bluuebunny/crossref_metadata_2025 huggingface dataset:
The Application of Health and Safety Guidelines to Out-of-Home Child Care Programs
Authors:   Committee on Early Childhood, Adoption, and Dependent Care
Published: December 2021

In the United States, the structure, espoused purpose, and quality of child care vary widely. Community programs that provide out-of-home care for infants and preschool children have evolved either with no community regulation or with a variety of different institutional or governmental supports and regulations.1 In general, infant and preschool programs are designed either to provide substitute care when parents work and/or to promote socialization and early education. Frequently, these programs serve children only for a portion of the day and for part of the week and year. Programs that primarily provide substitute care are usually called "day care." Included in this grouping are "family day care" and "large family day care," programs in which children are cared for in someone's home, and "center day care," programs in which children receive care in settings specifically intended for that purpose. The labels traditionally applied to early education programs are "nursery school" or "preschool." These labels are not necessarily mutually exclusive.

The American Academy of Pediatrics believes that education, in the broad sense, and the care of infant and preschool children are inseparable.1 In fact, the new terminology applied to these services for young children is "early childhood education/care programs." Young children are constantly learning while they play and while they engage in everyday activities.2,3 Also, young children in educational settings require "care" in the sense of needing to be comforted and to be instructed in the development of health behaviors such as hand washing and controlling their own excretions. In all settings, the safety of children should be assured.
DDAVP Approval Question
Authors: Fefferman Richard A.
Published: December 2021

I wish to applaud the efforts of Moffatt et al1 to dispel the idea promulgated by its manufacturer that administering deamino-8-D-arginine vasopressin (DDAVP) is the most effective, or is even a particularly effective, treatment for nocturnal enuresis. However, I was disappointed in the accompanying editorial by Rappaport2 in two regards. He mentions, without questioning, the suggestion "that at least a component of the etiology of enuresis is secondary to a deficiency of a nocturnal surge of antidiuretic hormone (ADH)."
Family-Centered Care
Authors: Cunningham Robert D.
Published: December 2021

I read "The Principles for Family-Centered Neonatal Care" with great interest. As a physician who has worked in a state government-operated neonatal intensive care unit follow-up clinic, I agree wholeheartedly with the principle of open and honest communication between parents and professionals, especially regarding poor developmental outcomes. Unfortunately, physicians, despite their own feelings about this issue, may come under pressure from third parties to withhold certain information from families.

In my own experiences, I have been drawn aside in private conversations and told that if I continue to tell parents that their child is mentally retarded or has cerebral palsy, it might have an adverse impact on my career.
Letter to the Editor
Authors: Roberton N. R.C.
Published: December 2021

No one could be keener than I am on keeping the parents of neonatal intensive care unit patients fully informed. Furthermore, I would be the first to agree that there comes a time in critically ill patients of all ages and all sizes when it is wrong to continue with intensive care, and, like everyone else involved in neonatal intensive care, I have often done so, but only after full discussion with parents, the nurses, and my colleagues.
Does Carnitine Administration Improve the Symptoms Attributed to Anticonvulsant Medications?: A Double-Blinded, Crossover Study
Authors: Freeman John M. , Vining Eileen P. G. , Cost Scott , Singhi Pratibha
Published: December 2021

Objective. This study was designed to assess the reported improvement in "well-being" perceived by parents when children who are taking anticonvulsant medications are administered carnitine.

Methodology. Forty-seven children with seizures who were taking either valproic acid or carbamazepine were enrolled in a placebo-controlled, double-blinded, crossover study of the effects of oral carnitine administration (100 mg/kilo) on their well-being as perceived by their parents. The well-being scores were assessed weekly by phone and in person at the start and end of each 4-week phase.

Results. The children's well-being scores improved weekly when either placebo or carnitine were administered. None of the analyses of improved well-being achieved statistical significance.

Conclusion. We believe this study documents the necessity for controlled trials when assessing the subjective, beneficial effects of medications. Carnitine is expensive, costing approximately $.30/kilogram of body weight per day ($6 per day for a 20 kilo child). It would not appear warranted to administer carnitine prophylactically to children on anticonvulsant medications for alleviating common, nonspecific symptoms. Because there are no reliable clinical or laboratory tests of symptomatic carnitine deficiency caused by anticonvulsant administration, how to identify children in need of carnitine, and when to administer carnitine therapeutically to children receiving valproate or other anticonvulsants is unclear.
Risk Factors for Pneumonia Among Children in a Brazilian Metropolitan Area
Authors: Victora Cesar G. , Fuchs Sandra C. , Flores José Antonio C. , Fonseca Walter , Kirkwood Betty
Published: December 2021

Objective. To investigate risk factors for pneumonia for infants <2 years of age.

Design. Hospital-based, case-control study with neighborhood control subjects.

Setting. Urban area in southern Brazil.

Subjects. Five hundred ten infants with radiologically confirmed pneumonia who were admitted to a pediatric hospital. One age-matched neighborhood control subject was selected for each case.

Results. Multiple conditional regression modeling was used to control for confounding, taking into account the hierarchical relationships between risk factors. The incidence of radiologically confirmed pneumonia was associated with low paternal education, the number of persons in the household, young maternal age, attendance at day-care centers, low birth weight and weight-for-age, lack of breast-feeding and of non-milk supplements, and a history of previous pneumonia or wheezing. Day-care center attendance showed the highest risk, with an adjusted odds ratio of 11.75.

