bluuebunny/crossref_metadata_2025 huggingface dataset:
Sports and the Child with Epilepsy
Authors:   Committee on Children with Handicaps,   Committee on Sports Medicine
Published: December 2021

The 1968 statement of the Committee on Children with Handicaps, "The Epilpetic Child and Competitive School Athletics," is restated with considerable modification.1

The responsibility for weighing the risks involved in athletic participation should be shared by the parents, the physician, and the child. Such risks should be weighed against the psychological trauma resulting from unnecessary restriction of physical activities. Parents should participate in all decisions. To the degree appropriate to the age and judgment of the child, his or her wishes should be considered. The young athlete must be taught that there is a risk of injury and he or she should be prepared to impose voluntary restrictions on physical activity depending upon the nature and frequency of seizures.

Proper medical management, good seizure control, and proper supervision are essential if children with epilepsy are to participate fully in physical education programs and interscholastic athletics. Common sense dictates that situations in which a seizure could cause a dangerous fall should be avoided. These situations include rope climbing, activity on parallel bars, and high diving. Swimming should be supervised; no competitive underwater swimming is acceptable Participation in contact or collision sports should be given individual consideration according to the specific problem of the athlete. Epilepsy per se should not exclude a child from hockey, baseball, football, basketball, and wrestling.

Physicians who take care of childen who are involved in athletics should realize that in today's culture, sports and athletic activity are extremely important to young people and that unnecessarily strict interpretation of medical conditions may in fact do more harm than good.
Gastroesophageal Reflux and Apnea
Authors: ORENSTEIN SUSAN R.
Published: December 2021

To the Editor.—

The series of papers on infant apnea in the May 1983 issue of Pediatrics was interesting reading. I am curious about two aspects of the esophageal pH probe studies reported by Rosen et al.1

The authors do not specify the temporal relationship between feeding and their polygraphic studies; presumably infants were fed during both the 12-hour nocturnal studies and the eight-hour daytime studies. The material fed is quite important in pH probe studies, because frank vomiting may occur following a milk meal without a drop in esophageal pH.
Disposition of Dietary Caffeine in Milk, Saliva, and Plasma of Lactating Women
Authors: Berlin Cheston M. , Denson H. Mark , Daniel Catherine H. , Ward Robert M.
Published: December 2021

Caffeine is present in many dietary substances; its appearance from these sources in human milk has not previously been studied in detail. Fifteen lactating women ingested a known amount of a caffeinated beverage (36 to 335 mg). Simultaneous milk and saliva samples were collected at intervals for the subsequent 12 hours and assayed for caffeine content. Eleven of 15 mothers excreted measurable caffeine in milk. Caffeine was detected by 15 minutes in saliva and milk; peak levels in milk (2.09 to 7.17 µg/mL) and saliva (1.24 to 9.22 µg/mL) were achieved within 1 hour. Elimination half-lives were 1.3 to 13.5 hours (mean 4.0 ± 3.7 [SD] hours) for saliva and 1.5 to 14.5 hours (mean 6.1 ± 4.4 [SD] hours) for milk. Assuming each infant would ingest 90 mL of milk every three hours for 24 hours after maternal ingestion of caffeine, it is possible to estimate potential exposure of the nursing infant to caffeine. The amount of caffeine available for infant absorption ranged from 0.01 to 1.64 mg or 0.06% to 1.5% of the maternal dose. Caffeine was not present in the infants' urine collected for five hours after the first nursing period. The maternal ingestion of a single cup of caffeinated beverage does not appear to present significant doses of caffeine to the nursing infant.
A Hospice for Children in England
Authors: BURNE S. R.
Published: December 2021

Despite enormous advances toward complete cure of many of the previously fatal illnesses of childhood, modern medicine remains unable to help a small but important minority of children. In cases of malignant disease, failure to respond to curative treatment may lead quickly to a terminal phase of illness, while at another extreme, the long-term degenerative illnesses may cause a child to deteriorate mentally and physically for up to two decades before an inevitably fatal outcome.

During the last 30 years, the hospice movement had had great success in providing continuing care and symptom relief for incurably ill adults.1 More recent work has demonstrated that similar principles of care can be used to help relieve the distress of dying children2,3 whereas a hospice setting has been suggested in order to allow humane natural death for malformed and extremely premature neonates.4
Edema, Hypoproteinemia, and Zinc Deficiency in Low-Birth-Weight Infants
Authors: Kumar Savitri P. , Anday Endla K.
Published: December 2021

Three premature infants with zinc deficiency who had an unusual presentation with generalized edema and hypoproteinemia between 5 and 9 weeks of age are described. The infants were fed their own mother's milk, supplemented with a proprietary formula after the first 2 to 3 weeks of life. None of the infants had diarrhea, liver disease, or urinary protein loss. Treatment with oral zinc supplements led to rapid resolution of the edema, with an increase in values for serum proteins, alkaline phosphatase, and zinc. There was no recurrence of symptoms following discontinuation of zinc therapy 1 month later. At 1-year follow-up, all infants were doing well and had normal growth and development. As zinc plays a critical role in nucleic acid and protein synthesis, it is postulated that dietary zinc deficiency in the phase of rapid postnatal growth precipitated edema and hypoproteinemia in these infants. Zinc deficiency should be included in the list of causes of generalized edema in the low-birth-weight infant.
The Changing Pattern of Primary Pediatric Care: Update for One Community
Authors: Roghmann Klaus J. , Hoekelman Robert A. , Mclnerny Thomas K.
Published: December 2021

