bluuebunny/crossref_metadata_2025 huggingface dataset:
A New Recommendation for Dietary Fiber in Childhood
Authors: Williams Christine L. , Bollella Marguerite , Wynder Ernst L.
Published: December 2021

Objective. The consumption of dietary fiber in childhood is associated with important health benefits, especially with respect to promoting normal laxation. Dietary fiber also may help reduce the future risk of cardiovascular disease, some cancers, and adultonset diabetes. At present, there are few specific guidelines for dietary fiber intake in childhood. Our goals were to review the benefits and risks of dietary fiber in childhood and to propose a safe and effective quantitative recommendation for the US pediatric population.

Method. Current intake of dietary fiber in childhood was reviewed, including data from the US Department of Agriculture Nationwide Food Consumption (1987-1988) and National Health and Nutrition Examination II (1976-1980) Survey. Current intake was compared with existing fiber recommendations, including the 0.5-g/kg guideline proposed by the American Academy of Pediatrics Committee on Nutrition. Recommended fiber intake was reviewed with respect to levels required for specific health benefits, as well as levels that may result in adverse health effects.

Results and Conclusions. A new recommendation for dietary fiber intake was developed, based on the age of the child, health benefits, and safety concerns. We recommended that children older than 2 years of age consume a minimal amount of dietary fiber equivalent to age plus 5 g/d. A safe range of dietary fiber intake for children is suggested to be between age plus 5 and age plus 10 g/d. This range of dietary fiber intake is thought to be safe even if intake of some vitamins and minerals is marginal, should provide enough fiber for normal laxation, and may help prevent future chronic disease.
An Overview of the Effects of Dietary Fiber on Gastrointestinal Transit
Authors: Hillemeier Craig
Published: December 2021

This article is a review of the effects that ingested dietary fiber has on gastrointestinal transit time. The various phases of gastrointestinal motility are considered, and the effect of fiber on these various components is explored. Fiber affects each phase of gastrointestinal motility differently; however, the most dramatic effect on decreased transit time and frequency of bowel movements results from the variations it causes in colonic transit time. The mechanisms of defecation in children and the ways in which fiber affects the frequency of bowel movements are emphasized. All types of fiber do not affect gastrointestinal transit in a similar manner, and different preparations of the same fiber either may delay or may increase the time of intestinal transit. In general, fiber is found to increase the frequency of bowel movements and may prove to be of considerable benefit in treating constipation, a common childhood disorder.
FATHERS IN NORWAY
Authors: L. J. F.
Published: December 2021

"Norway's "father quota," which forces fathers to use their four-week paid paternity leave or forsake it, spurs more dads to take the leave, up to 25% of those eligible from just 1.5% the year before. Previously they could transfer the time off to the child's mother.

Norway is considered a leading family-friendly country, offering generous parental-leave policies, including 52 weeks' maternity leave at 80% salary or 42 weeks at 100%. Now, Norwegians can also stretch paid parental leave over 2½ years under a government-funded program developed by a group of trade unions and employers. In the first eight months of the program, about 1200 parents took advantage of it—8% of those eligible—including 120 fathers.
Detection of Mycobacterium tuberculosis in Clinical Specimens From Children Using a Polymerase Chain Reaction
Authors: Smith Kim Connelly , Starke Jeffrey R. , Eisenach Kathleen , Ong Lydia T. , Denby Melissa
Published: December 2021

Objective. We evaluated the usefulness of the polymerase chain reaction (PCR) using the insertion sequence IS6110 as the target for DNA to detect Mycobacterium tuberculosis in clinical specimens from children.

Study Design. This was a prospective, controlled, blinded study comparing PCR on clinical specimens, mycobacterial culture, and clinical diagnosis.

Patients. Sixty-five hospitalized children were evaluated, 35 with tuberculosis disease and 30 controls. Cases were defined by culture and/or specific clinical criteria. Controls included patients with tuberculosis infection but no detectable disease as well as patients free of tuberculosis infection and disease.

Results. Polymerase chain reaction had a sensitivity of 40% and a specificity of 80% compared with clinical diagnosis. Mycobacterial culture had a sensitivity of 37%. The combination of culture and PCR identified 19 of 35 children (54%) with clinically diagnosed tuberculosis. There were six children with false-positive PCR results: One had tuberculosis infection without disease, two had Mycobacterium avium lymphadenitis, and three had diagnoses unrelated to tuberculosis.

Conclusions. The sensitivity of PCR is comparable to that of culture for detecting M tuberculosis in children, and may strengthen and hasten the clinical diagnosis in culture-negative patients. However, because of the limitations in specificity, the results of PCR alone are insufficient to diagnose tuberculosis in children. Although ongoing refinements in PCR techniques should improve the specificity of this test, epidemiologic and clinical information continue to be the most important consideration in the diagnosis of tuberculosis in culture-negative children.
Assessment of Immunization Compliance Among Children in the Department of Defense Health Care System
Authors: Lopreiato J. O. , Ottolini M. C.
Published: December 2021

Objective. To describe immunization rates among children enrolled in the Department of Defense health care system and to determine risk factors for delay.

Design. Cross-sectional survey of immunization records and demographic characteristics among parents of children presenting for acute care at seven pediatric clinics operated by the Department of Defense.

Participants. Subjects were 1977 children aged 2 months to 18 years.

