bluuebunny/crossref_metadata_2025 huggingface dataset:
Positron Emission Tomography in the Newborn: Extensive Impairment of Regional Cerebral Blood Flow with Intraventricular Hemorrhage and Hemorrhagic Intracerebral Involvement
Authors: Volpe Joseph J. , Herscovitch Peter , Perlman Jeffrey M. , Raichle Marcus E.
Published: December 2021

Of all patients with intraventricular hemorrhage, those with hemorrhagic intracerebral involvement exhibit the highest rates of mortality and neurologic morbidity and, indeed, account for the vast majority of all neurologic impairment in infants with intraventricular hemorrhage. Insight into the basic nature of the critical cerebral involvement requires determination of regional cerebral blood flow, previously not possible. Positron emission tomography (PET) now provides the capability of measuring regional cerebral blood flow with high resolution and little risk. In this study, we utilized PET in six premature infants (920 to 1,200 g) with major intraventricular hemorrhage and hemorrhagic intracerebral involvement to measure regional cerebral blood flow during the acute period (5 to 17 days of age). Cerebral blood flow was determined after intravenous injection of H2O, labeled with the positron-emitting isotope, 15O (oxygen 15). Findings were similar and dramatic in all six infants. In the area of hemorrhagic intracerebral involvement, little or no cerebral blood flow was detected. However, in addition, surprisingly, a marked two- to fourfold reduction in cerebral blood flow was observed throughout the affected hemisphere, well posterior and lateral to the intracerebral hematoma, including cerebral white matter and, to a lesser extent, frontal, temporal, and parietal cortex. In the one infant studied a second time, ie, at 3 months of age, the extent and severity of the decreased cerebral blood flows in the affected hemisphere were similar to those observed on the study during the neonatal period. At the three autopsies, the affected left hemisphere showed extensive infarction, corroborating the PET scans. These observations, the first demonstration of the use of PET in the determination of regional cerebral blood flow in the newborn, show marked impairments in regional cerebral blood flow in the hemisphere containing an apparently restricted intra cerebralhematoma, indicating that the hemorrhagic intracerebral involvement is only a component of a much larger lesion, ischemic in basic nature, ie, an infarction. This large ischemic lesion explains the poor neurologic outcome in infants with intraventricular hemorrhage and hemorrhagic intracerebral involvement.
Treatment of Children with Posttraumatic Transient Loss of Consciousness
Authors: Dershewitz Robert A. , Kaye Bennett A. , Swisher Charles N.
Published: December 2021

Recommendations for the treatment of asymptomatic children who have had a brief period of loss of consciousness due to blunt head trauma are anecdotal and vary greatly. The purpose of this study is to define the range of practice in treating children with uncomplicated loss of consciousness by determining: (1) the frequency of "routine" hospitalization for observation and (2) those criteria which, when present, result in hospitalization. A total of 957 pediatricians representing five groups of physicians responded to a nationwide questionnaire survey to determine current treatment practices for uncomplicated loss of consciousness. Of all directors of pediatric emergency rooms and pediatric chief residents, 44% routinely hospitalize all patients who have had loss of consciousness. Academic child neurologists and child neurologists in private practice hospitalize these patients least frequently, 29% and 31%, respectively (P < 0.05). Of pediatricians in private practice, 38% admit all children with loss of consciousness. Pediatricians from all groups who do not routinely hospitalize all children with uncomplicated loss of consciousness showed similarity in the criteria they use for admission. These variables include: abnormal vital signs (97% to 100%), skull fracture (96% to 100%), suspicion of child abuse (93% to 100%), observation of a change in level of consciousness (92% to 99%), unreliable caretaker at home (91% to 98%), vomiting (90% to 99%), history of a change in level of consciousness (88% to 100%), duration of loss of consciousness (88% to 96%), seizure (77% to 94%), age of child (62% to 75%), child nearly back to normal (32% to 48%), dizziness (22% to 49%), witness of loss of consciousness not reliable (24% to 36%), headache (9% to 16%), and decision deferred to neurosurgeon (2% to 7%). Criteria for the hospitalization of children with loss of consciousness need to be developed.
Cutaneous Amebiasis
Authors: RIMSZA MARY ELLEN
Published: December 2021

In Reply.—

Brook has heightened the pediatrician's awareness of anaerobic etiologies of cutaneous abscesses, especially in the perineal area. He suggests that our patient may have had an anaerobic infection rather than cutaneous amebiasis, although our patient had an open ulcer rather than a closed abscess. In our patient, aerobic and anaerobic cultures of the genital lesions grew coagulase-negative staphylococci and diphtheroids. Viral cultures were sterile. Cultures of the genital ulcers, vagina, and rectum were negative for Neisseria gonorrhoea.
Theophylline Toxicity
Authors: SAHNEY SHOBHA
Published: December 2021

In Reply.—

Kossoy et al are reporting five patients with high theophylline levels who had no adverse effects when managed conservatively. Their data are in agreement with what was stated in our paper.
Misconceptions About Sleep
Authors: GUILLEMINAULT C. , ARIAGNO R. , KOROBKIN R. , COONS S.
Published: December 2021