The changing pattern of pediatric practice in the Rochester, New York, community between the late 1960s and the late 1970s is described, and some extrapolations for the next decade are discussed. The child population shrunk from 243,000 in 1970 to 192,000 in 1980 and is expected to decrease further to 160,000 in 1990, possibly stabilizing at 140,000 by 2000. The number of pediatric beds as well as occupancy rates declined, but the number of full-time equivalent practicing pediatricians increased slightly. One third of them are now practicing out of neighborhood health centers or health maintenance organizations. Problems of manpower shortage and inadequate access to care for the inner city residents have long since disappeared. Utilization rates by race and socioeconomic area are similar once the children enter the care system. For "well child" care, however, there may still be lower utilization for blacks, especially for older children. The high "market penetration" for child health services by pediatricians, and the high proportion of well child visits (40%) among all visits, may be atypical for the nation as a whole, but is probably indicative of what pediatric care elsewhere will be in the future. Fewer children, and less acute care per child, will allow pediatricians to focus increasingly on preventive, developmental, and psychosocial needs.
Prevention of Perinatal Transmission of Chronic Hepatitis B Surface Antigen (HBsAg) Carrier State
Authors: SALVIOLI GIAN PAOLO , FALDELLA GIACOMO , ALESSANDRONI ROSINA , LANARI MARCELLO
Published: December 2021

To the Editor.—

All over the world, groups with the highest risk of hepatitis B virus (HBV) infection are being identified in order to define correct immunoprophylaxis programs.1,2 It has been suggested that all infants born to HBsAg-positive mothers, irrespective of whether they are HBeAg positive or not, are in need of immediate protection.3,4 In support of this necessity, Sinatra and colleagues5 report three cases of perinatal transmitted acute icteric hepatitis B in infants born to HBsAg-positive and anti-HBe-positive carrier mothers.
Malpractice Issues
Authors: BRENT ROBERT L.
Published: December 2021

In Reply.—

As Hecht points out, certain physicians and scientists appear repetitively as expert witnesses. This is less important than the fact that some witnesses, whether they testify frequently or rarely, are not experts and present a distorted and partisan view of the scientific material that they are presenting to the court. I agree with Hecht that the fees are soaring and frequently unreasonable. Although there appears to be a correlation of the very high fees with the most irresponsible witnesses, this is not necessarily always an accurate assumption.
Hemorrhagic Periventricular Leukomalacia and Spastic Diplegia
Authors: LEVENE M. I. , WIGGLESWORTH J. S. , DUBOWITZ V.
Published: December 2021

In Reply.—

We are in complete agreement with Kuban and Gilles on the continued importance of pathologic verification as the gold standard to which clinical diagnostic techniques are compared, and this remains the major basis of our own work, although such verification is inevitably limited by low mortality rates and problems in obtaining consent for autopsy. The points they make on the specificity of the areas of increased echodensity which we have equated with hemorrhagic periventricular leukomalacia (PVL) are important.
Effect of Prophylactic Phenobarbital on Intraventricular Hemorrhage in High-Risk Infants
Authors: Bedard Mary P. , Shankaran Seetha , Slovis Thomas L. , Pantoja Alfonso , Dayal Bimleshwar , Poland Ronald L.
Published: December 2021

Forty-two premature infants less than 24 hours of age, with normal admission echoencephalograms, were randomly assigned to control or phenobarbital treatment groups. Infants in the treated group received two loading doses of 10 mg/kg of phenobarbital 12 hours apart, followed by a maintenance dose of 2.5 mg/kg every 12 hours for 6 days. Serial echoencephalograms were obtained in both groups. The groups were comparable with regard to birth weight, gestational age, and potential risk factors for subependymal-intraventricular hemorrhage. Ten infants (48%) in each group developed hemorrhage. The hemorrhages in the phenobarbital-treated group were significantly less severe than those in the control group. The phenobarbital-treated infants who bled, however, were also significantly larger and more mature than control infants who bled. The results of this study indicate no effect of phenobarbital on the incidence of subependymal-intraventricular hemorrhage, but a possible beneficial effect on the severity of hemorrhage.
Hyperammonemia in Lysinuric Protein Intolerance
Authors: Kato Tomoaki , Mizutani Naoki , Ban Masakazu
Published: December 2021

Two brothers with hyperdibasicaminoaciduria and postprandial hyperammonemia showed characteristics of lysinuric protein intolerance. Intravenous alanine load produced hyperammonemia that was aborted by oral supplementation with arginine in one brother but not in the other, although both patients had almost the same intestinal malabsorption of arginine. This occurrence suggests that even a small amount of arginine, when absorbed into the blood, can normalize the affected ammonia metabolism of lysinuric protein intolerance. Two patients with cystinuria developed marked hyperammonemia when they received an intravenous alanine load after a 19-hour fast. As both patients displayed a reduced plasma concentration of arginine and ornithine at this time, the hyperammonemia was assumed to arise from the low plasma amino acid level. It seems likely that a decrease in plasma levels of urea cycle substrate causes a failure of the tissue urea cycle metabolism. Thus the impaired ammonia metabolism in lysinuric protein intolerance would be attributed to the low plasma arginine and ornithine levels.
Watch Out for `Old' Ipecac
Authors: HUFF MARVIN R. , MANSKE THOMAS A. , FORSYTH CLAIRE , DRIVER PAUL
Published: December 2021

