bluuebunny/crossref_metadata_2025 huggingface dataset:
Very Low Birth Weight Infants: Effects of Brain Growth During Infancy on Intelligence Quotient at 3 Years of Age
Authors: Hack Maureen , Breslau Naomi
Published: December 2021

To evaluate the role of postnatal growth on IQ at 3 years of age, 139 appropriate for gestational age, very low birth weight infants (<1.5 kg) born in 1977 and 1978 were studied at 40 weeks (term), and at 8, 20, and 33 months (corrected) of age. Weight, height, and head circumference were measured at each age, neurologic status was measured at 20 months, and Stanford Binet IQ at 33 months. Multiple regression analysis revealed that head circumference at 8 months of age is the best growth predictor of IQ at 3 years of age. Path analysis was performed to measure the effects of biologic and social factors measured earlier in life on IQ at 3 years. These factors explained 43% of the variance in IQ at 3 years of age. Head circumference at 8 months had a direct effect on IQ at 3 years, controlling for all other variables in the model. Neonatal risk had an indirect effect via head circumference. Neurologic impairment had direct and indirect (via head circumference) effects; race and socioeconomic status had direct effects on IQ but no effects on growth at 8 months of age. Thus, brain growth at 8 months significantly influenced 3 year IQ at 3 years of age among very low birth weight infants, even when medical and sociodemographic variables were controlled.
Maternal Cocaine Abuse and Effect on the Newborn
Authors: Madden John D. , Payne Terrence F. , Miller Sue
Published: December 2021

Cocaine has been increasingly available to a wider population of potential users in the United States. Information concerning possible effects of this agent on the fetus and newborn is lacking. We observed eight infants whose mother's gave a history of cocaine abuse and, in whom, results of a urine screen for cocaine were positive. We observed no evident symptomatology or signs of teratogenicity on these infants. Although this is encouraging, more studies, including Brazelton assessment, and long-term follow-up of infants born to cocaine-abusing mothers is necessary.
Benefits/Risks of Syrup of Ipecac
Authors: MOFENSON HOWARD C. , CARACCIO THOMAS R.
Published: December 2021

The status of syrup of ipecac as a nonprescription drug has helped reduce the death rate in children, ages 1 to 5 years. The drug has proven safe and effective in children in the recommended doses. To deprive parents of ready access to ipecac syrup would result in increased disability and death from poisoning and more emergency department visits.
Serum Vitamin E Levels in the Very Low Birth Weight Infant During Oral Supplementation
Authors: Neal Patricia R. , Erickson Pat , Baenziger John C. , Olson John , Lemons James A.
Published: December 2021

A prospective study was initiated to monitor serum tocopherol levels in all infants admitted to Indiana University Medical Center with birth weights <1,500 g. These infants routinely receive 100 mg/kg/d of oral vitamin E (Aquasol E tocopherol acetate) every six hours. Levels are determined weekly or semiweekly using a modification of the fluorometric method of Hanson and Warwick. Vitamin E dosage is adjusted regularly to achieve levels ≥3.5 mg/dL. During the 6 months of this study, a total of 76 patients had 567 serum measurements. Of these, 220 levels (38%) were ≥3.5 mg/dL, 71 (13%) were ≥5.5 mg/dL, and 15 (2.7%) were >8 mg/dL. Serum tocopherol levels often (1) remained ≥3.5 mg/dL for several days after oral supplementation was discontinued or (2) again became ≥3.5 mg/dL on a reduced dosage of 25 to 50 mg/kg/d. These data indicate that infants weighing <1,500 g at birth who are receiving oral vitamin E supplementation at 100 mg/kg/d will have varied serum levels with a significant percentage exceeding 3.5 mg/dL.
Psychosocial Issues in Pediatric Organ Transplantation: The Parents' Perspective
Authors: Gold Larry M. , Kirkpatrick Beverly S. , Fricker F. Jay , Zitelli Basil J.
Published: December 2021

The process of organ transplantation for a child has a profound impact on the entire family. Parents are faced with a number of psychosocial stresses many of which are unique in a pediatric hospital setting. We report the information provided by parents who have participated in a support group established for those with children undergoing heart and liver transplantation. Descriptive information gathered throughout the past 4 years in this group suggests that there are three specific stages that these families must endure: preoperative, perioperative, and long-term postoperative. The major psychosocial obstacles for families at each stage of the transplant process are described in detail. This information provides the health care professional with a basic framework to understand and provide guidance to the families of transplant patients.
Acute Steroid-Induced Tetraplegia Following Status Asthmaticus
Authors: Kaplan Peter W. , Rocha Wilson , Sanders Donald B. , D'Souza Bernard , Spock Alexander
Published: December 2021

A 10-year-old girl was treated for an acute asthmatic attack with ventilation and a high-dose steroids regimen. An areflexic paralysis of the four limbs was noted when artificial ventilatory support was withdrawn. Electromyography and a muscle biopsy revealed marked myopathic features. We discuss the unusual presentation of an acute steroid-induced myopathy in an asthmatic patient.
Effects of Maternal Smoking and Caffeine Habits on Infantile Apnea: A Retrospective Study
Authors: Toubas Paul L. , Duke James C. , McCaffree Mary Anne , Mattice Cynthia D. , Bendell Debra , Orr William C.
Published: December 2021