To the Editor.—

It was with interest that we read the article on obstructive apnea in human infants by van Someren and Stothers.1 We would, however, like to correct some of the misconceptions concerning our work. We did not find that "the only difference between `near miss SIDS infants' and control groups was an increased frequency of short 3- to 6-second periods of mixed and obstructive apnea in the high risk group." As written in Pediatrics,2 we found that "the total number of mixed and obstructive apnea greater than 3 seconds during total sleep time, between 3 weeks and 4½ months statistically differentiated the two groups."
Quality of Life
Authors: WILL MADELEINE
Published: December 2021

To the Editor.—

The article by Singer, "Sanctity of Life or Quality of Life?" (Pediatrics 1983;72:128-129) chronicled and supported the decline in the sanctity of life ethic; Singer also unwittingly chronicled a decline in the quality of our understanding and respect for persons with disabilities.

The article, which compares severely disabled infants unfavorably with pigs and dogs, is not only needlessly provocative, but disregards among other things, the constitutional rights of disabled citizens. In Singer's words, the lives of these Americans are "demonstrably awful."
Annual Summary of Vital Statistics—1982
Authors: Wegman Myron E.
Published: December 2021

Data for this article, as in previous reports,1 are drawn principally from the Monthly Vital Statistics Report,2-5 published by the National Center for Health Statistics. The international data come from the Demographic Yearbook6 and the quarterly Population and Vital Statistics Report, 7both published by the Statistical Office of the United Nations, which has also been kind enough to provide directly more recent data. Except for mortality data by cause and age, which are based on a 10% sample, all the US data for 1982 are estimates by place of occurrence based upon a count of certificates received in state offices between two dates, one month apart, regardless of when the event occurred. Experience has shown that for the country as a whole the estimates are very close to the subsequent final figures. There are, however, considerable variations in a few of the states, particularly in comparing data by place of occurrence with data by place of residence. State information should be interpreted cautiously.
Acute Monarticular Arthritis Caused by Herpes Simplex Virus Type I
Authors: RAMAFEDI GARY , MULDOON ROBERT L.
Published: December 2021

Numerous viruses have been described as potential causes of acute arthritides.1-3 Recently, herpes simplex virus (HSV) type I has been implicated as a possible etiologic agent in acute arthritis in adults.4-6 The purpose here is to review evidence of the role of herpes viruses in acute arthritis and to report the isolation of HSV from the synovial fluid of a child with arthritis.

CASE REPORT

A 6-year-old of Mexican descent was admitted to the hospital because of the acute onset of pain and swelling in her light knee. The patients had been well until four days prior to admission when she developed fever and painful oral lesions.
What Is the Best Test for Iron Deficiency?
Authors: DINE MARK S.
Published: December 2021

To the Editor.—

We are indebted to Oski et al1 and to the 38 children who received injections of iron dextran for demonstrating the importance of determining not only which children had iron deficiency anemia but also those with iron deficiency without anemia. However, the primary physician needs a screening test that is efficient and not costly. Unfortunately, the history and physical examination are not effective screens for the identification of children at risk—with the exception of those children drinking in excess of one quart of milk a day.2
Outcome of Complicated Pregnancies of Less Than 27 Weeks of Gestation
Authors: KILBRIDE HOWARD W. , ELLIOT JOHN P.
Published: December 2021

To the Editor.—

The article by Bennett et al1 is one of several recent reports2,3 presenting outcome data on very low-birth-weight infants. These reports address the question: what is the lowest birth weight that justifies resuscitation and intensive care? Perinatal and obstetrical management decisions relating to the outcome of infants weighing less than 800 g are so numerous that the relevant question should be: at what gestational age will the perinatal team provide intensive management of the maternal-fetal unit?
Subgaleal Hemorrhage
Authors: BEAUCHAMP CHARLES J. , METCALF MARY BETH
Published: December 2021

To the Editor.—

Falvo et al1 reported two cases of subgaleal hematoma resulting from tight braids or ponytails, and they described their surgical management. We wish to report a similar case and suggest alternative management.

A 4-year-old girl was brought to the emergency room after her mother noted she had "lumps" on her head. Except for a mild cough of recent onset, she was in good health. Physical examination revealed a soft, nonpitting, and impressively fluctuant swelling underlying the entire scalp.
`The Kid' Has a Name
Authors: RAWLINGS JAMES S.
Published: December 2021

To the Editor.—

As defined in The American Heritage Dictionary of the English Language (Boston, Houghton Mifflin Co, 1979): Kid (kid) n. 1. A young goat. 2. Leather made from the skin of a young goat. 3. Slang. a. A child. b. A young person. -adj. 1. Made of kid. 2. Informal. Younger: My kid brother. -tr. Informal. 1. To mock playfully; to tease. 2. To deceive in fun; to fool. English kide, kyde from Old Norse kidh, young goat.
Vasodilator Therapy in Children: Acute and Chronic Effects in Children with Left Ventricular Dysfunction or Mitral Regurgitation
Authors: Beekman Robert H. , Rocchini Albert P. , Dick Macdonald , Crowley Dennis C. , Rosenthal Amnon
Published: December 2021

