bluuebunny/crossref_metadata_2025 huggingface dataset:
Score for Neonatal Acute Physiology: Validation in Three Kaiser Permanente Neonatal Intensive Care Units
Authors: Escobar Gabriel J. , Fischer Allen , Li De Kun , Kremers Robert , Armstrong Mary Anne
Published: December 2021

Background. Measurement of the severity of illness is a research area of growing importance in neonatal intensive care. Most severity of illness scales have been developed in tertiary care settings. Their applicability in community neonatal intensive care units has not been tested.

Objectives. Our goal was to assess the operational characteristics of the score for neonatal acute physiology (SNAP): the relationship to birth weight, the length of total hospital stay, and in-hospital mortality.

Methods. We assigned SNAP scores prospectively to all inborn admissions at three community neonatal intensive care units during an 11-month period. Data on other neonatal predictors (eg, birth weight and the presence of congenital heart disease) were also collected. We measured in-hospital mortality, the experience of interhospital transport to a higher level of care, and total hospital stay.

Results. We found that the SNAP's relationship to birth weight was similar to previous reports. The SNAP's perinatal extension is a reliable predictor of newborn in-hospital mortality, with an area under the receiver operator characteristic curve of 0.95. The SNAP is also a good predictor of total hospital length of stay, whether by itself (by which it can explain 31% of the total stay) or in combination with other variables. Its predictive ability is better among infants of low birth weight (<2500 g) than among those of normal birth weight (≥2500 g). The SNAP's predictive power was most limited among infants admitted to rule out sepsis. The predictive ability of a model containing birth weight, the SNAP, and transport status was not improved by the inclusion of two major diagnostic categories, the presence of congenital heart disease or complex illness.

Conclusion. Although it has definite limitations among infants who weigh 2500 g or more, the SNAP is a potent tool for outcomes research. Modification of some of its parameters could result in a multifunctional scale suitable for use with all birth weights.
Human Milk, Breastfeeding, and Transmission of Human Immunodeficiency Virus in the United States
Authors:   Committee on Pediatric AIDS
Published: December 2021

When making recommendations concerning feeding options for infants, health care providers in the United States must balance the potential for transmission of HIV through human milk with the known benefits of breastfeeding. Additional epidemiologic studies are needed to assess accurately the actual risk of HIV transmission to infants from human milk in the United States. However, because HIV transmission via human milk is possible, knowledge of the HIV serostatus of pregnant women is important to determine whether breastfeeding is appropriate.
Comparison of Diphtheria-Tetanus-Two Component Acellular Pertussis Vaccines in United States and Japanese Infants at 2, 4, and 6 Months of Age
Authors: Rothstein Edward P. , Kamiya Hitoshi , Nii Ritsue , Matsuda Tadashi , Bernstein Henry H. , Long Sarah S. , Hosbach Philip H. , Meschievitz Carlton K. ,   PENNRIDGE PEDIATRIC ASSOCIATES
Published: December 2021

Objective. We compared the diphtheria and tetanus toxoids and bicomponent acellular pertussis vaccine (DTaP) responses in Japanese and United States infants.

Design. This was a double-blind, comparative study.

Setting. Private pediatric practices in Japan and the U.S. participated.

Subjects. One hundred eighty-nine healthy 2-month-old infants were tested.

Interventions. Infants were immunized at 2, 4, and 6 months of age. The Japanese formulation (DTaP-J) contained 20 µg of pertussis toxin (PT) and 20 µg of filamentous hemagglutinin (FHA); the U.S. formulation (DTaP-US) contained 23.4 µg of each antigen. Parents used a standard form to record adverse experiences. Serum was obtained before the first immunization, 2 months after the second immunization, and 1 month after the third immunization.

Measurements. Differences in DTaP-J and DTaP-US were evaluated in Japanese infants immunized subcutaneously (SC). Differences due to ethnicity and to route of administration were compared in U.S. infants immunized with DTaP-US SC or intramuscularly (IM). An indirect enzyme-linked immunosorbent assay was used to determine immunoglobulin G antibody responses to PT, FHA, and tetanus toxoid. Neutralizing antibody to PT was measured by a Chinese hamster ovary cell assay. Diphtheria antitoxin was assayed by serum neutralization on VERO cells.

Results. Statistical differences (P < .05) in adverse events included less fatigue after immunization with DTaP-US compared with DTaP-J. Erythema of more than 2.5 cm was more frequent, but erythema less than 2.5 cm was less frequent in Japanese infants compared with U.S. infants. Fewer Japanese infants were febrile (> 38°C), tired, or irritable. Subcutaneous immunization resulted in a greater frequency of erythema and induration. The DTaP-US resulted in an equivalent response to PT and a greater response to FHA. More Japanese infants demonstrated at least a fourfold response over preimmunization antibody values to FHA. In U.S. infants, antibody responses to the contained pertussis antigens were equivalent after IM and SC administration. Compared with Japanese infants receiving DTaP-J SC, U.S. infants receiving DTaP-US IM had equivalent responses to PT and a greater response to FHA.