Conclusions. In addition to continued efforts toward appropriate case management, actions directed against the above risk factors may help prevent the major cause of deaths of children younger than 5 years.
Concerned About Ribavirin Recommendations
Authors: Pope John F. , Besunder James B. , Kumar Mary L. , Super Dennis M.
Published: December 2021

The Committee on Infectious Diseases of the American Academy of Pediatrics recently published new guidelines for using ribavirin in treating respiratory syncytial virus (RSV).1 In updating previous guidelines, the Committee, based on the study by Smith et al,2 added the recommendation that all RSV-infected patients who require mechanical ventilation should receive ribavirin. We believe the Committee's broad recommendation for using this drug in mechanically ventilated patients is premature. We have concerns about the Smith study that call into question their conclusions regarding the efficacy of ribavirin in mechanically ventilated children.
Letter to the Editor
Authors: Marks Melvin M.
Published: December 2021

Pope et al have concerns about the American Academy of Pediatrics Committee on Infectious Diseases recommendation for using ribavirin in RSV patients who are mechanically ventilated. The Committee based these recommendations not only on the study published by Smith et al, but also on observations on individual patients in clinical situations where experienced care-takers have reported favorable clinical outcomes and safety. Sources included members of the Committee, the Food and Drug Administration, the pharmaceutical manufacturer, a National Institutes of Health panel of scientists, and reviewers and representatives from the National Institute of Occupational Safety and Health.
Glucocorticoid-Responsive Hypotension in Extremely Low Birth Weight Newborns
Authors: Reynolds John W. , Hanna Cheryl E.
Published: December 2021

We read the paper by Helbock et al1 with great interest. Their finding of glucocorticoid responsive hypotension in extremely low birth weight newborn infants is consistent with the syndrome we2 and others3 have reported in published abstracts not referenced by Helbock et al.1 It is very important that the possibility of a relative adrenocortical hypofunction occurring in a subset of 23- to 26-week premature infants be recognized. The incidence will depend on the many factors influencing organogenesis and hormone receptor number and activity in this early gestational period.
Letter to the Editor
Authors: Baraff Larry J.
Published: December 2021

Many of the bedside assessments that physicians perform as part of the history and physical examination may be viewed as "tests" and, as such, may be subjected to analysis of their diagnostic discrimination.1 To determine the clinical utility of a test we need to determine: 1) precisely how it is to be done, 2) the range of normal values, and 3) its value to predict a clinical abnormality. The latter is done by Bayesian analysis, ie, when we suspect a clinical condition how often does a patient who tests positive have the condition and how often does a patient who tests negative not have the condition.
The Incidence of Prenatal Syphilis at The Boston City Hospital: A Comparison Across Four Decades
Authors: Klass Perri E. , Brown Elizabeth R. , Pelton Stephen I.
Published: December 2021

Objective. To examine the incidence and epidemiologic correlates of congenital syphilis at an inner-city Boston hospital, and draw comparisons with the situation at the same hospital 40 years ago.

Design. Chart review and comparison with data collected in 1951.

Setting. Maternity and pediatric services at Boston City Hospital.

Methods. A study conducted in 1951 on the maternity service of Boston City Hospital in which demographic data were collected on all women admitted in labor over a 5-month period was replicated. Serologic testing for syphilis was carried out on these women, and the demographic and medical correlates of positive maternal syphilis serology were examined. This study was repeated exactly 40 years later, using the cord blood screening for syphilis done routinely at delivery and a review of prenatal records.

Results. From a group made up largely of married white women in 1951, the study population shifted in 1991 to a group made up mostly of minority women, with 75% unmarried. In 1951, 24 patients were diagnosed with syphilis either before or during the pregnancy, giving a prevalence rate of 2.4%. In 1991, 25 of 647 women were diagnosed with syphilis, for a prevalence rate of 3.9%. The women with positive cord blood serologies had a higher rate of other sexually transmitted diseases and substance abuse. No symptomatic cases of congenital syphilis were seen in 1951 or in 1991, although at least 11 of the 26 infants born to mothers with positive serologies in 1991 received intravenous penicillin therapy.

Conclusions. The continued prevalence of diagnosed syphilis in women at delivery reflects an inner-city epidemic of congenital syphilis that is tied to substance abuse, human immunodeficiency virus, and changing social patterns, as well to older problems of serologic screening, prenatal care, treatment failures, and maternal reinfection. It is essential that screening programs be maintained and improved in this high-risk population, and that infants born to mothers with positive serologies receive full and adequate treatment if there is any doubt at all about their infection status.
Simethicone in the Treatment of Infant Colic: A Randomized, Placebo-Controlled, Multicenter Trial
Authors: Metcalf Thomas J. , Irons Thomas G. , Sher Lawrence D. , Young Paul C.
Published: December 2021

Objective. To determine the efficacy of simethicone in the treatment of infant colic.

Design. Randomized, double blind, placebo-controlled.

Setting. Three general pediatric practices in distinct geographic regions.

Patients. Eighty-three infants between 2 and 8 weeks of age with infant colic.

Interventions. Treatment with simethicone and placebo in double blind crossover fashion.