To determine the acute and chronic effects of vasodilator therapy in children, vasodilator therapy was evaluated in 13 children (aged 0.2 to 14.5 years) with severe left ventricular dysfunction or mitral regurgitation. In seven children, nitroprusside increased cardiac index by an average of 33% (P < .01) and increased stroke index by 29% (P < .01). In eight children, hydralazine caused a 31% increase in cardiac index (P < .01) and a 27% increase in stroke index (P < .02). Ten children received chronic oral vasodilator therapy and were followed for 5.7 ± 1.4 (SEM) months. Early clinical improvement was observed in every child. Symptoms of heart failure diminished in all, and five children became entirely asymptomatic. A significant (P < .05) improvement was noted in growth velocity, respiratory rate, heart size, and incidence of gallop rhythm after 1 month of therapy. The duration of the beneficial response to vasodilator therapy varied considerably, however, and significant improvement for the group was not found after 1 month. Four children had sustained clinical improvement for 6 months or longer, but the others experienced recurrent heart failure within 1 to 4 months.
Efficacy of a Programmed Calculator for Constant-Infusion Medication Calculations
Authors: Kelly Kevin J. , Neu Josef , Rice Thomas B. , Crim Wendell , Eisenberg Carl
Published: December 2021

A program for calculation of constant-infusion vasoactive medications on a hand-held programmable calculator was evaluated in terms of accuracy and time saved v conventional means of calculation. All groups, with the exception of the pharmacists, showed a statistically significant improvement in accuracy and time saved when using the programmable calculator. These results indicate that use of the programmable calculator may significantly save time and reduce errors on dose calculation of potentially dangerous drugs in pediatric and neonatal intensive care units.
A Reexamination of the Role of Oxygen in Retrolental Fibroplasia
Authors: Lucey Jerold F. , Dangman Barbara
Published: December 2021

A critical review of the liteature of retrolental fibroplasia indicates that the cause of this disease is not yet known.

Oxygen is certainly a critical factor but it is still not possible to make precise recommendations as to the amount or the duration of therapy that is safe. We have overemphasized the role of oxygen in the past, and as a result of this the false impression has been created that RLF is a disease that can be prevented. This gross oversimplification of a complex disease with multiple causes has resulted in many unjustified malpractice claims.

A study of the present epidemic indicates that excessive oxygen administration probably plays a minor role, in contrast to the first epidemic in which prolonged oxygen administration was clearly a major factor.

A reasonable working hypothesis is that the developing retina is highly sensitive to any disturbance in its oxygen supply, either hyperoxemic or hypoxemic. The retinal circulation is subject to the same wide fluctuations as the cerebral circulation in newborn infants.134 The very low-birth-weight, sick premature infant suffers from a number of conditions, many of which can seriously disturb the retinal circulation, resulting in hypoperfusion and ischemia. These factors (immaturity, hyperoxia, hypoxia, blood transfusions, intraventricular hemorrhage, apnea, infection, hypercarbia, hypocarbia, patent ductus arteriosus, prostaglandin synthetase inhibitors, vitamin E deficiency, lactic acidosis, prenatal complications, genetic factors) may all be present in an infant. They may interact to produce various degrees of retinal damage. Nearly all of these factors cannot be prevented or controlled by our present methods of care.

Unfortunately, this means that RLF is an extremely difficult disease to prevent, treat, or investigate. A disease of this complexity with multiple causes will require very large numbers of infants in any controlled study of a therapy. Retrolental fibroplasia should not be considered an avoidable iatrogenic disease in very low-birth-weight infants. Its cause in these infants is not known.
Congenital Juvenile Chronic Myelogenous Leukemia: Case Report and Review
Authors: Clark Reese H. , Taylor Leslie L. , Wells Robert J.
Published: December 2021

The case of a patient with ecchymosis, hepatomegaly, leukocytosis, thrombocytopenia, and anemia at birth is presented. Throughout his course, thrombocytopenia, anemia, and leukocytosis without a marked increase in the number of blast forms in either peripheral blood or bone marrow persisted until the patient developed a blast crisis shortly before his death at age 4 months. This patient is the youngest reported to have the juvenile form of chronic myelogenous leukemia and the first that in the present era can be considered congenital in origin.
Zinc in Formulas
Authors: HAMBIDGE K. MICHAEL
Published: December 2021

To the Editor.—

Bhatia and Fomon1 have demonstrated that the quantities of calcium and phosphorus delivered to formula-fed infants may bear little relationship to the label claims. They also warned that, although their report was restricted to these two nutrients, other formula components may also be involved in discrepancies between what is present in the bottle and what is delivered to the infant. Confirmation of this prediction is provided by recent éxperience with measurements of zinc concentrations in Similac Special Care (Ross Laboratories, Columbus, OH) during the course of zinc balance studies on very low-birth-weight premature infants in our neonatal Clinical Research Center.
Breast-Feeding and Illness
Authors: HOLMES GRACE E. , HASSANEIN KHATAB M. , MILLER HERBERT C.
Published: December 2021

In Reply.—

We elected not to quantify the severity of the infections among the 251 infants in our study, because we did not personally see all the infants at the time of their infections, and because only five of the 251 were hospitalized. Cunningham selected infants with four types of infection which he labeled as "more serious illnesses" and "significant illness" from our list which contained more than a dozen different types of infection. He based his conclusions on these four types or groups of infection.

