bluuebunny/crossref_metadata_2025 huggingface dataset:
Humeral Fractures Without Obvious Etiologies in Children Less Than 3 Years of Age: When Is It Abuse?
Authors: Strait Richard T. , Siegel Robert M. , Shapiro Robert A.
Published: December 2021

Objective. To determine the occurrence and frequency of abuse in children with humeral fractures without immediately obvious etiologies who are less than 3 years old and present with arm injuries.

Methods. A retrospective chart review was conducted of all children less than 3 years old treated for a humeral fracture at Children's Hospital Medical Center between July 1, 1990, and September 10, 1993. One hundred twenty-four charts of children with humeral fractures were reviewed for possible abuse using previously developed criteria. Charts were evaluated independently by the investigators. Consensus was reached on classification of each chart into the following categories: abuse, indeterminate, or not abuse.

Results. Abuse was diagnosed in 9 of 25 (36%) children less than 15 months of age, but in only 1 of 99 (1%) children older than 15 months (P < .05). Abuse was excluded in 91 of 124 (73%) children. No determination of abuse (indeterminate) could be made in 23 of 124 (18.5%) children. In children less than 15 months of age, abuse was diagnosed in 2 of 10 (20%) with supracondylar fractures and in 7 of 12 (58%) with spiral/oblique fractures.

Conclusion. The prevalence of abuse in our children presenting with humeral fractures was much lower than in other published reports, especially in the children over the age of 15 months. However, we found a higher prevalence of supracondylar fractures associated with abuse than those same reports. Given these findings, abuse should be considered in all children less than 15 months of age with humeral fractures, including those with supracondylar fractures. The majority of humeral fractures in children are accidental, especially beyond the age of 15 months.
Sex Chromosome Tetrasomy and Pentasomy
Authors: Linden Mary C. , Bender Bruce G. , Robinson Arthur
Published: December 2021

Sex chromosome abnormalities occur in at least 1 in 400 births and include the well-described 47,XXX, 47,XXY, 47,XYY, and 45,X karyotypes. The addition of more than one extra X or Y chromosome occurs rarely, and little information is available in the medical literature. Individual case reports make up most of this body of knowledge, and all are based on subjects who identified themselves postnatally. Many were ascertained through screenings of institutions and hospitals; thus, there is no unbiased information on the natural history of poly X and Y karyotypes. A direct relationship between the number of additional sex chromosomes and the severity of the phenotype is generally assumed. The purpose of this article is to summarize what is known about these conditions and to present 10 additional cases. The karyotypes include, 48,XXXX, 49,XXXXX, 48,XXYY, 48,XXXY, 49,XXXXY, 49,XXXYY, 48,XYYY, 49,XYYYY, and 49,XXYYY.
Treatment of Acute Streptococcal Pharyngitis and Prevention of Rheumatic Fever: A Statement for Health Professionals
Authors: Dajani Adnan , Taubert Kathryn , Ferrieri Patricia , Peter Georges , Shulman Stanford ,   Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young,   American Heart Association
Published: December 2021

Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A β-hemolytic streptococcal (GAS) tonsillopharyngitis. Diagnosis of GAS pharyngitis is best accomplished by a throat culture. Penicillin (either oral penicillin V or injectable benzathine penicillin) remains the treatment of choice, because it is cost effective, has a narrow spectrum of activity, has long-standing proven efficacy, and GAS resistant to penicillin have not been documented. Various macrolides, oral cephalosporins, and other β-lactam agents are acceptable alternatives, particularly in penicillin-allergic individuals.

The individual who has had an attack of rheumatic fever is at very high risk of developing recurrences after subsequent GAS pharyngitis and needs continuous antimicrobial prophylaxis to prevent such recurrences (secondary prevention). The duration of prophylaxis depends on the number of previous attacks, the time lapsed since the last attack, the risk of exposure to streptococcal infections, the age of the patient, and the presence or absence of cardiac involvement. Penicillin is again the agent of choice for secondary prophylaxis, but sulfadiazine or erythromycin are acceptable alternatives in penicillin-allergic individuals.

This report is an update of a 1988 statement by this committee. It expands on the previous statement, includes more recent therapeutic modalities, and makes more specific recommendations for the duration of secondary prophylaxis.
Hepatitis in Association With Human Herpesvirus-7 Infection
Authors: Hashida Tetsuo , Komura Emiko , Yoshida Maki , Otsuka Takuji , Hibi Shigeyoshi , Imashuku Shinsaku , Imashuku Shinsaku , Ishizaki Tohru , Yamada Akira , Suga Sadao , Asano Yoshizo
Published: December 2021

Human herpesvirus-7 (HHV-7), a newly identified lymphotropic member of the herpes family, has recently been isolated from the peripheral blood mononuclear cells (PBMC) of healthy individuals.1 Similar to human herpesvirus-6 (HHV-6), HHV-7 has been found to prevalently infect children at younger ages.2-4 HHV-6 is known to be a causative agent of exanthema subitum,5 and has also been identified in cases of fatal fulminant hepatitis,6 hemophagocytic syndrome,7 encephalitis,8 and intussusception.9 Moreover, HHV-6 infection with severe consequences has been reported in bone marrow and organ transplant patients undergoing immunosuppressive therapy.10-12 Although HHV-7 has recently been isolated from the PBMC of the patients with chronic fatigue syndrome13 and of a child with symptoms mimicking chronic Epstein Barr virus (EBV) infection,14 it is as yet unknown what other diseases are associated with this newly isolated HHV-7 virus infection.
Letters to the Editor
Authors: Myer Charles M.
Published: December 2021

