. We also present the combined psychophysiological approach we used to identify and release the underlying affect, which resulted in the complete, immediate, and to date, lasting remittance of our patient's symptoms.
Apparent Proteinuria as a Consequence of Sodium Bicarbonate Ingestion
Authors: WECHSLER DAN , IBSEN LAURA , FOSARELLI PATRICIA
Published: December 2021

An infant who is brought to an emergency department with vague symptoms poses a difficult problem for the pediatrician. The presence of specific findings on laboratory screening tests often helps to narrow the differential diagnosis, enabling appropriate treatment. Unexpected laboratory results, however, may lead the physician astray in making the correct diagnosis. It is important to interpret laboratory results within the context of the entire clinical picture and to keep in mind the limitations of certain of these tests. We report a case of apparent proteinuria in a 7-week-old infant caused by the addition of baking soda to his formula, and point out that careful history-taking may help to avoid an extensive diagnostic workup.
Another View of Cholesterol Screening
Authors: STAINES ANTHONY
Published: December 2021

To the Editor.—

Drs Garcia and Moodie, in their paper on "Routine Cholesterol Surveillance in Childhood," propose that "routine cholesterol screening in all children is appropriate,"1 and advise us that "current recommendations" (the American Academy of Pediatrics recommendations),2 could miss 50% of significantly hypercholesterolemic patients who are at risk for future premature ischemic heart disease. Is this a fair conclusion from their data?

For another pediatrician, the natural question is "Can I generalize from these results to the children whom I see?" The authors say that their study population was the first 6500 white, middle class children attending for well child visits, "randomly included."
Information on Nicotine Abuse
Authors: BERLIN CHESTON M.
Published: December 2021

In Reply.—

We appreciate the opportunity to respond to Dr Moore's letter and to add to the documentation of nicotine and its metabolite cotinine in the milk of nursing mothers who smoke. Luck and Nau1,2 have published a series of papers that demonstrate that infants of smoking mothers have measurable concentrations of both nicotine and cotinine in their serum and urine. Transfer of nicotine from maternal serum to milk is rapid (increase can be seen within minutes of a mother smoking a cigarette) and dose-dependent; the more cigarettes smoked per day, the higher the milk concentrations of nicotine and cotinine.2,3
NURSES' DUTIES ONE HUNDRED YEARS AGO
Authors: Marcuse Edgar K.
Published: December 2021

The following job description was given to floor nurses by a hospital in 1887:

In addition to caring for your fifty patients, each nurse will follow these regulations:

1. Daily sweep and mop the floors of your ward, dust the patient's furniture and window sills.

2. Maintain an even temperature in your ward by bringing a scuttle of coal for the day's business.

3. Light is important to observe the patient's condition. Therefore, each day fill kerosene lamps, clean chimneys and trim wicks. Wash the windows once a week.

4. The nurse's notes are important in aiding the physician's work. Make your pens carefully; you may whittle nibs to your individual taste.

5. Each nurse on day duty will report every day at 7 a.m. and leave at 8 p.m. except on the Sabbath on which day you will be off from 12 noon to 2 p.m.

6. Graduate nurses in good standing with the director of nurses will be given an evening off each week for courting purposes or two evenings a week if you go regularly to church.

7. Each nurse should lay aside from each pay day a goodly sum of her earning for her benefits during her declining years so that she will not become a burden. For example, if you earn $30 a month you should set aside $15.

8. Any nurse who smokes, uses liquor in any form, gets her hair done at a beauty shop, or frequents dance halls will give the director of nurses good reason to suspect her worth, intentions and integrity.
Urinary Tract Infections in Febrile Infants Younger Than 8 Weeks of Age
Authors: Crain Ellen F. , Gershel Jeffrey C.
Published: December 2021

In this prospective study of 442 infants younger than 8 weeks of age who attended a pediatric emergency department with temperature ≥100.6°F (38.1° C), urinary tract infections (UTIs) were found in 33 patients (7.5%), 2 of whom were bacteremic. Clinical and laboratory data were not helpful for identifying UTIs. Of the 33 patients with UTIs, 32 had urinalyses recorded; 16 were suggestive of a UTI (more than five white blood cells per high-power field or any bacteria present). Of the 16 infants with apparently normal urinalysis results, three had an emergency department diagnosis suggesting an alternative bacterial focus of infection. If the physician had decided on the basis of apparently normal urinalysis results to forgo obtaining a urine culture, more than half of the UTIs would have been missed. Bag-collected specimens were significantly more likely to yield indeterminate urine culture results than either catheter or suprapublic specimens. In addition, uncircumcised males were significantly more likely to have a UTI than circumcised boys. These results suggest that a suprapubic or catheter-obtained urine specimen for culture is a necessary part of the evaluation of all febrile infants younger than 8 weeks of age, regardless of the urinalysis findings or another focus of presumed bacterial infection.
The Potentially Suicidal Student in the School Setting
Authors:   Committee on School Health
Published: December 2021