Outcome Measures. Immunization rates were measured for various age strata from infancy to adolescence.

Results. The overall immunization rate was 84%. By age 2 years, 86% of patients had received four diphtheriatetanus -pertussis, three oral polio, Haemophilus influenzae type b, and measles-mumps-rubella (MMR) vaccines. At school entry, 87% of children were fully immunized for diphtheria-tetanus-pertussis and MMR. However, only 50% of adolescents were up-to-date, primarily because of failure to receive booster doses of MMR. Seventy-nine percent of parents whose children were delayed thought that they were up-to-date. Factors associated with immunization delay included incorrect parental perception of immunization status, failure to keep routine health maintenance visits, and non-white race. Socioeconomic status, parental education level, access to care, and family mobility had no effect on immnization status.

Conclusions. Although immunization rates for preschoolers approached national goals, accessibility to care and free vaccines did not guarantee immunization compliance, especially among adolescents. Most patients with delayed vaccinations were older children and adolescents whose school and parental reports of immunization status were incorrect. Immunization delay in our study was primarily the result of a failure to track patients and notify parents of when immunizations were due.
Practice Parameter: The Management of Acute Gastroenteritis in Young Children
Authors:   SUBCOMMITTEE ON ACUTE GASTROENTERITIS,   PROVISIONAL COMMITTEE ON QUALITY IMPROVEMENT
Published: December 2021

This practice parameter formulates recommendations for health care providers about the management of acute diarrhea in children ages 1 month to 5 years. It was developed through a comprehensive search and analysis of the medical literature. Expert consensus opinion was used to enhance or formulate recommendations where data were insufficient.

The Provisional Committee on Quality Improvement of the American Academy of Pediatrics (AAP) selected a subcommittee composed of pediatricians with expertise in the fields of gastroenterology, infectious diseases, pediatric practice, and epidemiology to develop the parameter. The subcommittee, the Provisional Committee on Quality Improvement, a review panel of practitioners, and other groups of experts within and outside the AAP reviewed and revised the parameter. Three specific management issues were considered: (1) methods of rehydration, (2) refeeding after rehydration, and (3) the use of antidiarrheal agents. Main outcomes considered were success or failure of rehydration, resolution of diarrhea, and adverse effects from various treatment options. A comprehensive bibliography of literature on gastroenteritis and diarrhea was compiled and reduced to articles amenable to analysis.

Oral rehydration therapy was studied in depth; inconsistency in the outcomes measured in the studies interfered with meta-analysis but allowed for formulation of strong conclusions. Oral rehydration was found to be as effective as intravenous therapy in rehydrating children with mild to moderate dehydration and is the therapy of first choice in these patients. Refeeding was supported by enough comparable studies to permit a valid meta-analysis. Early refeeding with milk or food after rehydration does not prolong diarrhea; there is evidence that it may reduce the duration of diarrhea by approximately half a day and is recommended to restore nutritional balance as soon as possible. Data on antidiarrheal agents were not sufficient to demonstrate efficacy; therefore, the routine use of antidiarrheal agents is not recommended, because many of these agents have potentially serious adverse effects in infants and young children.

This practice parameter is not intended as a sole source of guidance in the treatment of acute gastroenteritis in children. It is designed to assist pediatricians by providing an analytic framework for the evaluation and treatment of this condition. It is not intended to replace clinical judgment or to establish a protocol for all patients with this condition. It rarely will provide the only appropriate approach to the problem. A technical report describing the analyses used to prepare this parameter and a patient education brochure are available through the Publications Department of the AAP.
High-frequency Oscillatory Ventilation as Rescue Therapy in Sick Preterm Neonates (≤1250 g): Outcome and Its Prediction
Authors: CHEUNG PO-YIN , ROBERTSON CHARLENE M. T. , PRASERTSOM WANNARAD , FINER NEIL N.
Published: December 2021

In their recent article, Paranka et al showed the lack of improvement in oxygenation after 6 hours of high-frequency oscillatory ventilation (HFOV) was associated with failure of HFOV and treatment with extracorporeal membrane oxygenation in term infants with severe respiratory failure. Rescue HFOV has also been used in treating critically ill very low birth weight infants with respiratory failure. We retrospectively reviewed the outcome of 52 preterm infants (gestation ≤30 weeks, birth weight ≤1250 g) treated with rescue HFOV in the Neonatal Intensive Care Unit, Royal Alexandra Hospital, Edmonton, Canada, between October 1988 through August 1993.
Rapid Streptococcal Tests
Authors: Gutman Steve
Published: December 2021

In the February 1996 issue of Pediatrics (1996;97:288), a letter to the editor by Drs S. DuBose Ravenel, Gregory Carl Ellis, and William N. Michal stated that". . . the OIA test has been approved by the Food and Drug Administration without any requirement for a backup culture..." The authors conclude that, based on two published papers1,2 and on their own experience, along with cost considerations, there are enough data to support the practice of utilizing the Strep A OIA method without performing backup cultures.
Fatal Dog Attacks, 1989-1994
Authors: Sacks Jeffrey J. , Lockwood Randall , Hornreicht Janet , Sattin Richard W.
Published: December 2021

Objectives. To update data on fatal dog bites and see if past trends have continued.

Design. To merge data from vital records, the Humane Society of the United States, and searches of electronic news files.