The debate continues! A recent article by Schunk et at1 stresses the safety and efficacy of Foley catheter removal of esophageal foreign bodies in selected circumstances. As Chairman of the Section on Otolaryngology and Bronchoesophagology and immediate Past President of the Society for Ear, Nose, and Throat Advances in Children, I feel compelled to offer an otolaryngology perspective to this controversial topic. In this regard, I am a "war veteran", having contributed an invited editorial to Pediatric Radiology in 1991 regarding the potential hazards of esophageal foreign body removal.2
The Economic Survival of Pediatric Practice
Authors: Hirsch Anthony T.
Published: December 2021

Many aspects of pediatric practice in the future are unclear. Among them is how pediatricians will be reimbursed. Based on trends established during the past 10 years, capitation is a likely mechanism. The advantages and disadvantages of capitation as a reimbursement mechanism—particularly as it compares with fee for service—are discussed, and a simplified description of how capitation rates are set is included.
Informed Consent, Parental Permission, and Assent in Pediatric Practice
Authors: Bartholome William G.
Published: December 2021

As the author of the first draft of the recently published Academy statement, Informed Consent, Parental Permission, and Assent in Pediatric Practice,1 I would like to comment on several of the "qualifying" or "clarifying" additions that have been made in this statement during its decade long struggle to gain Academy approval. I am particularly concerned about the possible misinterpretation of three of these additions. The first addition is the statement, "Parents and physicians should not exclude children and adolescents from decision-making without persuasive reasons"
Chorioamnionitis and Early Lung Inflammation in Infants in Whom Bronchopulmonary Dysplasia Develops
Authors: Watterberg Kristi L. , Demers Laurence M. , Scott Susan M. , Murphy Shirley
Published: December 2021

Objective. The development of bronchopulmonary dysplasia (BPD) often has been attributed to injury from mechanical ventilation and supplemental oxygen. Early lung inflammation in infants with BPD has been thought to be secondary to these factors. The purpose of this study was to evaluate whether preexisting (prenatal) inflammation may be a primary causative factor in the development of BPD.

Methods. Intubated newborns of less than 2000 g birth weight were prospectively enrolled. The presence or absence of chorioamnionitis was documented. Lung inflammation was evaluated on days 1, 2, and 4 of intubation by assaying concentrations of interleukin 1β(IL-1β), thromboxane B2, leukotriene B4, and prostaglandin E2 in tracheal lavages. Infants in whom BPD developed were compared with those in whom it did not using these measures.

Results. Fifty-three infants were enrolled; 41 survived. Thirty-eight had respiratory distress syndrome; 15 were intubated for other diagnoses. Infants prenatally exposed to chorioamnionitis were less likely to present with respiratory distress syndrome; however, chorioamnionitis was significantly associated with both the presence of IL-1β from the first day of intubation and the development of BPD. Tracheal lavage concentrations of IL-1β were higher in infants in whom BPD developed. Thromboxane B2 concentrations were similar on day 1 but were higher on days 2 and 4 in infants in whom BPD developed.

Conclusions. In this study, intubated infants weighing less than 2000 g at birth in whom BPD developed had increased exposure to inflammation prenatally (chorioamnionitis) and evidence of increased lung inflammation from the first postnatal day. We speculate that chorioamnionitis may accelerate lung maturation but that it also causes lung inflammation and subsequent lung injury in intubated infants, fostering the development of BPD.
WHAT A SHAMEFUL CONTRAST!
Authors: Student
Published: December 2021

Poor children in the United States are poorer than the children in most other Western industrialized nations, as young Americans suffer the brunt of several trends toward greater economic inequality, a new study shows . . . The United States has the widest gap between rich and poor . . . the United States also has less generous social programs than the other 17 countries in the study.

In 1950, fewer than 1 million American families earned as much as $60,000 in today's money. So rare was real wealth that the Census Bureau did not even keep numbers on incomes greater than that. As recently as 1967, only slightly more than 1 million American families earned more than $100,000 a year (in 1993 dollars) . . . But by 1980, 2.7 million lucky households counted incomes of more than $100,000. And by 1993, this group has doubled again, to 5.6 million households. And nearly 1 million American households were enjoying incomes over $200,000 . . . Nothing like this immense crowd of wealthy people has been seen in the history of the planet.
Varicella Vaccine
Authors: PLOTKIN STANLEY A.
Published: December 2021

The development and licensing of a vaccine for varicella in the United States has taken an incredible length of time. From the first report by Takahashi et al in 1974 until final American licensure in 1995, extensive studies were conducted by many investigators. Despite this long gestation period, which could have produced an elephant, there is some danger that the result will be a mouse, in that use of the vaccine since licensure has been far from universal. Recommendations by the American Academy of Pediatrics' Red Book Commitee and the Advisory Committee on Immunization Practices (statement in preparation, June 1995) may change that picture, but judging from conversations I have had, many American pediatricians have reservations concerning the varicella vaccine.
In Reply: Dexamethasone Therapy For Bacterial Meningitis
Authors: WALD ELLEN R.
Published: December 2021

