bluuebunny/crossref_metadata_2025 huggingface dataset:
Freshwater Submersion Injuries in Children: A Retrospective Review of Seventy-Five Hospitalized Patients
Authors: Noonan Lindsay , Howrey Rick , Ginsburg Charles M.
Published: December 2021

Objective. To determine whether or not selected victims of submersion accidents can be safely managed as outpatients.

Design. Retrospective chart review.

Setting. Children's Medical Center of Dallas.

Patients. One hundred forty-eight charts reviewed, comprising all hospital admissions after submersion accidents from April 1987 to April 1994.

Results. Of the 148 patient charts that were reviewed, 73 patients were excluded from the study for the following criteria: endotracheal intubation before initial medical evaluation; transfer form an inpatient unit of another medical facility; history of preexisting neurologic, neurodevelopmental, and/or pulmonary disease. Of the 75 evaluable patients, 3 were directly admitted to the inpatient service with no documented initial medical evaluation reported in the medical record. Of the remaining 72 patients, 62 (86%) were symptomatic at the time of the initial medical evaluation in the emergency department; 10 patients (14%) were asymptomatic. Seventy percent of the initially asymptomatic patients and 57% of patients who were symptomatic at the time of initial medical evaluation were asymptomatic by 8 hours after the submersion event. By 18 hours postsubmersion, all patients who were initially asymptomatic and 72% of initially symptomatic patients were normal. Thirty-five percent and 80% of patients who had abnormal initial physical examinations and abnormal chest x-rays had a normal physical examination by 8 hours and 18 hours, respectively, and all remained normal.

Conclusions. Routine hospital admission of all children who have had immersion accidents is unnecessary.
Pain and Human Immunodeficiency Virus Infection in Children
Authors: Yaster Myron , Schechter Neil
Published: December 2021

There are remarkably few studies of the clinical presentation of pain syndromes and pain management in children infected with the human immunodeficiency virus (HIV). In a report that should serve as a clarion wake-up call to all physicians who treat HIV-infected children, Hirschfeld et al1 report in this issue of Pediatrics that the prevalence of pain in HIV-infected children approaches 60%.

As physicians, we have a fundamental obligation to manage pain and relieve patient suffering as a crucial element of our professional commitment to patient care.2,3 These are not merely lofty ideals; effective pain management produces myriad patient benefits, including reduced morbidity and mortality, early mobilization, and shortened hospital stays.4
Neonatal Group B Streptococcal Vertebral Osteomyelitis
Authors: Barton Leslie L. , Villar Rodrigo G. , Rice Sydney A.
Published: December 2021

Neonatal osteomyelitis is an uncommon entity with major involvement of lower- and upper-extremity long bones. Vertebral osteomyelitis represents only 1% to 2% of such cases1,2 and may pose a diagnostic conundrum, with disastrous consequences if diagnosis and therapy are delayed. We report a neonate with the unique association of vertebral osteomyelitis and group B streptococcal infection. The dual medical and surgical approach to this disease, necessary for successful outcome, is described.

CASE REPORT

A 1-month-old boy was admitted to the hospital for evaluation of a posterior thoracic mass. He was born to a 25-year-old gravida 2, para 2 woman after a full-term pregnancy.
Letter To The Editor
Authors: Jones Ros , Elbourne Diana
Published: December 2021

Our 3-year follow-up study1 was initiated for precisely the reasons cited by Frank and Lecuona (ie, to go beyond the neonatal period to assess the longer term effects of dexamethasone). This is particularly so in the stratum in which there was little neonatal benefit (ie, those infants not ventilator-dependent at the time of dexamethasone/placebo administration). But it is not true to say that there were no beneficial effects of dexamethasone; in the stratum of infants who were ventilator-dependent at trial entry, dexamethasone significantly reduced the length of time they spent on the ventilator, as well as suggesting a tendency to reduce the time spent on supplemental oxygen and in hospital.
Dear Colleague
Authors: Sahler O. J. , Couto Jim
Published: December 2021

The American Academy of Pediatrics Department of Education and the Division of Sections are pleased to present this supplement to PEDIATRICS. This is the first supplement devoted entirely to abstracts of presentations given at the Academy's Annual Meeting. It contains a vast array of subspecialty information in a structured abstract format, which will be indexed in the journal and be retrievable through all of the document delivery systems which feature PEDIATRICS. It will also be available on the yearly CD ROM update of PEDIATRICS. In addition this publication will serve as a guide and timetable for the Academy's Section programs which will be offered at the AAP 1996 Annual Meeting to be held October 25-30 in Boston. Please remember to bring this, your complimentary copy, to the meeting! A limited number of additional copies for your personal use or distribution to colleagues will be available at the meeting.

Sections are arranged alphabetically. A Section's educational schedule appears first, followed by the complete text of the abstracts. Abstracts are identified by a number that appears in the left column of the schedule; this same number will identify the expanded text. Abstracts are numbered consecutively within each Section. Please note that the Section on Allergy, Section on Emergency Medicine, and Section on Surgery have elected to print their schedule only.