Results. A total of 166 treatment periods, ranging from 3 to 10 days, were evaluated in the 83 infants. Compared to baseline, improvement in symptoms was reported for 54% of the treatment periods, worsening was reported for 22%, and, for 24%, there was no change. The likelihood of the treatment period being rated as showing improvement, worsening, or no change was the same whether the infant was receiving placebo or simethicone. Twenty-eight percent of he infants responded only to simethicone, 37% only to placebo, and 20% responded to both. No statistically significant differences were noted among these three groups of responders. No difference could be shown even when infants with "gas-related symptoms" (by parental report) were separated out as a group.

Conclusion. Although both produced perceived improvements in symptoms, simethicone is no more effective than placebo in the treatment of infantile colic.
RELATIONSHIP BETWEEN INDEBTEDNESS AND THE SPECIALTY CHOICES OF GRADUATING MEDICAL STUDENTS
Authors: L. J. F.
Published: December 2021

Analysis of data from the 1992 GQ has shown that educational debt was not a factor significantly influencing most graduates' specialty choices . . . As a strong or major influence, debt affected the specialty choices of only 6.2% of the 1992 graduates who had decided on a specialty. However, for students with debts of $75,000 or more, debt became more important, having a strong or major influence on the choices of surgical (13.9%) and support (20.3%) specialties. Although the effects of debt on specialty choice were found to be small . . . it is disturbing to note that over 20% of medical school graduates have such levels of indebtedness.

Length of residency training, as a factor affecting specialty choice, generally was a strong or major influence for only 9.0% of respondents. However, this number increased to 20.5% for respondents with debts of $75,000 or more who planned generalist specialty certification, suggesting that high debt turned students toward, as well as away from, the generalist specialties.
Sexual Politics and Child Protection: They Don't Mix
Authors: Krugman Richard D.
Published: December 2021

The article by Jenny, Roesler, and Poyer in this issue of Pediatrics takes a look at a purported link between homosexuality and the sexual abuse of children. They find no such evidence. The study was prompted by the passage of a constitutional amendment in Colorado in 1992 that prohibited communities from enacting laws including homosexuals in antidiscrimination statutes. The amendment has subsequently been ruled unconstitutional by the Colorado Supreme Court, but other states are considering such legislation as of this writing. Part of the argument used by proponents of these amendments has been that children are at risk of being sexually abused by homosexuals, and therefore the inclusion of gays and lesbians as a class in antidiscrimination statutes would be hazardous to children and would protect molesters.
Pediatric Defibrillation: Current Flow Is Improved by Using "Adult" Electrode Paddles
Authors: Atkins Dianne L. , Kerber Richard E.
Published: December 2021

Objective. Current flow, the major determinant of defibrillation success, depends on delivered energy and transthoracic impedance. Previous experimental data suggest that transthoracic impedance is higher using "pediatric" electrode paddles compared to the larger "adult" electrode paddles. There are few data from actual shocks to support the experimental studies. The purpose of this study was to measure transthoracic impedance during actual shock delivery and to determine the optimal electrode paddle size for pediatric defibrillation and cardioversion.

Methods. We prospectively evaluated all shocks of ≤ 20 joules given to pediatric patients at the University of Iowa from 1988 to 1992. Data collected included energy selected by the operator, energy delivered by the defibrillator, peak current flow and transthoracic impedance. Data were analyzed by unpaired t test and linear regression.

Results. Fifty-five shocks were delivered to 20 patients, age newborn to 8 years. Thirty-seven shocks were given with "pediatric" electrode paddles (surface area 21 cm2) and 18 with "adult" electrode paddles (surface area 83 cm2). Selected energy correlated well with delivered energy (r = .98, P < .0001). Delivered energy using "pediatric" electrodes did not differ from that delivered with "adult" electrodes (8.0±0.9 joules vs 10.5 ± 1.2 joules P > .1). However transthoracic impedance was significantly higher with "pediatric" electrodes (78.1±4.4 ohms vs 54.6 ± 2.7 ohms P < .0008), resulting in lower peak current flow through "pediatric" electrode paddles (6.2±0.5 amps vs 8.7 ± 0.5 amps P < .002). There was no correlation between joules/kg and peak current flow (r = .26, P > .05).

Conclusion. Use of "pediatric" electrode paddies results in higher transthoracic impedance and thus lower peak current flow. In pediatric defibrillation, larger "adult" electrode paddies should be used as soon as chest size permits (approximateiy 10 kg). Lower transthoracic impedance results in higher current flow that facilitates cardioversion and defibrillation.
BLUE CROSS FREEZES TOP EXECUTIVES' PAY
Authors: L. J. F.
Published: December 2021

ALBANY, Jan. 27 (AP)—The financially troubled Empire Blue Cross and Blue Shield, under fire for its top executives' pay, has frozen the salary of its chief executive at $600,000, officials said today.

Empire, New York State's largest insurer, has also frozen the base pay of other top executives, although these officials can get raises if they are promoted or if they significantly exceed performance goals

The company has been criticized for Albert Cardone's $600,000 salary.