Conclusions. United States infants receiving an IM injection of a U.S.-produced bicomponent DTaP vaccine produced antibody responses to the contained pertussis antigens at least equal to those of Japanese infants receiving a similar bicomponent DTaP vaccine shown to be effective in older Japanese children.
Differentiating Cyclic From Chronic Vomiting Patterns in Children: Quantitative Criteria and Diagnostic Implications
Authors: Pfau Brad T. , Li B U.K. , Murray Robert D. , Heitlinger Leo A. , McClung H. Juhling , Hayes John R.
Published: December 2021

Objective. To establish criteria to differentiate two patterns of vomiting and to identify the predominant diagnoses for each one.

Methods. All children 2 to 18 years of age referred to a pediatric gastroenterology service who presented with recurrent vomiting (three episodes of vomiting within a 3-month period) as a primary complaint from 1985 to 1991 were retrospectively reviewed (n = 106). The vomiting pattern (emeses per hour and episodes per month), diagnostic studies, and therapeutic responses were compared by Mann-Whitney U and x2 tests.

Results. Based on the criteria of peak intensity (four or more emeses per hour) and frequency (nine or fewer episodes per month), two subgroups were differentiated: children with a cyclic pattern (n = 34), who vomited at a higher peak intensity (12.6 ± 1.6 vs 1.5 ± 0.1 emeses per hour) but at a lower frequency (1.9 ± 4.8 vs 36.6 ± 0.3 episodes per month) than those with a chronic pattern (n = 72). Among children with a cyclic pattern, nongastrointestinal (65%) causes, especially abdominal migraine, predominated over gastrointestinal ones (12%), whereas among those with a chronic pattern, gastrointestinal disorders (76%), especially peptic and infectious disorders, predominated over nongastrointestinal ones (10%).

Conclusions. On the basis of quantitative historical criteria, children with recurrent vomiting can be classified into two subgroups that seem to be clinically and etiologically distinct. Abdominal migraine was the dominant diagnosis in those with cyclic vomiting, whereas peptic and infectious gastrointestinal disorders predominated in those with chronic vomiting. This differentiation between cyclic and chronic patterns of vomiting may be a useful diagnostic clue to the clinician.
Internet List Servers and Pediatrics: Newly Emerging Legal and Clinical Practice Issues
Authors: ELLIOTT STEPHEN J. , ELLIOTT ROBYN C.
Published: December 2021

The Internet is an electronic communications network that spans the globe, and is commonly used to disseminate information relevant to medicine. Many issues resulting from the use of the Internet for medical purposes have never required consideration before. For example, citations that refer to Internet sources (eg, References 3-5 below) have yet to be standardized by the American Medical Association or the British Medical Association.

The Internet list server devoted to topics in neonatology has been operational for more than 1 year. A useful analogy to a list server might be the editorial correspondence section of a journal. In the case of list servers, however, a message posted by an author to the list server is electronically and automatically mailed to all subscribers and is neither peer reviewed nor edited.
Bilateral Cystic Periventricular Leukomalacia in the Premature Infant: Associated Risk Factors
Authors: Perlman Jeffrey M. , Risser Rick , Broyles R. Sue
Published: December 2021

Background. Bilateral cystic periventricular leukomalacia (PVL) is a major cause of neurodevelopmental delay in the premature infant. Thus, early identification of the preterm infant at highest risk for the subsequent development of this lesion is critical.

Objectives. The three objectives of this case-control study were: (1) to determine the basic characteristics of cystic PVL, (2) to assess the relationship of perinatal clinical events and PVL, and (3) to ascertain the feasibility of identifying early those preterm infants at highest risk for the development of PVL.

Methods. The medical records and cranial ultrasound scans (HUSs) were reviewed for 632 infants weighing less than 1750 g who were admitted to the neonatal intensive care unit between January 1992 and December 1993. PVL developed in 14 infants of 1285 ± 301 g birth weight (BW) and 29.4 ± 1.5 weeks' gestational age (GA); severe intraventricular hemorrhage (n = 21) and intraparenchymal echodensity (n = 12) developed in 33 infants of 904 ± 248 g BW and 26.6 ± 1.8 weeks' GA; and 585 infants of 1315 ± 324 g BW and 29.7 ± 2.4 weeks' GA with normal HUS findings (n = 473) or grade I or II intraventricular hemorrhage (n = 112) served as a comparison group.

Results. Cystic PVL was observed in 14 (2.3%) of 632 infants weighing less than 1750 g, more specifically, in 3.2% of infants weighing less than 1500 g. Cysts were noted from the 7th to 14th days of life in 10 infants and from the 20th to 46th days of life in 4 infants. Ten (70%) of the infants had relatively benign clinical courses, and most cases were detected by routine HUS surveillance. Overt hypotension in the immediate perinatal period was noted in 3 (21%) infants; late hypotension developed in 1 additional infant. Univariate analysis indicate that two clinical indicators, prolonged rupture of membranes (PROM) and chorioamnionitis, were significant predictors of PVL. For PROM, the odds ratio estimate and the 95% confidence limit are 6.59 and 1.96 to 22.10, with a sensitivity of 28.6% and positive predictive value of 11.5%. Similar values for chorioamnionitis are 6.77 (1.77 to 25.93), with a sensitivity of 21.4% and positive predictive value of 11.5%.