To the Editor.—

The use of Syrup of Ipecac by poison centers and hospital emergency room physicians has become a valuable means of gastric removal of various orally ingested poisonous substances. In the domestic poisoning situation, the efficacy of this method is even more important as it is frequently the "only" available therapy in the home, due to its over-the-counter status. With the availability, awareness, and use of Syrup of Ipecac by the general public, health professionals must ensure appropriate use and storage of the product.
Intracranial Lesions of Congenital Cytomegalovirus Infection Detected by Ultrasound Scanning
Authors: Butt W. , Mackay R. J. , de Crespigny L. Ch. , Murton L. J. , Roy R. N.D.
Published: December 2021

Four cases of congenital cytomegalovirus infection associated with previously unreported intracranial lesions—paraventricular cysts and intraventricular Strands and mild ventriculomegaly—are described. These findings may have serious implications regarding the long-term neurologic prognosis for infants with congenital cytomegalovirus infection.
Science and Empiricism in Pediatrics
Authors: Goldbloom Richard B.
Published: December 2021

Whatever the duration of your experience in looking after children, it doesn't take many years before you can look back with some amusement on abandoned practices in child care. The further you retrospect, the more ludicrous some of the antique customs seem—proving the fundamental equation that comedy equals tragedy plus time.

As we read or listen to scientific presentations laden with chi-squares and P values—measures of a significance that is sometimes more mathematical than social, we might easily be seduced into believing that the age of scientific reason had arrived—that our every daily act in caring for children and their families had been tested and proven efficacious in accordance with the rigorousrules of scientific evidence.

But notwithstanding our scientific airs and graces, pediatric empiricism is still with us, in our sophisticated and prestrigious tertiary care hospitals and in daily clinical practice in this community. Let me cite a few instances to support the notion that our management of the commonest childhood illnesses is still rooted as much in empiricism as in science. Let me also suggest that those very empiricisms identify research priorities and call for a new collegiality between pediatric clinicians and researchers. Too often we pediatricians come to be labeled as either "academic" or "practicing"—an artificial distinction which excludes the combination of qualities to which most of us aspire, thus doing us all a disservice.

One of our peculiar inconsistencies is that the rigor with which we apply the rules of scientific proof is highly situational. Before we allow a new vaccine or antibiotic to be released for use among the general public, we and our governments insist on the critical review and publication of carefully controlled trials, first in laboratory animals and finally in groups of consenting humans.
Methemoglobinemia in an Infant Treated with the Folk Remedy Glycerited Asafoetida
Authors: KELLY KEVIN J. , NEU JOSEF , CAMITTA BRUCE M. , HONIG GEORGE R.
Published: December 2021

Methemoglobinemia can be caused by inherited enzyme deficiencies or abnormal hemoglobin structure. Methemoglobinemia may also be the result of oxidative stress that overwhelms normal red cell protective mechanisms.1

We present a case of methemoglobinemia in an infant who was treated with gum asafoetida, a compound used as a folk remedy and contained in certain foods. Laboratory investigation demonstrated an oxidizing effect of asafoetida on fetal hemoglobin but not on adult hemoglobin. This chemical, which is sold over the counter in pharmacies, must be considered as being potentially life threatening if given to infants.

CASE REPORT

A previously well, 5-week-old black male infant was admitted to the hospital six hours after the onset of tachypnea, grunting, and cyanosis.
The `Baby Doe' Rule: Is It All Bad?
Authors: JOHNSON DANA E. , THOMPSON THEODORE R.
Published: December 2021

There can be little doubt that the majority of professionals involved in newborn intensive care strongly disagree with the present administration's views on how to ensure optimal care to handicapped and critically ill newborns. The list of stated objections is lengthy and is heatedly spiced with references to "Big Brother Doe" (Minneapolis Star and Tribune, April 13, 1983, P 15A) and "Ethical Decisions by Edict".1 Disquieting reports have circulated on disruptive and unjustified investigations of wrongdoing in newborn intensive care units by poorly coordinated "Baby Doe squads."2 Most neonatologists and intensive care nurses, when imagining themselves in such a defensive position, would find little if anything positive to say about the regulation.
Mental Health Problems of Children: Analysis of a Cumulative Psychiatric Case Register
Authors: Roghmann Klaus J. , Zastowny Thomas R. , Babigian Haroutun M.
Published: December 2021

The advent of community mental health centers has brought a marked increase in treatment of mental health problems of children, especially for minorities. The number of children receiving care and the prevalence and the utilization rates by age, sex, and race from 1960 to 1977 in a large metropolitan county in upstate New York have been described previously. For the same time and community, the episodes of care by diagnostic grouping, type and length of treatment, and health status at the end of an episode have now been examined. An increase in treatment occurred in two areas: situational disorders and behavioral disorders. The number of treatments for psychotic, neurotic, and personality disorders remained stable. Affective and psychotic disorders emerged as qualitatively unique problems which often required multiple treatments and predicted high adult utilization. The average length of treatment for all episodes was 110 days. One third of the treatment episodes were associated with an improved health status. Most contacts were for first episodes, but a few patients had an extraordinarily large number of treatment episodes. A comparison with mental health problems seen in pediatric practice is presented.
Bleeding in Cystic Fibrosis?
Authors: ROSENSTEIN BERYL J.
Published: December 2021

To the Editor.—

I read with interest the article by Lane and colleagues1 in which they described a fatal intracranial hemorrhage in a normal infant secondary to vitamin K deficiency. In their patient, vitamin K deficiency was attributed to lack of newborn prophylaxis, with breast-feeding and antibiotic administration as possible contributing factors.