A great deal of time and effort has been volunteered by Academy Section members to develop these programs and to write and coordinate the abstracts for this special supplement.

In particular, we would like to acknowledge the contributions of Kathleen Ozmeral (editor); Michael Welch, MD (Allergy); Derek Fyfe, MD (Cardiology); Mitch Feldman, MD (Computers and Other Technologies); Brahm Goldstein, MD (Critical Care); Milton Tenenbein, MD, and Jennifer Pratt Cheney, MD (Emergency Medicine), David Aronsson, MD, and Randall Loder, MD (Orthopaedics); William Engle, MD, and Tom Wiswell, MD (Perinatal Pediatrics); N.
Nicotine Patch Therapy in Adolescent Smokers
Authors: Smith Todd A. , House Roy F. , Croghan Ivana T. , Gauvin Thomas R. , Colligan Robert C. , Offord Kenneth P. , Gomez-Dahl Leigh C. , Hurt Richard D.
Published: December 2021

Objective. To evaluate the safety, tolerance, and efficacy of 24-hour nicotine patch therapy in adolescent smokers who were trying to stop smoking.

Design. Nonrandomized, open-label, 6-month clinical trial.

Setting. Five public high schools in the Rochester, MN, area.

Subjects. Twenty-two adolescent smokers, aged 13 through 17 years, with current smoking rate of 20 or more cigarettes per day (cpd).

Intervention. Daily nicotine patch therapy for 8 weeks (22 mg/d for 6 weeks followed by 11 mg/d for 2 weeks). Weekly individual behavioral counseling and group support continued for 8 weeks with follow up visits at 3 and 6 months and a mailed survey at 1 year.

Main Outcome Measures. Self-reported smoking abstinence verified by expired air carbon monoxide of 8 ppm or less, nicotine withdrawal symptoms, adverse experiences, and blood cotinine levels.

Results. Subjects had a mean ± SD smoking rate of 23.3 ± 5.0 (range, 20 to 35) cpd at study entry and 2.6 ± 1.6 years of smoking; the mean age was 15.9 ± 1.2 (range 13 through 17) years, and 68% were girls. Of the 22 participants, 19 (86%) completed patch therapy, 3 (14%) had biochemically validated smoking cessation at week 8, and 1 continued to be smoke free at 3 and 6 months after patch initiation. There was a significant decrease from baseline in the mean nicotine withdrawal scores for days 4 and 7 of week 1 and the mean for weeks 2 through 8. Skin reactions were the most common adverse event. As the worst skin reactions, 55% had erythema only, 5% had erythema and edema, and 9% had erythema and vesicles, whereas 32% had no skin reactions. Other reported adverse events were headaches (41%), nausea and vomiting (41%), tiredness (41%), dizziness (27%), and arm pain (23%). None of these were considered serious, life threatening, or led to the discontinuation of patch therapy. In adults with comparable smoking rates, we found that the adolescents had lower blood cotinine levels. Those smoking 20 to 25 cpd had cotinine levels of 146 ± 84 (adolescents) vs 260 ± 98 (adults) ng/ml, and those smoking 26 to 35 cpd had levels of 169 ± 73 vs 276 ± 110 ng/ml, respectively.

Conclusion. Nicotine patch therapy seems safe in adolescent smokers. Placebo-controlled trials are needed to establish the efficacy of nicotine patch therapy in adolescents.
Iodine, Thyroid Function, and Very Low Birth Weight Infants
Authors: Parravicini Elvira , Fontana Corinna , Paterlini Giuseppe L. , Tagliabue Paolo , Rovelli Franco , Leung Kenneth , Stark Raymond I.
Published: December 2021

Objective. Research was undertaken to test two hypotheses. First, during the early neonatal period, thyroid function of very low birth weight (VLBW) infants is suppressed by exposure to iodine-containing antiseptic solutions and/or iodized contrast media. Second, this suppression is more pronounced in small for gestational age (SGA) infants.

Methods. Urinary iodine concentration and thyroid function measurements were obtained prospectively from 44 VLBW infants with gestational ages at birth of 30 ± 2.3 weeks and weights of 1223 ± 231 g. Eleven of these infants were SGA. The infants were grouped according to iodine exposure: 18 infants had no increased exposure and served as control infants; 9 infants were exposed to an iodine-containing antiseptic (povidone iodine); 12 infants were exposed to an iodized contrast medium (iopamidol); and 5 infants were exposed to both agents. Urinary iodine and serum free triiodothyronine, free thyroxine, and thyrotropin were measured on days 1, 7, 14, 21, and 28 of life.

Results. During the period of maximum exposure (days 1 to 7), the concentration of iodine in the urine of study infants was 2 to 4 orders of magnitude greater than that in the urine of control infants (123 ± 141 µg/L). During the subsequent 3 weeks, levels of urinary iodine in study infants returned to levels that were not significantly different from controls. On day 7 of life, iodine-exposed infants had a significantly higher mean thyrotropin level than control infants, whereas on day 28, free triiodothyronine and thyroxine levels were lower. Of the 26 iodine-exposed infants, 6 had transient hyperthyrotropinemia and 2 had transient hypothyroidism. When exposed to iodine, SGA infants had more labile thyroid function than normally grown iodine-exposed or control infants. These SGA infants had significantly lower levels of thyroid hormones in umbilical cord blood, increased production of thyroid hormones on day 14 of life, and lower levels again at 1 month.