Setting. United States.

Subjects. U.S. residents dying in the U.S. from 1989 through 1994 from dog bites.

Results. We identified 109 dog bite-related fatalities, of which 57% were less than 10 years of age. The death rate for neonates was two orders of magnitude higher than for adults and the rate for children one order of magnitude higher. Of classifiable deaths, 22% involved an unrestrained dog off the owner's property, 18% involved a restrained dog on the owner's property, and 59% involved an unrestrained dog on the owner's property. Eleven attacks involved a sleeping infant; 19 dogs involved in fatal attacks had a prior history of aggression; and 19 of 20 classifiable deaths involved an unneutered dog. Pit bulls, the most commonly reported breed, were involved in 24 deaths; the next most commonly reported breeds were rottweilers (16) and German shepherds (10).

Conclusions. The dog bite problem should be reconceptualized as a largely preventable epidemic. Breedspecific approaches to the control of dog bites do not address the issue that many breeds are involved in the problem and that most of the factors contributing to dog bites are related to the level of responsibility exercised by dog owners. To prevent dog bite-related deaths and injuries, we recommend public education about responsible dog ownership and dog bite prevention, stronger animal control laws, better resources for enforcement of these laws, and better reporting of bites. Anticipatory guidance by pediatric health care providers should address dog bite prevention.
Allergic Reactions in Rheumatic Fever Patients on Long-term Benzathine Penicillin G: The Role of Skin Testing for Penicillin Allergy
Authors: Markowitz Milton , Lue Hung-Chi
Published: December 2021

An injection of 1.2 million U benzathine penicillin G (BPG) every 3 or 4 weeks has proven by far to be the most effective method to prevent recurrences of acute rheumatic fever.1-3 The efficacy of this method of prophylaxis was first demonstrated more than 40 years ago, and since its introduction, it has played a major role in reducing the morbidity and mortality from rheumatic fever.4

Rheumatic fever causes 25% to 40% of all cardiovascular diseases in developing countries.5 Because of the impact of this disease on public health, the World Health Organization (WHO) has helped establish programs for prevention of recurrent attacks of rheumatic fever in many developing countries.6 WHO recommends BPG as the prophylactic drug of choice. One of the problems encountered has been the high drop-out rates among patients enrolled in these programs. Among the reasons for discontinuing prophylaxis is the fear of an allergic reaction.7

The initial study using BPG for the prevention of recurrences of rheumatic fever in children and adolescents reported only 5 (1.2%) mild allergic reactions among 410 patients receiving monthly injections.1 Since then, although rheumatic fever prevention in the United States (U.S.) has consisted almost exclusively of using BPG, there been very few documented reports of serious allergic reactions in rheumatic fever patients on long-term prophylaxis. The only fatalities reported in the American literature occurred in four adults with advanced rheumatic heart disease.8,9

The salutary experience with BPG in the U.S. contrasts sharply with the numerous anecdotal reports of fatal allergic reactions to BPG in many developing countries.
Psychosocial Function During Treatment for Familial Hypercholesterolemia
Authors: Tonstad Serena , Nøvik Torunn Stene , Vandvik Inger Helene
Published: December 2021

Objective. To determine whether children treated for familial hypercholesterolemia (FH) have greater psychosocial dysfunction compared with their peers.

Children. Children were 86 boys and 66 girls 7-16 years of age attending a lipid clinic. They were screened and instructed to follow a diet low in saturated fat and cholesterol 18 months to 9 years earlier (mean, 4 years), and their mean dietary intake, estimated by a quantitative food frequency questionnaire, was within recommended limits. One-fourth had lost a parent or had a parent who had had cardiovascular disease due to FH (parental disease group).

Methods. Results of the Child Behavior Checklist, Teacher's Report Form, and Youth Self-Report were compared with a population sample. A semistructured interview, the Child Assessment Schedule, was administered to the children with FH and a well-functioning comparison group from the population (epidemiologic cohort; n = 62).

Results. Psychosocial scores were similar in the children with FH and the population sample. The Child Assessment Schedule showed that, compared with the epidemiologic cohort, children with FH did not have increased symptoms in any area of function, and scores for family, mood, and expression of anger were lower (less symptomatic). The prevalence of psychiatric diagnoses was 10%, which was not greater than expected. Children from the parental disease group had higher symptom scores in the areas of school and expression of anger than the rest of the children with FH. Their mean Children's Global Assessment Score (CGAS, which gives average children scores of 70-79) was slightly lower (77 vs 79). Belonging to the parental disease group predicted a lower CGAS in multivariate regression analyses, as did male sex, parental divorce, and low parental educational level. These factors explained up to 19% (95% confidence interval, 9%-31%) of the variance in CGAS.

Conclusions. We found that the prevalence of psychosocial dysfunction was not greater than expected in children treated for FH. Psychosocial function within the group was associated with the usual demographic characteristics and with the loss or disease of a parent, beyond the period of bereavement or immediately after the event.
THE RELATIONSHIP BETWEEN PARENTAL AND CHILDREN'S SERUM IMMUNOGLOBULIN E (IgE) AND ASTHMA
Authors: Galant Stanley P.
Published: December 2021

Purpose of the Study. To examine parental factors that influence bronchial asthma and immunoglobulin E (IgE) levels in their children.