It is important to point out that a bleeding disorder can be the presenting manifestation of cystic fibrosis during the first year of life and that this possibility needs to be considered in the differential diagnosis in all infants with evidence of vitamin K deficiency.
Why Do We Keep Using Phototherapy in Healthy Newborns?
Authors: HEIN HERMAN A.
Published: December 2021

To the Editor.—

Prevention of kernicterus is a laudable pursuit. However, unsubstantiated beliefs about neonates at risk for kernicterus may have caused numerous babies to receive needless phototherapy and/or exchange transfusions. Early studies that suggested the association of bilirubin levels greater than 20 mg/dL and kernicterus, and on which modern policy seems to be based, were heavily slanted toward babies who were preterm or had hemolytic disease or sepsis.1-3 Few, if any data attest to the risks of bilirubin levels in excess of 20 mg/dL but less than 25 mg/dL in otherwise healthy, term neonates.
Atlantoaxial Instability in Down Syndrome
Authors:   Committee on Sports Medicine
Published: December 2021

Some issues related to participation in certain sports by persons with Down syndrome require clarification.

Since 1965 there have been occasional reports about a condition described at various times as instability, subluxation, or dislocation of the articulation of the first and second cervical vertebrae (atlantoaxial joint) among persons with Down syndrome.1-15 This condition has also been found in patients with rheumatoid arthritis,16,17 abnormalities of the odontoid process of the second cervical vertebra,4,5,12,13,15 and various forms of dwarfism.18 Atlantoaxial (C-1, C-2) instability has not attracted general attention because clinical manifestations are rare and the condition is limited to a small portion of the population. The incidence of atlantoaxial instability among persons with Down syndrome has been reported by various observers to be 10% to 20%.2,9,15 When atlantoaxial instability results in subluxation or dislocation of C-1 and C-2, the spinal cord also may be injured. This is a rare but serious complication.

In March 1983, the Special Olympics, Inc, sponsors of a nationwide competitive athletic program for developmentally disabled persons, without prior announcement, mandated for participants with Down syndrome special precautions to prevent serious neurologic consequences from stress on the head and neck in sports competition.19 Although thousands of persons with Down syndrome have taken part in sports events during the 15-year history of the Special Olympics without a known occurrence of neurologic complications due to participation, the new directive requires all persons with Down syndrome who wish to participate in certain sports that might involve stress on the head and neck (gymnastics, diving, pentathlon, butterfly stroke in swimming, diving start in swimming, high jump, soccer, and warm-up exercises that place undue stress on the head and neck muscles) to have a medical examination, lateral-view roentgenograms of the upper cervical region in full flexion and extension, and certification by a physician that the examination did not reveal atlantoaxial instability or neurologic disorder.
Care of Infants with Myelomeningocele
Authors: DEKLOTZ RICHARD L.
Published: December 2021

To the Editor.—

In the article by Gross et al1, the topic of infection was not addressed. In two of the references that they cited, there was a 60% greater incidence of meningitis or ventriculitis in the groups with delayed closure compared with the groups with immediate closure. The numbers in the Smyth et al article2 are 8/53 (15%) infected in the group with immediate closure and 11/46 (24%) in the group with delayed closure. In the Sharrard et al study3 the numbers are 5/20 (25%) infected in the group with immediate closure and 8/20 (40%) in the group with delayed closure.
Care of Infants with Myelomeningocele
Authors: FARBER JON MATTHEW
Published: December 2021

To the Editor.—

I greatly appreciated the article by Gross et al1 describing their program's approach to the difficult medical and ethical question of dealing with infants with myelcmeningocele. There is one potentially quite disturbing point in their article, however, which I feel cannot be allowed to go unnoticed. A program that allows for the nontreatment of these children must have superb selection criteria for deciding who is treated and who is not. The authors state that there were five infants for whom they did not recommend intervention, but the parents still wished it, so treatment was given.
Cost-Benefit Analysis of Neonatal Intensive Care for Infants Weighing Less Than 1,000 Grams at Birth
Authors: Walker Donna-Jean B. , Feldman Allan , Vohr Betty R. , Oh William
Published: December 2021