He has calculated rates of illness per 100 infants. However, in calculating rates, the numerator must have all events that are being measured and each event must be in the denominator.
Newborn Screening
Authors: LEVY HAREY L. , MITCHELL MARVIN L. , RIDLEY STEPHEN E.
Published: December 2021

To the Editor.—

With publication of recommendations on newborn screening by the Committee on Genetics of the American Academy of Pediatrics1 and now similar recommendations by McCabe et al,2 a consensus on realistic procedures for newborn screening is developing. These procedures have been successfully followed for almost a decade by a number of state laboratories and include: (1) obtaining a blood specimen from all newborn infants prior to hospital discharge regardless of how early in life this occurs as phenylketonuria (PKU) and congenital hypothyroidism can be identified in most infants even during first hours of life;
Minimal Change Nephrotic Syndrome in Children: Deaths During the First 5 to 15 Years' Observation
Authors:   Report of the International Study of Kidney Disease in Children
Published: December 2021

Of 521 children with a previously untreated nephrotic syndrome, as defined by proteinuria ≥40 mg/h/m2 and serum albumin ≤2.5 g/dL, entering the International Study of Kidney Disease in Children between January 1967 and April 1976, 389 showed minimal changes on renal biopsy. Of these, seven boys and three girls died, all before July 1972. Infection was the cause of death in six patients. One child died of dural sinus thrombosis, one died as a result of cardiorespiratory failure following salt-poor albumin infusion, and another died from chronic renal failure due to focal and segmental glomerulosclerosis not apparent on initial biopsy. The mode of death in the remaining child was uncertain. Analysis according to histopathologic subgroups of minimal change disease showed no statistically significant differences in the incidence of deaths, although mesangial abnormalities and tubular atrophy were associated with higher mortality than nil disease or focal glomerular obsolescence. Nine of the ten children who died had either failed to respond to initial prednisone therapy (initial nonresponders, n = 5), or responded but relapsed during the initial 8 weeks of treatment (early relapser, n = 4), even though only one quarter of the total sample were nonresponders or early relapsers (P < .0005). Nearly one fifth of all initial nonresponders with minimal change nephrotic syndrome died. Thus the pattern of response to initial steroid therapy in patients with minimal change nephrotic syndrome may have prognostic significance.
Verapamil Poisoning in an Infant
Authors: Passal Donald B. , Crespin Frank H.
Published: December 2021

An 11-month-old female infant accidentally ingested 400 mg of verapamil. The patient developed coma, seizures, respiratory depression, bradycardia, and hypotension. Seizures have not previously been described in association with verapamil therapy or poisoning. She was successfully resuscitated with intravenous normal saline, calcium chloride, isoproterenol, and dopamine. A description of some of the manifestations of verapamil poisoning is given, and suggestions are made for several modalities of treatment, with emphasis on the use of intravenous calcium.
How Dangerous Are Blood Transfusions in `Premies'?
Authors: WEINBLATT MARK E.
Published: December 2021

To the Editor.—

Piccoli et al1 reported an uncommon, but highly interesting report of transfusion-acquired malaria in a neonatal intensive care unit. In addition to alerting pediatricians about this rarely suspected malady in newborns, the report also serves to publicize a more common problem frequently overlooked in neonatal centers.

Because premature neonates require only small volumes of blood transfusions at any given time, it is in the best interests of optimal utilization of a limited resource, human blood, to divide a single unit of donor blood into several small aliquots for multiple transfusions.
Suctioning and Cerebral Blood Flow
Authors: VOLPE JOSEPH J. , PERLMAN JEFFREY M.
Published: December 2021

In Reply.—

We regret not knowing the results of our study, designed to define the systemic and cerebral hemodynamic effects of suctioning in the preterm infant, before we did the study. Thereby, we could have answered Trevathan's questions, and as he suggests, avoided the need for prospective study of the relationship of these hemodynamic effects to the subsequent occurrence of intraventricular hemorrhage (IVH). The design of such a study will be particularly complex and certainly will require very much more than performing ultrasound scans before onset of suctioning.
Frostbite
Authors: ROWLINGSON JOHN C. , CARRON HAROLD
Published: December 2021

To the Editor.—

Upon reading the article by Brown et al,1 concerning frostbite in children resulting in digital deformity, we were struck by the subsequent changes shown in the radiographs which were similar to those associated with chronic reflex sympathetic dystrophy (RSD). In both syndromes there is an induced vascular insufficiency which apparently disrupts the normal mineralization process in bone. This results in spotty osteoporosis at first and, later, a picture of diffuse bony atrophy in RSD.2 These same changes are part of the radiographic picture described in the two cases of frostbite.1
Asbestosis and Old Incubators
Authors: FUENFER MICHAEL M.
Published: December 2021

To the Editor.—

The Armstrong X-4 model 500 baby incubator (Fig 1) has been a fixture in newborn nurseries in North America since its introduction in 1948. A survey of hospitals in northern Connecticut revealed that 12 of 17 nurseries are currently using the original X-4 incubator or its more recent version, the X-P, model 22 baby incubator, still in production (Ohio Medical Products). Incubators manufactured up to and including 1974, contained an asbestos gasket around the outer rim of the incubator top upon which the lid of the warmer closes.
Cerebral Infarction Related to Neck Position
Authors: ZIMMERMAN ANDREW W.
Published: December 2021