Dr Bonadio has combined outcome data from four prospective, randomized, double-blind, placebo-controlled trials assessing the effect of adjunctive corticosteroid therapy on the outcome of bacterial meningitis in children treated with a third-generation cephalosporin. Similar to the previously published meta-analysis included in the article by Schaad et al, Dr Bonadio's analysis includes all etiologies of bacterial meningitis without clarifying whether a beneficial effect applies to particular bacterial species. Fifty-two to 82% of cases in each of the trials were comprised of Haemophilus influenzae type b, a bacterial species that is now a rare cause of meningitis in the United States.
"DR UNNECESSARY"
Authors: L. J. F.
Published: December 2021

The old reality for many psychiatrists was a private practice filled with long-term patients who paid $100 or more for 50 minutes of talk. The new reality? Managing medication for up to 30 new patients a week for half the hourly fee—and answering to case managers who aren't even doctors.

No wonder the number of U.S. medical school graduates in psychiatric residencies dropped nearly 12%—to 3909 from 4447—between 1988 and 1994.

The blame—or the credit—goes to managed care, the catchall term for the revolution that has swept through both the medical and mental health care fields in recent years. Desperate to cut runaway health insurance costs, most companies have axed longstanding fee-for-service plans and instead steer employees seeking psychiatric treatment to health maintenance organizations or specialized managed-care firms.

These organizations decide the type and amount of care patients receive. Psychiatrists have to get with the program—and agree to its treatment plans and fee schedules—or watch the bulk of their practices disappear. Only the rare psychiatrist can attract private patients wealthy enough to pay for traditional psychotherapy without the benefit of insurance.
Fundus Pigmentation in Retinopathy of Prematurity
Authors: Monos Tova , Rosen Shirley D. , Karplus Michael , Yassur Yuval
Published: December 2021

Objective. A prospective study design was used to investigate the association between different degrees of fundus pigmentation and the incidence of retinopathy of prematurity (ROP) among very low birth weight infants in a large neonatal intensive care unit.

Methods. The study group consisted of 161 infants weighing 1500 g or less at birth and included all infants born from 1988 to 1990 who survived at least 10 weeks. Presence or lack of any acute stage ROP was determined by weekly ophthalmological examination from the age of 4 weeks. The degree of fundus pigmentation was recorded for each infant during the first examination.

Results. Infants with dark fundus pigmentation were found to be at half the risk of developing ROP as compared with the infants having light/medium fundus pigmentation (relative risk 0.5;95% confidence interval = 0.2-1.1). When controlling for birth weight, gestational age, length of oxygen therapy, and ethnic group in multivariate analysis, dark pigmentation was an independent and statistically significant protective factor (odds ratio = 0.09, 95% confidence interval = 0.02-0.6). None of the infants with Stage III ROP or higher had dark pigmentation.

Conclusion. We speculate that large amounts of melanin in the retinal pigment epithelium or choroid may protect the dark-pigmented very low birth weight infant from developing ROP.
Radiation Exposure From Diagnostic Radiographs in Extremely Low Birth Weight Infants
Authors: Wilson-Costello Deanne , Rao Pejavar S. , Morrison Stuart , Hack Maureen
Published: December 2021

Objective. We sought to examine radiation doses received by infants of less than 750 g birth weight from radiographs.

Methods. We examined the radiology records, including radiograph films, of all 25 surviving infants with birth weight less than 750 g admitted to our center during 1991. The standard method of neonatal radiation dose calculation was modified to consider the body size, postnatal growth, and extramedullary hematopoiesis of the extremely low birth weight infant. To determine overall radiation exposure, we calculated an effective dose equivalent, which is the sum of weighted organ dose equivalents.

Results. The infants had a mean of 31 radiographs performed, including 17 chest radiographs, 5 babygrams, and 9 abdominal radiographs. The majority of chest radiographs and babygrams were performed in the first month, whereas abdominal radiographs increased during the second month of life. Total-body radiation dose and total effective dose equivalent by the standard and modified methods, respectively, for single exposures ranged from 0.01 to 0.02 millisieverts (mSv) for a chest radiograph, from 0.02 to 0.04 mSv for a babygram, and from 0.01 to 0.03 mSv for an abdominal radiograph. Surface organs including the skin, breast, and thyroid received the largest radiation doses. The effective dose equivalent per infant for all radiographs was 0.72 mSv according to the modified method, compared with a total-body dose of 0.40 mSv using the standard method. However, infants with chronic lung disease or necrotizing enterocolitis received up to 1.5 mSv total-body dose, including 3.3 mSv to the breast, 2.4 mSv to the thyroid, and 2.3 mSv to the testes.