To evaluate the relationship of antecedent maternal smoking and caffeine consumption habits on the occurrence of apnea in their offspring, rates for central and obstructive apnea were analyzed in a cohort of mother-infant pairs. The mothers of 298 infants with apnea responded to a questionnaire completed prior to a nine-hour polysomnogram performed as part of the patients' evaluations. Cigarette consumption estimates were computed on a 20-cigarette per pack basis, and caffeine intake, based on dietary sources (coffee, tea, chocolate, and colas), was summarized as milligrams of caffeine consumed per day. Rates of central and obstructive apnea of 6 to 10 seconds in duration were calculated. Multiple linear regression analysis determined that smokers tended to be younger and have lower birth weight infants who presented earlier with apnea than infants of nonsmokers. Increased rates of central apnea occurred in infants of smokers as compared with infants of nonsmokers. During pregnancy, a pack per day increase in maternal smoking habit was associated with a 1.88/h increase in central apneas in their offspring (P <.01). Maternal smoking after delivery had a similar relationship. Obstructive apnea rates were similar in both groups. Both central and obstructive apnea rates associated positively with increasing maternal caffeine consumption. Smoking habits and caffeine ingestion were correlated (P < .01). Infants with apnea have greater rates of central apnea when their mothers smoke during pregnancy. Therefore, a history of nicotine consumption should be included in the medical history of infants presenting with apnea.
Absent Hypoxic and Hypercapneic Arousal Responses in Children With Myelomeningocele and Apnea
Authors: Ward Sally L. Davidson , Nickerson Bruce G. , van der Hal Andre , Rodriguez Antonio M. , Jacobs Robert A. , Keens Thomas G.
Published: December 2021

Hypoxic and hypercapneic arousal responses from quiet sleep were tested in seven infants with myelomeningocele and Arnold-Chiari malformation who were symptomatic with apnea and/or hypoventilation. All infants with myelomeningocele required tracheostomy and posterior fossa decompression. Responses were compared with those of nine healthy control infants. To assess hypoxic arousal, inspired Po2 was decreased until the end-tidal (alveolar) Po2 reached 45 mm Hg for a maximum of three minutes. Eleven studies were performed in seven infants with myelomeningocele, and arousal occurred in only two studies (18.2%). Eight of nine control infants aroused to hypoxia (89%). To test hypercapneic arousal, inspired Pco2 was increased until end-tidal Pco2 reached 60 mm Hg for a maximum of three minutes. Eight studies were performed on six infants with myelomeningocele, and arousal occurred in three studies (37.5%). All seven control infants studied aroused to hypercapnea (100%). Three infants with myelomeningocele subsequently died. Infants with myelomeningocele, Arnold-Chiari malformation, and apnea or hypoventilation have arousal deficits to respiratory stimuli.
Ultrasonography in the Radiologic Evaluation of Children With Urinary Tract Infection
Authors: Alon Uri , Pery Menucha , Davidai Giora , Berant Moshe
Published: December 2021

A prospective blind study comparing the findings of ultrasonography, intravenous pyelography, and voiding cystourethrography was conducted on 81 patients to examine the place of ultrasonography in the initial radiologic evaluation of children with urinary tract infection. The patients' mean age was 4.8 years; 15 were male. Forty-eight were inpatients (mean age, 3.2 years) and 33 were outpatients (mean age, 7.2 years). In 29 patients (35.8%) abnormality of the urinary system was detected by one or more of the three imaging procedures; 21 were inpatients and eight were outpatients. The most frequent finding was vesicoureteral reflux, occurring in 62.1% of the pathologic cases. The findings at ultrasonography correlated well with those of intravenous pyelography in 73 of the 81 studies (90.1%), but they failed to demonstrate double collecting systems and several of the minor changes. However, ultrasonography in combination with cystourethrography identified all patients who had abnormal urinary systems, except for two children with negligible findings. Moreover, ultrasonography and cystourethrography together identified all 11 patients, nine of them inpatients, in whom surgical treatment was indicated. It is concluded that ultrasonography can successfully replace intravenous pyelography as a screening imaging procedure for the urinary system, but because of the superiority of intravenous pyelography in the detection of some types of lesions, intravenous pyelography will be required whenever ultrasonography or cystourethrography results are abnormal. Accordingly, and in view of the differences in the frequency and severity of pathologic findings between outpatients and hospitalized patients, the following protocol is suggested for the radiologic evaluation of children with urinary tract infection: For outpatients, cystourethrography can be performed 4 to 6 weeks after cessation of antibiotic therapy. If the study is normal, ultrasonography can be done; if this is also normal, no further radiologic workup is needed. Only when cystourethrography or ultrasonography findings are abnormal is intravenous pyelography also indicated. For hospitalized patients, especially young children, ultrasonography can be used as the early screening procedure, within two to four days after the diagnosis of urinary tract infection. If the results are normal, cystourethrography can follow after 4 to 6 weeks; if abnormal, cystourethrography can be performed after ten to 14 days. Here, too, intravenous pyelography is needed only when ultrasonography and/or cystourethrography results are abnormal.
Neonatal Neurosonographic Correlates of Cerebral Palsy in Preterm Infants
Authors: Graziani Leonard J. , Pasto Matthew , Stanley Christian , Pidcock Frank , Desai Hemant , Desai Shobhana , Branca Paul , Goldberg Barry
Published: December 2021