Methods. The data in this study were derived from the Tucson Epidemiological Study of Airways Obstructive Diseases since 1972. Eleven evaluation periods have been performed since that time. Asthma histories were established by questionnaire. IgE levels were obtained in 738 children, 1043 fathers, and 1261 mothers. IgE levels were determined by paper radioimmunosorbent (PRIST) technique. IgE Z scores were established. An IgE Z score is the number of standard deviations IgE differs from matched age and sex-matched subjects and log corrected. Skin tests were performed by prick technique to house dust, mold, grass, tree and weed mix and appropriate controls.

Results. The percentage of children with bronchial asthma increased with the presence of asthma in parents so that 11.5% of children with asthma occurred in families with no parental asthma compared with 48.6% when both parents had asthma. The rate of childhood bronchial asthma was significantly related to parental IgE levels only when the mother and father had bronchial asthma (43% vs 20%) and much less so (22% vs 10%), when there was no parental asthma. In addition, asthma in the child proved to be a highly significant determinant of the child's IgE Z score, even after correcting for parental IgE Z score. The presence of atopy (ie, positive skin tests) was also not a significant determinant of IgE levels in asthmatic children.

Discussion. The authors conclude that the inheritance of IgE is only one factor related to the development of asthma, and is limited as a predictor.
ENCEPHALOPATHY IN CHILDREN WITH PERINATALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS INFECTION
Authors: Navarro Maritza , Hanson I. Celine
Published: December 2021

HIV-induced encephalopathy is common among children with vertically acquired HIV (10% of HIV infected children; 23% of children with AIDS). HIV encephalopathy represents 12% of first-reported ADCs and 12% of subsequent ADCs. Most cases were diagnosed by 3 years of age and the highest risk occurred during the first year of life. No demographic or birth characteristics predicted the development of encephalopathy. An association between cardiomyopathy and encephalopathy was noted. Children with HIV encephalopathy were severely immunodeficient, and survival time was poor. This report demonstrates the dramatic clinical effect of HIV infection in producing marked immunosuppression with impact on additional organ systems; ie, central nervous system.
A SINGLE ATAXIA TELANGIECTASIA GENE WITH A PRODUCT SIMILAR TO PI-3 KINASE
Authors: Gern James E.
Published: December 2021

ATM is the sole gene responsible for AT. The sequence analysis of ATM suggests that the gene product is involved in signal transduction, DNA repair, and cell cycle control, which are all processes known to be defective in AT.
Early Diagnosis of Coarctation of the Aorta in Children: A Continuing Dilemma
Authors: Ing Frank F. , Starc Thomas J. , Griffiths Sylvia P. , Gersony Welton M.
Published: December 2021

Because late repair of coarctation of the aorta (COA) is associated with premature cardiovascular disease in adult life, early detection and treatment is important.

Objectives. To determine the timing of referral to see whether early detection of COA has improved in the past decade, to evaluate the pattern of and reasons for medical center referral, and to assess the clinical signs relating to the diagnosis of COA.

Methods. The records of 50 consecutive patients older than 1 year who had surgical repair of COA from 1980 to 1990 were reviewed. The age of referral, pattern of referral, and presence of standard clinical signs of COA were analyzed, and data were compared with those from the previous decade.

Results. The mean and median ages at referral were 8.4 and 5.8 years, respectively. Pediatricians accounted for 64% of the referrals. A specific diagnosis of COA was made in 2 (4%) of 50 patients before referral to a pediatric cardiologist. The most consistent clinical findings were a cardiac murmur and a systolic blood pressure gradient between the arms and legs of greater than 10 mm Hg, which were both present in all patients. Lower-extremity pulses were decreased in 37 (74%) and absent in 9 (18%). Forty-seven children (94%) had upper-extremity hypertension (>95th percentile for age); 25 (50%) had systolic blood pressure higher than 140 mm Hg. COA would have been missed in 82% of children if absent lower-extremity pulses were required as a diagnostic feature. These findings were similar to those reported by our institution in the previous decade, suggesting that early detection has not improved.

Conclusions. The timing of, reasons for, and sources of referral for COA in this study, compared with data from the previous decade, indicate no improvement in early detection of COA by pediatricians. Screening all children for COA by routinely measuring upper- and lower-extremity blood pressures during at least one physical examination after the newborn period is mandatory.
Pediatric Locum Tenens Provided by an Academic Center
Authors: Poole Steven R. , Efird Deb , Wera Tom , Fox-Gliessman Deb , Hill Kathryn
Published: December 2021

Background. Locum tenens, the use of a substitute physician to replace a physician who must be temporarily absent from his practice, is widely accepted in the United States. Locum tenens has not previously been described or studied in pediatric practice.

Objective. This article describes a locum tenens service for Colorado and Wyoming pediatricians provided by the Division of General Pediatrics and Pediatric Emergency Medicine at the University of Colorado School of Medicine and the Children's Hospital of Denver. An analysis and an evaluation of the program are presented, and implications are discussed.

Methods. All program data were prospectively collected and tabulated and later analyzed for the period from July 1, 1994, through June 30, 1995. A survey of all physicians using the Pediatric Locum Tenens Service was conducted within 2 months of service to evaluate the program and to refine the orientation, credentialing, and evaluation processes.