Cost-benefit analysis was performed on the care of 247 infants weighing between 500 and 999 g at birth, admitted to Women and Infants Hospital of Rhode Island between January 1977 and December 1981. The neonatal mortality was 68%. Eighty-seven percent of the survivors were evaluated neurodevelopmentally for 1 to 5 years: 74% were normal or minimally impaired, 10% were moderately impaired, and 16% were severely handicapped. Using these data in conjunction with cost information obtained from the hospital and therapeutic care facilities for handicapped children, total lifetime costs for the care of these infants were estimated. In 1982 dollars, present values of costs ranged from $362,992 per survivor for those weighing between 600 and 699 g to $40,647 per survivor for those weighing between 900 and 999 g, resulting in an inverse correlation between cost per survivor and birth weight (P < .001). We estimated present values of expected lifetime earnings per survivor, with a range of zero earnings for infants between 500 and 699 g, to $77,084 for those with birth weight of 900 to 999 g. It is concluded that from the standpoint of cost-benefit analysis as was used for this study population, neonatal intensive care may not be justifiable for infants weighing less than 900 g at birth.
Limitations of Transcutaneous Po2 and Pco2 Monitoring in Infants with Bronchopulmonary Dysplasia
Authors: Rome Ellen S. , Stork Eileen K. , Carlo Waldemar A. , Martin Richard J.
Published: December 2021

Despite the well-documented correlation between transcutaneous and arterial Po2 and Pco2 in sick neonates, the effect of maturation on this relationship has not been well characterized. Eight premature infants with bronchopulmonary dysplasia (BPD) and indwelling arterial lines beyond the immediate neonatal period were studied. Transcutaneous Po2 always underestimated Pao2 beyond 10 weeks of postnatal life, such that transcutaneous Po2 - Pao2 was -16 ± 5 torr (P < .001). Corrected transcutaneous Pco2 simultaneously overestimated PaCo2 by 9 ± 3 torr (P < .001), although this occurred over a wider range of postnatal ages. Transcutaneous Po2 monitoring may be a useful tool for estimating Pao2 in this population, provided an appropriate correction is made beyond 10 weeks of age. It is suggested that caution be exercised when using transcutaneous Pco2 measurements to estimate absolute arterial values in older infants with bronchopulmonary dysplasia.
Coronavirus?
Authors: PAYNE CLAIRE M. , RAY C. GEORGE
Published: December 2021

To the Editor.—

We read with great interest the paper by Rousset et al1 in which the presence of coronavirus-like particles in intestinal lesions of neonates with necrotizing enterocolitis was described. The presence of viral particles in thin-sectioned material is often difficult to demonstrate because of the striking similarity of some viral particles to normal cell organelles and structures. We agree with the authors that coronavirus-like particles may be an etiologic agent in some cases of neonatal necrotizing enterocolitis of nonbacterial origin2,3; we do not agree, however, that their published electron micrographs unequivocally demonstrate viral particles.
Introduction to Preventive Pediatrics
Authors: Lovejoy Frederick H.
Published: December 2021

Pediatricians can do much to ensure an active, forceful, and rational approach to the prevention of childhood injury and disease. The extent of progress over the next decade will, in large measure, be determined by the ability of pediatricians to work with the nonmedical community in implementing meaningful accident prevention efforts.
Photodosimeter Badge System
Authors: Scheidt Peter C. , Sternthal Phyllis M. , Anderson Robert , Studholme Robert , Bryla Dolores A. , Fetterly Karen L.
Published: December 2021

The Committee on Phototherapy in the Newborn of the National Academy of Sciences has recommended10 development of a compact system to continuously measure radiant energy exposure of infants treated with phototherapy. A small bilirubinimpregnated photodosimeter film badge was developed by the Beckman Instrument Company for this purpose and was used during the National Institute of Child Health and Human Development (NICHD) phototherapy study. This report summarizes the results of data obtained with this measurement device and briefly describes the performance of this system.

METHODS

The film badge dosimeter system consists of a 5.2x2.6-cm plastic badge composed of an imbedded disk of bilirubin cast in a polymeric substrate and sandwiched between two layers of clear plastic. Before exposure to light, the badge exhibits a high optical density at 460 nm due to a relatively high concentration of bilirubin. The optical density of the badge at 400 to 500 nm decreases as a function of the total dose of light within the action spectrum for the photodecomposition of bilirubin to which the badge has been exposed. Initial optical density at 460 nm is measured by a densitometer designed and dedicated specifically for this purpose. After exposure, the optical density is again measured by insertion into the densitometer; the total dosage, which is the time-integrated irradiance received by the badge during the photodecomposition process, is derived from the difference in optical density between the two readings. (A description of the calibration of the badge is available on request from Biometry Branch, Epidemiology and Biometry Research Program, National Institute of Child Health and Human Development, Bethesda, Maryland.)
The National Institutes of Health Point of View
Authors: LILLY JOHN R.
Published: December 2021

In Reply.—

Except for the unquestionably magnified personal commendation, Randolph's letter presents a reasonable analysis of the potential hazards of National Institutes of Health (NIH) consensus panels. In fact, his is the most well-balanced of more than two dozen letters and telephone calls I have received since publication of "Biliary Atresia and Liver Transplantation: The National Institutes of Health Point of View (Pediatrics 1984;74:159-160). For the most part, these communications have been from pediatric surgeons who take hot exception, not to liver transplantation per Se, but to what is perceived as a deliberate decision by their pediatric colleagues to withhold surgical treatment (other than liver transplantation) from patients with biliary atresia.
Misleading Editorial
Authors: STICKLER G. B.
Published: December 2021