Serial neurosonographic examinations are routinely performed at frequent intervals during the nursery course of all preterm infants of 33 weeks or less gestation who are admitted to the intensive care nursery of Thomas Jefferson University Hospital. After discharge, the following survivors during the past 5 years had repeated ultrasound examinations until the anterior fontanel closed and clinical assessments until the presence or absence of cerebral palsy at a minimum age of 12 months was established: (1) all infants with grade III/IV intracranial hemorrhage, periventricular echodensity and periventricular cyst formation, (2) selected infants with either normal ultrasound findings or grade I/II intracranial hemorrhage. Fifteen survivors were found to have cerebral palsy, and all had at least one of the following ultrasound abnormalities: (a) diffuse, bilateral, and multiple periventricular cysts 3 mm or more in diameter that persisted beyond term age, (b) bilateral asymmetrical dilation of the lateral ventricles following grade III intracranial hemorrhage with small periventricular cysts, and (c) ventricular porencephaly following an ipsilateral grade IV intracranial hemorrhage. The periventricular cysts were usually preceded by extensive echodensities of the white matter surrounding the lateral ventricles; these findings were suggestive of periventricular leukomalacia and were the most common abnormal findings on ultrasound in the infants with cerebral palsy. Of 124 infants without cerebral palsy, 121 had no or less severe abnormal findings on ultrasound; the exceptions were three infants with bilateral persistent large periventricular cysts who had normal motor development in late infancy.
Corroborative Evidence for the Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants
Authors: Wiswell Thomas E. , Roscelli John D.
Published: December 2021

We report the results of a two-part study examining the incidence of urinary tract infection during the first year of life. In the first part of the investigation, we reviewed the occurrence of urinary tract infection in a cohort of 3,924 infants born at our institution during a 4-year period. Infection developed in 16 infants (0.41%). The incidence of urinary tract infection in noncircumcised males was greater than the incidence in both female (P < .004) and circumcised male (P < .001) infants. In the second part of the study, we explored the frequency of urinary tract infection in all infants born in US Army hospitals, worldwide, over a 10-year period. There were 422,328 infants born in army facilities during this time period. Subsequent hospitalization for urinary tract infection occurred for 1,825 (0.43%) infants during the first year of life. Overall, there was no male preponderance for infections in early infancy compared with females. After an equivalent incidence during the first month of life, female infants had significantly more infections than did male infants (P < .001). However, noncircumcised male infants had a higher incidence of urinary tract infection than female infants (P < .001). Additionally, noncircumcised male infants had a tenfold greater incidence of infection than circumcised male infants (P < .001). There was a significant decrease in the circumcision frequency rate during the 10-year study period (from 85.4% to 73.9%, P < .001). As the number of circumcisions decreased, there was a concomitant increase in the overall number of urinary tract infections in males (P <.02). A reduced incidence of infection may be at least one medical benefit of routine neonatal circumcision.
Morbidity Following Minor Head Trauma in Children
Authors: Casey Rosemary , Ludwig Stephen , McCormick Marie C.
Published: December 2021

Head trauma, the most common form of accidental injury among children, is a source of concern for parents and pediatricians. Parents worry about a child's loss of intellectual function. Pediatricians often see the well-documented sequelae of severe head trauma as a basis for parental instructions on observation of a child after minor head injury. A prospective study of 321 children, 6 months to 14 years of age, who had sustained minor head injury within the previous 24 hours was conducted in the emergency department of the Children's Hospital of Philadelphia. Parents of all children completed a ten-minute triage questionnaire and received discharge instructions after their child had received standard medical management. One month after the injury, a questionnaire was administered in a telephone interview to assess the child's physical health status, social or functional limitations, and behavior problems. Physical morbidity was rare, and headache, the most frequent complaint, occurred in only 7% of the children. However, parents reported substantial functional morbidity, and there were significantly more behavioral problems in the 2- to 14-year-old head trauma patients than reported for the standard normal population. Therefore, children who have sustained minor head trauma manifest substantial functional morbidity despite the rarity of physical sequelae. This functional morbidity probably reflects parental overreaction and possibly family dysfunction. It is recommended that pediatricians who have determined that a child's head injury is mild should focus parental education on the rarity of physical sequelae and the importance of the child's returning to a normal routine.
Lessons From the E-Ferol Tragedy
Authors: Balistreri William F. , Farrell Michael K. , Bove Kevin E.
Published: December 2021