To the Editor.—

Hope et al1 are correct in pointing out that a congenital vascular abnormality in the vertebrobasilar system, when compromised by head position or neck manipulation, can contribute to ischemic lesions. The patient they described is similar in some ways to a previously reported patient2 whose ischemic lesion followed chiropractic manipulation of the neck. A striking similarity was a family history that was positive for migraine. Individuals who inherit a migraine diathesis may be susceptible to ischemic injury when the neck is rotated and hyperextended, particularly in the presence of a congenital hypoplastic vertebral artery.
An Abnormality of Neutrophil Adhesion: Autosomal Recessive Inheritance Associated with Missing Neutrophil Glycoproteins
Authors: Kobayashi Kunihiko , Fujita Kyoko , Okino Fumiko , Kajii Tadashi
Published: December 2021

A 3-month-old Japanese female infant, with persistent navel infection due to Pseudomonas aeruginosa since birth and recurrent bacterial skin infections, was found to have a severe abnormality of neutrophil adhesion on a surface, leading to a lack of chemotaxis and a mild impairment of phagocytosis. Neither neutrophil bactericidal activity nor nitroblue tetrazorium reduction was impaired. Sodium dodecyl sulfate polyacrylamide-gel electrophoresis of neutrophil membrane proteins from the patient disclosed the lack of two glycoproteins, one with a molecular weight (mol wt) of 110 K on the cell surface, and the other with mol wt of 115 K, possibly in intracellular membranes. The levels of the two glycoproteins were below normal in neutrophils from both parents, with the 110 K glycoprotein reduced to half the normal level. These findings indicate that the disease was inherited in an autosomal recessive fashion.
Impact of Preadmission Evaluations on Elective Hospitalization of Children
Authors: Goldbloom Richard B. , Macleod Marjorie U.
Published: December 2021

It was hypothesized that a well-organized evaluation of children scheduled for elective medical admission would: (1) significantly reduce average length of stay; (2) meet with parent satisfaction; and (3) significantly reduce health care costs. To test this hypothesis, a system of preadmission procedures was established for patients scheduled for elective medical admission to a 332-bed tertiary care pediatric hospital, and the impact of the system on these three parameters was evaluated. Compared with 167 concurrent control patients and 379 historical matched control patients, a highly significant shortening of length of hospital stay was associated with the preadmission program. Preadmission evaluation was associated with a reduction of 2.31 days in mean hospital stay and of three days in median stay as compared with number of days for concurrent control patients (P < .01). Patient and staff satisfaction was high. The extension of such a program to most elective medical admissions should result in significant savings in health care costs and reduction in family inconvenience.
Birth Weight and α-Fetoprotein in the Newborn
Authors: MIZEJEWSKI GERALD J. , BELLISARIO RONALD , CARTER THOMAS P.
Published: December 2021

To the Editor.—

While assessing the potential use of α-fetoprotein (AFP) as a diagnostic aid to newborn screening, we developed a method of reliably and reproducibly measuring AFP concentrations in minute samples of dried blood.1 To determine AFP normal ranges for healthy neonates during the first postnatal week, a radioimmunoassay commercial kit was adapted to measure AFP in 1.6-mm disks (0.75 µL of blood) punched from dried blood spots. In further studies2 we observed that an entirely new perspective emerges when birth weight is taken into account.
Role of Zinc in Testicular Function of Chronic Renal Failure
Authors: NISHI YOSHIKAZU , HATANO SHUICHI , AIHARA KATSUAKI , USUI TOMOFUSA
Published: December 2021

To the Editor.—

We read with great interest the paper of Marder et al1 on hypergonadotropism in peripubertal boys with chronic renal failure. However, their discussion does not mention the role of zinc in testicular function.

Zinc deficiency not only reduces zinc levels in the reproductive tissues but also impairs the responsiveness of the Leydig cells to gonadotropins, and thus may cause primary hypogonadism in humans as well as in experimental animals.2-4 Moreover, testicular hypofunction, elevated serum gonadotropin levels, and subnormal plasma zinc levels have been reported in renal failure.5,6
Role of Zinc in Testicular Function of Chronic Renal Failure
Authors: MARDER HAROLD K. , SRIVASTAVA LAXMI S. , BURSTEIN STEPHEN
Published: December 2021

In Reply.—

We thank Nishi et al for outlining the role that has been suggested for zinc in normal testicular function and the speculation that zinc deficiency might contribute to the hypergonadotropic hypogonadism found in males with chronic renal failure. We have no data concerning zinc levels in our patients, and so we felt we could offer no further insight into the possibility that zinc deficiency might play a role in the etiology of the hypergonadotropism we described.
The Society for Behavioral Pediatrics: A New Portal in a Rapidly Moving Boundary
Authors: Cohen Michael I.
Published: December 2021

In January 1976, at the first meeting of the members of the Task Force on Pediatric Education, its chairman, Henry Kempe, made the following statement: All who care about children must care deeply about the education of those who provide their health services. To paraphrase a basic tenet of the report of the Task Force: pediatric education must be based on what is best for infants, children, and adolescents. It cannot be based on what is best for doctors, faculty, departments, and hospitals.1

The underlying hypothesis was that health needs must form the basis for pediatric education.2 Any rationale for change should therefore be predicted on unmet health needs. To again quote Kempe from his 1978 presidential address to the American Pediatric Society3 on the same topic: "the concept that educational activities in our departments should relate to the health needs of children was not as universally accepted as you might think. A few feel to this day that it should be the other way around—that the needs of their departments should be addressed by a ready supply of sick and funded children, each in their appropriate subspecialty."