Education about depression and identification and referral for treatment of the depressed or drug-abusing student are important strategies in reducing the tragedy of suicide among adolescents. Pediatricians should work with local school personnel toward the implementation of the suicide-reduction strategies identified in this statement. The American Academy of Pediatrics strongly recommends that prevention programs be built into the education system. To be successful, such programs must involve school personnel, community medical professionals, child psychiatrists, students, and parents.
Letter to the Editor
Authors: Paradise Jan E. , Rostain Anthony L. , Nathanson Madelaine
Published: December 2021

We appreciate Dr Fay's interest in our report. However, our data do not support his assertion that "incorrect" allegations of sexual abuse when parents dispute child custody or visitation are "exceedingly common." The outcome measure we assessed was not truth but rather substantiation of cases by a child protection agency. Other observers have found higher rates than we did of "fictitious" sexual abuse allegations; but, as we noted in our discussion, bias in their selection of cases limits the generalizability of their findings.
Confounders Are Always a Problem
Authors: Brunskill Andrew J.
Published: December 2021

Readers who were intrigued by the surprisingly general beneficial effects of measles vaccine reported by Holt et al1 may be interested to know that a precedent exists for such a finding. A series of articles by Black, Fox, Elveback, and co-workers2-6 deserve greater attention. In three independent and classic studies, they documented that preschool children with a history of measles infection had lower cognitive test scores than measles-susceptible children. This effect occurred despite use of approximately six covariates for adjustment.
Umbilical Venous Catheter vs Umbilical Artery Catheter
Authors: Kitterman Joseph A.
Published: December 2021

In their commentary,1 Drs Dudell, Cornish, and Bartlett note that the measurement of mixed venous saturation (SVo2) is routine for infants receiving extracorporeal membrane oxygenation; in such infants, SVo2 can be measured easily without further invasive procedures. The authors recommend that clinicians use SVo2 measurements "more routinely" in other sick newborn infants and state that the measurement can be made with "relative ease" by inserting an umbilical venous catheter into the right atrium. This recommendation raises some concerns:
Letter to the Editor
Authors: Cornish J. Devn , Dudell Golde G.
Published: December 2021

The concerns raised by Dr Kitterman regarding potential inaccuracies of and risks related to umbilical venous catheterization are true and well stated. Indeed, the authors have great respect for the points he makes.

Nonetheless, it is still the case that arterial oxygen tension is an indirect and a potentially misleading indicator of the adequacy of oxygenation in newborn patients. Although the placement of such catheters is associated with significant risks, these risks are at most comparable to and may in fact be significantly less than those associated with umbilical artery catheterization.
Nebulized Albuterol in Acute Childhood Asthma: Comparison of Two Doses
Authors: Schuh Suzanne , Reider Michael J. , Canny Gerald , Pender Emily , Forbes Thomas , Tan Yok K. , Bailey David , Levison Henry
Published: December 2021

Thirty-three children and adolescents from 5 to 17 years of age with moderate to severe acute asthma were given nebulized albuterol therapy in either a high (0.30 mg/kg body weight) or standard (0.15 mg/kg) dose administered at three hourly intervals in a randomized double-blind study. The high-dose hourly regimen resulted in significantly greater improvement in the forced expiratory volume in 1 second (FEV1). Furthermore, patients receiving the high dose showed a steady improvement in the FEV1 from the start to the end of the study, whereas FEV1 plateaued after the second dose in the standard-dose group. Although a rise in heart rate and a fall in serum potassium level occurred, neither of these changes nor other side effects were different in the two groups. The high-dose therapy resulted in much higher serum albuterol levels than the standard dose. There was no correlation between the drug levels and side effects or initial and subsequent FEV1. It is concluded that occasional hourly high-dose albuterol therapy should be considered for some pediatric patients with acute asthma of moderate severity, especially those who relapse between doses.
Intake and Food Sources of Dietary Fat Among Schoolchildren in The Woodlands, Texas
Authors: McPherson R. Sue , Nichaman Milton Z. , Kohl Harold W. , Reed Debra B. , Labarthe Darwin R.
Published: December 2021