Conclusion. In VLBW infants, the use of iodine-containing antiseptic solutions and iodized contrast media results in massive uptake of iodine that is associated with alterations in thyroid function. It is reasonable to suggest that, whenever possible, iodized products should be avoided in VLBW infants, because their routine use results in exposure to excessive loads of iodine, which can be associated with hyperthyrotropinemia and hypothyroidism.
Methylphenidate Dosing: Twice Daily Versus Three Times Daily
Authors: Stein Mark A. , Blondis Thomas A. , Schnitzler Eugene R. , O'Brien Tara , Fishkin Julie , Blackwell Brad , Szumowski Emily , Roizen Nancy J.
Published: December 2021

Objective. To evaluate the short-term efficacy and side effects associated with two methylphenidate hydrochloride (MPH) dosing patterns.

Methods. Twenty-five boys with attention deficit hyperactivity disorder (ADHD) participated in a 5-week, triple-blind, placebo-controlled, crossover evaluation of MPH administered twice (b.i.d.) versus thrice (t.i.d.) per day (mean dose 8.8 ± 5 mg, .30 ± .1 mg/kg/dose). Four dosing conditions (placebo, titration [gradual increase to target dose], b.i.d., and t.i.d.) were used. Dependent measures obtained on a weekly basis included: parent and teacher ratings of child behavior, parent-child conflicts, parent report of stimulant side effects, child self-report of mood symptoms, a sleep log, laboratory measures of attention, and actigraphic recording of sleep activity.

Results. All dosing conditions resulted in significant effects on ADHD symptoms when compared with baseline. Relative to placebo, t.i.d. dosing was characterized by improvement on the greatest number of behavioral measures, and both b.i.d. and t.i.d. were generally more effective than titration. Direct comparisons of b.i.d. and t.i.d. dosing revealed that t.i.d. was associated with greater improvement on the Conners Parent Rating Scale Impulsivity/Hyperactivity factor, with a similar marginally significant effect for the ADD-H Teacher Rating Scale Hyperactivity factor. The analysis of clinically significant change favored a three-times-a-day dosing schedule over placebo on both parent and teacher ratings of impulsivity/hyperactivity and attention. Compared with placebo, appetite suppression was rated, on average, as more severe in the t.i.d. and titration conditions, but not in the b.i.d condition. However, the number of subjects who exhibited any or severe appetite suppression did not differ significantly between the b.i.d. and t.i.d. schedules. Although there was no difference in sleep duration for children on b.i.d. and t.i.d. schedules, total sleep time appeared to decrease slightly on t.i.d. relative to placebo according to both parent ratings and actigraphic assessment. There were no significant differences between b.i.d. and t.i.d. on any other side effects or sleep variables.

Conclusions. For many children with ADHD, t.i.d. dosing may be optimal. There are few differences in acute side effects between b.i.d and t.i.d. MPH dosing. The dosing schedule should be selected according to the severity and time course of ADHD symptoms rather than in anticipation of dosing schedule-related side effects.
What Clinicians Want to Know About Teaching Families New Disciplinary Tools
Authors: Wissow Lawrence S.
Published: December 2021

NOT ALL FAMILIES HAVE THE SAME EDUCATIONAL NEEDS

Dr Howard's paper points out that punishment (one way of decreasing undesired behaviors) is only part of a larger system for helping children develop adaptive interpersonal skills and culturally acceptable patterns of conduct. Parents also rely on promoting a close relationship with their child, reinforcing positive behaviors, and helping children learn a set of basic behavioral rules that are adaptable to changing situations. One of the things that we don't know about families using corporal punishment is the extent to which they lack skills in all of these areas or whether, at the risk of gross oversimplification, we would suggest that they change nothing except to replace one form of punishment (spanking) for another. In some families, corporal punishment occurs in the context of poor parent-child relationships and other forms of emotionally harsh punishment, and in other families it does not.1,2

WHAT ROLE DO PRIMARY CARE PROVIDERS HAVE IN PARENTING EDUCATION?