"Those who cannot remember the past are condemned to repeat it."—G. Sabtatana

Several factors combined to suggest that supplemental vitamin E should be administered to low birth weight infants. The persistent concern and controversy, the latter confounded by a paucity of data, have been discussed in recent editorials.1,2 At birh, tissue stores of the naturally occurring lipidsoluble antioxidant vitamin E (α-tocopherol) are low. The amount of total tocopherol in the tissue of premature infants is approximately one half that of full-term infants. 3 Maternal vitamin E supplementation seems to have minimal effect on serum vitamin E levels in the newborn because there is poor placental transfer; maternal blood levels are higher than cord levels.1-3
Cultural "latrogenic" Cleft Palate
Authors: BARAKAT AMIN Y. , ITANI USAMA , ZAYTOUN GEORGE M.
Published: December 2021

Pediatricians are familiar with congenital cleft palates and those occurring as a part of a multisystem abnormality. We have encountered a child with a cultural "iatrogenic" cleft palate.

The patient is a 5-year-old girl who appeared normal until 4 months of age, at which time she became febrile and had difficulty breathing as a result of an upper respiratory tract infection. She was not attended to by a physician, but a uvulectomy, supposedly to prevent respiratory distress, was performed by a laywoman considered by the villagers to be a "specialist" in the procedure.

Following the uvulectomy, the infant experienced feeding difficulty, choking on solid and liquid foods.
Screening for Developmental Disabilities
Authors:   Committee on Children With Disabilities
Published: December 2021

Early identification and treatment of developmental disabilities that cause school-related problems is of considerable importance to practicing pediatricians. The motivation for early identification programs is: (1) to identify the barriers to children's participation in the educational process, (2) to assist these children and their families in finding medical, educational, or other appropriate services, and (3) to overcome or mitigate the adverse effects of the disability.

The need for visual and auditory examinations to identify deficits in these areas is readily accepted. Use of these examinations is standard practice. However, use of preschool examinations for developmental problems, potential learning disabilities, and mental retardation needs to be encouraged. These disorders, which may be less obvious, may have a major impact on the physical and mental health of children and their families.

Screening identifies most children who have or who are at risk of having developmental disabilities. Pediatricians have the opportunity to incorporate screening examinations in the context of well-child care and to refer their patients for confirmatory testing by an appropriate consultant, if indicated.

The conduct of a scheduled health evaluation, as described in Academy guidelines,1 includes a systematic evaluation of development at all ages, commencing in the perinatal period. Simple instruments that identify developmental problems are readily available.2-4 These tests assure early identification of a range of developmental disabilities.

Specific safeguards, including carefully developed guidelines and procedures, should accompany the application of such screening tests when practiced as part of a large community-based program, as well as in the pediatrician's office. Participation by pediatricians in the development and implementation of these screening procedures will assure that such efforts are comprehensive and effective.
Self-Regulation of Stimulation by Premature Infants
Authors: Thoman Evelyn B. , Graham Susan E.
Published: December 2021

Premature babies are capable of seeking contact with a source of rhythmic stimulation that reflects their own breathing rhythm. Optional stimulation, in the form of a "breathing" stuffed bear, was made available to premature infants, 32 to 35 weeks' gestational age. The bear's breathing rate was matched to that of each individual infant during quiet sleep. Other infants were exposed to a bear that did not breathe, and some infants were not exposed to a bear. All infants were monitored continuously using time-lapse video. After 2 to 3 weeks' exposure, those infants with a breathing bear-showed significantly more contact with their head, body, or limbs than either of the control groups (for the no-bear group, contact with the area that would have been occupied by the bear was determined to describe the contact that might have been expected by chance). In addition, the infants given the opportunity to self-regulate their stimulation showed greater amounts of quiet sleep than the other two groups.
Toluidine Blue in the Detection of Perineal Lacerations in Pediatric and Adolescent Sexual Abuse Victims
Authors: McCauley Jeanne , Gorman Richard L. , Guzinski Gay
Published: December 2021

Posterior fourchette lacerations are suggestive of sexual assault, and toluidine blue dye has increased the detection of these lacerations in adult rape victims. This study investigated the use of toluidine blue dye in the pediatric (0 to 10 years) and adolescent (11 to 18 years) patients to detect posterior fourchette lacerations in sexually abused and control populations. Application of toluidine blue dye increased the detection rate of posterior fourchette lacerations from 4% (1/25) to 28% (7/25) (P < .05, Fisher exact test) in adolescent sexually abused patients and from 16.5% (4/24) to 33% (8/24) (P = .318, Fisher exact test) in pediatric sexually abused patients. Posterior fourchette lacerations occurred with the same frequency in sexually abused adolescents and sexually active controls adolescents. In the pediatric aged population, 33% of the sexually abused group had lacerations detected, whereas none of the control patients had lacerations. The presence of posterior fourchette lacerations in the pediatric aged patient is strongly suggestive of sexual abuse. Toluidine blue increases the detection of posterior fourchette lacerations in children and adolescents (P < .001, Fisher exact test). The application of toluidine blue dye to highlight posterior fourchette lacerations is an important addition to tools already used in the evaluation of the sexually abused patient.
Questioning Role of Hypochloremia in Bronchopulmonary Dysplasia
Authors: PERLMAN JEFFREY M. , DAWSON JEFF
Published: December 2021

In Reply.—

We appreciate the interest in our report published in Pediatrics (1986;77:212-216). The three letters raise similar questions, and in response we would like to make three points.