To investigate the nutrient intake and food use patterns among schoolchildren, diet was assessed among 138 children and adolescents in grades 5 through 12 using three random, nonconsecutive, 1-day food records. Mean intake of total fat, saturated fat, and polyunsaturated fat as percent of calories was 35.6%, 13.4%, and 6.6%, respectively. Among all subjects, 17% consumed diets containing <30% of calories from fat, 34% consumed3≥8% of calories from fat, 7% consumed <10% of calories from saturated fatty acids, and >97% ate <300 mg of cholesterol per day. While intake of calories, sodium, and β-carotene per 1000 kcal was higher in subjects consuming higher fat diets, intake of other micronutrients was either higher among those eating low-fat diets or did not differ by level of fat intake. Differences were seen in the amount of saturated fat and cholesterol that individual food sources contributed to the diets of subjects eating high and low fat diets. These cross-sectional data show that a substantial proportion of children and adolescents in this population are consuming diets low in fat and cholesterol without systematic differences in intake of other nutrients, suggesting that current dietary guidelines regarding fat intake are attainable within the current food use pattern of healthy, school-aged children and adolescents.
Chronic Fetal Hypoxia and Sudden Infant Death Syndrome: Interaction Between Maternal Smoking and Low Hematocrit During Pregnancy
Authors: Bulterys Marc G. , Greenland Sander , Kraus Jess F.
Published: December 2021

To investigate the hypothesis that chronic fetal hypoxia contributes to the etiology of sudden infant death syndrome (SIDS), a possible interaction between the effect of maternal cigarette smoking and low hematocrit during pregnancy on the risk of SIDS was studied using the US Collaborative Perinatal Project cohort. The 193 SIDS cases identified in the cohort were analyzed with 1930 controls randomly selected from infants who survived the first year of life. After adjustment for maternal age, infants born to mothers who smoked 10 or more cigarettes per day and who were anemic (hematocrit less than 30%) during pregnancy were at a much higher risk of SIDS than infants born to mothers who did not smoke and were not anemic (odds ratio = 4.0; 95% confidence limits, 2.1 and 7.4). Smoking 10 or more cigarettes per day vs none increased the risk of SIDS by 70% among women with hematocrit at or above 30% but increased risk threefold among women with hematocrit below 30%. After adjustment for more potential confounders in a logistic regression model, the effect of smoking on SIDS continued to increase with lower levels of hematocrit during pregnancy. Birth weight accounted for very little of these associations. Low hematocrit was not a risk factor for SIDS among nonsmokers but became an important predictor among heavy smokers. These findings are in agreement with the hypothesis that chronic fetal hypoxia may predispose to SIDS, possibly by impairing the normal development of the fetal central nervous system.
Open Lung Biopsy in the Critically III Newborn
Authors: Cheu Henry W. , Lally Kevin P. , Clark Reese , Harrell Susan , Null Donald
Published: December 2021

Experience with 17 open lung biopsies in critically ill premature neonates was reviewed. Despite their small size, prematurity, and near maximal ventilator requirements, the infants suffered no significant complications. In three cases, an infectious agent was identified. In one case end-stage lung fibrosis associated with persistent (>3 months), severe respiratory failure prompted termination of support. In the remainder of the cases, definitively ruling out infection allowed the confident trial of a course of steroids in an attempt to treat bronchopulmonary dysplasia. Unlike older patients, the definitive diagnosis of no infection in the premature neonate is just as informative as the diagnosis of an infection. Used judiciously, open lung biopsy can be performed in the premature infant with acceptable morbidity and mortality.
Outcome and Predictors of Outcome in Pediatric Submersion Victims Receiving Prehospital Care in King County, Washington
Authors: Quan Linda , Wentz Kim R. , Gore Edmond J. , Copass Michael K.
Published: December 2021

Predictors of outcome in pediatric submersion victims treated by Seattle and King County's prehospital emergency services were studied. Victims less than 20 years old were identified from hospital admissions and paramedic and medical examiners' reports. The proportion of fatal or severe outcomes in patients were compared with various risk factors. Of 135 patients, 45 died and 5 had severe neurologic impairment. A subset of 38 victims found in cardiopulmonary arrest had a 32% survival rate, with 67% of survivors unimpaired or only mildly impaired. The two risk factors that occurred most commonly in victims who died or were severely impaired were submersion duration greater than 9 minutes (28 patients) and cardiopulmonary resuscitation duration longer than 25 minutes (20 patients). Both factors were ascertained in the prehospital phase of care. Submersion duration was associated with a steadily increasing risk of severe or fatal outcomes: 10% risk (7/67) for 0 to 5 minutes, 56% risk (5/9) for 6 to 9 minutes, 88% risk (21/25) for 10 to 25 minutes, 100% risk (4/4) for >25 minutes. None of 20 children receiving >25 minutes of cardiopulmonary resuscitation escaped death or severe neurologic impairment. Our rates for saving all victims, particularly victims in cardiopulmonary arrest, are considerably higher than has been reported before for children. Prompt prehospital advanced cardiac life support is the most effective means of medical intervention for the pediatric submersion victim. Prehospital information provided the most valuable predictors of outcome.
Successful Renal Transplantation Accelerates Development in Young Uremic Children
Authors: Davis Ira D. , Chang Pi-Nian , Nevins Thomas E.
Published: December 2021