In Reply.—

Lildholdt's comments are perplexing. He is the author of an extensive prospective study of tympanotomy in 150 children with primary secretory otitis.1 He inserted a ventilation tube into one ear and left the other tympanic membrane intact. His patients were children ranging in age from 1 to 10 years with a mean age of 3.9 years. He noted suppuration in 25% of the ears with ventilation tubes in the follow-up period which averaged 3.2 years.
CHALLENGE TO A CHERISHED NOTION
Authors: Student
Published: December 2021

What is startling about Jerome Kagan's book, The Nature of the Child, is its strong challenge to a number of beliefs about children that are so widely accepted—by parents, therapists and even some of Mr. Kagan's colleagues—that they are taken as givens. These include some treasured notions—the notions that a certain set of essential experiences in children's home life allows them to grow into healthy and happy adults, that the temperament of the infant foretells the character of the child, that the child's personality foreshadows the adult's and that the child's psychological traits are shaped by what happens between parent and child.

It is not, Mr. Kagan argues, that the parent-child bond does not matter—just that the specifics of parenting are not so crucial to the child's future as parents would like to think. While some lay readers may be taken aback by Mr. Kagan's questioning of such golden tenets of modern parenthood, many therapists no doubt will be upset by his assault on some basic premises of their calling. Foremost among these is his attack on the notion that, as he puts it, "a mother's love for her infant is necessary for the child's future mental health," or, more technically, that a bond of secure attachment to a parent during the first three years of life leaves the child less vulnerable to later psychological disorders.
Bovine Surfactant (Surfactant TA) Therapy in Immature Baboons with Hyaline Membrane Disease
Authors: Vidyasagar D. , Maeta H. , Raju T. N.K. , John E. , Bhat R. , Go M. , Dahiya U. , Roberson Y. , Yamin A. , Narula A. , Evans M.
Published: December 2021

As a prelude to clinical trials with a bovine surfactant (surfactant TA), in human infants with hyaline membrane disease, pulmonary and hemodynamic changes following its instillation in premature baboons were investigated. Baboons, delivered by cesarean section at 141 ± 3.5 days (mean ± SD, 77% gestation), were provided with intensive care. At 2 hours of age in one group (n = 10), 100 mg/kg of surfactant TA (reconstituted bovine surfactant, Tokyo Tanabe Co., Tokyo) was instilled into the lungs. Sequential measurements and monitoring of pulmonary and hemodynamic variables were carried out in these ten baboons and in a control group of five baboons for 16 hours, at which time the experiments were electively terminated. At birth, the pulmonary compliance, findings of chest radiographs, ratio of arterial Po2 to alveolar Po2, and respirator variables needed to maintain normal blood gas and acid base status were identical in both groups and indicative of severe hyaline membrane disease. Following surfactant instillation, the treated group demonstrated a rapid increase in Po2 with significantly improved ratio of arterial Po2 to alveolar Po2 (from a mean ± SD pretreatment value of 0.21 ± 0.11 to 0.45 ± 0.11 by 16 hours). Pulmonary compliance improved similarly (from pretreatment value of 0.18 ± 0.06 mL/cm H2O/kg to 0.27 ± 0.09 mL/cm H2O/kg). Significant reduction in respirator support variables could be achieved in all treated animals; however, in the control animals, the pulmonary status worsened as evidenced by increasing mean airway pressure and respirator variables to keep normal blood gas and acid base status, thus worsening compliance. At autopsy, pulmonary pressure-volume curves were significantly different with large hysteresis obtained in the surfactant-treated group. Although no deleterious effect on hemodynamics was noted in surfactant TA-treated animals, a large patent ductus arteriosus was demonstrated by aortography. Increased lung blood flow, probably due to a large patent ductus arteriosus flow, was demonstrated by radiolabeled microsphere technique. The physiologic significance and clinical relevance of these findings in premature baboons treated with surfactant TA are discussed.
Nutritionally Relevant Supplementation of Vitamin B6 in Lactating Women: Effect on Plasma Prolactin
Authors: Andon Mark B. , Howard Mary P. , Moser Phylis B. , Reynolds Robert D.
Published: December 2021

Pharmacologic doses of vitamin B6 administered to lactating women have been reported to suppress plasma prolactin. As a result, some physicians have recommended restriction of vitamin B6 intake for lactating women. In the present investigation, 20 lactating women were given supplemental doses of vitamin B6, 0.5 to 4.0 mg/d, beginning 24 hours after delivery. Plasma prolactin, plasma pyridoxal phosphate, and breast milk total vitamin B6 concentrations were determined during the first 9 months postpartum. Women receiving the supplement of 4.0 mg compared with 0.5 mg of vitamin B6 per day had significantly higher plasma pyridoxal phosphate (P < .01) and breast milk total vitamin B6 concentrations (P < .05) beginning at 1 month postpartum and continuing through the duration of the study. Plasma prolactin concentrations were not significantly different between the two groups. The percentage of all women, regardless of treatment, in whom lactation persisted at 1 and 2 weeks and 1, 3, 6, and 9 months were 100%, 100%, 100%, 90%, 80%, and 65%, respectively. All women who ceased to lactate during the study reported doing so by choice. Nutritionally relevant doses of vitamin B6 elevated plasma pyridoxal phosphate and breast milk total vitamin B6 concentrations of lactating women without reducing plasma prolactin concentration or halting lactation.
Pediatric Hospice Care
Authors: Corr Charles A. , Corr Donna M.
Published: December 2021