First, including the two infants in the control group who died with the infants in the study group still resulted in significant differences between the two groups regarding duration of furosemide (Lasix) therapy, hypochloremia, or metabolic alkalosis (P > .001). Second (as noted in our discussion), bronchopulmonary dysplasia is a complex disease process.
Transdermal Patch Poisoning
Authors: HAMBLIN JOAN E. , MARTIN CHARLES A.
Published: December 2021

To the Editor.—

We wish to report a case of an accidental ingestion of clonidine from a transdermal patch by a 9-month-old baby. A.M., a 9-month-old boy, was seen in a local emergency room six hours after he had accidentally mouthed a transdermal clonidine patch. A.M.'s father had applied a 2.5-mg transdermal clonidine patch to his left wrist under his watch ten to 12 days earlier for BP control. The night before the incident, the father had removed his watch.
Epidemiology of School Injuries: A 2-Year Experience in A Municipal Health Department
Authors: Sheps Samuel B. , Evans G. Dewey
Published: December 2021

School injuries occurring in a municipal school system during a 2-year period were reviewed to identify epidemiologic features of school injuries, to determine data requirements for ongoing injury surveillance, and to identify potential preventive strategies. Overall, 3,009 injuries were reported (2.82/100 students per year). Elementary school students had only a slightly higher rate (2.85) than secondary school students (2.78). However, the cause, nature, school location of injury, and body area injured formed distinct patterns in these two groups. Playgrounds were responsible for the highest overall and elementary school rates, whereas sports areas and classrooms had the highest rates among secondary school students. Falls were the most frequent cause of injury in elementary schools whereas, as expected, sports injuries were the most frequent cause among secondary school students. Contusions and abrasions of the head were the most frequent type of injury for both groups, although more common among elementary school students, whereas fractures, sprains, strains, and dislocations were more frequent among secondary school students. Although the proportion of severe injuries to secondary school students was slightly higher (39 v 35%), the rate of referral of students to a hospital or physicians among secondary school students (1.21 per 100 student-hours) was almost twice the rate of elementary school students (0.65 per 100 student-hours). Problems with definition of injury severity and the need to explore the social aspects of schools as a factor in injuries emerged as important considerations for future research.
Health Insurance Coverage and Physician Use Among Children With Disabilities: Findings From Probability Samples in Five Metropolitan Areas
Authors: Butler John A. , Singer Judith D. , Palfrey Judith S. , Walker Deborah K.
Published: December 2021

The effect of insurance coverage on physician use for children in the United States who have been identified as disabled by their schools under the provisions of the Education for All Handicapped Children Act (PL 94-142) is examined. The research is based on identically drawn stratified random samples of children from the elementary school special education populations of five large metropolitan school systems. It was found that (1) health insurance coverage was a predictor of whether a disabled child had seen a doctor in the past year even after adjustment for site, family background characteristics, type and severity of childhood disability, and structural access factors (adjusted odds ratio, 1.76, P < .05); (2) Hispanic children with disabilities were more likely than white children to be without any health insurance (adjusted odds ratio, 3.63; P < .001), but there was no similar statistically significant difference between blacks and whites; and (3) wide variations persist in scope of insurance payment for care, such that parents of publicly insured children paid out of pocket for only 5% of all physician visits as compared to 30% of visits for the privately insured. Even for children with various lowprevalence disabilities, when privately insured, parents paid out of pocket for 23% of all physician visits. These data help clarify the extent of health insurance coverage among children with disabilities and indicate that insurance remains an important predictor of physician use even though it continues to pay for only certain elements of care.
Delay in Caffeine Elimination in Breast-Fed Infants
Authors: Le Guennec Jean-Claude , Billon Bernard
Published: December 2021

Because of a persistently elevated caffeine half-life observed in a breast-fed infant during caffeine maintenance therapy, we conducted this prospective iongitudinal study in two groups of infants (five exclusively breast-fed and 12 formula-fed). After 46 weeks' postconceptional age, all five breast-fed infants had a marked delay in caffeine elimination, compared with one infant in the formula-fed group. Four breast-fed infants had measurements of significantly longer caffeine half-lives compared with 12 formula-fed infants (76 ± 13 hours v 21 ± 28 hours and 54 ± 9 hours v 16 ± 13 hours at 47 to 50 weeks and 51 to 54 weeks postconceptional age, respwxricwly), as well as significantly higher trough blood levels (three- to five-fold) after 46 weeks' postconceptional age. The fifth breast-fed infant accumulated caffeine secondary to a steep increase in caffeine half-life from 102 hours at 44 weeks to 372 hours at 51 weeks. The elevated blood caffeine levels in breast-fed infants was not related to higher daily dosage of caffeine citrate (4.4 mg/kg compared with 8.3 mg/kg in the formula-fed group at 56 weeks' postconceptional age). Daily consumption of caffeine was low or nonexistent in four nursing mothers, and transfer of caffeine to the infant was considered to be trivial. The findings from this study suggest, as does breast milk jaundice due to inhibition of glycuronyl transferase, that some components of human milk (free fatty acid, lipase activity, or other factors) inhibit or repress the postnatal normal maturation process of caffeine metabolism by hepatic cytochrome P-450.
Pain—A Subject Ignored
Authors: RANA SOHAIL R.
Published: December 2021