If indeed we care about children and their health needs and truly wish to realign clinical programs, educational policies, and research strategies along a track that will meet these needs and thus improve the health status of America's children, the first objective must be a reasoned assessment of the unmet health needs of our young. This same rationale holds true in the area of developmental and behavioral pediatrics.
Welcome to the Faculty or the Franchise?
Authors: McDonald J. M.
Published: December 2021

Well, Dr Smith, we're delighted that you could come back to join us. Your chairman and future colleagues have given you their highest recommendation, and the department seems very eager to have you.

Let's see here. You're 32, Harvard undergrad, biochemistry major. That thesis on the micromolecular rearrangements leading to carcinogenesis at the P 189 locus was pretty hot stuff—comes from getting started early with a first-rate team. Top 10% of the class. House staff at Hopkins—one of our great institutions—tough training. Three years in Dr Winstead's lab at NIH.
Imitation and Substitute Milks
Authors:   Committee on Nutrition
Published: December 2021

Since the publication of a statement on filled and imitation milks by this Committee in 1972,1 there have been both a proliferation of fabricated products that simulate milk and changes in regulations concerning them. Currently,"substitute" milk is defined by the Food and Drug Administration as nutritionally equivalent to whole or skim milk based upon its content of only 14 on 15 nutrients, omitting many nutrients that are recommended as necessary components of infant formula.2 There is no current requirement that these products undergo testing to evaluate their biologic activity or the bioavailability of these components. Fabricated products that simulate milk but do not meet the standard of identity for substitute milk proposed in 19783 must be labeled as "imitation" milk.

Neither substitute nor imitation milks meet the nutritional requirements for infant formula as proposed by this committee and incorporated into the Infant Formula Act of 1980. They should not be used as a major source of nutrition for infants. Popularity, extravagant claims, and special marketing practices cannot make white liquids nutritionally equivalent to infant formula.
Bleeding in Cystic Fibrosis?
Authors: LANE PETER A. , HATHAWAY W. E.
Published: December 2021

In Reply.—

We agree with Rosenstein that the possibility of fat malabsorption should be considered in any infant with vitamin K deficiency. In addition to cystic fibrosis, biliary atresia,1 α-1-antitrypsin deficiency,2 and abetalipoproteinemia3 have all been seen in infancy with vitamin K deficient hemorrhage. Certainly, a sweat chloride test, fractionated bilirubin determination, and review of the peripheral blood smear for acanthocytes would be important in the evaluation of such patients. Our patient had no acanthocytes, a normal α-1-antitrypsin level, and no evidence of biliary atresia or cystic fibrosis at autopsy.
Whole Cow's Milk, Age, and Gastrointestinal Bleeding
Authors: WILSON JOHN F.
Published: December 2021

To the Editor.—

The recent statement by the American Academy of Pediatrics' Committee on Nutrition1 raises "unanswered" questions. There may be an answer to question 3: "Can the change to cow's milk when the unfant is 6 months old produce anemia from occult blood loss when the milk is fed in excessive amounts and there is no iron supplementation?"

[See table in the PDF file]

The answer is to be found in a review of the research records of the 34 subjects in a 1974 report2; the records contain detailed dietary histories recorded by me.
New Sign of Middle Ear Disease?
Authors: PASCOE JOHN M.
Published: December 2021

To the Editor.—

For years I have observed children pulling on their ears "in sickness and in health." Now, my 11-month-old daughter has introduced me to a new symptom of middle ear disease that was not described during my medical school or residency training. In addition, I have never observed it in my patients.

She developed a right purulent otitis media and was treated with antibiotics. Following ten days of antibiotic therapy, she developed a persistent middle ear effusion for about 2 months.
New International Classification of Retinopathy of Prematurity
Authors: PATZ ARNALL
Published: December 2021

The new international classification of the acute retinopathy of prematurity appearing in this issue1 is a timely and important contribution to the ocular examination and management of the retinopathy in these premature infants.

During the epidemic period of the retinopathy of prematurity, generally designated then as retrolental fibroplasia, the survival rate of very small premature infants with birth weight less than 1,000 g was less than 10%. By the 1980s, due to improved neonatal care, that survival rate has increased by fourfold or greater. These low-birth-weight infants, who are at the highest risk of developing the retinopathy of prematurity, are surviving today, but in the early 1950s they would not have lived long enough to develop the disease.
Neonatal Mortality Statistics
Authors: SEPKOWITZ SAMUEL
Published: December 2021

To the Editor.—

Shapiro et al1 are properly cautious in attributing any decline in neonatal mortality to the use of neonatal intensive care. There was no decrease in mortality in 1976, the first year of their area-wide program, when compared with the 1974 to 1975 base line.2 Furthermore, the 17.9% decline in neonatal mortality between 1976 and 1978 to 1979 appears to be due to factors other than neonatal intensive care when weight-specific declines are considered.