The concept of pediatric hospice care is in many ways a new one that is subject to misunderstanding, especially as to its character and scope. Nevertheless, with or without this particular title, implementation of pediatric hospice care may already be underway via existing caregivers and provider systems, and further development is dependent in large part upon the sensitivity, expertise, and cooperation of pediatricians and their colleagues. To encourage the collaborative effort that is required, this article reviews: the main principles of the hospice philosophy that are relevant to pediatric care, three types of situations involving children to which those principles might be applied, the wide range of needs and bewildering variety of factors that may complicate such care, three basic contexts within which this sort of care can be delivered, the multiplicity of skills that are relevant to this approach to care, and the many ways in which services can be provided.
Munchausen Syndrome by Proxy
Authors: SHELDON STEPHEN H.
Published: December 2021

To the Editor.—

The article, "Munchausen Syndrome by Proxy: An Outpatient Challenge," by Vincent L. Guandolo, MD,1 was read with interest. It was a compelling description of a very worrisome problem for all professionals involved in providing for the welfare of children. Munchausen syndrome by proxy results in multiple hospitalizations and unnecessary painful, invasive, and expensive procedures. The potential consequences warrant accurate early diagnosis, management, and disposition.

Seizures secondary to Munchausen syndrome by proxy may be fictitious (the parent deliberately providing a false history) or may be an actual convulsive episode precipitated by an action of the parent (eg, anoxic seizures secondary to smothering).2 A misdiagnosis of epilepsy is common and consequences range from the persistence of fictitious symptoms into adulthood to death of the child.
Cardiac Output Changes in Newborns With Hyperbilirubinemia Treated With Phototherapy
Authors: Walther Frans J. , Wu Paul Y. K. , Siassi Bijan
Published: December 2021

Phototherapy is known to increase peripheral blood flow in neonates, but information on the associated cardiovascular effects is not available. Using pulsed Doppler echocardiography we evaluated cardiac output and stroke volume in 12 preterm and 13 term neonates during and after phototherapy. We concomitantly measured arterial limb blood flow by strain gauge plethysmography and skin blood flow by photoplethysmography. Cardiac output decreased by 6% due to reduced stroke volume during phototherapy, whereas total limb blood flow and skin blood flow increased by 38% and 41%, respectively. Peripheral blood flow increments tended to be higher in the preterm than in the term infants. The reduced stroke volume during phototherapy may be an expression of reduced activity of the newborn during phototherapy. For healthy neonates the reduction in cardiac output is minimal, but for sick infants with reduced cardiac output, this reduction may further aggravate the decrease in tissue perfusion.
Twenty Years of Renal Transplantation in Children
Authors: Potter Donald , Feduska Nicholas , Melzer Juliet , Garovoy Marvin , Hopper Susan , Duca Robert , Salvatierra Oscar
Published: December 2021

Two-hundred three children 1 to 16 years of age received kidney transplants during a 20-year period, 100 from living donors and 103 from cadaver donors. The overall survival rate was 79%. Actuarial patient and kidney survival rates at 15 years were 79% and 52%, respectively, for recipients of living donor kidneys and 57% and 19%, respectively, for recipients of cadaver donor kidneys. One of two children who received transplants in 1964 was alive 20½ years later. Twenty-nine children had kidneys that had functioned more than 10 years; their mean serum creatinine concentration was 1.7 mg/dL and 24 were fully rehabilitated. Eighteen were more than 2 SD below the mean height of normal chidren, however. Comparison of survival rates during successive 5-year intervals showed significant improvement in patient survival during the 20-year period and smaller improvements in kidney survival after 1979. Patient survival after living donor transplants during the last 10 years was 100%, and kidney survival during the last 5 years was 92%. Improvement was attributed to the effect of experience, as well as to changes in immunosuppressive therapy in 1972 and the introduction of donor-specific transfusions in 1978.
Kawasaki Syndrome, Reye Syndrome, and Aspirin
Authors: TAKAHASHI MASATO , MASON WILBERT
Published: December 2021

To the Editor.—

Aspirin is the mainstay of therapy for Kawasaki syndrome. Its early initiation and continued low-dose therapy have been effective in reducing morbidity and mortality.1 However, a dark cloud of fear has arisen for those physicians and parents involved with Kawasaki syndrome. A number of reports, including a pilot study by the Public Health Service Task Force, cite association between use of aspirin and Reye syndrome.2

Let us examine epidemiologic features of both syndromes.
Lectures on the Diseases of Children by Eli Ives, MD, of Yale and New Haven: America's First Academic Pediatrician
Authors: Pearson Howard A.
Published: December 2021

Eli Ives of New Haven, CT and Yale University was a successful and respected practitioner, professor, and medical statesman. For nearly 40 years between 1813 and 1852, he lectured to an estimated 1,500 Yale medical students on materia medica, botany, the theory and practice of medicine, and the diseases of children. Some of those lectures, meticulously recorded in flowing penmanship by Yale medical students during this time, are preserved in the manuscript and archives section of Yale University's Sterling Library. The Ives Lectures on Diseases of Children represent the first systematic and dedicated American course of instruction in what today is known as the specialty of pediatrics.