Dr Howard shows that a variety of behavioral interventions are available, that they have demonstrable effects, and that they work for a variety of populations. Most of the studies she described, however, would have to be classified as efficacy studies. We now know these interventions work in the hands of clinical psychologists in laboratory conditions with selected patients. What do we know about how to build these into routine pediatric practice, especially those that require several training sessions and specialized training materials?3 Research in adult mental health services suggests one direction to pursue—the development of novel collaborative arrangements between behavioral specialists and primary care providers.
The Ribavirin Debate
Authors: Granger Colin D.
Published: December 2021

The Committee on Infectious Diseases of the American Academy of Pediatrics, in its recent reassessment of the use of ribavirin (Virazole) in the treatment of respiratory syncytial virus (RSV) infections, raises questions regarding the evidence supporting the drug's clinical effectiveness.1

The clinical utility of ribavirin was well-documented and endorsed in the Committee's 1993 recommendations.2 In the current statement, however, the Committee has emphasized that individual practitioners are in the best position to determine the appropriate use of ribavirin, based on the particular clinical situation and their own preference.
Letter To The Editor
Authors: Kopjar Branko , Wickizer Thomas
Published: December 2021

We appreciate commendations and valuable comments brought by Battaglia and Kiser regarding our analysis of injuries occurring in day care center versus home environment. They suggest a possible alternative interpretation of the data we report in the paper. In particular, they note the possibility that differences in exposure-adjusted injury rates among children in home versus day-care settings may result from differences in the propensity of parents and day care staff to seek medical treatment for children with minor injuries.
Measles Vaccination During the Respiratory Virus Season and Risk of Vaccine Failure
Authors: Edmonson M. Bruce , Davis Jeffrey P. , Hopfensperger Daniel J. , Berg Jeffrey L. , Payton Leonard A.
Published: December 2021

Objective. To determine whether measles vaccine failure is more common in persons who were vaccinated during the respiratory virus season, when they were more likely to have had concurrent minor illnesses.

Design. Population-based case series and case-control study.

Setting. Wisconsin and Ohio.

Subjects. The case series included all 545 of the states' residents who had confirmed measles reported during 1985 through 1990 and a history of receiving a single dose of measles vaccine during 1975 through 1988 at 15 to 59 months of age. In a case-control study restricted to 1984 through 1988 vaccinees, season of vaccination was compared in 170 case children and 6070 control students.

Main Outcome Measure. Risk of clinical vaccine failure after measles vaccination during the respiratory virus season (September through May) or the peak season (November through March) compared with summertime (June through August), after adjustment for age at vaccination and place of residence.

Results. In the case series of persons with vaccine failure, the proportion who had been vaccinated during the respiratory virus season (74.7%) was no greater than expected (September through May = 74.8% of the year). In the case-control study, vaccination during the respiratory virus season (odds ratio, 0.92; 95% confidence interval, 0.66 to 1.30) or the peak season (odds ratio, 0.93) did not increase the risk of vaccine failure.

Conclusion. Despite the high and strongly seasonal prevalence of viral respiratory illness in young children, routine childhood measles vaccination during the respiratory virus season does not increase their risk of vaccine failure. Findings provide epidemiologic support for recently strengthened recommendations that measles vaccination not be deferred in children with minor respiratory illnesses.
Multiple Organ Failure After Ingestion of Pennyroyal Oil From Herbal Tea in Two Infants
Authors: Bakerink James A. , Gospe Sidney M. , Dimand Robert J. , Eldridge Marlowe W.
Published: December 2021

Background Hepatic and neurologic injury developed in two infants after ingestion of mint tea. Examination of the mint plants, from which the teas were brewed, indicated that they contained the toxic agent pennyroyal oil.

Methods. Sera from each infant were analyzed for the toxic constituents of pennyroyal oil, including pulegone and its metabolite menthofuran.

Results. Fulminant liver failure with cerebral edema and necrosis developed in the first infant, who died. This infant was positive only for menthofuran (10 ng/mL). In the other infant, who was positive for both pulegone (25 ng/mL) and menthofuran (41 ng/mL), hepatic dysfunction and a severe epileptic encephalopathy developed.

Conclusions. Pennyroyal oil is a highly toxic agent that may cause both hepatic and neurologic injury if ingested. A potential source of pennyroyal oil is certain mint teas mistakenly used as home remedies to treat minor ailments and colic in infants. Physicians should consider pennyroyal oil poisoning as a possible cause of hepatic and neurologic injury in infants, particularly if the infants may have been given home-brewed mint teas.
Policy Update: Medical Staff Appointment and Delineation of Pediatric Privileges in Hospitals
Authors:   Committee on Hospital Care
Published: December 2021

The review and verification of credentials and the granting of clinical privileges are required of every hospital to ensure that all members of its medical staff are competent and fully qualified to provide specified levels of patient care. The credentialing process involves: (1) a detailed assessment of the professional and personal backgrounds of each practitioner seeking privileges; (2) the assignment of privileges appropriate for the clinician's training and experience; (3) ongoing monitoring of the professional activities of each staff member through the hospital's quality assessment and performance programs; and (4) the penodic reappointment of the medical staff based on performance objectively measured by published standards.

Credentialing must be thorough, fair, timely, confidential, and clearly described in the medical staff bylaws. Criteria used for delineation of clinical pnivileges must be well defined, based on realistic national and local standards, regularly updated to reflect advances in medicine, and uniformly used for all applicants. The process should include reviews by peers and at least three of the following individuals or groups: department chairperson, department credentialing committee, hospital medical staff credentialing committee, medical staff executive committee, medical director, and the governing board of the hospital.