Conclusions. Radiation doses received by infants of less than 750 g birth weight are small in comparison with the range of doses that form the basis of risk estimates for cancer.
Aluminum Toxicity in Infants and Children
Authors:   COMMITTEE ON NUTRITION
Published: December 2021

Dialysis encephalopathy and fracturing osteomalacia, which occur in hemodialysis units that use dialysis fluid contaminated with aluminum, have largely disappeared. This has been accomplished by establishing standards for safe concentrations of aluminum in dialysates. Infants, children, and adults with chronic renal failure who are not receiving dialysis have been shown to be at risk for aluminum intoxication from the oral administration of aluminum-containing phosphate binders. This complication should be avoided with the use of phosphate binders that do not contain aluminum and the use of other measures to control hyperphosphatemia.

A number of substances commonly administered intravenously, including calcium and phosphorus salts and albumin, have high levels of aluminum. Premature infants receiving intravenous fluid therapy may accumulate aluminum and show evidence of aluminum toxicity. Efforts are being made to reduce the levels of aluminum in products added to intravenous solutions; these efforts must continue.

Some infant formulas may contain relatively high concentrations of aluminum. The reported concentrations of aluminum in soy formulas and premature infant formulas are higher than those in other infant formulas. The potential impact of these formulas on the aluminum intake of premature infants and infants with impaired renal function should be recognized, although it is not clear that toxic effects result from the use of the formulas in these situations.
Inhaled Nitric Oxide Trials: "Vive la différence!"
Authors: DAVIDSON DENNIS
Published: December 2021

The commentary by Drs Abman and Kinsella entitled "Inhaled Nitric Oxide for Persistent Pulmonary Hypertension of the Newborn: The Physiology Matters!" provides one important and valid viewpoint concerning the optimal design of clinical trials in this area of neonatology. The approach that they advocate involves individualized and meticulous care of persistent pulmonary hypertension of the newborn (PPHN) patients depending on their underlying disease, using whatever conventional or rescue therapy (before extracorporeal membrane oxygenation [ECMO] is needed to support the patient, while testing the efficacy of inhaled nitric oxide (I-NO).
In Reply: Supplemental Security Income to Children and Adolescents
Authors: PERRIN JAMES M.
Published: December 2021

We appreciate the thoughtful letter from Dr Copeland. Much of the growth of the child and adolescent Supplemental Security Income (SSI) program in the past few years has appropriately provided children and adolescents with substantial disabilities in low-income families both financial support and access to Medic-aid. Yet, as Dr Copeland notes, the program has several problems, and the Academy has gone on record in recent months in ways generally consistent with Dr Copeland's concerns.
Varicella Vaccine and Susceptible Pregnant Mothers
Authors: KAN BRIAN D. , AULT MARK J. , GREENSPOON JEFFREY S.
Published: December 2021

Although the American Academy of Pediatrics Committee on Infectious Diseases presented an excellent review on the use of varicella vaccine in children, we are concerned about their recommendation to give the vaccine to children of pregnant women. The Committee recommends, "A pregnant mother or other household member is not a contraindication for vaccination of the child." In contrast, the manufacturer gives the following precaution: "Vaccine recipients should avoid close association with susceptible high-risk individuals (eg, newborns, pregnant women, and immunocompromised persons."
The Critical Role of Provider Practices in Undervaccination
Authors: Grabowsky Mark , Orenstein Walter A. , Marcuse Edgar K.
Published: December 2021

There are five principal ways providers can raise immunization coverage levels among their patients. First, assure that all appropriate opportunities for vaccination are taken. Second, give patients all vaccines for which they are eligible. Third, use only valid contraindications. Fourth, assess immunization status and immunize at all visits, regardless of the reason the parent is seeking care. Fifth, implement aggressive reminder systems to notify parents when immunizations are due.

The information presented here suggests that some changes in the way physicians deliver vaccinations are needed. Vaccination is one of the most beneficial services providers can give their patients. In addition to avoiding unnecessary suffering through prevention of disease, disability, and death, vaccination saves society from $6 for every $1 spent on oral poliovirus vaccine19 to $29.00 for every $1.00 spent on diphtheria-tetanus-pertussis vaccine.20 As health care providers, we have an opportunity to assure that our patients get the full benefit of this service. These results suggest that, once motivated, physicians and nurses should be able to determine the best way to get their patients vaccinated using a variety of techniques.
Acute Renal Failure Secondary to Pyelonephritis
Authors: Turner Mary Ellen , Weinstein Jonathan , Kher Kanwal
Published: December 2021

Pyelonephritis is an unusual cause of acute renal failure in children with an anatomically normal urinary tract and no other predisposing conditions. On the other hand, acute renal failure due to acute pyelonephritis has been reported in adults, and is often associated with pregnancy, solitary kidney, indwelling catheter or use of nonsteroidal medications.1-3 We report the case of a 12-year-old girl with normal renal anatomy and no known predisposing conditions who developed acute renal failure during the course of acute bacterial pyelonephritis, and who recovered completely after appropriate antibiotic therapy.

CASE REPORT

A previously healthy 12-year-old female was admitted to the Children's National Medical Center with a 1-week history of vomiting, diarrhea, and abdominal cramping.
Markers for Primary Care: Missed Opportunities to Immunize and Screen for Lead and Tuberculosis by Private Physicians Serving Large Numbers of Inner-city Medicaid-eligible Children
Authors: Fairbrother Gerry , Friedman Stephen , DuMont Kimberly A. , Lobach Katherine S.
Published: December 2021

Objective. This study examines coverage levels for immunization, missed opportunities to immunize, and extent of lead and tuberculosis screening in inner-city storefront physician offices and then relates child, visit, and physician characteristics to missed opportunities.