To examine the impact of renal transplantation on subsequent development of children with chronic renal failure, 37 children undergoing primary renal transplantation at or before 30 months of age whose allograft functioned for at least 1 year were prospectively studied. Psychometric tests were performed an average of 4 months before transplantation; reevaluation was done an average of 14 months after surgery. Comparison of individual pretransplantation and posttransplantation mental development scores in 33 patients, assessed by either Bayley Mental Development Index or Stanford-Binet Intelligence Quotient, revealed an average increase of 12.6 (P < .001). After transplantation, there was a significant improvement in mental performance in 12 of 18 patients (P < .02) from the range of mild delay (Mental Development Index or Stanford-Binet IQ score = 50 to 69) to the range of normal mental development (70). The Bayley Psychomotor Development Index scores were frequently lower than Mental Development Index scores and also increased an average of 14.4 (P < .01) after transplantation in all 12 patients with paired data. Significant individual improvement in occipital-frontal circumference standard deviation score (P < .001) was noted in 24 children after transplantation. It is concluded that successful renal transplantation in young children with chronic renal failure is often associated with significant improvements in cognitive and psychomotor function, as well as improved cephalic growth.
Exposure to a Chloride-Deficient Formula During Infancy: Outcome at Ages 9 and 10 Years
Authors: Malloy Michael H. , Willoughby Anne , Graubard Barry , Lynch Judy , McCarthy Mary , Moss Howard , Vietze Peter , Rhoads George , Berendes Heinz
Published: December 2021

A school-based survey of the 1978 to 1979 birth cohort of two metropolitan Washington, DC, counties was conducted to find children who had been exposed to the chloride-deficient formulas Neo-Mull-Soy and Cho-Free during infancy. Children who had ingested other soy formulas that had an adequate chloride content were also found and matched to the exposed children by sex, race, birth weight, the age of the child, the mixed feeding status of the child, and maternal education. One hundred seventy-one of the exposed children and 261 soy control children were given a battery of psychologic tests in their homes to determine whether there had been any effect on intellectual development as a result of exposure to the chloride-deficient formulas. There were no differences in scores between the groups on the Wechsler Intelligence Scale for Children-Revised, the Boston Naming Test, the Rey-Osterrieth Test, or the FAS Verbal Fluency Test. There was no correlation between duration of exclusive exposure to the chloride-deficient formulas and the Wechsler Intelligence Scale for Children-Revised Full-Scale IQ Score (Pearson product-moment r = -.0825, P = .28). These results cannot be extrapolated to exposed children with documented hypochloremic metabolic alkalosis. It is concluded that in children without documented evidence of hypochloremic metabolic alkalosis, exposure to the chloride-deficient formulas Neo-Mull-Soy or Cho-Free during infancy has not resulted in any long-term adverse effects on cognitive development.
Febrile Status Epilepticus
Authors: Maytal Joseph , Shinnar Shlomo
Published: December 2021

As part of a study of status epilepticus in children (Maytal J, Shinnar S, Moshe SL, Alvarez LA. Pediatrics. 1989;83:323-331); 44 children with febrile convulsions lasting more than 30 minutes were followed for a mean of 28 months (range 4 to 72). Thirty children were followed prospectively. Children with prior afebrile seizures or evidence of acute central nervous system infection were excluded. Nine (20%) children had prior neurological deficits. The duration of the febrile seizure was 0.5 to 1 hour in 41 cases (85%), 1 to 2 hours in 5 (10%), and greater than 2 hours in 2 children (5%). No child died or developed new neurological deficits following the seizures. The risk of recurrent seizures was increased, but only in the group with prior neurological abnormality. Six (66%) of these children had subsequent febrile seizures compared with 12 (34%) of the normal children (P = .08). Three (33%) had recurrent febrile status epilepticus compared with only 1 (3%) normal child (P = .023). The 2 children in the prospective arm of the study with recurrent febrile status epilepticus were both neurologically abnormal (P = .035). All 3 of the children who subsequently had afebrile seizures (2 prospective) were neurologically abnormal (P = .006 overall, P = .035 for prospective only). It is concluded that the occurrence of febrile status epilepticus in a neurologically impaired child is a risk factor for subsequent febrile as well as afebrile seizures. The occurrence of febrile status epilepticus in an otherwise normal child does not significantly increase the risk for subsequent febrile (brief or prolonged) or afebrile seizures in the first few years following the episode.
Lactose-Reduced Formulas for the Treatment of Persistent Diarrhea
Authors: Caballero Benjamin , Solomons Noel W.
Published: December 2021