The statement examines, in depth, the essential elements of a credentials review for both initial and subsequent medical staff appointments along with suggested criteria for the delineation of clinical privileges in pediatrics. For ease of reference, credentialing checkoff lists and a sample form for the delineation of privileges are included. Because of the significant differences in individual hospitals (ie, size, services offered, location, population served, and organization of the medical staff) no one method of credentialing is universally applicable.
High-Frequency Jet Ventilation in the Early Management of Respiratory Distress Syndrome Is Associated With a Greater Risk for Adverse Outcomes
Authors: Wiswell Thomas E. , Graziani Leonard J. , Kornhauser Michael S. , Cullen James , Merton Daniel A. , McKee Linda , Spitzer Alan R.
Published: December 2021

Objective. The objective of this investigation was to determine if high-frequency jet ventilation (HFJV) used early in the treatment of premature infants with respiratory distress syndrome was effective in reducing pulmonary morbidity without increasing the occurrence of adverse neurologic outcomes.

Study Design. A total of 73 premature infants who met the inclusion criteria (gestational age of less than 33 weeks, birth weight of more than 500 g, age of less than 24 hours, need for assisted ventilation with peak inspiratory pressure of more than 16 and FIO2 more than 0.30, and roentgenographic evidence of respiratory distress syndrome) were randomized to either conventional (n = 36) or to high-frequency jet (n = 37) ventilation. Our goals were to maintain the infants on the assigned ventilator for at least 7 days unless they could either be extubated or meet crossover criteria. Univariate analyses were initially used to compare the two groups. Stepwise logistic regression was subsequently used to assess whether various factors independently influenced adverse outcomes.

Results. The two groups of infants were similar in all obstetrical, perinatal, and neonatal demographic characteristics. The mean birth weight and gestational age in the conventional group were 930 g and 26.6 weeks and in the HFJV group, 961 g and 26.9 weeks. The infants were randomized at similar ages (7.1 and 7.3 hours of life, respectively). Their prerandomization ventilator settings and arterial blood gases were nearly identical. There were no differences in pulmonary outcomes (occurrence of air leaks, need for oxygen or ventilation at 36 weeks postconception), and there were no differences in the mean number of days oxygen was required, number of days ventilated, or length of hospital stay. Infants ventilated with HFJV were significantly more likely to develop cystic periventricular leukomalacia (10 vs 2, P = .022) or to have a poor outcome (grade IV hemorrhage, cystic periventricular leukomalacia, or death) (17 vs 7, P = .016). Logistic regression analysis revealed HFJV to be a significant independent predictor of both cystic periventricular leukomalacia and a poor outcome. The presence of hypocarbia was not an independently significant predictor of adverse outcomes.

Conclusions. With the HFJV treatment strategy that we used, use of the high-frequency jet ventilator in the early management of premature infants with respiratory distress syndrome resulted in significantly more adverse outcomes than in those treated with conventional mechanical ventilation.
Would Better Adherence to Guidelines Improve Childhood Immunization Rates?
Authors: Lieu Tracy A. , Black Steven B. , Sorel Michael E. , Ray Paula , Shinefield Henry R.
Published: December 2021

Objective. To evaluate the contribution of three provider practices to underimmunization of children with financial coverage for vaccines.

Design. Retrospective cohort study of children in a large health maintenance organization, based on computerized databases and chart review.

Setting. Large health maintenance organization in northern California.

Patients. The population included 24 268 children who had at least one immunization recorded in the health plan tracking system and had continuous health plan membership between 15 and 24 months of age in 1992 through 1993. The study group (N = 4691) were those who had missed one or more of the immunizations due during their second year.

Results. Most (57%) of the underimmunized children had made at least one clinic visit between 15 and 24 months of age. Among those underimmunized children who made well care visits, 90% had been partially immunized at the visit but had not been simultaneously given all vaccines for which they were eligible. When a provider did not give all possible vaccines simultaneously, there was a 9% chance that the child would go on to miss the remaining immunization. Simultaneous administration alone would have achieved full second year coverage of 30% of the underimmunized children in this population. Most underimmunized children (53%), including 35% of those children who had not made any well care visits, had made urgent visits between 15 and 24 months of age. Chart review of randomly sampled patients showed no obstacle or contraindication to immunization at 79% of urgent visits and at 71% of well care visits at which vaccines were withheld. A policy to use weekday urgent visits to promote immunization could potentially reach 27% of the underimmunized children.

Conclusions. Provider practices play an important role in underimmunization of children who have insurance coverage for vaccines. Of the three guidelines evaluated, simultaneous administration of all possible vaccines has the greatest potential effectiveness to improve coverage rates in this population. Other guidelines, such as immunizing at urgent visits, are potentially effective but their costs and logistics need further study.
A Randomized Controlled Trial of Prenatal Pediatric Visits for Urban, Low-income Families
Authors: Serwint Janet R. , Wilson Modena E. H. , Vogelhut Judith W. , Repke John T. , Seidel Henry M.
Published: December 2021

Background. Prenatal pediatric visits have been recommended by the American Academy of Pediatrics to allow the pediatrician to counsel parents on infant care issues, establish a supportive relationship, and provide pediatric practice information to parents. We hypothesized that prenatal pediatric visits would have an impact on breastfeeding decisions, health care behaviors, health care utilization, and the doctor-patient relationship.