[The vice president of government operations] said the criticism was unfounded because Mr. Cardone is underpaid by industry standards.
SEASON OF BIRTH AND NEURODEVELOPMENTAL DISORDERS: SUMMER BIRTH IS ASSOCIATED WITH DYSLEXIA
Authors: Livingston Richard , Adam Balkozar S. , Bracha H. Stefan
Published: December 2021

Objective: Increased risk for certain psychiatric disorders has been associated with season of birth. This study was undertaken to look for hypothesized season-of-birth effects for dyslexia, schizophrenia spectrum disorders, and neurological soft signs in children and adolescents. Method: Month of birth and the diagnostic findings in question were examined based on charts from a clinic population of 585 boys. Odds ratios and etiological fractions were calculated. Results: Neurological soft signs showed a sporadic peak for June births and schizophrenia spectrum showed a peak for August and November. A smooth curve suggesting true seasonality was evident in dyslexia for births in May, June, and July. For different 5-year birth cohorts, early summer birth accounts for 24 to 71% of cases of dyslexia. Conclusions: The authors suggest that viral infection, especially influenza, during the second trimester of pregnancy is the most attractive hypothesis to explain these findings. If this hypothesis is supported, immunization in women of child-bearing age could reduce the incidence of dyslexia. Secondary prevention could also be enhanced by early identification and treatment of children who were exposed in utero.
Letter to the Editor
Authors: Gorelick Marc H. , Shaw Kathy N. , Baker M. Douglas
Published: December 2021

We do not disagree with many of the points made by Dr Harris and his colleagues. Specifically, we do not advocate eliminating this test. In our discussion, we state, "Our results suggest several important limitations to the use of capillary refill in the assessment of circulatory status in children." All tests have limitations, and appropriate utilization by clinicians requires knowledge of those limitations. Our study was intended simply to evaluate one such potential limitation, ie, cool ambient temperature.
Letter to the Editor
Authors: Halsey Neal A. , Hall Caroline B.
Published: December 2021

Dr Vegnente et al raise an important point regarding the different concentrations of antibodies to hepatitis B surface antigen (anti-HBsAg) in preparations of hepatitis B immune globulin (HBIg) prepared by manufacturers outside the United States. The American Academy of Pediatrics (AAP) recommendations were based on products manufactured in the United States (US). These products have been standardized to contain anti-HBsAg concentrations equivalent to or exceeding the potency of anti-HBsAg in a reference standard hepatitis B immune globulin (human) prepared by the Food and Drug Administration (FDA).
Letter to the Editor
Authors: Scholl Theresa O. , Hediger Mary L. , Schall Joan I.
Published: December 2021

After reading the recent article entitled "Adolescent Gestational Weight Gain and Birth Weight" by Stevens-Simon, McAnarney, and Roghmann1 we were puzzled by the statistical techniques used and by the stated conclusions, many of which appear unwarranted given the data as presented in the article. Specifically, the authors concluded that their "... data do not support the thesis that younger adolescents compete with their fetuses for nutrients; in fact, younger study adolescents transferred more of their gestational weight gain to their fetuses than did older adolescents."
GROWTH IN ATOPIC ECZEMA
Authors: Stempel David
Published: December 2021

This study demonstrated that impaired growth was noted only if the severity of atopic dermatitis extended over 50% of the body surface area. The severity of atopic dermatitis may have obscured any effect of restrictive diet and potency of topical steroid since children with more severe disease were more likely to use these therapeutic modalities.
ALLERGENS IN SCHOOL DUST: I. THE AMOUNT OF THE MAJOR CAT (Fel d I) AND DOG (Can f I). ALLERGENS IN DUST FROM SWEDISH SCHOOLS IS HIGH ENOUGH TO PROBABLY CAUSE PERENNIAL SYMPTOMS IN MOST CHILDREN WITH ASTHMA WHO ARE SENSITIZED TO CAT AND DOG
Authors: Graft David F.
Published: December 2021

Purpose of the Study. To measure the levels of cat and dog allergens in schools.

Methods. Dust samples from four Swedish schools were taken from floors and the horizontal surfaces of chairs and tables. The levels of cat allergen (Fel d I) and dog allergen (Can f I) in these dust samples were measured.

Results. Higher amounts of cat allergen were found on chairs than on tables or floors. The concentration of dog allergen was 2 to 20 times higher than cat allergen.

Reviewer's Comments. Children and teachers who have close contact with cats and dogs bring these allergens into the school environment. Concentrations of these allergens were high enough to cause symptoms in sensitized children.
CLINICAL EVALUATION FOR SINUSITIS: MAKING THE DIAGNOSIS BY HISTORY AND PHYSICAL EXAMINATION
Authors: Adinoff Allen
Published: December 2021

The authors conclude that general internists, focusing on five clinical findings and their overall clinical impression, can effectively stratify patients with sinus symptoms as having a high, intermediate, or low probability of sinusitis.
ACCURACY OF THE DEATH CERTIFICATE IN A POPULATION-BASED STUDY OF ASTHMATIC PATIENTS
Authors: Goldsobel Alan B.
Published: December 2021

Death certificate diagnosis of asthma as the underlying cause of death had a low sensitivity, but high specificity. Asthma mortality rates, determined from death certificate data, may indeed underestimate actual asthma-related mortality.
IMPACT OF CHILDHOOD ASTHMA ON HEALTH
Authors: Randolph Christopher
Published: December 2021

Purpose of the Study. To determine the disease burden resulting from asthma and to determine the functional status of asthmatics versus those without.