Conclusions. (1) Most cases of symmetric cystic PVL occurred in infants with relatively benign clinical courses and were only detected by routine ultrasound screening. (2) Postnatal systemic hypotension seems to be an uncommon associated event. (3) Preterm infants born to mothers with PROM and/or chorioamnionitis seem to be at an increased risk for the development of PVL and should be carefully evaluated.
Cocaine-exposed Preterm Neonates Show Behavioral and Hormonal Differences
Authors: Scafidi Frank A. , Field Tiffany M. , Wheeden Abigail , Schanberg Saul , Kuhn Cynthia , Symanski Robert , Zimmerman Eugene , Bandstra Emmalee S.
Published: December 2021

Objective. Prematurity has been associated with prenatal cocaine exposure, but most studies on the behavioral effects of prenatal cocaine exposure have been restricted to full-term infant samples. The current study focused on behavioral and hormonal responses in preterm cocaine-exposed infants compared with a cohort of non-cocaine-exposed infants of similar gestational age.

Methodology. A comparison between 30 cocaine-exposed and 30 non-cocaine-exposed preterm neonates suggested that the cocaine-exposed neonates were born to mothers who had higher parity and more obstetric complications. In addition, mothers of cocaine-exposed preterm neonates visited, touched, held, and fed their infants less frequently than mothers of nonexposed infants.

Results. The cocaine-exposed infants had smaller head circumferences at birth, spent more time in the neonatal intensive care unit, and had a greater incidence of periventricular-intraventricular hemorrhages. They also had inferior Brazelton cluster scores, including lower state regulation and range-of-state scores, and greater depression. During sleep-wake behavior observations, they showed difficulty maintaining alert states and self-regulating their behavior, and they spent more time in indeterminate sleep and had decreased periods of quiet sleep and increased levels of agitated behavior, including tremulousness, mouthing, multiple limb movements, and clenched fists. Finally, higher urinary norepinephrine, dopamine, and cortisol levels and lower plasma insulin levels were noted in the cocaine-exposed preterm neonates.

Conclusions. These findings highlight the need for follow-up assessments and early intervention.
A Controlled Trial of Dexamethasone to Prevent Bronchopulmonary Dysplasia in Surfactant-treated Infants
Authors: Rastogi Alok , Akintorin Subuola M. , Bez Michelle L. , Morales Pablo , Pildes Rosita S.
Published: December 2021

Background. Surfactant therapy now has a well-established role in the treatment of neonates with respiratory distress syndrome but has failed to reduce the incidence of bronchopulmonary dysplasia (BPD). We conducted a double-blind, placebo-controlled trial to test the hypothesis that dexamethasone therapy given during the first 12 days of life to very low birth weight infants would be synergistic to surfactant in preventing BPD.

Methods. Seventy surfactant-pretreated infants (700-1500 g) who had severe respiratory distress syndrome (a/A ratio, 0.18 ± 0.10; mean airway pressure, 11.1 ± 1.9 cm H2O; fraction of inspired oxygen, 0.81 ± 0.22) were enrolled to receive a 12-day course of dexamethasone (n = 36) or saline placebo (n = 34) starting within the first 12 hours after birth. The starting dose of dexamethasone was 0.5 mg/kg per day, and it was tapered progressively.

Results. Ventilator variables at 5 to 14 days were significantly improved in those infants who received dexamethasone compared with those who received the placebo. The effect seem to be more marked in infants weighing less than 1250 g at birth. Significantly more infants could be extubated by 14 days of age in the dexamethasone group (26 of 32 vs 14 of 32). Dexamethasone therapy reduced the incidence of BPD at 28 days (odds ratio, 0.1; 95% confidence interval, 0.03 to 0.3) and eliminated BPD at 36 weeks' postconceptional age. Dexamethasone-treated infants had greater weight loss at 14 days (12.9 ± 6.4% vs 3.7 ± 8.6%, respectively) and higher blood pressures from days 3 to 10. However, no differences were seen in time to regain birth weight, hypertension (1 infant in each group), or incidence of intraventricular hemorrhage.

Conclusions. We found an additive effect between dexamethasone and surfactant in improving pulmonary status and reducing the incidence of BPD. Compared with the placebo, dexamethasone therapy was more effective in reducing the incidence of BPD in surfactantpretreated very low birth weight infants.
Detection of Human Immunodeficiency Virus Type 1 (HIV-1) DNA and p24 Antigen in Breast Milk of HIV-1-Infected Ugandan Women and Vertical Transmission
Authors: Guay Laura A. , Hom David L. , Mmiro Francis , Piwowar Estelle M. , Kabengera Sam , Parsons Jana , Ndugwa Christopher , Marum Lawrence , Olness Karen , Kataaha Peter , Jackson J. Brooks
Published: December 2021

Objective. To determine the correlation between the detection of human immunodeficiency virus type 1 (HIV-1) in breast milk, the duration of breastfeeding, and vertical transmission of HIV-1 infection in Ugandan women.