Results During the year, 35 pediatricians (14% of pediatricians in Colorado and Wyoming) made 97 requests for 398 days of locum tenens coverage. Coverage was used for vacation (85%), medical education (10%), medical leave (3%), and family matters (2%). Solo and rural pediatricians used the service at a higher rate than pediatricians in group or urban practices. Eighty-six percent had never used locum tenens coverage before because of either the expense (67%) or their unwillingness to trust their practices to physicians or services with whom or with which they were unfamiliar (50%). The majority (83%) were willing to pay an amount for locum tenens equal to the net income derived from the locum tenens coverage in the practice. None indicated a willingness to pay more than that. Referrals and admissions to the Children's Hospital from the pediatricians who used the service increased by 22% during the study period compared with the preceding year, whereas referrals and admissions increased by 9% among all other colorado and Wyoming pediatricians. All pediatricians completed surveys, and satisfaction with the locum tenens pediatricians, charges, and program administration was high. Their suggestions are described.

Discussion. The following topics are discussed: (1) the economics of pediatric locum tenens; (2) the use of a locum tenens service as a physician relations program by children's hospitals or academic departments of pediatrics; (3) guidelines for orientation of locum tenens pediatricians; and (4) a proposed evaluation and credentialing process for locum tenens physicians.
Evaluation and Preparation of Pediatric Patients Undergoing Anesthesia
Authors:   Section on Anesthesiology Bridges Committee
Published: December 2021

The preparation of a child who is about to undergo surgery or anesthesia involves the child's family, primary care physician, anesthesiologist, surgeon, and, many times, other specialists. Communication among the individuals caring for the patient is paramount for the smoothest periopenative course. Established lines of communication permit the efficient and meaningful transfer of patient information and provide the most efficient means of informing the patient about necessary procedures. Familiarity with operating room and day surgery unit policies (eg, NPO guidelines, arrival times, and preoperative educational programs) helps alleviate patient and parent anxiety.
Letter To The Editor
Authors: Wall Michael A. , Severson Herbert , Andrews Judy , Lichtenstein Ed , Zoref Leslie
Published: December 2021

Two studies have been published in which the major purpose was to reduce infant exposure to environmental tobacco smoke (ETS) by moving the source of the smoke away from the infant.1,2, Neither study showed a reduction in mean infant urine cotinine levels although Greenberg and associates did find a reduction in reported smoke exposure and a reduction in persistent respiratory symptoms in lower socioeconomic level children. One may interpret the data of Greenberg et al to mean that mothers in the intervention group knew the right thing to say in response to a survey.
Apolipoprotein E Polymorphism and Serum Lipids in a Randomized, Prospective Trial of an Infant Diet With Reduced Saturated Fat and Cholesterol
Authors: Lapinleimu Helena , Viikari Jorma , Rönnemaa Tapani , Välimäki Ilkka , Tuominen Juhani , Marniemi Jukka , Ehnholm Christian , Jokinen Eero , Simell Olli
Published: December 2021

Background. The inherited apolipoprotein E (apoE) phenotype may determine effectiveness of dietary atherosclerosis prevention. This study analyzes the effects of apoE phenotypes on changes in serum lipid concentrations in a 6-month prospective, randomized trial of a low-saturated-fat, low-cholesterol diet in infancy.

Patients and Methods. One thousand sixty-two healthy infants were randomized to intervention and control groups at the age of 7 months. Counseling was provided to the intervention families when the children's ages were 7, 8, and 10 months. Dietary goals were the child's intake of energy ad libitum, fat at 30% to 35% of energy, cholesterol at less than 200 mg/d, and saturated, monounsaturated, and polyunsaturated fatty acids at a 1:1:1 ratio. Control families consumed an unrestricted diet. The apoE phenotype of 846 of the infants was determined; serum lipid and lipoprotein concentrations were measured at 7 and 13 months of age; and nutrient intakes were analyzed using 3-day food records at 8 and 13 months of age.

Results. At 7 months of age, serum cholesterol concentration was higher in apoE4-positive infants (E2/E4, E3/E4, and homozygous E4) than in apoE4-negative infants (159 ± 31 mg/dL [4.10 ± 0.81 mmol/L] vs 150 ± 29 mg/dL [3.89 ± 0.74 mmol/L]). The high-density lipoprotein cholesterol concentration was slightly lower in apoE4-positive infants than in apoE4-negative infants (34 ± 8 mg/dL [0.88 ± 0.20 mmol/L] vs 35 ± 7 mg/dL [0.91 ± 0.19 mmol/L]). Between 7 and 13 months of age, the serum cholesterol concentration in infants in the intervention group was unchanged, apoB concentration increased slightly, and apoAl concentration decreased. In the control infants, serum cholesterol concentration increased 9 ± 25 mg/dL (0.24 ± 0.65 mmol/L), apoB concentration increased markedly, and apoAl concentration was stable. Changes in serum lipid and apo concentrations that resulted from the dietary intervention were independent of the apoE phenotype.