Study Population. A multi-state probability sample of civilian U.S. residents for the National Health Interview Survey (NHIS); 17 110 households of individuals residing in the U.S.

Findings. The prevalence of asthma in children under 18 years of age in the U.S. was 4.3% in 1988 and 3.2% in 1981 . The difference between the prevalence of asthma was statistically significant with an estimated 2.7 million children <18 years of age reported to have asthma over the past year. The added burden experienced by children with asthma was an additional 10.1 million days missed from school, 12.9 million contacts with medical doctors and 200 000 hospitalizations. 30% of children had limitation of activity compared to 5% without asthma. Black children had more severe functional disability and hospitalizations than whites with asthma. 35% of hospitalizations for asthma and 77% of all days in the hospital were accounted for by 10% of children with asthma or severe disease.

Reviewer's Comments. These statistics are largely preventable with preventive asthma management reiterated to the patients and frequent follow up visits.
ALLERGIST INFLUENCE IN ASTHMA CARE
Authors: Galant Stanley P.
Published: December 2021

Purpose of the Study. To determine whether care by an allergist reduces the morbidity for asthma specifically by decreasing the need for hospitalizations and emergency room visits.

Methods. This was a retrospective chart review of patients first seen between June 1985 and June 1986 and followed the second year either in an allergy clinic or in a general pediatric clinic. Charts were analyzed for demographic information; information regarding hospitalizalions, emergency room visits, and intensive care unit admissions; medications, including bronchodilators, systemic steroids and inhaled steroids, and home nebulizer; and home peak flow meters. There were 209 charts reviewed initially. Of these, 83 patients were then followed by allergists, 40 by non-allergists, and 86 were lost to followup.

Findings. There was no statistically significant difference in patient characteristics of asthma at baseline, except that those followed by allergists had a significant increase in the use of oral steroids. There was a significant difference in favor of the allergy followup group for decrease in hospitalization rate and emergency room visits. In terms of medication, there was no significant difference in the use of theophylline, beta2-agonists, or home nebulizers, but there was a statistically significant increase in the use of cromolyn sodium and inhaled steroids, the use of spacers for the metered-dose inhalers, use of home peak flow monitoring, and a decreased incidence of intensive care admissions. Interestingly, there was no change in pets or smoking in the children's environment.

Reviewer's Comments. This study suggests that the followup of asthmatics by an allergist is superior to the non-allergist.
INPATIENT MANAGEMENT OF STATUS ASTHMATICUS
Authors: Bell Thomas
Published: December 2021

Purpose of the Study. To find causes of increasing asthma mortality by assessing patterns of physician management in a university hospital setting.

Study Population. The charts reviewed represented 130 admissions for 98 patients, some admitted more than once, ranging in age from 19 to 67. Seventy-four were women.

Methods. 130 charts, representing 13 months status asthmaticus admissions were reviewed in detail for numerous parameters. These data were then utilized to answer two questions applied to each day of hospitalization: Did physicians document the severity of the attack and its response to therapy using findings on physical exam and objective indices of airflow obstruction? What treatments were used?

Findings. Despite its university setting where high standards of practice would be expected, several striking findings emerge. Peak flows or spirometry were measured in only a minority of patients. On day one 55% of patients had peak flows recorded, on day two an additional 13%. In 41 cases peak flow was never recorded. Spirometry was never recorded on the first day, and only 22% of patients ever had this measured. Since oximetry is not mentioned I assume this was rarely, if ever, measured. Most objective measures found on physical examination are likewise rarely recorded except for wheezing and use of accessory muscles on the first day (the mean length of stay was 5.5 days). Examination of treatments used is much as would be expected: Only 74% received intravenous theophylline, and 9% had no steroids during their entire stay. On discharge 17% had no stated follow-up plan.
EXTRACORPOREAL LIFE SUPPORT FOR STATUS ASTHMATICUS
Authors: Bell Thomas
Published: December 2021

Purpose of the Study. This report presents the experience with one case of status asthmaticus who failed to respond to mechanical ventilation and was successfully managed with extracorporeal life support (ECLS) using venovenous bypass. The purpose is to inform the practitioner of an additional therapy, potentially of benefit, in management of asthma complicated by treatment-resistant respiratory failure.

Methods. Low volume venovenous bypass with extracorporeal life support resolved severe respiratory failure in a 23-year-old female asthmatic over a 22-hour period after failure of 5 hours of mechanical ventilation. Bypass was initiated remotely by an ECLS team using a portable ECLS circuit before the 180-mile transport to the "nearby" center. Details of the technique are presented.

Conclusion and Reviewer's Comments. This may be the first instance where asthma was the primary indication for ECLS; other asthmatics have been so treated, but for other complicating conditions like pneumonia and adult respiratory distress syndrome. This report provides a further alternative therapy, even in somewhat remote areas, for asthma-caused respiratory failure.
THE EFFECT OF AGE ON BRONCHODILATOR RESPONSIVENESS
Authors: Chipps Bradley E.
Published: December 2021

Young children (<3 yrs) can be trained to do forced expiratory maneuvers and appear not to respond as well to inhaled beta agonist. The finding may be underestimated in the study, because the patients received the same dose of beta agonist. Even though older children received less beta agonist per kilogram, they responded to a greater degree and did not reach a plateau in the dose response curve after the last nebulized dose. These findings should be considered in the dosing recommendations for beta agonist for the treatment of reactive airway disease.
DOES ASTHMA OR TREATMENT WITH THEOPHYLLINE LIMIT CHILDREN'S ACADEMIC PERFORMANCE?
Authors: Chipps Bradley E. , Ostrom Nancy
Published: December 2021

Purpose of the Study. To determine the effect of theophylline and asthma on academic performance as measured by scores on standardized achievement tests.