Methods. A prospective study of HIV-1 infection in pregnant Ugandan women and their infants has been ongoing since 1990 with follow-up of mother-infant pairs for at least 2 years. Expressed breast milk specimens were collected from 201 HIV-1-seropositive and 86 HIV-1-seronegative Ugandan women approximately 6 weeks after delivery. The presence of HIV-1 DNA in the cellular fraction of the breast milk was detected by polymerase chain reaction (PCR), and HIV-1 p24 antigen was detected in the cell-free breast milk supernatant using p24 antigen enzyme immunoassay (EIA) after immune complex dissociation (ICD). The duration of breastfeeding and the clinical status of the mothers and their children were recorded. HIV-1 EIA, Western blot, PCR, or p24 antigen detection were used for the determination of the HIV-1 infection status of the children.

Results. Of the 201 HIV-1-infected women studied, 47 had HIV-1-infected children, 143 had children who seroreverted, and 11 had children of indeterminate status. Breast milk supernatants were available for ICD p24 antigen testing from 188 of the HIV-1-infected women and none had detectable p24 antigen. Breast milk cell pellets were available and contained amplifiable DNA in 125 of the HIV-1-infected women (20 transmitters, 104 nontransmitters, 1 indeterminate). HIV-1 DNA was detected by PCR in 72% (75/104) of nontransmitters and 80% (16/20) of the transmitters. The duration of breastfeeding by transmitter mothers (15.8 months) was not significantly different from nontransmitter mothers (14.4 months).

Conclusions. No correlation was found between the detection of HIV-1 in breast milk or the duration of breastfeeding and transmission of HIV-1 infection in this study of Ugandan women.
Neurodevelopmental Outcome at 36 Months' Corrected Age of Preterm Infants in the Multicenter Indomethacin Intraventricular Hemorrhage Prevention Trial
Authors: Ment Laura R. , Vohr Betty , Oh William , Scott David T. , Allan Walter C. , Westerveld Michael , Duncan Charles C. , Ehrenkranz Richard A. , Katz Karol H. , Schneider Karen C. , Makuch Robert W.
Published: December 2021

Objectives. Low-dose indomethacin has been shown to prevent intraventricular hemorrhage (IVH) in very low birth weight neonates, and long-term neurodevelomental follow-up data are needed to validate this intervention. We hypothesized that the early administration of low-dose indomethacin would not be associated with adverse cognitive outcome at 36 months' corrected age (CA).

Methods. We enrolled 431 neonates of 600 to 1250 g birth weight with no IVH at 6 to 12 hours in a randomized, prospective trial to determine whether low-dose indomethacin would prevent IVH. A priori, neurodevelopmental follow-up examinations, including the Stanford-Binet Intelligence Scale and Peabody Picture Vocabulary Test-Revised, and standard neurologic examinations were planned at 36 months' CA.

Results. Three hundred eighty-four of the 431 infants survived (192 [92%] of 209 infants receiving indomethacin versus 192 [86%] of 222 infants receiving saline), and 343 (89%) children were examined at 36 months' CA. Thirteen (8%) of the 166 infants who received indomethacin and 14 (8%) of 167 infants receiving the placebo were found to have cerebral palsy. There were no differences in the incidence of deafness or blindness between the two groups. For the 248 English-monolingual children for whom IQ data follow, the mean gestational age was significantly younger for the infants who received indomethacin than for those who received the placebo. None of the 115 infants who received indomethacin was found to have ventriculomegaly on cranial ultrasound at term, compared with 5 of 110 infants who received the placebo. The mean ± SD Stanford-Binet IQ score for the 126 English-monolingual children who had received indomethacin was 89.6 ± 18.92, compared with 85.0 ± 20.79 for the 122 English-monolingual children who had received the placebo. Although maternal education was strongly correlated with Stanford-Binet IQ at 36 months' CA, there was no difference in educational levels between mothers of the infants receiving indomethacin and the placebo.

Conclusions. Indomethacin administered at 6 to 12 hours as prophylaxis against IVH in very low birth weight infants does not result in adverse cognitive or motor outcomes at 36 months' CA.
A Review of the Outcomes of Parental Use of Nonabusive or Customary Physical Punishment
Authors: Larzelere Robert E.
Published: December 2021

The most important finding of the review is that there are not enough quality studies that document detrimental outcomes of nonabusive physical punishment to support advice or policies against this age-old parental practice. Only 30 relevant journal articles were found from 1974 through 1995, an average of less than 1 1/2 per year. Next, many of the studies had methodological weaknesses, and the stronger ones were more likely to find beneficial outcomes of physical punishment. A particularly pervasive weakness was that no prospective or retrospective study controlled for the original frequency or severity of child problem behavior, which would be like studying cancer recurrences following radiation treatment without taking into account the severity or existence of the original cancer. More quality research is needed on nonabusive physical punishment. Public and private agencies should make quality research on the broader topic of parental discipline a top priority.

How parents use discipline tactics may be more important than which ones they consider off limits. Effects of physical punishment, as well as nonphysical punishment, probably depend on when and how parents implement it, its role in their overall approach to parental discipline, and the overall parentchild relationship. Other aspects of parental discipline may be more important indicators of dysfunctional parenting than whether parents spank or not.
Pediatric Head Injuries and Deaths From Bicycling in the United States
Authors: Sosin Daniel M. , Sacks Jeffrey J. , Webb Kevin W.
Published: December 2021

Objective. To estimate the potential benefit of increasing bicycle helmet use among children and adolescents in the United States.