Methods. We conducted a randomized controlled trial of prenatal pediatric visits for urban, low-income families to measure the impact on breastfeeding decisions, infant car safety seat use, circumcision, health maintenance, and emergency room visits and the pediatrician's perception that he/she would know the mother better. Pregnant women were recruited prenatally from the obstetrics clinic. Outcomes were measured by maternal interview prenatally and when the infant was 2 months old, in addition to review of the nursery record. Physicians were interviewed after the 2-month visit. Health care utilization was measured by chart review at 7 months.

Results. A total of 156 pregnant women were enrolled and randomized, 81 to the intervention group and 75 to the control group. Of mothers who breastfed, 45% in the intervention group changed their mind in favor of breastfeeding after enrollment compared with 14% in the control group. Mothers in the intervention group compared with the control group were more likely to make fewer emergency room visits, 0.58 compared with 1.0. Pediatricians were more likely to think that they knew mothers in the intervention group well, 54% versus 29% in the control group, yet 67% of mothers in both groups agreed their pediatrician knew them well. There were no differences between groups in initiation or duration of breastfeeding at 30 or 60 days, infant car safety seat use, circumcision, or health maintenance visits.

Conclusions. Prenatal pediatric visits have potential impact on a variety of health care outcomes. Among urban, low-income mothers, we found beneficial effects on breastfeeding decisions, a decrease in emergency department visits, and an initial impact on the doctor-patient relationship. We suggest urban practices actively promote prenatal pediatric visits.
Parental Attitudes Do Not Explain Underimmunization
Authors: Strobino Donna , Keane Virginia , Holt Elizabeth , Hughart Nancy , Guyer Bernard
Published: December 2021

Objective. This article describes the results of a community-based study to determine the effect of family knowledge and attitudes on the immunization rates of a random sample of children younger than 2 years in the poorest census tracts of Baltimore.

Design and Methods. The two sources of data were (1) parent interviews that provided data on knowledge, attitudes, and beliefs related to immunization and sociodemographic characteristics, and (2) medical record audits from which data on immunization status were obtained. The protection motivation theory, a model of behavioral change, was used to select the variables to assess the relation of parental attitudes with immunization status. A multivariate logistic regression analysis included only variables found to be significantly associated with immunization outcome in the preliminary analysis.

Results. Mothers were well informed and generally had favorable attitudes toward immunizations. Immunization status was more strongly associated with the sociodemographic characteristics of the children than with the protection motivation theory variables. Only two protection motivation theory variables were associated with more than one immunization outcome. The children of mothers who perceived that timing of vaccination did not matter were less likely to be immunized than children of care takers who thought that it did matter and children whose parents believed in the safety of multiple immunizations were less likely to be immunized than children whose parents did not hold this belief.

Conclusions. In this study, parents' attitudes and beliefs had little effect on their children's immunization levels. Interventions intended to heighten parental awareness about immunization may have little impact. In poor urban neighborhoods, African-American children whose mothers are young, have multiple siblings, and do not use the Women, Infants and Children program may be at highest risk for delayed immunization.
TEEN-AGE PREDATORS
Authors: Student
Published: December 2021

Americans rightly believe that something fundamental has changed in our patterns of crime, namely the threat of serious crimes committed by youngsters who afterwards show us the blank, unremorseful stare of a feral, presocial being.
OUCH!
Authors: Student
Published: December 2021

Meta-analysis is an attempt to compose a great silk purse out of a multitude of sows' ears.
Questions About Varicella Vaccine
Authors: HURST PETER L.
Published: December 2021

Plotkin's informative commentary entitled "Varicella Vaccine" cites reservations of "many American pediatricians" as reason for the vaccine's low acceptance. From a public health perspective, I question whether use of a vaccine ought to be determined by individual physicians instead of groups of experts like the Committee on Infectious Diseases of the American Academy of Pediatrics. I also wonder whether the reluctance to endorse the vaccine is not related to its cost. An informal survey disclosed a range of $60 to $100 per immunization.
TOSSING TEN HEADS IN A ROW
Authors: Student
Published: December 2021

[Think of a coin-tossing tournament.] One player tosses and the other calls; the winner advances. The winner of this tournament will be that single player who has won n consecutive coin-tosses without a loss, depending on how many rounds it takes to complete a tournament.

There is something strange and trivial about this tournament, but what is it? The winner does have a rather remarkable property. How often have you ever met anyone who just won, say, ten consecutive coin-tosses without a loss? Probably never. The odds against there being such a person might seem enormous, and in the normal course of events, they surely are. If some gambler offered you ten-to-one odds that he could produce someone who before your very eyes would proceed to win ten consecutive coin-tosses using a fair coin, you might be inclined to think this a good bet. If so, you had better hope the gambler doesn't have 1,024 accomplices (they don't have to cheat—they play fair and square). For that is all it takes 2 competitors) to form a ten-round tournament. The gambler wouldn't have a clue, as the tournament started, which person would end up being the exhibit A that would guarantee his winning the wager, but the tournament algorithm is sure to produce such a person in short order—it is a sucker bet with a surefire win for the gambler.
THE CRUCIAL QUESTION
Authors: Student
Published: December 2021

[The Question] ... consists of asking in your own mind, on hearing a scientific experiment described: "What hypothesis does your experiment disprove?"