To the Editor.—

The majority of hospitalized children with severe pain do not receive optimal analgesia for its relief. Our opinion is based upon personal experience, communication with colleagues, and published surveys.1,2 Misuse of analgesics includes subtherapeutic doses, "prn" orders, inappropriately long intervals between doses, and use of placebos to prove that pain is not organic. This maltreatment reaches cruel proportions in infants and neonates when surgical procedures are sometimes performed without anesthesia and postoperative analgesia.
Digoxin Inactivation by the Gut Flora in Infancy and Childhood
Authors: Linday Linda , Dobkin Jay F. , Wang Timothy C. , Butler Vincent P. , Saha Jnan R. , Lindenbaum John
Published: December 2021

Inactivation of digoxin by reduction of the lactone ring has recently been shown to occur in one third of adults and to be mediated by anaerobic intestinal bacteria. Children from birth through adolescence were studied to determine the pattern of development of this gut flora-mediated process. None of 36 digitalized infants 8 months of age or less excreted reduced digoxin metabolites in the urine. The adult pattern of digoxin reduction product excretion by one third of patients was observed after 16 months of age; however, high levels of digoxin reduction products such as are found in 10% of adults were not encountered in children less than 9 years of age. Even though reduced metabolites were not formed in vivo early in life, stool cultures of 20 of 73 infants younger than 8 months of age contained digoxin reduction product-forming bacteria at high concentrations, in some instances as early as the second week of life. Maturation of the gut flora with respect to digoxin metabolism appears to be a protracted process. The relative digoxin resistance of infants and children is not due to bacterial inactivation.
Binding Effect of Albumin on Uptake of Bilirubin by Brain
Authors: Robinson P. J. , Rapoport S. I.
Published: December 2021

A mathematical model is presented to describe quantitatively the uptake of bilirubin into the brain from blood, under conditions of extensive binding to plasma proteins. The model relates bilirubin uptake to the rate constants for dissociation and association of the albumin/bilirubin complex and to the transit time of blood through brain capillaries. A rational basis is given for deciding between the total or the free bilirubin concentration as an appropriate indicator of brain exposure to the toxic effects of bilirubin. The effect of competition for binding sites by drugs such as sulfonamides on the brain uptake of bilirubin is also described quantitatively.
Health Care of Foster Children
Authors:   COMMITTEE on EARLY CHILDHOOD, ADOPTION, and DEPENDENT CARE
Published: December 2021

Children entering foster care generally have a higher than average number of health problems, and the care they receive is usually insufficient to meet their needs. These circumstances arise from the preplacement history of these children and from within the dual systems of foster care and publicly funded health care to which responsibility for their well-being is assigned.

BACKGROUND

Children enter foster care because their parents are unwilling or unable to provide for their physical and emotional needs. Most often, these children come from single-parent households where poverty, lack of formal education, and absence of social support contribute to inadequate and inappropriate child care. More than 80% of the children have experienced physical or sexual abuse and/or neglect. Their previous health care is likely to have been fragmented. As a consequence, foster children are likely to have unrecognized or untreated chronic disorders, a high rate of emotional and developmental problems, and impaired school performance.

Placement of children into foster care is ordinarily a court-ordered process used when the application of resources by social service agencies fail to, or appear unlikely to, improve a home situation deemed detrimental to the children's well-being. Foster care is intended to be a planned temporary service designed to strengthen families and to enhance the quality of life for children. The imposed separation of children from parents is a decision intended to be based on the best interests of the children. It is to be an opportunity for families to receive the social support and counsel they require to be reconstituted.
ABSORPTION OF α-TOCOPHEROL AND TOCOPHERYL ESTERS BY PREMATURE AND FULL TERM INFANTS AND CHILDREN IN HEALTH AND DISEASE
Authors: FILER LLOYD J. , WRIGHT STANLEY W. , MANNING MARY PARKE , MASON KARL E.
Published: December 2021

The ability of premature and full term infants in health and disease to absorb vitamin E (tocopherol) was determined using the technic of multiple withdrawals of small samples of capillary blood at three hour intervals following an oral dose of α-tocopherol or α-tocopheryl esters.

Premature infants were found to absorb vitamin E as well as full term infants, when compared on the basis of the area under the curve for a 12 hour period following an oral dose of tocopherols at 20 mg./kg. body weight. This is in marked contrast to the diminished ability of the premature infant to utilize vitamin A and fats.

In a series of 29 infants, those disease states diagnosed as fibrocystic disease of the pancreas, diarrhea and cirrhosis were characterized by a poor response to the test, i.e., the tolerance curve was low. Others, infants with a variety of disorders not associated with fat or fat-soluble vitamin intolerance, had characteristic absorption curves with a maximum nine hours after receiving oral tocopherol.