Among the larger babies, birth weight greater than 2,500 g, there was a 24.8% reduction in weight-specific neonatal mortality.
Cystic Fibrosis Study Questioned
Authors: WAGENER JEFFREY S. , TAUSSIG LYNN M. , CORRIGAN JAMES J.
Published: December 2021

To the Editor.—

Ater and associates1 reported that patients with cystic fibrosis (CF) increase their hemoglobin values while receiving oral iron therapy, and they suggested that this indicates a relative iron deficiency which helps to explain why hypoxic patients with CF do not develop polycythemia. Similar data have been reported by Nickerson and colleagues.2 However, neither study related hematologic response to degree of hypoxia and both studies failed to recognize that polycythemia is not a necessary response to chronic hypoxia.
Equation Error
Authors: MITSUOKA J. CHRIS , FLECK RICHARD J.
Published: December 2021

In Reply.—

We thank McCormick for pointing out the error in equation 1. The correct term should be: Cpo e-Ke(t + t'). The term (t) should be considered to be the elapsed time from the beginning of the maintenance infusion.

The assumptions in the program are based upon theoretically ideal circumstances, that is, the loading dose is delivered precisely over 30 minutes beginning immediately after the initial serum level is drawn. The instant the loading dose is delivered, the maintenance infusion is initiated.
Health Care Use by Children Receiving Mental Health Services
Authors: Kelleher Kelly , Starfield Barbara
Published: December 2021

Reduction in medical care utilization is one criteria for assessing the impact of mental health treatment for children with psychosocial problems. This reduction has been termed the "offset" effect. Almost all published research concerning offset after mental health treatment concerns adults, and the few studies in pediatric populations are limited by methodologic problems. A study of health care utilization after mental health treatment for children was conducted. Mental health treatment for psychosocial problems was significantly associated with decreased use of medical care only for older children, after potentially confounding variables were controlled for. Furthermore, this decreased use was found only for nonmental health specialty care visits. No reduction in primary care visits occurred. Other factors such as previous patterns of use and the presence of other morbidity were stronger predictors of subsequent primary health care use than was mental health treatment. Mental health treatment does not have a major impact on the high utilization of most children with psychosocial problems in pediatric settings. Because the reasons for this may be particular morbidity patterns in these children, future studies should include some measure of case mix as a potentially important variable in assessment of mental health treatment effects.
Autologous Blood Transfusion in Pediatrics
Authors: DEPALMA LOUIS , LUBAN NAOMI L. C.
Published: December 2021

Public concern about the risk of transfusion-transmitted disease, especially acquired immunodeficiency syndrome, has resulted in unprecedented growth in autologous blood donation programs.1 In addition to eliminating transfusion-transmitted viral diseases, the use of autologous blood transfusion avoids the risk of sensitization to red blood cell antigens and subsequent antibody formation. Although there are many published studies that illustrate both the effectiveness and safety of such programs,2-4 there are comparatively few that specifically address the pediatric patient.

Autologous transfusion is defined as the collection and reinfusion of a patient's own blood. This may be accomplished by one of three modalities: (1) preoperative blood donation with subsequent blood bank storage and reinfusion during or following surgery; (2) acute normovolemic hemodilution, whereby blood is collected immediately preceding or following anesthetic induction and reinfused at the end of the surgical procedure; and (3) intraoperative and postoperative blood salvage, whereby blood shed into the operative field or enclosed space is collected, washed, and reinfused during or after surgery.
Neonatal Bacteremia and Circumcision
Authors: BRAUN DAVID
Published: December 2021

To the Editor.—

Wiswell and Geschke recently reported a decreased incidence of neonatal bacteremia among circumcised babies.1 Surprisingly, the neonatal bacteremia rate in the whole population was 40 per 136 086 (0.029%). In other studies, the rate of bacteremia has been substantially higher (0.1% to 1.0%2). If these other estimates apply, a large majority of the babies in question were missed in the analysis. The authors suggest that some portion of the patients were admitted to other hospitals and thus could have been missed.
More on Risks of Circumcision
Authors: WISWELL THOMAS E.
Published: December 2021

In Reply.—

Dr Williams asks, does this settle the debate regarding the "cause and effect" relationship of the intact prepuce and urinary tract infections?1,2 Perhaps not in and of itself; however, three other investigators3-5 recently confirmed our previous observations regarding this association. The risk for urinary tract infection during infancy appears to be at least 10- to 39-fold higher among uncircumcised boys.

What are the reasons boys are not circumcised? I do not have a proportional breakdown, but the two broad categories are (1) parental choice for their healthy child following informed consent counseling and (2) one of several presupposed "medical" contraindications, including prematurity, neonatal illness (pneumonia, persistent pulmonary hypertension, etc), known family history of "bleeding disorders," and recognized genitourinary malformations (most commonly hypospadias).
From Circumstance to Mechanism in Pediatrics During the Hopkins Century
Authors: Eisenberg Leon
Published: December 2021

In the beginning was the Word, and the Word was The Johns Hopkins. In the beginning, like Janus, the Roman God of thresholds, the new medicine was double-faced,1 the one visage gazing inward at the mechanisms of disease, the other outward at the social circumstances in which disease occurs. With time, the very success of the search for mechanisms displaced the concern for circumstances.