Study Population. One hundred children with asthma who had siblings within 4 years of age who did not require any regular medications. All subjects had taken standardized achievement tests within 4 years. All were patients in health care facilities staffed by the authors.

Methods. Parents were interviewed regarding any perceived effect of asthma or asthma medication on their child's learning. Medical records were reviewed regarding medication prescribed at the time of the testing session. Results of the Iowa Tests of Basic Skills (ITBS) for grades 1 through 8 and Iowa Tests of Educational Development (ITED) for grades 9 through 12 were obtained from the testing agency.

Findings. The mean scores for reading, mathematics, and composite for both groups were 0.6 to 0.8 standard deviations above the national averages. The asthma and control groups did not significantly differ on scores of the ITBS or ITED. The number of children with scores below the 10th percentile was similar (3% asthma and 5% siblings). Of the asthmatic children, 72% were taking maintenance theophylline, and this group did not significantly differ from the whole. Parental interviews revealed that 23% attribute behavioral problems to the disease itself. The parents ascribe learning problems to asthma in 23% of the patients and 18% of the parents believed asthma medications produced learning difficulties.

Reviewers' Comments. The study supports lack of demonstrable effect of asthma or maintenance theophylline therapy on standardized test performances.
HUMAN IMMUNODEFICIENCY VIRUS-INFECTED ADOLESCENTS: THE FIRST 50 PATIENTS IN A NEW YORK CITY PROGRAM
Authors: McAnelly George , Shearer William T.
Published: December 2021

This study identifies a large cohort of HIV-infected adolescents cared for in a multidisciplinary program. Since the subjects were selected because of their risk of HIV-infection, differences between the HIV-positive and -negative groups were minimized. Rates of STDs, drug use, and prior sexual abuse were much higher in both groups than those reported in population-based studies of adolescents; thus, behavior profiles can play a role in identifying high-risk adolescents.

In adolescents, sexual behavior and sexual identity are often not the same, and thus AIDS prevention programs designed for the homosexual community are often not recognized as relevant by adolescents engaging in same-sex encounters. Virtually all HIV-positive females in this study apparently contracted HIV through heterosexual intercourse. None of the females were able to consistently convince their partners to use a condom. The majority of the HIV-positive adolescents reported more than 10 life-time sexual partners. There was a strong association between crack/cocaine use and increased numbers of sexual partners, termed "survival-sex." Traditional safer-sex messages are unlikely to reach teens attempting to survive on the street. Comprehensive drug treatment programs must be developed as a component of HIV prevention in adolescents. Medically, 80% of seropositive adolescents were asymptomatic by history and physical, yet by CD4 counts, nearly half were eligible for antiretroviral treatment. Adequate referral sources for comprehensive medical care should be linked to HIV counseling and testing programs for youth.

After being informed of their seropositivity, most adolescents assumed they were going to die within a year. With a realistic message of hope, many of the adolescents were able to make positive changes in their lives, and the HIV infection became an organizing force in their lives.
TRANSIENT SEROREVERSION IN CHILDREN BORN TO HUMAN IMMUNODEFICIENCY VIRUS 1-INFECTED MOTHERS
Authors: Pacheco Susan E. , Shearer William T.
Published: December 2021

Purpose of the Study. To review the clinical and laboratory data of three infants born to HIV-1-infected mothers, who became HIV-1 seronegative after 6 months of age, but subsequently became HIV-infected and seropositive.

Study Population. Three infants are described from a cohort of 218 born to HIV seropositive mothers at the Maternity Ward of the Centre Hospitalier de Kigali, Rwanda, enrolled from November 1988 to June 1989. Of these, 140 infants (64.2%) became HIV-1 seronegative (based on a minimum of two negative serum samples). Three (2.1 %) of these 140 infants were subsequently found to be seropositive for HIV-1 antibodies after 6 to 9 months of seronegativity. The infants had no history of blood transfusion or exposure to contaminated needles. They were breast-fed during at least 18 months of their lives.

Methods. Sera were screened for anti-HIV-1 antibodies by ELISA, and those positive were confirmed by Western Blot (WB). Serum immunoglobulins were measured by radial immunodiffusion. Mononuclear cell subpopulations were analyzed using indirect immunofluorescence and monoclonal antibodies. A double PCR was performed with three pairs of HIV-1-specific oligonucleotide primers with amplified sequences located in the gag, pol, and env region of the HIV-1 genome. A positive PCR was defined as a detectable signal for at least two of the three primer pairs.