Design. All bicycle-related deaths (Multiple Cause-of-Death Public Use Data Tapes, 1989 through 1992) and bicycle-related injuries treated in sampled emergency departments (National Electronic Injury Surveillance System, 1989 through 1993) were used to calculate traumatic brain injury-associated death and head injury rates per 1 000 000 US residents. Preventable injuries and deaths were estimated by calculating the populationattributable risk of head injury due to nonuse of bicycle helmets.

Patients. US residents aged 0 through 19 years who were injured or who died as a result of a bicycle crash.

Results. An average of 247 traumatic brain injury deaths and 140 000 head injuries among children and adolescents younger than 20 years were related to bicycle crashes each year in the United States. As many as 184 deaths and 116 000 head injuries might have been prevented annually if these riders had worn helmets. An additional 19 000 mouth and chin injuries were treated each year. The youngest age groups had the highest proportions of both head and mouth injuries.

Conclusion. There continues to be a need to advocate for greater use of bicycle helmets, particularly among young children. Helmet design changes should be considered to prevent mouth injuries.
Children Who Have Attentional Disorders: Interventions
Authors: Culbert Timothy P. , Banez Gerard A. , Reiff Michael I.
Published: December 2021

The treatment of attentional disorders (ADs) has been the subject of much controversy. Sound treatment programs must address a myriad of issues other than the three core symptoms of AD: inattention, impulsivity, and hyperactivity. Intervention programs purportedly leading to positive long-term outcomes have been studied inadequately. The few treatment plans shown to result in long-term improvement in outcome for children and families have used multiple modalities. Such plans integrate medical, psychological, psychosocial, and educational interventions; provide for case management; and educate and empower families as advocates. Very little actually is known about how treatments for ADs interact with each other, and it has been quite difficult to document the advantages of adding psychosocial treatments to psychopharmacologic treatments, although studies are under way to address these issues. Some of the few studies assessing the long-term efficacy of multimodality treatment programs have shown that although drug treatment alone leads to little measurable change, a combination of medication, psychological treatments, and appropriate classroom interventions leads to improved long-term outcomes. These outcomes include a reduction in antisocial behavior, improved social relationships, enhanced academic performance, improved self-esteem, and decreased delinquent behavior.

The treatment team for children who have AD should consist of a partnership that includes the child, family, significant school personnel, and the physician.
Psychosomatic Disorders: The Approach
Authors: Rickert Vaughn I. , Jay M. Susan
Published: December 2021

Pediatricians frequently encounter patients in their daily clinical practice who present having chronic or recurrent symptoms that do not suggest a physical disorder. In fact, social, emotional, or behavioral problems can constitute up to 25% of visits in a pediatric practice, and it has been estimated that as many as 68% of children who present for medical treatment have psychological factors associated with somatic complaints. These clusters of symptoms typically are referred to as a psychosomatic illness and usually require more time to treat than an acute infection such as otitis media. Additionally, the approach, diagnostic evaluation, and treatment plan require careful construction, which places an increased burden on the pediatrician to "cure" the patient and relieve parent, environment, and other associated stressors in a limited time.

Research suggests that as much as 10% of a pediatric practice is comprised of patients who have a psychosomatic diagnosis. Studies have suggested that psychosomatic symptoms peak during certain ages (age 7 for boys and at ages 6 and 16 for girls) or by diagnosis (psychogenic pain found more commonly among girls and afflicts children ages 4 to 12 years more frequently). Among children, these chronic and vague somatic symptoms frequently include recurrent abdominal pain, headache, and musculoskeletal pain.
Lyme Disease
Authors: Baltimore Robert S. , Shapiro Eugene D.
Published: December 2021

Introduction and Definitions

Lyme borreliosis (Lyme disease) is a systemic infection caused by a spirochete, Borrelia burgdoferi. It is the most common vector-borne disease in the United States.

Lyme disease was first described in Lyme, Connecticut (hence its name), where a cluster of children who had unexplained arthritis first were brought to medical attention by one of their parents. Investigation of this "epidemic" of arthritis led to the description of Lyme arthritis and ultimately to the discovery of its bacterial etiology. The clinical manifestations of Lyme borreliosis are protean; this, coupled with the practical difficulties of confirming the diagnosis in many patients, has led to many misconceptions about Lyme disease. Indeed, there is much we do not know about the disease, which was only recognized in the US as a distinct entity slightly more than 15 years ago, and the cause of which was first identified only about 10 years ago.

Epidemiology

ECOLOGY AND TRANSMISSION

Borrelia burgdorferi is transmitted by ticks of the Ixodid species. In the US, the common vectors are Ixodes dammini (the deer tick), reported to be the same species as I scapularis, in the Northeast and the Midwest and I pacificus (the western black-legged tick) on the Pacific Coast. Ixodes ticks are much smaller than the common wood tick; the nymphal Ixodes tick is about the size of a pencil point (1 to 2 mm).
Consultation with the specialist
Authors: Rubenstein Jeffrey S.
Published: December 2021

Case Presentation

A 2-year-old boy is brought to the emergency room by ambulance after being found "unresponsive" by his parents. He has been in good general health, has had no fever or other symptoms of infectious processes, has been taking no medications, and was "his normal self" until immediately prior to being found.