This goes straight to the heart of the matter. It forces everyone to refocus the central question of whether there is a testable scientific thesis or not.
Comments From the Co-Editors
Authors: Dewitt Thomas G. , Roberts Kenneth B.
Published: December 2021

"It takes about 6 to 12 months to learn how to practice in an office after completing a residency in pediatrics." This common assertion has been heard so frequently as to have become almost axiomatic. It reflects what has been termed the "residency-practice training mismatch," a problem more extreme in pediatrics than in any other specialty. The effort to combat the mismatch by providing pediatrics residents "real world" experience in community settings is not new, but the movement has taken on new momentum. The Residency Review Committee Program Requirements now mandate "structured educational experiences that prepare residents for the role of advocate for the health of children within the community." Several programs nationally have led the way in developing, implementing, and evaluating models in practices, schools, and various community agencies. The conference, of which this supplement is a summary, provided a "State of the Art" review of basic and applied educational principles for residency education in community settings.

The forerunner of the conference was an invitational symposium in Worcester, MA, on June 13 and 14, 1992, supported by the Maternal and Child Health Bureau. The 1992 conference brought together experienced, knowledgeable individuals from programs with education activities in their communities and served as the basis for the development of Pediatric Education in Community Settings. A Manual. The manual was supported by the Maternal and Child Health Bureau, the American Academy of Pediatrics, and the Ambulatory Pediatric Association. The 1996 national conference was designed to take place shortly after the printing of the manual, to reinforce basic elements of education—with special reference to education outside the hospital setting—and to promote active discussion and networking.
The "Angel Dust" States: Phencyclidine Toxicity
Authors: Cohen Sidney
Published: December 2021

Phencyclidine (1-[1-phenylcyclohexyl]piperidine, PCP, hog, sheets, angel dust, Sernylan, and many other common names) is a primate anesthetic that has emerged as a common drug of abuse and as a medical emergency problem during the past few years. Phencyclidine abuse is primarily a youthful activity. It is associated with multiple clinical states, an unusual amount of aggressive behavior, and a variety of problems in management.1

Thirty years ago phencyclidine was developed as an intravenous anesthetic for humans, but the frequency and intensity of emergence deliriums made it unsuitable. It is currently used as a veterinary anesthetic. Because of the availability of its precursors, its ease of manufacture, and its relative inexpensiveness, it became a common street drug during the late 1960s. At that time it was sold when mescaline, psilocybin, or tetrahydrocannabinol was requested, and it served as a virtually universal adulterant for hallucinogens. Not highly regarded among users of psychedelics, it was only infrequently purchased under its own name. During the past few years the picture has changed. Now it is a preferred substance, the most widely available and used hallucinogen. It usually is consumed as part of a polydrug abuse pattern along with alcohol, sedatives, and marihuana.

PREVALENCE

The extent of its usage is not easily assessed, the wide variety of names and of dosage forms make surveys imprecise.
Pharmacologic Management of Childhood Asthma
Authors: Rachelefsky Gary S.
Published: December 2021

Asthma is characterized by an increased responsiveness of the airways to various stimuli, which results in narrowing of the airways and in a prolongation of the expiratory phase of respiration; in the early phase the airway obstruction is usually completely reversible, either spontaneously or as a result of therapy. There are three therapeutic approaches to asthma: the avoidance of allergens and irritants causing or aggravating the disease; the use of immunotherapy; and the use of pharmacologic agents.

Increasing knowledge of the pathophysiologic aspects of bronchial asthma in the past decade has led to significant advances in its pharmacologic management. The basic alteration of respiratory function is an increased resistance to flow of air through the airway secondary to a combination of three factors: smooth muscle spasm, mucosal edema, and retained viscid secretions. In mild asthma and during remissions the airways less than 2 mm in diameter (the small airways) are obstructed, whereas during an acute attack and with chronicity, both small and large airways are involved. Although both phases of respirations are affected, the increased airway obstruction is more pronounced during expiration.

EVALUATION OF THE ASTHMATIC CHILD

The diagnosis of asthma is based on history, characteristic physical findings and laboratory tests. Asthmatic attacks of infants are usually associated with viral upper respiratory infections; the infants are usually febrile and frequently have otitis media.
Television and Children
Authors: Rothenberg Michael B.
Published: December 2021

Much of the programming and commercial message content of television programs being watched by children and youth is potentially, and often demonstrably, a mental and physical health hazard to the young. This is particularly true for those viewers who are at high risk because of ongoing conditions, such as developmental disabilities, mental retardation, psychoses, and impulse disorders.