Results. The infants were HIV-1 seropositive until 6 months of age and were seronegative on the following examination at 9 months of age. They remained seronegative for 6-9 months when HIV seropositivity was again noted. Case 1 had a normal physical examination until seroconversion at 15 months (hepatosplenomegaly was noted once at 3 months of age).
MYCOBACTERIUM AVIUM INTRACELLULARE COMPLEX INFECTION IN HIV-INFECTED CHILDREN
Authors: Church Joseph
Published: December 2021

HIV-infected children are at risk for developing disseminated MAC infection. Children older than 5 years and those with CD4+ T-cell counts <100/mm3 (<100 x 106/liter) are at greatest risk.
TUBERCULOSIS IN HUMAN IMMUNODEFICIENCY VIRUS-INFECTED CHILDREN: A FAMILY INFECTION
Authors: Church Joseph
Published: December 2021

TB is a growing problem among inner city children born to HIV-infected parents and in this setting must be considered a family infection.
CARDIAC MORBIDITY AND RELATED MORTALITY IN CHILDREN WITH HIV INFECTION
Authors: Church Joseph
Published: December 2021

Cardiac morbidity and mortality are common complications of advanced HIV infection in children. Encephalopathy or Epstein-Barr virus coinfection identifies children at high risk for these complications.
IMMUNOLOGIC, PSYCHOLOGICAL, AND NEUROPSYCHOLOGICAL FACTORS IN MULTIPLE CHEMICAL SENSITIVITY: A CONTROLLED STUDY
Authors: Adinoff Allen
Published: December 2021

Immunologic testing failed to confirm findings from earlier uncontrolled studies, mitigating against proposed immunologic mechanisms. The decreased memory and concentration frequently described in multiple chemical sensitivity were not confirmed by neuropsychological testing. Psychological symptoms, although not necessarily etiologic, are a central component of chemical sensitivity.
TREATMENT OF ADULT VARICELLA WITH ORAL ACYCLOVIR: A RANDOMIZED, PLACEBO-CONTROLLED TRIAL
Authors: Adinoff Allen
Published: December 2021

Early therapy with oral ACV decreases the time to cutaneous healing of adult varicella, decreases the duration of fever, and lessens symptoms. Initiation of therapy after the first day of illness is of no value in uncomplicated cases of adult varicella. The absence of serious complications of varicella precluded any evaluation of the possible effect of ACV on these outcomes.
THE GENE INVOLVED IN X-LINKED AGAMMAGLOBULINEMIA IS A MEMBER OF THE SRC FAMILY OF PROTEIN-TYROSINE KINASES
Authors: Abernathy-Carver Katherine J. , Liu Andrew
Published: December 2021

Purpose of the Studies. X-linked agammaglobulinemia (XLA) is a humoral immunodeficiency characterized by recurrent bacterial infections. Affected males lack mature B cells and serum immunoglobulins of all isotypes. They have a normal number of pre-B cells in the bone marrow, which suggests a defect in the pathway of B cell development. These two research groups sought to identify the gene and protein product responsible for this disorder.

Findings. Both groups, using different methodologies, successfully identified the mutant gene on the X chromosome, and characterized the defective protein product in a total of 10 XLA patients. The protein is a cytoplasmic tyrosine kinase. Other tyrosine kinases are known to play a critical role in signal transduction pathways that stimulate cell growth and differentiation.

Reviewers' Comments. These papers represent a major breakthrough in the understanding of XLA. More research is needed to explain how this defective protein results in this disorder. However, this opens the door for prenatal diagnosis and possible gene therapy in the future.
Identification of Potentially Avoidable Pediatric Hospital Use: Admitting Physician Judgment as a Complement to Utilization Review
Authors: Soulen Jeffrey L. , Duggan Anne K. , DeAngelis Catherine D.
Published: December 2021

Objective. To determine, for acute general pediatric admissions, 1) the proportion of admissions that the admitting physician would identify as potentially avoidable; 2) services that might help reduce avoidable admissions; 3) potential savings in hospital days through eliminating avoidable admissions; 4) the role that social factors play in admission decisions; and 5) if admitting physician judgment provides a valuable complement to Utilization Review (UR) in identifying avoidable admissions.

Methods. A questionnaire was used to determine the proportion of 600 acute general pediatric admissions considered potentially avoidable by the admitting physician and to identify services required to prevent such admissions. Savings through eliminating potentially avoidable admissions and social factors influencing admission decisions were examined. Physicians' and UR assessments of necessity of inpatient care were compared.

Results. Admitting physicians judged 28% of admissions as potentially avoidable, citing alternative services for each avoidable admission. Eliminating all avoidable admissions would have reduced hospital days by 7.7%. Physicians identified 6% of admissions as social admissions, most commonly due to an overwhelmed family. UR identified 1% of potentially avoidable admissions as unnecessary.

Conclusion. Incorporating admitting physician judgment may significantly improve current efforts to identify and reduce avoidable hospital use.
Low Density Lipoprotein Cholesterol/Apolipoprotein B-100 Ratio: Interaction of Family History of Premature Atherosclerotic Coronary Artery Disease With Race and Gender in 7 to 11 Year Olds
Authors: Islam Syed , Gutin Bernard , Manos Tina , Smith Clayton , Treiber Frank
Published: December 2021

Background. In adults, a low density lipoprotein cholesterol (LDL-C)/apolipoprotein B-100 (ApoB) ratio is an indicator of ApoB-enriched small dense LDL, which is associated with premature coronary artery disease (CAD). Since this LDL subclass may be inherited, we investigated whether a low LDL-C/ApoB ratio was associated with a positive family history of premature CAD in young children.