Methodology. With the use of a nested sampling strategy, 232 charts were selected for review in 31 physician's offices. Charts selected were for children 0 to 35 months of age who had three or more visits in more than 3 months. Physicians were selected from those in specific low-income New York inner-city neighborhoods who submitted large volumes of Medicaid billing claims. Variables examined were missed opportunities to immunize, immunization coverage levels, lead, and tuberculosis screening. The outcome measure was missed opportunities to immunize.

Results. Only 26% of the children were up to date for their age for diphtheria, tetanus, pertussis (DTP), oral polio vaccine (OPV), and measles, mumps, rubella (MMR) compared with a city-wide coverage level of 49%. Children who were not up to date for immunization coverage were more likely not to be up to date for lead (RR = 1.24, CI 0.96 to 1.60) or tuberculosis (RR = 1.54, CI 1.14 to 2.08) screening. Physicians miss opportunities to immunize in 84% of the eligible visits. Opportunities to immunize are missed more frequently at sick care or follow-up visits (95% and 91% missed opportunities) than at well care visits (41% missed opportunities).

Conclusions. The quality Of pediatric primary care given by these inner-city storefront physicians is suboptimal. Sick and follow-up visits predominate; well care visits are infrequent. If care is to be improved, Medicaid reimbursement policies, which make delivery of well care unprofitable, will need to be changed. In addition, monitoring the quality of care will need to be more aggressive. In the near future children who receive Medicaid in New York will be in managed care. If reimbursement and monitoring policies that provide incentives for delivering pediatric primary care are to be in place, it will be the managed care plans that implement this.
Partial Amputation of Glans Penis During Mogen Clamp Circumcision
Authors: Strimling Bruce S.
Published: December 2021

Although no numerical data are available, the most common techniques for performing newborn circumcision in the United States involve the use of the Plastibell, the Gomco clamp, and the Mogen clamp, likely in that order. The Mogen clamp (see Fig 1 and 2) is the least familiar to most pediatricians. It has a number of advantages when compared with the other techniques:

1. the one size of the Mogen fits all;

2. it is the most rapid;

3. the Mogen instrument allows full visualization of exactly how much prepuce to remove.

In Mogen circumcision however, the glans is not visualized before removal of the prepuce.
Three-Versus Four-week Administration of Benzathine Penicillin G: Effects on Incidence of Streptococcal Infections and Recurrences of Rheumatic Fever
Authors: Lue Hung-Chi , Wu Mei-Hwan , Wang Jou-Kou , Wu Fen-Fen , Wu Yu-Nian
Published: December 2021

Objective. To investigate the effects of 3-week versus 4-week administration of benzathine penicillin G (BPG) on the incidence of Group A streptococcal infections and the recurrences of rheumatic fever (RF).

Study Design. We started, in 1979, randomly allocating all patients with RF to a 3-week or 4-week BPG prophylaxis program. They were examined at the RF clinic, every 3 to 6 months, and at any time they did not feel well. During 1979 to 1989, throat cultures and sera for antistreptolysin O and streptozyme titers were obtained at each clinic visit. Chest radiographs, electrocardiogram, color Doppler echocardiograms, and acute phase reactants were obtained.

Subjects. Two hundred forty-nine patients fulfilled the revised Jones criteria and were followed until December 1991: 124 in the 3-week and 125 in the 4-week program. Their age, sex, weight, percentage with history of RF, severity of cardiac involvement, follow-up duration, and compliance to program were comparable. Eight hundred eighty throat cultures were collected in the 3-week program and 770 were collected in the 4-week program. Six hundred sixteen and 627 sera were determined in each program for antistreptolysin O, and 582 and 592 sera for streptozyme titers.

Results. True streptococcal infections occurred in both programs: 39 infections in the 3-week program, and 59 infections in the 4-week program (7.5 vs 12.7 per 100 patient-years). Four infections with no antibody response occurred in the 3-week program, and three such infections in the 4-week program. Nine RF recurrences occurred in 8 patients in the 3-week program, and 16 recurrences in 16 patients in the 4-week program. Prophylaxis failure occurred in 2 of 124 patients in the 3-week program, and in 10 of 125 patients in the 4-week program (0.25 vs 1.29 per 100 patient-years). The overall recurrences/infections rate in each program was comparable, 13.6% vs 15.5%, but the recurrences/infections rate due to prophylaxis failure was higher in the 4-week program than in the 3-week program, 3.0% versus 9.7%.