During the 1820s, Ives' title at Yale was Professor of Materia Medica, Botany, and the Diseases of Children and so he held the earliest American academic appointment in pediatrics. There were other early 19th century academic physicians with demonstrated interest and involvement in children and their diseases.1 These pediatric pioneers included William Potts Dewees of the University of Pennsylvania and John Eberle of the Jefferson and Cincinatti Medical Colleges who authored early American pediatric textbooks. However, they did not have formal academic titles nor did they present separate substantive courses in pediatrics at their institutions.

By the latter half of the 19th century pediatrics began to attain academic recognition in the United States. Dr Abraham Jacobi of New York established a children's clinic at the New York Medical College in 1861. He held the academic title of Professor of Infantile Pathology and Therapeutics and lectured on the diseases of children.
Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients
Authors:   Committee on Drugs Section on Anesthesiology
Published: December 2021

Clarification

The AAP Committee on Drugs and Section on Anesthesiology wish to clarify those portions of the Guidelines (Pediatrics 1985;76:317-321, August) that pertain to an intravenous line.

Under some circumstances (eg, very short procedures, availability of persons skilled in establishing intravenous lines in children), it may not be necessary that an intravenous line be in place. Therefore, the Guidelines are modified as follows.

In section II, "Deep Sedation," the recommendation should read:

Patients receiving deep sedation should have an intravenous line in place or have immediately available a person skilled in establishing intravenous infusions in pediatric patients.

In section III, "General Anesthesia: Intravenous Access," the recommendation should read:

Patients receiving ambulatory general anesthesia shall have an intravenous line in place or have immediately available a person skilled in establishing intravenous infusions in pediatric patients.
Auditory Testing and Bilirubin
Authors: NAKAMURA HAJIME
Published: December 2021

In Reply.—

We appreciate the comments of Shapiro and Hecox regarding our article. Their primary concerns relate to the methodologic and analytic aspects of our study.

1. Auditory nerve and brainstem response patterns obtained by "logon" stimulus differ significantly from those by "click" stimulus; although interpeak latencies in these two instruments generally agree, absolute latencies do not. This is caused by start time definition. The preferred "time zero" is the instant that the stimulus pulse impacts on the tympanic membrane with the instrument Teledyne TA-1000.
Varied Types of Urinary Calculi in a Patient With Cystinosis Without Renal Tubular Acidosis
Authors: Black Joe , Stapleton F. Bruder , Roy Shane , Ward Jewell , Noe H. Norman
Published: December 2021

Renal calculi have rarely been cited as a major manifestation of cystinosis. We report a case history of a child with multiple urate calculi and a calcium oxalate stone resulting from proximal tubular dysfunction that was not associated with bicarbonate wastage.
Second Testing for Hypothyroidism
Authors: LEVINE GILBERT D. , THERRELL BRADFORD L.
Published: December 2021

To the Editor.—

The article by La Franchi et al (Pediatrics 1985;76:734-740) regarding newborn screening for hypothyroidism at two time periods in the Northwest Regional Screening Program (NWRSP) confirms the experiences previously reported for Texas.1,2 Since the beginning of our hypothyroid screening program in 1980, a second test at 1 to 4 weeks has been strongly recommended. Since 1983, this specimen has been required on infants screened prior to 36 hours of age or prior to 24 hours of protein intake.
Severe Reactivation of Sunburn Following Methotrexate Use
Authors: MALLORY SUSAN B. , BERRY D. H.
Published: December 2021

Methotrexate is not an infrequently used drug in chemotherapy protocols. The following, however, is an uncommon side effect of this medication.

CASE REPORT

A 13-year-old white boy was diagnosed as having non-Hodgkin's lymphoma by lymph node biopsy 2 years prior to the onset of his dermatitis. While on a fishing trip in May 1984, a mild sunburn developed after 1½ hours in the sun. Two days later, his sunburn was barely noticeable. He underwent chemotherapy which included highdose intravenous methotrexate with leucovorin rescue, as well as intrathecal methotrexate, cytarabine, and hydrocortisone. Shortly after the injection of intravenous methotrexate, he noted tingling and burning at the sites of his resolving sunburn.
Prediction of the Progression of Chronic Renal Failure in Children: Are Current Models Accurate?
Authors: Tabak Michael A. , Christenson Peter C. , Fine Richard N.
Published: December 2021

Mathematical models have been used since 1976 in an attempt to predict the progression of chronic renal failure. These models have used the serum creatinine level as either a reciprocal or logarithmic plot against time. The accuracy of such predictions are characterized by either a correlation coefficient (r value) or prediction error (time at which dialysis was predicted minus time at which dialysis actually occurred). Retrospectively, we analyzed 37 children who progressed to end-stage renal disease, grouped them by their respective primary diseases, and calculated both r values and prediction error for each individual and group. Although r values for each group (with the exception of patients less than 1 year of age) were comparable, prediction errors were widely disparate among the various groupings. Individuals within each of the groups had disparate values even though identical r values were present. These observations indicate that predictive models using serum creatinine levels are of limited clinical use and are least useful for patients younger than 1 year of age.