Patients who are unresponsive and unarousable are in coma. The term altered consciousness represents the spectrum of abnormalities that exists between the immediate capability for normal wakefulness and true coma. For the purposes of this review, the two terms will be used interchangeably because their causes are similar and usually differ only in severity.

Pathophysiology

Two areas of the brain are responsible for consciousness: the ascending reticular activating system (ARAS) and the cerebral cortex. The ARAS is located in the brain stem from the level of the medulla to the level of the midbrain and sends multiple afferent neurons to the cortex. Disruption of this system can lead to disorders of consciousness. The cerebral cortex is the much more common site where dysfunction can cause coma. Any injury or illness that affects the cerebral cortex globally can cause coma or altered consciousness.

Differential Diagnosis

Altered consciousness in children can be caused by injuries or illnesses that affect the central nervous system directly or can be a manifestation of other systemic disease (Table 1).
Children of Gay or Lesbian Parents
Authors: Gold Melanie A. , Perrin Ellen C. , Futterman Donna , Friedman Stanford B.
Published: December 2021

There are no data to suggest that children who have gay or lesbian parents are different in any aspects of psychological, social, and sexual development from children in heterosexual families. There has been fear that children raised in gay or lesbian households will grow up to be homosexual, develop improper sex-role behavior or sexual conflicts, and may be sexually abused. There has been concern that children raised by gay or lesbian parents will be stigmatized and have conflicts with their peer group, thus threatening their psychological health, self-esteem, and social relationships. These fears and concerns have not been substantiated by research. Pediatricians can facilitate the health care and development of these children by being aware of these and their own attitudes, by educating themselves about special concerns of gay or lesbian parents, and by being a resource and an advocate for children who have homosexual parents.
Consultation with the Specialist
Authors: DeAngelis Catherine
Published: December 2021

A child or adolescent who has ataxia should stimulate a pediatrician to consider a broad array of possible diagnoses. The incoordination of muscle action can be caused by pathology located anywhere from the cerebral cortex to the involved muscle. Ataxia can be frightening to all involved, and the tendency is to call a neurologist quickly. However, without the information gathered from a careful history and physical examination, unnecessary expensive tests might be ordered and consultation with the neurologist would not be efficient.

The Table provides an extensive but not exhaustive list of possible causes of ataxia. However, the omitted diagnoses are extremely rare and most likely would be made only by a subspecialist after an exhaustive evaluation. The most common causes of ataxia generally can be diagnosed and managed by the general pediatrician. They fall in the categories of acute infectious, postinfectious, and metabolic etiologies. The diagnoses that are life-threatening if not diagnosed and treated rapidly must be considered first, and they also fall primarily in the infectious and metabolic categories. These include acute bacterial infections and metabolic aberrations, such as hypoglycemia, hyponatremia, hyperammonemia, and ingestion of alcohol and other drugs and toxins. Neoplasias and vascular problems are less common but also can fall in this category; they generally require management by a subspecialist.
Tongue-tie: Management of a Short Sublingual Frenulum
Authors: Levy Paul A.
Published: December 2021

Tongue-tie, or ankyloglossia, historically has been believed to cause speech defects, as well as breastfeeding difficulties and dental problems. St. Mark wrote, "The string of his tongue was loosed and he spoke plain," and midwives in the 15th century reportedly kept a fingernail sharp to cut the frenula of all newborns in an attempt to prevent possible speech problems. Only within the last century has it become acceptable not to perform frenulotomy for children who have ankyloglossia.

During early development the tongue is fused to the floor of the mouth. Cell death and resorption free the tongue, with the frenulum left as the only remnant of the initial attachment.
Alcohol Abuse
Authors: Takahashi Ayame , Franklin John
Published: December 2021

Introduction

Alcohol and illicit drug use and associated problems within the adolescent population continue to be a great concern. Accidental death and injury in this age group frequently is alcohol- or drug-related. Venturesomeness and impulsiveness combined with alcohol can produce disastrous results. Alcohol use is more likely to cause an adolescent to be sexually irresponsible, which can lead to sexually transmitted diseases and pregnancy. There has been an alarming growth in human immunodeficiency virus (HIV)-positive rates recently among the adolescent population. Finally, teenagers who abuse alcohol are more likely to drop out of school, thus damaging their long-term employment prospects.

Definition

The American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV) defines alcohol dependence, a substance use disorder, as a maladaptive pattern of alcohol use leading to clinically significant impairment or distress as manifested by three of the following seven symptoms occurring during the same 12-month period: tolerance; withdrawal; use greater than intended; inability to cease use; time-consuming activities associated with use; social, occupational, or recreational dysfunction; and continued use despite knowledge of physical or psychological problems. Abuse is defined as one or more of the following: failure to fulfill major roles at home or school, recurrent use in hazardous situations, recurrent legal problems, and use despite persistent social or interpersonal problems.
Year Four
Authors: H. R. J.
Published: December 2021

It does not seem possible we are beginning year IV of PREP. Those who have been with us since the beginning will recall that the Pediatrics Review in Education Program, PREP, is designed as a six-year cycle. Each year objectives are developed by panels of pediatricians drawn from practice and teaching for two areas: Recent Advances of importance to the general pediatrician and Topics for Annual Review. Recent Advances cover the entire field of pediatrics, but are limited to information developed in the past six years; Topics are limited to a cluster area with no time limitation. For the 1982/83 Year, the Topics for Annual Review include community health, school health, accidents, poisoning and trauma, athletics and physical fitness, learning disabilities and school adjustment problems, adolescent medicine, delinquency, and drug abuse.
Knee Problems in Adolescents
Authors: Garrick James G.
Published: December 2021

Among children and adolescents there are few, if any, anatomic regions giving rise to as many orthopedic problems as the knee. Not only is the knee most commonly injured in sports and recreational activities, it is also the anatomic area that most often requires surgical intervention as a result of the injuries.