Conclusions. This 12-year prospective and controlled study documented that streptococcal infections and RF recurrences occurred more often in the 4-week program than in the 3-week program. The risk of prophylaxis failure was fivefold greater in the 4-week program than in the 3-week program.
Assuring Quality of Care for Children With Special Needs in Managed Care Organizations: Roles for Pediatricians
Authors: Ireys Henry T. , Grason Holly A. , Guyer Bernard
Published: December 2021

Increasing numbers of children with special health care needs are enrolling in managed care programs. Although managed care may improve service coordination and use of primary care, it may also threaten health outcomes for these children by potentially decreasing access to the range of needed services, eroding progress in developing community-based service systems, and failing to assure quality of care. To date, few frameworks have been proposed to assess quality of care for this population of children in managed care organizations. In this article, we adapt the Institute of Medicine's definition of quality and identify six key components: content of service delivery systems, the nature of desired health outcomes, risks associated with service delivery, constraints of care, interpersonal dimensions, and attention to developmental issues. These components can be assessed at three levels: the individual, the health plan, and the community. Pediatricians and other child health professionals have critical roles to play in assuring that policies and practices within managed care organizations promote a high quality of care for this vulnerable population of children.
Practice Variations by Population: Training Significance
Authors: Feigin Ralph D. , Drutz Jan E. , Smith E. O'Brian , Collins Carol Ritter
Published: December 2021

Objective. This study sought to examine variations in the frequency of procedures performed and patterns of care of sick infants and older children by general pediatricians in different sized communities. The results of the study will be considered in developing relevant educational experiences for postgraduate trainees.

Methodology. Questionnaires were sent to 1412 Texas pediatricians requesting frequency information for 29 procedures and whether they provided various levels of care to sick infants and older children. Responses were tabulated by the size of the community in which each pediatrician practiced.

Results. Fifty-four percent of the questionnaires were returned. The proportion of pediatricians performing each procedure was significantly different for all but 8 of the 29 procedures between communities of less than 100 000 and more than 100 000 population. For all procedures with significant differences, the proportion of physicians performing the procedures was significantly greater for pediatricians practicing in communities of less than 100 000 population. No significant difference was found between the proportion of pediatricians providing newborn level II and III care; however, more than 65% of both groups provided level II care. Physicians in communities of less than 100 000 population were more likely to provide intermediate and intensive care beyond the newborn period.

Conclusion. The general practice rotation in the community setting will not provide adequate training experiences for many of the procedures currently being performed by general pediatricians.
Influenza Vaccination of Children During Acute Asthma Exacerbation and Concurrent Prednisone Therapy
Authors: Park C. Lucy , Frank Arthur L. , Sullivan Myrtis , Jindal Parveen , Baxter Barbara D.
Published: December 2021

Objectives. The influenza vaccination rate is very low among children with moderate to severe asthma. This may be partly because of poor patient motivation and failure to visit clinics for vaccination. Another important factor may be health care providers' deferral of vaccination because of concern about the efficacy and safety of influenza vaccination during asthma exacerbations and concurrent prednisone therapy. We therefore examined the safety and immunogenicity of influenza vaccination during acute asthma exacerbation with concomitant prednisone therapy.

Setting. A pediatric allergy and pulmonology clinic and a pediatric emergency department.

Design. Children (n = 109) with a known diagnosis of asthma 6 months to 18 years of age were recruited. All participating patients, 59 without asthma symptoms (no prednisone, control group) and 50 with acute asthma exacerbation requiring prednisone burst therapy (prednisone group) received trivalent subvirion influenza vaccine. Fifteen children in the control group and 12 in the prednisone group received a booster dose according to American Academy of Pediatrics guidelines. Serum antibody titers to influenza A/Beijing/32/92 (H3N2), influenza A/Texas/36/91 (H1N1), and influenza B/Panama/45/90 were measured before and 2 weeks after vaccination. Adverse effects noted within 48 hours after vaccine dose were ascertained during the follow-up visit.

Results. The antibody response was analyzed by comparing mean postvaccine titers, the percentage of patients achieving protective antibody levels (≥5log2), and the percentage of patients achieving rises in titers of 2log2 or greater. Antibody responses to influenza A/Beijing/32/92 (H3N2) and influenza A/Texas/36/91 (H1N1) in the prednisone-treated and control groups were not different. A significantly better response to the influenza B/Panama/45/90 antigen was seen in the prednisone group for all three parameters. Children who received a booster dose and the subgroup of children with low prevaccination titers (≤3log2) showed similar patterns. Adverse effects, including asthma exacerbation, local swelling at the injection site, fever, rash, and headache were not different in the two groups.
Growth Hormone Increases Breast Milk Volumes in Mothers of Preterm Infants
Authors: Gunn Alistair J. , Gunn Tania R. , Rabone Diana L. , Breier Bernhard H. , Blum Werner F. , Gluckman Peter D.
Published: December 2021

Aims. To determine the galactopoietic response to recombinant human growth hormone (hGH) in mothers of premature infants with inadequate lactation.

Study Design. Prospective placebo-controlled, double-blind trial.

Subjects. Twenty healthy mothers on no concurrent medication, with infants born between 26 and 34 weeks' gestation with insufficient milk production for their infants' needs.

Interoentions. Ten mothers received hGH, .2 IU/kg/day subcutaneously to a maximum of 16 IU/day, for 7 days, while 10 mothers received the same volume of placebo. One mother from each group withdrew from the study.

Outcome Measures. Maternal milk production and plasma concentrations of insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), and growth hormone (GH) were determined before starting treatment and 1 day after stopping therapy. A nurse measured the amount of milk expressed (5 to 6 times daily) plus, if the infant was suckling, weighed the infant before and after feeding.