To the Editor.—

Intestinal lactase activity in childhood can be reduced transiently by several diseases. In developing countries, the most common of these diseases are protein-energy malnutrition and persistent diarrhea. Under these conditions, the use of microbial β-galactosidase for predigestion of dietary lactose is being used as a means of reducing lactose intake while maintaining the quality of the therapeutic diets.

In a report by Penny et al,1 the effects of intact and lactose-hydrolyzed formulas on stool output and nutrient absorption in 63 Peruvian children with >4 days of postenteritis diarrhea were compared.
Sex-Specific Dysanapsis and the Effect of Passive Smoking Among Asthmatics
Authors: Kauffmann Francine
Published: December 2021

To the Editor.—

From a study conducted on 415 asthmatic children aged 1 to 17 years, Murray and Morrison1 observed a greater effect of passive smoking on lung function in boys than in girls and in older than in younger children. They interpret their findings by the cumulative effect of maternal smoking and the known susceptibility of boys to asthma. Different growth patterns between boys and girls may be an additional hypothesis to explain their observations.
Neonatal Choreoathetosis Following Prenatal Exposure to Oral Contraceptives
Authors: Profumo Robert , Toce Suzanne , Kotagal Suresh
Published: December 2021

To the Editor.—

This report describes a hitherto unrecognized complication of neonatal choreoathetosis following accidental use of oral contraceptives by the mother during most of pregnancy.

A 10-day-old infant was examined for feeding difficulties. The 28-year-old gravida 2, para 2 mother was unaware of the pregnancy until its 30th week and took Ortho-Novum 10/11-28 (containing 0.5 mg of norethindrone and 0.035 mg of ethinyl estradiol) continuously until then. She denied drug abuse. The infant was born at 36 weeks gestation following a normal delivery with a birth weight of 2470 g and Apgar scores of 5 and 7 at 1 and 5 minutes, respectively.
Retinal Hemorrhage After Cardiopulmonary Resuscitatíon
Authors: Hertle Richard W. , Quinn Graham E. , Duhaime Ann-Christine
Published: December 2021

To the Editor.—

We read with interest the report of Drs Goetting and Sowa on "Retinal Hemorrhage After Cardiopulmonary Resuscitation in Children: An Etiologic Reevaluation." The authors have provided valuable insight into the etiology and incidence of retinal hemorrhages after resuscitative efforts. This is an important observation, because some authors and clinicians equate the presence of retinal hemorrhages with child abuse.1-3,5 However, we feel that the 10% (2 of 20) incidence of retinal hemorrhages in their study population may be an underestimate due to a technical difficulty.
Retinal Hemorrhage After Cardiopulmonary Resuscitatíon
Authors: Goetting Mark G.
Published: December 2021

In Reply.—

Doctor Hertle and associates raise an important point regarding the incidence of retinal hemorrhages after cardiopulmonary resuscitation. It seems likely that the true incidence of retinal hemorrhages may be higher than we reported, because our method of detection is less sensitive than indirect ophthalmoscopy. However, there is a good reason for using direct ophthalmoscopy, because this is the method by which most clinicians would detect retinal hemorrhage. The purpose of our paper was to demonstrate that these hemorrhages can occur following cardiopulmonary resuscitation and are not necessarily due to preceding trauma.
Aluminum and Infants
Authors: Goyens Philippe , Brasseur Daniel
Published: December 2021

To the Editor.—

Litov and co-workers1 address an important question regarding aluminum loading in infants. Aluminum is a toxic element. Its retention results in an increase in the body burden of aluminum. This has been shown to be a health hazard in patients with compromised kidney function and in those receiving total parenteral nutrition.