In a series of 14 children and 1 adult, patients with sprue, celiac syndrome and lupus erythematosis were noted to absorb tocopherols poorly. Metabolic disorders with associated hypercholesterolemia were observed to give abnormally high values for the area under the curve.

A comparison of vitamin A absorption with vitamin E or tocopherol absorption in a series of 10 observations indicated that patients responding poorly to one test did poorly in both.

No difference in response was noted when various esterified forms of tocopherol were administered in place of α-tocopherol. This is contrary to the reported increase in biologic potency (rat assay) of the esterified forms of tocopherol.

An index calculated from the fasting and nine hour levels of serum tocopherol which corrected for the tocopherol equivalents supplied by the ester forms compared favorably with the area measurements and failed to demonstrate any difference in absorption of the free versus ester tocopherol.
SOME OBSERVATIONS ON FACIAL PARESIS IN THE NEWBORN INFANT: ETIOLOGY AND INCIDENCE
Authors: HEPNER W. R.
Published: December 2021

The incidence of facial paresis in 875 consecutive mature cephalic births was 6.4%. The use of forceps was found not to influence the incidence of facial paresis. Pressure on the sacral prominence during labor is probably responsible for the majority of facial pareses seen in the newborn infant.
HEAT PROSTRATION IN FIBROCYSTIC DISEASE OF THE PANCREAS AND OTHER CONDITIONS
Authors: KESSLER WALTER R. , ANDERSEN DOROTHY H.
Published: December 2021

Twelve cases of heat prostration in infants and children are reported. Ten of these occurred during the New York City heat wave of August 1948.

Seven of these patients had cystic fibrosis of the pancreas. These patients differed from those with heat prostration but without fibrocystic disease in the following ways: They were considered to be doing well prior to the acute onset; the onset was later in the course of the heat wave than was the case in the nonfibrocystic patients; onset was with vomiting; the clinical response to therapy was prompt while the return of plasma chlorides to normal was more gradual.

Patients with fibrocystic disease of the pancreas are especially susceptible to heat prostration during prolonged periods of high atmospheric temperature. This fact has a practical application in prophylaxis for known cases of this disease, and in arousing a suspicion of the disease in infants and children with heat prostraton who have previously been considered healthy.
MYOSITIS OSSIFICANS PROGRESSIVA
Authors: RILEY HARRIS D. , CHRISTIE AMOS
Published: December 2021

Four new cases of myositis ossificans progressiva have been presented and the literature on the subject has been reviewed.

At the onset typical cases will usually develop palpable masses over the fascial planes of the head and neck. Biopsy of these lesions suggests tumor tissue but this subsequently goes on to calcification and ossification.

This point illustrates that the disease title—myositis ossificans—is really a misnomer since there is no calcification of muscles themselves but rather a calcification of the connective tissue between the muscles.

When the disease progresses as illustrated by the cases reported, they frequently present themselves with gait or posture disturbance or with other orthopedic complaints. Microdactylism and hallux valgus deformity of the great toe are two of the outstanding findings.

The cases reported illustrate the various stages of the disease under discussion. From inflammation, swelling, induration of the muscles and connective tissues to tumefaction, the disease finally progresses to calcification in from 2 to 8 months. Finally, the calcification progresses to ossification and severe crippling. Serial illustrations and roentgenograms on several of these cases illustrate these progressive changes.

All biochemical determinations have been normal but marked subjective improvement following cortisone therapy in one early case suggests the possible relationship of this disease process to disturbed steroid metabolism.
SPECIAL REVIEWS
Authors: GLICKLICH LUCILLE BARASH
Published: December 2021

This paper presents a review of enuresis from an historical aspect. It begins with a discussion of the treatment of the enuretic problem in primitive civilizations and carries its colorful history through to the close of the 19th century. There follows a short discussion of the modern psychologic theories concerning its etiology. In conclusion there is reemphasis of the statement that enuresis is a symptom, not a disease, and as such it is only by greater understanding of the individual underlying pathology that enuresis can be successfully treated.
Vascular Basis for Neural Tube Defects: A Hypothesis
Authors: Stevenson Roger E. , Kelly JoAnn C. , Aylsworth Arthur S. , Phelan Mary C.
Published: December 2021

A hypothesis is set forth that neural tube defects are produced by inadequate nutrient supply to the rapidly growing neural folds. According to this hypothesis, a delay in establishing blood flow or an aberration of blood supply to neural tissue may interfere with nutrition and prevent neural tube closure. The hypothesis was tested by examining the vasculature of fetuses with spinal neural tube defects. In each case, the arterial supply to the region of the neural tube defect was disturbed. Because development of arterial supply to the neural folds predates neural tube closure, these vascular abnormalities are considered to be primary malformations that lead to neural tube defects rather than secondary morphologic disturbances resulting from neural tube defects.
Clinical Guidelines for the Pediatrician
Authors: Stickler Gunnar B.
Published: December 2021

Much of clinical medicine is still based on empiricism, particularly the approach to diagnosis. One aspect of diagnosis that is talked about is the intuition of the experienced clinician. Most physicians working in a referral center have developed certain guidelines for themselves and have adopted suggestions from their teachers and colleagues. Some of these rules are recorded in books and essays, and others are passed by word of mouth from one generation of physicians to the next. It should not be necessary to emphasize that these are rules and not laws. Indeed, exceptions occur, and if there are not too many, they tend to prove the validity of a rule.