Conclusions. The apoE phenotype influenced serum cholesterol concentration markedly by 7 months of age. Between the ages of 7 and 13 months, a reduced saturated fat and cholesterol diet effectively prevented the ageassociated increases in serum cholesterol and non-highdensity cholesterol concentrations that were obvious in the control infants. The effects of the diet occurred in the infants independently of the apoE phenotype.
Idiopathic Disseminated Bacillus Calmette-Guérin Infection: A French National Retrospective Study
Authors: Casanova Jean-Laurent , Blanche Stéphane , Emile Jean-François , Jouanguy Emmanuelle , Lamhamedi Salma , Altare Frédéric , Stéphan Jean-Louis , Bernaudin Françoise , Bordigoni Pierre , Turck Dominique , Lachaux Alain , Albertini Marc , Bourrillon Antoine , Dommergues Jean-Paul , Pocidalo Marie-Anne , Le Deist Françoise , Gaillard Jean-Louis , Griscelli Claude , Fischer Alain
Published: December 2021

Objective. Disseminated bacillus Calmette Guérin (BCG) infection after inoculation of live vaccine is considered to result from impaired immunity of the child. However, in half of the cases, regarded as idiopathic, no well-defined immunodeficiency condition can account for the infection. The objective of the present study is to report the prevalence, clinical features, associated infections, and outcomes of children with idiopathic disseminated BCG infection.

Design. National retrospective survey during the period from 1974 through 1994 in France.

Setting. All neonatology and pediatrics units in primary care and referral centers throughout France.

Patients. Data were collected from 595 (82%) of 721 units, 377 (93%) of 407 centers, and 320 (93%) of 345 cities. Selection criteria included BCG infection, dissemination to at least two areas beyond the inoculation site, and no well-defined immunodeficiency condition. Sixteen children (8 girls and 8 boys), born to families unrelated to each other but often consanguinous (5 of 16), satisfied the criteria; children were born in France (11 of 16) or abroad (5 of 16).

Results. The minimal prevalence rate was estimated at 0.59 cases per 1 million vaccinated children born in France. Clinical features included fever and cachexia, disseminated BCG infection to lymph nodes (15 of 16), skin (13 of 16), soft tissues (11 of 16), lungs (11 of 16), spleen (11 of 16), liver (11 of 16), and bones (9 of 16). Eight children had associated or subsequent severe opportunistic infection (50%), with either nontyphi Salmonella enterica serotypes (7 of 16) or Mycobacterium abscessus (1 of 16). The outcome was poor: 8 children (50%) died; the cause of death was BCG infection for most children (7 of 8); 8 survived until the last follow-up (50%).

Conclusions. Idiopathic disseminated BCG infection is a rare but severe complication of BCG vaccination. The infection probably results from an as yet unknown genetically determined immunodeficiency condition that affects the killing of intracellular bacteria such as BCG and Salmonella.
Spanking and Triage
Authors: Colvard Karen
Published: December 2021

There is not much about corporal punishment in this article, but I understand that Dr Chamberlin argues, by omission, that spanking is only a bit player in the complex interplay of risks that threaten the future development of a child. A concerned society will do what it can broadly to increase the information and practical support available to families, which might prevent a variety of problems created or exacerbated by upbringing and experiences in childhood. One question for this meeting is: would the American Academy of Pediatrics be contributing to this broad mandate for prevention with a statement that focuses on spanking or other mild punishment, or does attention to a small problem draw attention from big problems that urgently need action?

I agree with Dr Chamberlin's argument for providing comprehensive services to all members of a community rather than targeting high-risk groups, except that I think his goals impractical given limitations on public funds for social services. How should we spend the small amount of public money available for the welfare of children?

Five to eight percent of all children have a temperamental problem with aggression; some 80% of boys growing up in poor, marginalized neighborhoods in US inner cities will be arrested for a violent crime before age 18. These data do not describe the same problem. We have heard several references in presentations here to the exceptional violence of US society and reports of studies that relate spanking to criminal violence in adulthood. Our cities do not have a patent on violence, and children everywhere deserve protection from abuse.
Letter To The Editor
Authors: Demers Robert R.
Published: December 2021

The AAP statement entitled "Reassessment of the Indications for Ribavirin Therapy in Respiratory Syncytial Virus Infections" by the Committee on Infectious Diseases1 recently published in this journal was noted with interest. It is extremely unfortunate that the Committee placed so little credence in the Stanford study published in the New England Journal of Medicine in 1991,2 while placing excessive confidence in the fatally flawed Wayne State study published in Critical Care Medicine in 1994.3 The Stanford study, among others, was criticized because ". . . the choice of water as a placebo . . . could have biased the results in favor of ribavirin efficacy."1
Pepper-Spray-induced Respiratory Failure Treated With Extracorporeal Membrane Oxygenation
Authors: Billmire Deborah F. , Vinocur Charles , Ginda Maureen , Robinson Nancy B. , Panitch Howard , Friss Helena , Rubenstein David , Wiley James F.
Published: December 2021

Self-defense sprays have been available to the general public since the 1970s. They are easily obtained and over 6 million spray units were sold in the United States in 1993 alone. The intent of these sprays is to cause skin and mucosal irritation without producing serious injury. We describe the accidental exposure to pepper-gas spray of an infant who experienced immediate life-threatening respiratory distress followed by progressive deterioration. Ultimately, he required extracorporeal membrane oxygenation (ECMO) for survival. The decision to place the infant on ECMO was made more difficult by the lack of information about potential reversibility with this rare toxic cause of respiratory failure.
The Provo Multicenter Early High-frequency Oscillatory Ventilation Trial: Improved Pulmonary and Clinical Outcome in Respiratory Distress Syndrome
Authors: Gerstmann Dale R. , Minton Stephen D. , Stoddard Ronald A. , Meredith Keith S. , Monaco Frank , Bertrand Jean Marie , Battisti O. , Langhendries J. P. , Francois A. , Clark Reese H.
Published: December 2021

Objective. To compare the hospital course and clinical outcome of preterm infants with respiratory distress syndrome treated with surfactant and managed with high-frequency oscillatory ventilation (HFOV) or conventional mechanical ventilation (CV) as their primary mode of ventilator support.