The aluminum content of soy-based infant formulas is known to be high.2 The authors report their finding of normal plasma aluminum levels in infants fed a soybased formula during the first 3 months of life, and they suggest that the ingestion of "amounts of aluminum severalfold greater than that found in human milk" is of no clinical relevance.
Hair Dryer Burns in Children
Authors: Prescott Paul R.
Published: December 2021

Three children with burn injuries caused by home hair dryers are described. In one patient the injury was believed to be accidental, and in the other two cases the injuries were deliberately caused by a caretaker. The lack of prior experience with hair dryer burns initially led to suspicion of other causes. The characteristics of each case aided in the final determination of accidental vs nonaccidental injury. These cases prompted testing of home hair dryers to determine their heat output. At the highest heat settings, the dryers rapidly generated temperatures in excess of 110°C. After the dryers were turned off, the protective grills maintained sufficient temperatures to cause full-thickness burns for up to 2 minutes. These cases and the results of testing demonstrate that hair dryers must be added to the list of known causes of accidental and nonaccidental burns in children.
Birth Interval Among Breast-Feeding Women Not Using Contraceptives
Authors: Rosner Audrey E. , Schulman Susan K.
Published: December 2021

One hundred twelve Orthodox Jewish mothers were surveyed by means of questionnaire about birth interval in relationship to formula-feeding (n = 30) and breast-feeding (n = 236) experiences in the absence of birth control. Analyses indicate that mothers who breast-fed have longer birth intervals than those who did not. Moreover, data obtained from the same mothers show that birth intervals preceded by breast-feeding were longer than those preceded by formula-feeding of the previous infant. For those mothers who breast-fed, there was significant positive correlation between duration of breast-feeding and the length of lactational amenorrhea and total birth interval. The age at which night feeding was terminated had corresponding but less strong associations with lactational amenorrhea and total birth interval.
Screening for Neuroblastoma in Infants: Investigate or Implement?
Authors: TUCHMAN MENDEL , LEMIEUX BERNARD , WOODS WILLIAM G.
Published: December 2021

The debate about whether to implement screening for neuroblastoma in North America is ongoing. Those in favor of implementing mass screening are quoting results from programs in Japan where the government has mandated neuroblastoma screening for infants.1-7 In North America, the Quebec Neuroblastoma Screening Study (QNS) has been established as a result of the collaboration between the Quebec Network for Genetic Medicine and the University of Minnesota. This controlled research project is studying the impact of screening infants for the preclinical detection of neuroblastoma on changes in population-based mortality caused by this tumor as well as on various biologic parameters and their relation to prognosis.8
Risks in Distance Running for Children
Authors:   Committee on Sports Medicine
Published: December 2021

In recent years, there has been a surge in the participation of children in distance running. It is not unusual for an aspiring prepubescent athlete to run 10 to 15 miles daily and to participate in distance races, including marathons (26.2 miles).

Although running is a natural activity that can maintain and improve aerobic fitness, racing and particularly training for long distances have their risks. Distance running may induce musculoskeletal, endocrine, hematologic, thermoregulatory, and psychosocial damage. Most reports on such potential damage have not been evaluated with proper epidemiologic scrutiny. It is unknown whether the risk is greater for children than for adults. Nevertheless, the American Academy of Pediatrics wishes to alert the physician to the presence of such risks. Even without established guidelines and extensive documentation, physicians can give children, parents, and coaches advice that fosters healthy physical and psychosocial growth.

The most common musculoskeletal problems in the young runner are overuse injuries (ie, those that result from a mechanical stress repeated during a long period). These include epiphyseal plate injuries, stress fractures, patellofemoral syndrome, and chronic tendonitis.1-4 The incidence of such injuries seems to be related to the total distance covered in training and competition.4 Such overuse injuries may lead to a chronic disability (eg, chronic arthritis and growth deformity). Therefore, early medical intervention is important.

Female distance runners often experience delayed menarche.5 Its etiology and relevance to health have yet to be established. In most cases, menarche will occur several months after cessation or reduction in volume of training.
Sports Deficit Disorder
Authors: CROOK WILLIAM G.
Published: December 2021

To the Editor.—

The commentary by Burke and McGee, "Sports Deficit Disorder," prompts me to write. These pediatricians said, "Once these children and their parents understand that it is not the child's fault that he is athletically inept, but rather that he suffers from a definite disease, then we feel that progress can be made to restore the child's damaged self-image."