Results. The mothers were enrolled 35 ± 26 days after birth; at this time the infants weighed 1.89 ± .64 kg. Milk production in hGH-treated mothers increased from 139 ± 49 mL/day to 175 ± 46 mL/day after 7 days of treatment (arise of 31%). Placebo-treated mothers showed no significant change from 93 ± 50 mL/day to 102 ± 69 mL/day (arise of 7.6%, not significant). Milk production increased in all treated mothers but decreased in 4 of 9 placebo mothers. Plasma concentrations of IGF-1 and IGFBP-3 increased in hGH-treated mothers but not placebo-treated mothers; there was no change in plasma GH levels in either group. No adverse effects were seen with hGH treatment in the mothers or infants.

Conclusions. hGH therapy in mothers with lactational insufficiency can improve breast milk volumes.
MOLECULAR IDENTIFICATION OF AN IMMUNOGLOBULIN E (IgE)-DEPENDENT HISTAMINE-RELEASING FACTOR
Authors: Sicherer Scott H. , Wood Robert A.
Published: December 2021

Purpose of the Study. The late-phase allergic response depends in part on histamine release from immunoglobulin E (IgE)-bearing basophils that collect at the site of allergic inflammation at a time when allergen has been metabolized. This phenomenon lead to the search for cytokines that can cause histamine release from basophils. Although several cytokines can cause basophil histamine release, only one histamine-releasing factor (HRF), which has been found in late-phase response fluids, causes histamine release only from basophils bearing IgE. In fact, this HRF only releases histamine from basophils bearing a particular type of IgE (termed IgE+) that is only produced by a subset of allergic individuals. This study sought to identify this HRF molecule.

Methods/Results. Fifty liters of supernatant containing HRF from a human macrophage line was concentrated and the proteins were separated by electrophoresis. Protein sequencing was performed on a 23-kD band and revealed extensive homology to a mouse protein, p21. and its human homologue, p23. Both of the genes for these proteins had been previously cloned because of extensive expression in tumor cells but no function had been ascribed to them. Both recombinant proteins caused histamine release from the human basophils of a subpopulation of donors, and this release was dependent on IgE. Polyclonal antibodies to the recombinant proteins were raised and were capable of removing the biologic activity of recombinant and native HRF. RNA blot analysis and reverse transcription polymerase chain reaction indicated that the HRF mRNA was ubiquitous and found in T cells, B cells, fibroblasts, and mononuclear cells.
COMPARISON OF ADENOSINE 5'-MONOPHOSPHATE AND METHACHOLINE FOR THE DIFFERENTIATION OF ASTHMA FROM CHRONIC AIRWAY DISEASES WITH THE USE OF THE AUSCULTATIVE METHOD IN VERY YOUNG CHILDREN
Authors: Kaplan Michael , Johnson Marion
Published: December 2021

Methacholine is a nonspecific bronchoconstrictor in children with pulmonary disease but adenosine, like exercise, is more specific for the diagnosis of asthma and can be used in very young children by the auscultative method.
A MULTI-INSTITUTIONAL SURVEY OF THE WISKOTT-ALDRICH SYNDROME
Authors: James John M.
Published: December 2021

Many patients with WAS have an atypical presentation, lack consistent laboratory findings, and a panel of diagnostic tests is often required to establish the diagnosis. Two high-risk subgroups were identified in the study population: patients with platelet counts < 10 000/mm3 at the time of diagnosis were at high-risk of bleeding, and patients with autoimmune disorders were at increased risk of having a malignancy.
Internet Listservers and Pediatrics: Newly Emerging Legal and Clinical Practice Issues II
Authors: De Ville Kenneth A.
Published: December 2021

Robyn and Stephen Elliott's recent and prescient commentary on the legal and clinical issues raised by physician communication on the Internet outlines the novel challenges represented by "listserver" dissemination of medical information.1 The Elliotts examined the reliability of such non-peer-reviewed information, its potential evidentiary weight in defense of a particular clinical decision, and the growing tendency of attorneys to request relevant electronic mail messages during pretrial discovery. The fact that messages posted on listservers may form the basis for clinical decisions raises another intriguing question: Does the rendering of a clinical opinion in response to a listserver query represent legal risk?
Ingestion of a Blister Beetle (Mecoidae Family)
Authors: Mallari Rolando Q. , Saif Mohammed , Elbualy Musallem S. , Sapru Anil
Published: December 2021

Cantharidin, the most important active principle of Cantharis vesicatoria (Spanish fly), has a long history. It is a medieval medicine, considered over a hundred years ago as the most powerful medicine on the Materia Medica. It has been used as a skin irritant, vessicant, and abortifacient, and has long been wrongly considered an aphrodisiac.1

The following cases appear exceptional in that the source of the poison—the blister beetle itself—was ingested, resulting in the manifestations of cantharidin poisoning.