Unlike the ankle in which the majority of injuries are sprains (ligament injuries), the knee encompasses almost unparalled anatomic diversity, thus incurring injuries involving ligaments, tendon, articular cartilage, fibrocartilage (menisci), and bone—all with great frequency. Coexistence of many of these injuries makes establishing a precise diagnosis exceedingly difficult, even for the orthopedist specializing in knee problems. Yet in the majority of instances, absolute diagnostic precision is not necessary for appropriate management. Indeed, many if not the majority of knee injuries seem to heal themselves adequately if only given the appropriate opportunity.

There are four conditions that merit immediate orthopedic referral: (1) intra-articular fractures, (2) grade III sprains (complete ligament tears), (3) grade III strains (complete muscle or tendon tears), and (4) mechanical blockage of normal knee motion. The majority of the remaining problems are initially managed nonoperatively and require referral only if recalcitrant. Thus, the initial evaluation of a knee problem requires that only two questions be answered: (1) should it be immediately referred, and (2) if not referred, how should it be managed?
Motor Vehicle Injury in Childhood
Authors: Christoffel Katherine K. , Tanz Robert
Published: December 2021

OVERVIEW OF EPIDEMIOLOGY

In 1980 approximately 2 million Americans of all ages sustained motor vehicle injuries, and more than 52,000 died. Of the victims, nearly one quarter of a million injuries and 4,100 deaths involved children less than 15 years of age. The National Highway Traffic Safety Administration (NHTSA) has estimated that approximately 2/100 infants born today will die in a traffic accident, and that two thirds of all infants born today will suffer injuries in such an accident. A statement by the American Association of Automotive Medicine, in its Guide for Medical Association Committee on Traffic Safety, helps to put the problem of motor vehicle injury further into perspective: "Cardiovascular disease, cancer, and stroke claim more lives, but many more young people, with many more remaining years of life, are killed or injured on the highway."

In the United States, motor vehicle injury is the leading killer of children aged 1 to 4 years and of young adults; it ranks ahead of the malignancies, infectious diseases, and congenital anomalies (Table 1). For infants <1 year of age, although the sudden infant death syndrome (SIDS) and diseases related to perinatal and birth disorders lead the list, motor vehicle mortality is actually higher for infants than for older children (Fig 1).
Glomerulonephritis
Authors: McCrory Wallace W.
Published: December 2021

The term glomerulonephritis is used to identify a group of renal disorders in which the major injury involves the glomerulus rather than the tubules, interstitial tissue, or vasculature. Primary glomerulonephritis (GN) refers to disorders that occur solely or primarily in the kidney in contrast to those associated with systemic diseases (ie secondary GN) (see Table 1).

The adjective acute (acute glomerulonephritis [AGN]) defines a characteristic clinicopathologic association with distinctive features of etiology, pathology, course, and prognosis. The majority of instances of AGN appear to occur after infection, and a number of bacterial and viral infections have been etiologically incriminated (Table 2).

Post streptococcal AGN (PSAGN) is the most common type. The clinical picture of AGN due to other infections may be indistinguishable from that usually associated with PSAGN. Only the absence of a prior streptococcal illness as evidenced by bacteriologic and serologic studies, and the temporal association with a viral syndrome distinguish such a patient. As the immediate and long-term prognosis of nonstreptococcal AGN is not as well known as that of PSAGN, a diligent effort should be made to identify the etiologic agent.

CLINICAL CHARACTERISTICS

AGN can be asymptomatic and only evident by laboratory findings. This has been the presentation in at least 50% of cases of PSAGN.
Rectal Bleeding in Childhood
Authors: Hillemeier Craig
Published: December 2021

The passing of blood through the rectum is not an uncommon event in the pediatric age group. The most likely etiology varies to a large degree depending upon the age of the patient. Fortunately, the risk of malignancy in children with lower gastrointestinal (GI) tract bleeding is considerably less than that of adults, and the degree of the invasive diagnostic work-up can often be far less extensive than that used in an adult with a similar clinical presentation.