Design. A prospective randomized clinical trial.

Setting. Three community-based level III neonatal intensive care units.

Subjects. A total of 125 neonates who were 35 weeks or less estimated gestation requiring intubation and assisted ventilation for respiratory distress syndrome with arterial to alveolar oxygen ratio less than .50.

Interventions. Patients were randomized to continue CV (61 patients) or be changed to HFOV (64 patients) after exogenous surfactant administration (100 mg/kg). HFOV was used in a strategy to promote lung recruitment and maintain lung volume. Protocol respiratory care guidelines were followed; otherwise routine care was provided by each neonatal intensive care unit.

Measurements and Main Results. No differences were noted in demographic features between the two study groups. The study population birth weight was 1.51 ± .47 kg (mean ± SD), gestational age was 30.9 ± 2.5 weeks, and study entry age was 2 to 3 hours. Patients randomized to HFOV demonstrated the following significant findings compared with CV-treated patients: vasopressor support was less intensive; surfactant redosing was not as frequent; oxygenation improved more rapidly and remained higher during the first 7 days; fewer infants required prolonged supplemental oxygen or ventilator support; treatment failure was reduced; more patients survived without chronic lung disease at 30 days; need for continuous supplemental oxygen at discharge was less; frequency of necrotizing enterocolitis illness was lower; there were fewer abnormal hearing tests; and hospital costs were decreased. No differences were seen between the two study groups in the frequency or severity of patent ductus arteriosus, air leak, retinopathy of prematurity, or intraventricular hemorrhage. Length of hospital stay and survival to discharge were similar for HFOV- and CV-treated infants.

Conclusions. When used early with a lung recruitment strategy, HFOV after surfactant replacement resulted in clinical outcomes consistent with a reduction in both acute and chronic lung injury. Benefit was evident for preterm infants both less than or equal to 1 kg and more than 1 kg. In addition, early HFOV treatment may have had a more global effect on patient health throughout the hospitalization, resulting in reduced morbidity and decreased health care cost.
Efficacy of Milk-based Diets in Persistent Diarrhea: A Randomized, Controlled Trial
Authors: Bhatnagar Shinjini , Bhan Maharaj K. , Singh Kiran D. , Saxena Shailendra K. , Shariff Malini
Published: December 2021

Objective. Previous studies have shown increased stool output when children with persistent diarrhea (PD) received milk as the predominant source of nutrition.

Methods. We evaluated the efficacy of milk given in modest amounts as a part of a mixed diet in children with PD. One hundred sixteen children 3 to 24 months of age with diarrhea for between 14 days and 12 weeks were allocated to milk-based (n = 60) or milk-free (n = 56) cereal dietary regimens. The two diets were isocaloric (86.9 calories/100 g for ≤9 months; 95.6 cal/100 g for > 9 months) consisting of puffed rice cereal, sugar, and oil differing in only their source of protein, which was either milk or egg white, respectively. An average of 30% of the calories were constituted by milk in the milk-cereal diet. Both diets were offered at the rate of 150 kcal/kg per day. Children receiving milk-cereal consumed an average of 1.9 g/kg lactose per day.

Results. The baseline characteristics in the two groups were similar. Comparable amounts of diet were consumed in both groups. The milk-cereal group did not have higher median (range) stool output (g/kg/h) compared with the milk-free group during a 0- to 48-hour (milk-cereal, 1.7 [0.2 to 8.7]; milk-free, 1.5 [0.1 to 6.6]) or 0- to 120-hour (milk-cereal, 1.6 [0.4 to 7.2]; milk-free, 1.3 [0.1 to 7.6]) period. The percentage of weight gain was similar in the two groups, and there were no significant differences in the duration of diarrhea. Overall, 23 children had treatment failures, 10 (17%) in the milk-cereal and 13 (23.6%) in the milk-free groups.

Conclusions. Our findings suggest that modest intakes of milk are well tolerated as a part of mixed diet during PD.
Home Therapy With Subcutaneous Immunoglobulin Infusions in Children With Congenital Immunodeficiencies
Authors: Abrahamsen Tore G. , Sandersen Heidi , Bustnes Alfhild
Published: December 2021

Objectives. Patients with congenital, humoral immunodeficiencies are usually treated with intravenous immunoglobulin infusions. Subcutaneous infusions have emerged as an alternative treatment modality also in children. Our institution has run a subcutaneous infusion home therapy program for 6 years, and the purpose of this report is to describe our experience with this regimen.

Methods. The subcutaneous therapy of eight patients with immunodeficiency (three with agammaglobulinemia, one with common variable immunodeficiency, one with severe combined immunodeficiency and bone marrow transplantation, and three with hyper-immunoglobulin M syndrome) was evaluated by chart review and a questionnaire answered by all the families. The infusions were given for at least 3 hours each week by a small syringe driver at home after the family had attended an intensive educational course at the hospital.