In recognition of this situation, the American Academy of Pediatrics and the American Academy of Child Psychiatry have both issued Position Statements on the effects of television viewing on children and youth. Both groups have recommended to their membership the inclusion, during their work with children and their families, of questions concerning the television viewing habits of the child and his on her family. Pediatricians and child psychiatrists have also been urged to make attempts to assess the impact of television viewing on children and youth and, where appropriate, make specific recommendations concerning viewing habits.

Pediatricians and child psychiatrists have been asked to familiarize themselves with current programs provided both by the commercial networks and the public broadcasting system which are deemed to have positive influences on the psychosocial growth and development of their child and adolescent viewers, so that this information can be passed on to children and their families.
Meningococcal Disease: Management of Contacts
Authors: Glasgow Lowell A.
Published: December 2021

Meningococcal disease is relatively uncommon in the United States at the present time. The epidemics which occurred at about eight to 12-year intervals during the first half of this century have not been observed since 1945, although such epidemics continue to be reported from other parts of the world. In the United States in recent years 1,400 to 1,600 cases are reported to the Communicable Disease Center annually, but it is estimated that as many as 3,000 to 6,000 cases occur each year. Approximately 50% of these cases are in children less than 4 years of age and more than two thirds of all patients are under 20 years of age.1 Unfortunately, the mortality rate remains high and the anxiety generated in contacts is striking. For these reasons, as well as the evidence that the incidence of disease is significantly increased in close contacts, an effective means of prophylaxis is needed. The efficacy of the sulfonamides in eradicating the carrier state and in preventing disease in contacts was clearly demonstrated in the 1940s. This approach to the control of meningococcal infections was effective for approximately 20 years until the appearance of sulfonamide-resistant strains. At present a new approach to prevention of meningococcal disease is evolving with the use of rifampin and the development of meningococcal vaccines.
Cost-Benefit of Urinary Tract Infection Work-up Debated
Authors: RAPKIN RICHARD H. , H. R. J.
Published: December 2021

Several letters have been received questioning whether Dr Rapkin's proposal for work-up of children with one urinary tract infection (UTI) was realistic (Pediatrics in Review 1:133, 1979). Dr Weagly of the Quincy Clinic, Quincy, Illinois, pointed out that the cost in their clinic was as follows:

[See table in the PDF file]

He feels that it is unrealistic to expect a family to attempt to finance this expense. He ends his thoughtful letter with "I feel that there must be a middle ground that will help the patient and still keep expenses under control." Dr Berger of the University of New Mexico School of Medicine, comments similarly that Dr Rapkin's recommendations that patients with even one documented UTI should have radiographs to rule out associated anomalies of the urinary tract, would be very costly.
Disseminated Intravascular Coagulopathy
Authors: Corrigan James J.
Published: December 2021

Disseminated intravascular coagulation is most common in children with bacterial septic shock, infants with severe respiratory distress syndrome, in giant hemangiomas, and in purpura fulminans. The diagnosis is suspected when purpuric bleeding and/or thrombosis occurs in those clinical settings known to have DIC associated with them. The coagulopathy is also suspected when the patient has thrombocytopenia and prolonged clotting times in coagulation screening tests (prothrombin time and partial thromboplastin time). Confirmation of the diagnosis requires further laboratory data. Although it would be ideal to have a complete analysis of all the coagulation factors, this is generally not universally available nor always necessary in all cases. In the absence of liver disease, the minimal criteria for diagnosis is the combination of thrombocytopenia, positive fibrinolytic split products, and hypofibrinogenemia (or prolonged thrombin time). In the presence of liver disease, reduced factor VIII and/or the presence of circulating soluble fibrin complexes would be needed to diagnose DIC. Once the diagnosis is established and the underlying illness identified and treated, the therapy of the DIC is generally supportive. Anticoagulation (heparin) management is rarely needed except in cases of purpura fulminans, where it can be lifesaving, and selected cases of giant hemangioma or malignancy. In cases of septic shock and in severe RDS, successful management of the shock and the respiratory failure will cause the DIC to disappear without the use of anticoagulation.
Controversies in Pediatrics: What Tests Are Indicated for the Child Under 2 with Fever
Authors: McCarthy Paul L.
Published: December 2021

Most articles in PEDIATRICS IN REVIEW are presented in a didactic manner, sometimes more so than the authors would like. But other topics are still so controversial that to present only one side or one view would do disservice to authors and readers. From time-to-time we will present such controversies in pediatrics in this section. Such an instance is "fever in young children." Since the studies a few years ago that demonstrated bacteremia in more of these children than most of us previously suspected, all of us are more anxious than before about such children. Can we trust our clinical judgment as to who requires blood cultures and antimicrobial therapy? What tests are useful in making this difficult decision? McCarthy has done a series of studies over the years which he summaries below. But the experts do not always agree. Smith has added his view of the problem. Unfortunately, some things in medicine are still not so clear. But the reader will know that experts share his uncertainties.

R.J.H

One of the common reasons that a child visits the pediatrician is for the evaluation of a febrile illness. In our emergency room, 20% of children evaluated have a fever. Therefore, a well thought out approach to the febrile child is essential in pediatric practice.