Bleeding anywhere throughout the GI tract will cause blood to be present in the stools. Melena refers to the passage through the rectum of black tarry stools and usually denotes bleeding from the upper gastrointestinal tract or small bowel. The tarry stools may be intermingled with maroon or red blood. Hematochezia is a passage of bright red blood through the rectum and usually indicates a source of bleeding low in the GI tract, often in the colon. However, inasmuch as blood exerts a strong Cathartic action, massive upper GI tract hemorrhage may occasionally present as bright red blood passed through the rectum. In most instances a negative gastric aspirate for blood will assure that the bleeding is distal to the ligament of Treitz

Many substances ingested by children may simulate fresh or chemically changed blood.
Infantile Acropustulosis and Granuloma Gluteale Infantum
Authors: Esterly Nancy B.
Published: December 2021

INFANTILE ACROPUSTULOSIS

In 1979, two reports, published simultaneously in the Archives of Dermatology, described a new cutaneous disorder, infantile acropustulosis.1,2 The authors of these papers indicated that patients with this eruption had been discussed at national dermatology meetings as early as 1976, although no studies had previously been documented in the literature. Both the presentations at meetings and the written descriptions evoked instant recognition of this entity by pediatric dermatologists, many of whom recalled the frustration of caring for such an infant whose eruption defied diagnosis and effective management.

Clinical Findings

Infantile acropustulosis is truly a disorder of infancy with onset usually between 2 and 10 months of age. However, both Kahn and Rywlin1 and Lucky and McGuire3 described infants purported to have lesions at birth. Despite the paucity of reported cases of infantile acropustulosis, the collected experience has suggested that black males have a predisposition for this eruption, although affected infants of both sexes and all races have been identified.

The lesions of this disorder are quite characteristic, demonstrating a rapid sequence of morphologic changes as they evolve. Early lesions are discrete, 1- to 2-mm erythematous papules, which became vesiculopustular within 24 hours (Fig 1, top left) and subsequently crust prior to healing.
Neonatal Seizures
Authors: Myers Gary J. , Cassady George
Published: December 2021

Neonatal seizures represent a challenge in diagnosis, etiologic determination, and treatment. Aggressive treatment is indicated, and the longterm outlook for those who survive is surprisingly good.
Diagnosis and Treatment of Gastroesophageal Reflux in Children
Authors: Herbst John J.
Published: December 2021

Gastroesophageal reflux is a common pediatric problem. It is a problem that may mimic many other conditions and the severity varies from inconsequential to life threatening. The challenge to the physician is to recognize the possibility of its occurrence and to proceed with history, physical examination, and testing to the extent that other conditions are excluded, giving consideration to the severity of the problem. The physician may employ many therapeutic modalities including surgery, while taking into consideration the type and severity of the patient's symptoms.
Renal Trauma
Authors: Reisman Lewis
Published: December 2021

Children are much more susceptible to injury from blunt abdominal trauma than are adults. Symptoms of renal injury include flank or abdominal pain and guarding, hematuria, and flank mass. An intravenous pyelogram is the first radiologic diagnostic procedure in nearly all cases of renal trauma. Most patients with renal trauma do not require surgical exploration of the injured kidney.
Neonatal Hyperammonemia
Authors: Donn Steven M. , Banagale Raul C.
Published: December 2021

Neonatal hyperammonemia is a life-threatening complication of several conditions seen in the newborn infant (Table 1). Some of these disorders are potentially reversible; others are amenable to long-term therapy if early diagnosis and aggressive management in the neonatal period can prevent the catastrophic neurologic deterioration that accompanies massive hyperammonemia.

Normal plasma ammonia concentrations for both term and preterm infants vary according to different laboratories and methods, from 50 to 150 µg/dl,1 but values greater than 75 µg/dl in the term infant and 150 µg/dl in the preterm infant are considered abnormal and should be investigated. Most of the neonatal hyperammonemic conditions produce ammonia concentrations that are several-fold greater than normal, so small interlaboratory differences are less important.

INCIDENCE

The true incidence of hyperammonemic conditions in the general population is not known. Many infants probably die before a diagnosis is made. Ornithine transcarbamylase deficiency and argininosuccinate lyase deficiency are the two most common of the five urea cycle defects, with the frequency of argininosuccinate aciduria estimated to be 1/70,000.2 When all of the disorders are taken together, the incidence approaches 1/30,000 births. The increased awareness of transient neonatal hyperammonemia in recent years has led to an increase in diagnosis, and, in our experience, it is more common than the inherited urea cycle enzyme defects.
Wilms' Tumor and Neuroblastoma in Children
Authors: D'Angio Giulio J.
Published: December 2021

Major advances have been made in the understanding and management of the malignant diseases of childhood. More than 50% of children with cancer can now be expected to survive five or more years; a few decades ago, most of these patients died within 1 year. These good results have been obtained through the use of combined-modality therapy; that is, the conjoined use of surgery, radiation therapy, and multiple-agent chemotherapy. Wilms' tumor provides a spectacular example (Fig 1). Although achieving higher cure rates, combined-modality treatment is often rigorous, and has its associated early and late complications. The goals of modern pediatric oncology reflect both of these facts. Higher cure rates continue to be sought, but there is a growing recognition that not all patients need maximum treatment. Therapy can now be modulated according to well-defined prognostic factors for most of the malignant conditions. In that way, the most aggressive therapies are reserved for those at highest risk, while those with a good prognosis can be managed less intensively. The objectives of modern management, then, are to cure most patients while at the same time minimizing, as much as possible, the associated deleterious late consequences of successful treatment.

wilms' tumor and neuroblastoma serve as good examples to demonstrate the above points.