Results. The children were given a total of approximately 1100 infusions. They started at the age of 2 to 8 (mean, 4.5) years and received these infusions for 1.5 to 6 (mean, 3) years. By administering immunoglobulin doses from 58 to 149 (mean, 97) mg/kg per week, trough serum immunoglobulin G values from 5.2 to 9.6 (mean, 7) g/L were obtained. No serious infections occurred. Short-lasting, local side effects such as swelling and redness were frequently reported, but pain or systemic adverse reactions during or after the infusions were never encountered.

Conclusions. Home therapy with subcutaneous immunoglobulin infusions in children with congenital immunodeficiencies is a feasible and safe treatment alternative.
A Controlled Trial of Nurse Practitioners in Neonatal Intensive Care
Authors: Mitchell-DiCenso Alba , Guyatt Gordon , Marrin Michael , Goeree Ron , Willan Andrew , Southwell Doris , Hewson Sheila , Paes Bosco , Rosenbaum Peter , Hunsberger Mabel , Baumann Andrea
Published: December 2021

Objective. To compare a clinical nurse specialist/neonatal practitioner (CNS/NP) team with a pediatric resident team in the delivery of neonatal intensive care.

Design. Randomized, controlled trial.

Setting. A 33-bed tertiary-level neonatal intensive care unit.

Patients. Of 821 infants admitted to the neonatal intensive care unit between September 1991 and September 1992, 414 were randomized to care by the CNS/NP team, and 407 were randomized to care by the pediatric resident team.

Intervention. Infants assigned to the CNS/NP team were cared for by CNS/NPs during the day and by pediatric residents during the night. Infants assigned to the pediatric resident team were cared for by pediatric residents around the clock. Neonatologists supervised both teams.

Measures. Outcome measures included mortality; number of neonatal complications; length of stay; quality of care, as assessed by a quantitative indicator condition approach; parent satisfaction with care, measured using the Neonatal Index of Parent Satisfaction; long-term outcomes, measured using the Minnesota Infant Development Inventory; and costs.

Results. There were 19 (4.6%) deaths in the CNS/NP group and 24 (5.9%) in the resident group (relative risk [RR], 0.78; confidence interval [CI], 0.43 to 1.40). In the CNS/NP group, 230 (55.6%) neonates had complications, in comparison with 220 (54.1%) in the resident group (RR, 1.03; CI 0.91 to 1.16). Mean lengths of stay were 12.5 days in the CNS/NP group and 11.7 days in the resident group (difference in means, 0.8 days; CI, -1.1 to 2.7). The performance on the indicator conditions was comparable in the two groups except for two instances, jaundice and charting, both of which favored the CNS/NP group. Mean scores on the Neonatal Index of Parent Satisfaction were 140 in the CNS/NP group and 139 in the resident group (difference in means, 1.0; CI, -3.6 to 5.6). In the CNS/NP group, 6 (2.6%) infants performed 30% or more below their age level in the Minnesota Infant Development Inventory, in comparison with 2 (0.9%) in the resident group (RR, 2.87; CI, 0.59 to 14.06) The cost per infant in the CNS/NP group was $14 245 and in the resident group $13 267 (difference in means, $978; CI, -1303.18 to 3259.05).

Conclusions. CNS/NP and resident teams are similar with respect to all tested measures of performance. These results support the use of CNS/NPs as an alternative to pediatric residents in delivering care to critically ill neonates.
Recruiting Community Faculty
Authors: Sharp Michael C.
Published: December 2021

The success of community-based resident education depends on a partnership between a residency program and a variety of individuals, physician and nonphysician, in the community. The process of recruiting community faculty in the education of pediatric residents begins with selection of learning objectives. Next, characteristics of effective teachers and teaching sites should be listed so that appropriate faculty may be identified and recruited. A residency program's existing physician network of both referring physicians and graduates of the residency is a good beginning point for making contacts. Selection of specific educational goals, objectives, and activities will lead to identification of potential nonphysician participants. Understanding why community colleagues might want to become part of the training program leads to techniques for contacting and recruiting them.
Abdominal Masses in the Newborn
Authors: Schwartz Marshall Z. , Shaul Donald B.
Published: December 2021

The presence of an abdominal mass in the neonatal period is common, occurring in approximately 1 infant in 1000 live births. Despite this relatively high incidence, the finding of an abdominal mass in a neonate can be alarming for both parents and physicians. Until recently, the identification of an abdominal mass was made by physical signs (ie, abdominal distention, palpable mass). However, in the past decade, fetal ultrasound has become technically refined and is more widely practiced. As a result, the presence of an abdominal mass in the fetus may be known long before birth, allowing for the formation of a specific diagnosis and treatment plan. In addition to fetal ultrasonography, a wide array of sophisticated imaging techniques have become available to aid in the diagnosis of an abdominal mass. However, in the cost-conscious environment in which health care must be provided, it is the physician's responsibility to evaluate an abdominal mass as cost effectively as possible. Early consultation among the pediatrician, pediatric radiologist, pediatric surgeon, and, in the case of prenatal diagnosis, the obstetrician can expedite this process.

Many abdominal masses are of the nonsurgical variety (ie, organomegaly or bladder distention). Most masses requiring surgical intervention are benign (87%), and the prognosis for neonates with an abdominal mass is good.