Although they wrote their delightful commentary "tongue-in-cheek," in my opinion, labeling other children with the diagnosis of "attention deficit disorder" and prescribing Ritalin may also need to be ridiculed.
Sports Deficit Disorder
Authors: FISCHER HOWARD
Published: December 2021

To the Editor.—

At last, a diagnosis! I am a 42-year-old pediatrician, and I believe I have Sports Deficit Disorder with Hypoactivity (SDDH), residual type. The McGee-Burke criteria are easily fulfilled by my childhood sports history. As an adult, my indifference to sports is so great that colleagues ask me if I was born in this country. Whenever I feel the urge to exercise, I lie down until it passes. Last year I was heard asking my 9-year-old daughter what teams were playing in the World Series.
Pediatric Emergencies
Authors: DIBONA FRANCIS J.
Published: December 2021

To the Editor.—

I read with interest the article "Pediatric Emergencies" in the May 1990 issue of Pediatrics in Review.1

I wonder why the levels described in the article are the reverse of those commonly used. When we talk about level III in newborn intensive care units, we are talking about the highest level, and level I refers to the lowest level. Would it not make more sense to insist on a uniformity in these levels?
INTRODUCTION
Authors: SCHECHTER NEIL L. , ALTMAN ARNOLD J. , WEISMAN STEVEN J.
Published: December 2021

Inadequate management of pain is a significant problem in all aspects of pediatric care. In every clinical situation which has been studied, children's pain receives far less attention than that of adults.1 Nowhere is this situation more unfortunate, however, er, than in the management of pain associated with childhood cancer. Poorly controlled cancer pain validates the worst fears of parents and children that cancer is accompanied by inevitable and excruciating pain. Inadequate control of the pain associated with diagnostic procedures creates an anticipatory dread in the child of the next procedure and colors his or her attitudes toward the hospital and the staff providing care.

This unfortunate situation has arisen partly because physicians dealing with these most devastatating of childhood diseases have not had easy access to information on the control of this most feared symptom. The complexities associated with research in childhood pain (in general, difficulties of assessment and ethical constraints) have been compounded by the relative rarity of childhood cancer and have resulted in limited research activity or interest in the management of cancer pain in children. The available research is often published in journals not generally read by those who care for children with cancer. Major pediatric texts contain virtually no information on the management of the pain associated with childhood cancer.2 The limitations of the available literature have allowed the development of few guidelines within institutions and virtually none across institutions (Hickman et al. 1988. Unpublished manuscript). As a result, the relative importance of adequate management of pain as well as specific treatment regimens are left to the discretion of the individual pediatric providers, most of whom have minimal training in this area.
Report of the Subcommittee on the Management of Pain Associated With Procedures in Children with Cancer
Authors: Zeltzer L. K. , Altman A. , Cohen D. , LeBaron S. , Munuksela E. L. , Schechter N. L.
Published: December 2021

The ideal goal of pain management for pediatric procedures is to make the procedure comfortable for the child and his or her parents. Success will be manifested by the child who is not afraid of subsequent procedures and not merely by a child who can be held still for procedures. This goal is often difficult to achieve entirely, but at least an attempt to achieve it should be considered as evidence for an adequate standard of care. The orientation of this section will be a developmental one, with specific recommendations for five age categories: 0 to 6 months of age, 6 months to 2 years of age, 2 to 5 years of age, 5 to 12 years of age, ≥12 years of age. Initially, we discuss general principles of pain management (Table 5). The painful procedures include bone marrow aspiration and biopsy (Table 6); lumbar puncture (Table 7); and needle sticks including intravenous and intramuscular injection, phlebotomy, finger sticks, heel lances, and suturing (Table 8). Nonpainful radiographic diagnostic and therapeutic procedures that require patient cooperation in remaining still (eg, computed tomographic scan, magnetic resonance imaging, radiation therapy) are also discussed (Table 9).

GENERAL PRINCIPLES OF MANAGEMENT

There are several principles of management that are applicable for all age groups and procedures. These points need to be highlighted because pediatric procedures currently are not being managed in an organized fashion at many hospitals and oncology units. In a survey of the major pediatric oncology centers, more than 75% of the centers had no defined protocol for procedures of pain management (Hickman et al. 1988.
Blood Pressure and Intraventricular Hemorrhage in Premature Infants
Authors: PERRY EDWARD H. , BADA HENRIETTA S. , DAY JOHN D. , KORONES SHELDON B. , ARHEART KRISTOPHER L. , MAGILL HUBERT L.
Published: December 2021

In Reply.—

We appreciate the interest and comments of Drs Puccio and Soliani regarding our article "Blood Pressure Increase, Birth Weight Dependent Stability Boundary and Intraventricular Hemorrhage."1 In response, we address the following points:

1. Although mean blood pressure (BP) values greater than 100 mm Hg were observed in some of our patients, these were quite rare. The mean BP was found to be less than 60 mm Hg 99% of the time. Thus, unless one is recording BPs through long periods and sampling quite often, the brief spikes likely would not be observed.
Children in the Norwegian Health Care System
Authors: Lie Sverre O.
Published: December 2021