I want to suggest some of the rules I have found useful. It is impossible to state who was the author of them, even if I might claim that most of them are my own. I hope they generate responses and discussion, which perhaps will lead to deletions, additions, and refinements.

1. Determine the true "chief complaint" and do not accept previous diagnoses as the chief complaint. For example, if a patient presents because of urinary frequency and painful urination, he or she is not complaining of a "urinary tract infection." The chief complaint should be listed in simple English as what the patient or parent states as the reason for consulting the physician and not as a previous diagnosis.

2. Listen to the mother or the primary caretaker; these persons are the best observers and describe the situation well.
Febrile Exudative Tonsillitis: Viral or Streptococcal?
Authors: Putto Anne
Published: December 2021

A prospective 1-year study of acute febrile exudative tonsillitis in 110 children was carried out. Viral infection was associated with 42% of the cases, β-hemolytic streptococci with 31% (12% group A), Mycoplasma pneumoniae with 5%, and unknown cause with 35%. More than one agent was implicated in 14% of the cases. Adenovirus was the viral agent most frequently (19%) recorded. Other viruses involved were Epstein-Barr virus, parainfluenza, influenza A, herpes simplex, and respiratory syncytial viruses. The responsible agent was found by rapid viral antigen detection in 20% of all cases and by rapid test for group A streptococcal antigen detection in 10%. Age was the most important factor in predicting the causative agent. Viral tonsillitis was most common in children younger than 3 years of age and group A β-hemolytic streptococci tonsillitis in children 6 years of age or more. Clinical analysis of the illness, WBC count, and ESR did not reveal differences that could help in differentiating bacterial from viral tonsillitis. All patients were treated with a regimen of oral penicillin. Fever associated with group A β-hemolytic streptococci tonsillitis responded to penicillin therapy significantly more rapidly than fever associated with viral infections. These observations demonstrate the prominent role of viruses in the etiology of febrile exudative tonsillitis, especially in young children, and reinforce the benefit of rapid tests before antibiotic therapy is started.
Hearing Loss in Infants With Persistent Fetal Circulation
Authors: Hendricks-Muñoz Karen D. , Walton Joseph P.
Published: December 2021

Infants with the diagnosis of persistent fetal circulation were evaluated for hearing loss. From Jan 1, 1982, to Jan 1, 1984, 28 infants with this diagnosis were retrospectively identified, and 18 were evaluated by formal audiologic testing. Additionally, 22 infants were prospectively followed by serial auditory evaluation from Jan 1, 1984, to Jan 1, 1986. Of the 40 infants evaluated, 21 were identified as having hearing impairment (52.5%), 14 of whom required hearing aids. For 82% of those retrospectively identified hearing-impaired infants who required hearing aids, parental concern was expressed for their lack of hearing acuity. This factor could have aided in the earlier recognition of these infants' impairment. Among those infants followed prospectively, formal audiologic testing, in some cases serially, was needed to diagnose a progressive hearing loss that was expressed at 6 to 8 months after discharge from the neonatal intensive care unit. Perinatal factors associated with the development and management of persistent fetal circulation were identified and compared in infants with comfirmed hearing loss and those with normal hearing. Variables related to those infants with hearing loss were as follows: degree of alkalosis, duration of ventilation, and possibly use of furosemide. We concluded from these results that infants with persistent fetal circulation have an extremely high incidence of sensorineural hearing loss and suggest serial formal audiologic evaluations to aid in detection of hearing-impaired infants.
Self-Esteem in Children Medically Managed for Attention Deficit Disorder
Authors: Kelly Patrick C. , Cohen Melvin L. , Walker William O. , Caskey Owen L. , Atkinson A. W.
Published: December 2021

Self-esteem was measured initially in a group of 21 eight- to 12-year-old children with newly diagnosed attention deficit disorder/hyperactivity and remeasured after 1-month courses of treatment with methylphenidate and placebo given in double-blind cross-over fashion. Multimodal management of all patients included diagnosis, demystification, medication, close follow-up with supportive counseling, and referral as indicated for psychosocial and educational assistance. Long-term follow-up of 12 children who continued to receive methylphenidate was done for an average of 16 months. Initial total self-esteem was low in 30% of all subjects, intermediate in 55%, and high in 15%. No statistically significant changes occurred in self-esteem during the short-term phase of the study despite clinically significant behavioral responses to medication as assessed by serial questionnaires. At long-term follow-up, total, general, and academic self-esteem scores were improved significantly, however. These findings indicate that many preadolescents with attention deficit disorder/hyperactivity exhibit low self-esteem. Despite clinical response to medication, short-term improvement in self-esteem may not occur; however, long-term, multimodal management that includes medication does appear to improve self-esteem.