CASE REPORT

Two siblings were referred to the Royal Hospital in Muscat on March 30, 1994, for repeated episodes of blood-stained vomitus and passage of reddish-colored urine after ingestion of a beetle they caught in a garden.
The Medium/The Message: Corporal Punishment, an Empirical Critique
Authors: Polite Kenneth
Published: December 2021

Before formally responding to Dr Graziano's article, it seems prudent to familiarize the reader with certain contextual elements pertinent to the conference, Dr Graziano's paper, and my critique. The American Academy of Pediatrics (AAP) invited a group of nationally known researchers and scholars to take an objective look at the empirical literature on the short- and long-term consequences of corporal punishment. Both the invitation to attend and the preconference materials made it clear that the conference was dedicated to objectivity, rather than an emotional debate. Consequently, any conclusions coming out of the conference were to be data-driven. Although such a commitment to empiricism is a commendable value, many reasonable professionals also hold the opinion that culture and experience shape the realities that individuals both perceive and attend to. All the reviews of the relevant literature on discipline and corporal punishment are shaped by the experiential and cultural baggage of the reviewers.

The present author is not excepted. Although personal musings are not often instructive in scholarly discourse, if the reader will bear with me, I would like to share a brief bit of personal experience and cultural background that may provide additional context for considering Dr Graziano's article, my critique, and the conference in question. In graduate school I was profoundly impacted by reading a philosophy of science book by Thomas S. Kuhn called The Structure of Scientific Revolutions (1962).1 Succinctly, it is Kuhn's thesis that science does not progress in the logical positivistic manner that we usually talk about.
DYEING FOR KOOL-AID
Authors: Barness L.
Published: December 2021

Kids may have finally found a use for the sugary drink Kool-Aid that nutritionists may approve of. Instead of drinking it, they put it in their hair. Youths stir cherry, kiwi lime or tropical punch Kool-Aid packets into a boiling pot of water then dunk their heads. Presto! Colored hair for an attractive price with no damaging chemicals. Kool-Aid offers added benefits: hair won't fall out of place when stuck together by the syrupy drink. Now if kids could only find something else to do with chips and candy ...
Graduated Licensure: A Win-Win Proposition for Teen Drivers and Parents
Authors: Rosenberg Mark L. , Martinez Ricardo
Published: December 2021

In this issue of Pediatrics, the American Academy of Pediatrics has taken a strong stand for safety in their policy statement entitled "The Teenage Driver." Among their recommendations, they call for graduated licensure for teenage drivers, a position we believe shows promise. Passing such legislation could be a critical step in reducing the leading cause of death in youth from 16 through 20 years old: motor vehicle crashes. Although teens constitute only 7% of the population of the United States, they account for 14% of all motor-vehicle deaths. More than 5000 teens die andi about a half-million are injured each year in traffic deaths.2
Medical Decisions: An Appeal for Reasonableness
Authors: Silverman William A.
Published: December 2021

Lewis Thomas wrote that when his father attended the College of Physicians and Surgeons of Columbia University at the turn of this century, medical teaching was just beginning to be influenced by the assertions of "therapeutic nihilism." This revolutionary thesis was a reaction to long-standing over-treatment by doctors with bleeding, cupping, violent purging, and the use of prescriptions compounded from long lists of bizarre substances and botanical extracts mixed together under the influence of nothing more than pure whim. The new teaching, led by William Osler at Johns Hopkins, argued that most of the remedies in common use were more likely to do harm than good: "There are only a small number of genuinely therapeutic drugs-digitalis and morphine the best of all." When Thomas himself entered medical school in 1933, very little had changed: "We were taught," he remembered, "that we could do nothing to change the course of the great majority of diseases we were so busy analyzing."

Despite this confession of helplessness (and unlike earlier times when physicians were regularly criticized for their pretensions and their greed), the profession began to enjoy unprecedented social esteem. Burnham labeled the first half of this century "American medicine's golden age." Publicity about medicine became increasingly favorable. It came to be regarded as a model profession; opinion polls from the 1930s to the 1950s consistently ranked doctors equal to or higher than Supreme Court justices. In 1952, an elderly doctor remembered that when he was young, the townspeople of Worcester, Massachusetts, customarily tipped their hats, in a gesture of respect to the physician as he passed by.
Impact of Music Lyrics and Music Videos on Children and Youth (RE9144)
Authors:   COMMITTEE ON COMMUNICATIONS
Published: December 2021

Music lyrics have undergone dramatic changes since the introduction of rock music more than 40 years ago. This is an issue of vital interest and concern for parents and pediatricians.

During the past four decades, rock music lyrics have become increasingly explicit—particularly with reference to sex, drugs, and violence. Recently, heavy metal and "gangsta rap" music lyrics have elicited the greatest concern. In some cases lyrics communicate potentially harmful health messages. Such lyrics are of special concern in today's environment, which poses unprecedented threats to the health and well-being of adolescents. Pregnancy, drug use, acquired immunodeficiency syndrome (and other sexually transmitted diseases), injuries, homicide, and suicide have all become part of the landscape of everyday life for many American teens.

At the same time, music is important to teenagers' identity and helps them define important social and subcultural boundaries. The results of one survey of 2760 14-to 16-year-olds in 10 different southeastern cities showed that that they listened to music an average of 40 hours per week. One Swedish study found that adolescents who developed an early interest in rock music were more likely to be influenced by their peers and less influenced by their parents than older adolescents.

To date, no studies have documented a cause-and-effect relationship between sexually explicit or violent lyrics and adverse behavioral effects. A possible explanation for this lack of finding is that teenagers often do not know the lyrics or fully comprehend their meaning. For example, in one study only 30% of teenagers knew the lyrics to their favorite songs, and their comprehension varied greatly.