Norway is a large, sparsely populated country with a long tradition of socialized health care. The health status of Norwegians is good, with life expectancy among the highest in Europe. Indicators of infant health are also good, although not among the best. Health services in Norway are in principle free of charge to all citizens, and the current health expenditure is about 6.8% of the Gross National Product. Preventive and curative pediatric services account for only 3% of this total. The structure of Norwegian health and social services is presented in this discussion, both in general terms and with particular attention to services for children.
Immunization Coverage Among Preschool Children: The United States and Selected European Countries
Authors: Williams Bret C.
Published: December 2021

In spite of difficulty measuring the effects of varying national immunization coverage rates, attaining high levels of immunization is a high priority for all countries. In addition, immunization rates among preschool children serve as a useful index of overall well child and preventive care. International comparisons reveal relatively low rates among all US children, especially minorities, attributable in part to poor utilization of routine preventive services. In the absence of a national initiative, various attempts to improve performance at local and state levels deserve attention. Renewed monitoring of immunization rates among preschool children in the United States is essential to assess current programs and future efforts.
Little Help from Article on Anaboiic Steroids
Authors: LEVINE RICK
Published: December 2021

To the Editor.—

As a high school teacher I have been looking for guidance on preventing the abuse of anabolic steroids by our students. The article "Anabolic Steroid Use by Male Adolescents" by Johnson et al1 not only failed to provide this guidance, but the results failed to support the authors' conclusions.

The study shows that, of the teenage users of steroids surveyed, 38% correctly identified liver disease, 35% cancer of the liver, and 30% stunted growth as side effects of steroid use.
Little Help from Article on Anaboiic Steroids
Authors: JOHNSON MIMI D.
Published: December 2021

In Reply.—

Thank you for your letter regarding the article, "Anabolic Steroid Use by Male Adolescents," published in the June 1989 issue Pediatrics. I will attempt to address each of your concerns. The intent of the article was: (1) to inform health care providers about the prevalence of use of anabolic steroids in a population of 11th grade male students, (2) to increase provider awareness of the knowledge and some of the beliefs held by steroid users, and (3) to encourage providers to become knowledgeable about these drugs, so that they might be able to offer more appropriate guidance to the teenager in the clinical setting.
Ibuprofen for Fever
Authors: LORIN MARTIN I.
Published: December 2021

To the Editor.—

I am writing to voice concern about the use of ibuprofen for simple antipyresis in infants and young children. Although there have been enough data about the new liquid preparation to convince the Federal Drug Administration to release it, it must be recognized that the total number of infants and young children reported who have received this drug is far from massive. Recognition of aseptic meningitis as a complication of ibuprofen therapy1,2 and reports of metabolic acidosis as a complication of overdosage3 are both relatively recent events.
More on Sports Deficit Disorder
Authors: STIRLING JOHN
Published: December 2021

To the Editor.—

It was most enlightening to read the article on "Sports Deficit Disorder" in the June issue of Pediatrics.1 Drs Burke and McGee deserve credit for their pioneering work in describing this tragic and all-too-common condition. As it happens, we in the Northwest independently have recognized the need for such a diagnosis and for appropriate therapy. We must, however, take issue with several of the recommendations made in Burke and McGee's article.

First, the sobriquet "Sports Deficit Disorder," while sounding properly medical (vague, yet alliterative), is perhaps too vague, and it offers no suggestion as to therapy.
Stridor: Intracranial Pathology Causing Postextubation Vocal Cord Paralysis
Authors: Chaten Frank C. , Lucking Steven E. , Young Edwin S. , Mickell John J.
Published: December 2021

During an 18-month period in a pediatric intensive care unit, nine patients with vocal cord paralysis were identified using flexible bronchoscopy. When tracheally extubated, each child was found to have stridor. The children ranged in age from 17 days to 5½ years. Two patients had unilateral paralysis, but neither required tracheostomy. Seven patients displayed bilateral abductor vocal cord paralysis. Of these, six patients required tracheostomy. Surgical injury to the recurrent laryngeal nerve was the probable cause in two patients. The other seven patients had neurologic disorders with documented or suspected increases of intracranial pressure. Four of the seven patients with bilateral abductor vocal cord paralysis regained cord mobility within 4 months. Both children with unilateral cord paralysis have no stridor and vocalize well 1 year later. Cord paralysis in the setting of intracranial hypertension probably results from compression or ischemia of the vagus nerve before it exits the skull. Early visualization of the larynx should be done in patients who become stridulous when extubated, especially those with prior thoracic procedures or with neurologic disorders associated with intracranial hypertension.