Methods. Subjects were 66 children aged 7 to 11 years who were recruited through a school-based family history survey, flyers, and hospital newspaper advertisements. They were divided according to family history and assessed for fatness, blood pressure, lipids, lipoproteins, and apoproteins.

Results. Family history interacted with gender such that girls with a positive family history had a lower LDL-C/ApoB ratio than girls with a negative family history, while the opposite was true in boys; ie, family history-positive boys had a higher ratio than family history-negative boys. The association of a low ratio with a positive family history was seen most clearly in white girls. Family history-positive whites had higher ApoB than family history-negative whites, whereas the pattern was reversed in the blacks. The LDL-C/ApoB ratio and ApoB were not related to other CAD risk factors such as fatness, blood pressure, or other lipids and lipoproteins.

Conclusion. In young children, a low LDL-C/ApoB ratio and high ApoB levels were associated with a positive family history of CAD only in the white girls, suggesting that this group is at increased risk of genetically mediated CAD.
Seroconversion Rates to Combined Measles-Mumps-Rubella-Varicella Vaccine of Children With Upper Respiratory Tract Infection
Authors: Dennehy Penelope H. , Peter Georges , Saracen Cheryl L.
Published: December 2021

Objective. To determine if upper respiratory tract infection (URI) affects the seroconversion rate or quantitative response to each component of a combined measles-mumps-rubella-varicella vaccine.

Subjects and methods. One hundred forty-nine children between 15 and 18 months of age were prospectively divided into two groups according to the presence of URI or recent history of URI symptoms within the 4 weeks before vaccination. Once stratified, 74 children in the healthy group and 75 children in the URI group were randomly assigned to receive one of three lots of measles-mumps-rubella varicella vaccine by subcutaneous injection into the deltoid area. Serum was obtained from each child just before vaccination and 4 to 6 weeks later for measuring antibody levels against each virus.

Results. Prevaccination antibody levels against each virus in the URI and healthy groups did not differ. Nine children had pre-existing antibodies to varicella and six to mumps; no child had positive serologies for measles or rubella before vaccination. Children with pre-existing antibody were excluded from analysis of seroconversion for that virus. Seroconversion to measles, mumps, and rubella occurred in 100% of children in both groups. Mean antibody levels did not differ between the healthy and URI groups for measles (111 vs 122), mumps (97 vs 108), or rubella (96 vs 102). Three (4%) of 70 children with URIs in whom varicella serologies were available failed to seroconvert to varicella vaccine although none of the 69 healthy children had vaccine failure (P = .24). The mean varicella antibody level was 11.3 ± 1.4 in the healthy children, which did not differ significantly from the level of 9.5 ± 0.9 in the URI group.

Conclusions. Seroconversion to measles, mumps, rubella, and varicella was not significantly affected by the presence of a concurrent or recent URI in 15-to 18-month-old children.
Immunization Practices of Pediatricians and Family Physicians in the United States
Authors: Szilagyi Peter G. , Hager Jonathan , Roghmann Klaus J. , Doane Cindy , Cove Lisa , Rodewald Lance E. , Humiston Sharon G. , Fleming Gretchen V. , Hall Caroline B.
Published: December 2021

Objective. To assess current practices and attitudes among pediatricians and family physicians across the United States regarding Immunizations.

Design. Survey of a random sample of pediatricians and family physicians.

Subjects. Fellows of the American Academy of Pediatrics (N = 746) and American Academy of Family Medicine (N = 429).

Survey topics. General Immunization practices (eg, types of visits during which vaccinations are provided, mechanisms to identify undervaccinated children); and opinions about perceived barriers to immunizations, acceptance of alternative sites for immunizations, and possible immunization requirements for Medicaid and The Special Supplemental Food Program for Women, Infants, and Children (WIC).

Results. Pediatricians and family physicians (combined) reported the following Immunizing children during acute illness visits (28%), follow-up visits (90%), and chronic illness visits (77%); using computer or reminder files to identify undervaccinated children (13%); and simultaneously administering four vaccines (diphtheria-tetanus-pertussis, oral poliovaccine, measles, mumps, and rubella and Haemophilus influenzae type b) to an eligible 18-month-old child (66%). Physicians perceived the following as barriers to immunizations missed preventive visits (40%), vaccine costs (24%), lack of insurance coverage (24%), inability to track undervaccinated patients (22%), incomplete immunization records (12%), and missed vaccination opportunities (12%). Physicians agreed with offering vaccinations during hospitalizations (51%) or emergency department visits (30%), and with immunization requirements for continued eligibility for Medicaid (66%) or WIC (64%). Pediatricians were more likely to vaccinate during chronic illness and follow-up visits, and were more likely to use systems to track undervaccinated children (P < .05); however, most immunization practices and attitudes of pediatricians and family physicians were similar. Physicians who graduated from medical school more recently and those in high-risk urban practices were more likely to vaccinate during acute illness visits, provide simultaneous vaccinations, and favor vaccinations in hospital settings.

Conclusions. Vaccination rates might be Improved by closer adherence to current immunization guidelines regarding vaccinations during all encounters and simultaneous vaccinations, by developing systems to identify undervaccinated children, and by reducing patient costs for vaccinations. Current immunization practices fall short of the immunization guidelines; changes in individual practice styles will be required to conform with these standards.