Is it hyperbole to aver that Hopkins was the Word for the education of American physicians in the scientific practice of medicine? This University began formal graduate education in the United States2; this Hospital introduced the graduated system of clinical instruction for house officers incorporated in a teaching hospital in place of preceptorships with specialist practitioners3-5; this Medical School inaugurated the full-time system in clinical departments, chose its faculty for competence in research as well as patient care, and became the prototype for academic excellence.4

Harvard's president, Charles W. Eliot, acknowledged this University's seminal role when he wrote2(p105):

The example of Johns Hopkins forced our faculty to put their strength into the development of education for graduates. . . . What was true of Harvard was true of every other university in the land.

Nor was Eliot6(p93) reticent in assessing the state of medical education B.H. (before Hopkins):

The ignorance and general incompetency of the average graduate of American medical schools at a time when he [sic] receives a degree which turns him loose upon the community, is something horrible to contemplate, considering the nature of the physician's functions and responsibilities.
Prevalence of Excess Lead Absorption and Associated Risk Factors in Children Enrolled in a Midwestern Health Maintenance Organization
Authors: Nordin James D. , Rolnick Sharon J. , Griffin Joan M.
Published: December 2021

Objective. To assess the prevalence of lead intoxication in children in a defined low-risk population at the new levels recommended by the Centers for Disease Control and Prevention.

Design. During an 11-month period, whole blood lead tests were performed on 4678 children at routine well-child visits at 9 months and 2 years of age. For the last 8 months of the study, parents were asked to complete a prescreening risk factor questionnaire at these visits. The questionnaire and blood lead results were then matched. Data were collected from October 1, 1991 through August 31, 1992.

Setting. The study subjects were all enrolled in Group Health, Inc, a large health maintenance organization. Its 17 staff model clinics serve urban and suburban populations in the Minneapolis-St. Paul area. More than 95% of the population had coverage based on employment, not Medicaid.

Results. Results indicated that 2.5% (n = 119) of the children had BPb levels ≥10 µg/dL. Urban clinics had rates of elevated BPb levels three to eight times those of suburban clinics (P < .00001), but the number of elevated BPb levels at the suburban clinics was greater than expected. BPb levels were significantly higher in summer and fall (P < .00001). The prescreening questionnaire addressed five areas potentially associated with risk according to the literature: housing, siblings with lead poisoning, parental hobbies or work involving lead, proximity to highways, and use of cultural medicines. Positive correlations were found between elevated BPb levels and residences built before 1950 (P < .00001). For children living in housing built before 1950, positive correlations were found between elevated blood lead levels and peeling paint (P < .01) or remodeling (P < .0001).

Conclusions. Children who are at low socioeconomic risk but who live in housing built before 1950 are at increased risk for lead poisoning. The risk is greater if the house has peeling paint and especially if there is recent or ongoing renovation. Recommendations based on these results and the Centers for Disease Control and Prevention guidelines are made for screening programs in similar populations, and for the need to increase community awareness concerning this issue.
Development of a Screening Tool for Prediction of Children at Risk for Lead Exposure in a Midwestern Clinical Setting
Authors: Rooney Brenda L. , Allen Brian K. , Strutt Pamela J. , Hayes Edward B.
Published: December 2021

Objective. Universal screening for childhood lead poisoning is becoming quite common, with many states having legislation requiring screening. We set out to determine whether a questionnaire could be used to identify children at risk for exposure to lead to determine whether selective screening of those at risk was possible.

Methods. Parents of 370 children 12 to 36 months of age having well-child examinations completed a questionnaire and their children were screened by a fingerstick capillary blood lead test at two clinics.

Results. Of patients from clinic A, 5.4% had lead levels ≥10 µg/dL compared with 16.8% of those from clinic B (P < .001). This difference between clinics could not be explained by the demographic characteristics of the patients or by differences in their potential exposures to lead. We evaluated the five questions suggested by Centers for Disease Control and Prevention for anticipatory guidance for their ability to identify children with elevated blood lead levels. In clinic A, this instrument had a sensitivity of 76.9% and a negative predictive value of 96.5%. In clinic B, it had a sensitivity of 63.6% and a negalive predictive value of 81.4% . Based on an assessment of significant items from a large questionnaire, we determined five questions that were the best predictors of risk. On the basis of this risk assessment, 100% of the children from clinic A with elevated lead levels and 90.9% of the children from clinic B with elevated lead levels were classified as being at "high risk." Had this risk assessment been used as an initial screen in this sample, 40% of the patients from clinic A and 37% of the patients from clinic B would not have been screened with a blood lead test, because they were classified as being at "low risk."

Conclusions. Results of this study suggest that there is great variability in the prevalence of elevated lead levels and potential risks between clinics within a fairly homogeneous community; however, selective screening with a community-specific questionnaire may be feasible if the prevalence is low and the risks to the population are known.