bluuebunny/crossref_metadata_2025 huggingface dataset:
Monitoring Patients in Pediatric Intensive Care
Authors: BUSHORE MARTHA
Published: December 2021

Physicians are responsible for cost containment. Use of more expensive hospital services for which less expensive hospital or outpatient services can be substituted without significant threat to outcome of clinical care will no longer be tolerated. Every service traditionally provided to inpatients will be scrutinized for possible delivery in a less expensive manner. The sophistication of these services has progressed dramatically in recent years. It was progressive to allow children with chronic pulmonary disease to access self-administered β-adrenergic inhalation treatments at home; it is progressive to allow parents to care for respirator-dependent infants and children at home. It was progressive to sustain life by providing inpatient intravenous hyperalimentation; it is progressive to sustain life by providing intermittent home hyperalimentation.
Farm Accidents
Authors: PAULSON JEROME A.
Published: December 2021

To the Editor.—

I hope the article by Cogbill et al1 (and the companion piece by Rivara2) will become the seminal work in an area that needs to become better described and evaluated.

There are two issues that I would like to raise. First, I question the low incidence of major long-term disability (1%) that they describe. It is not clear the length of time after the injury that was covered in the retrospective review of the outpatient charts.
Fresh Frozen Plasma Partial Exchange Transfusion and Necrotizing Enterocolitis
Authors: WISWELL THOMAS E. , CORNISH J. DEVN
Published: December 2021

To the Editor.—

In their article, Black et al1 cite a surprising incidence of complications of polycythemia in their partial exchange transfusion-treated v their nonexchange populations. Of particular note is the remarkable incidence of necrotizing enterocolitis (eight of 43 patients or 18.6%) in the exchange group. In the nonexchanged group, no infants were so affected. In a previously reported prospective study of 7,133 consecutive live births at Tripler Army Medical Center, Hawaii, a total of 82 infants were identified as having neonatal polycythemia (venous hematocrit 65% or greater).2
Influence of Xanthines on Gastroesophageal Reflux in Infants at Risk for Sudden Infant Death Syndrome
Authors: Vandenplas Yvan , De Wolf D. , Sacre L.
Published: December 2021

Theophylline and caffeine are two drugs frequently administered to infants at risk for sudden infant death syndrome, because of their stimulatory effects on the respiratory system. These drugs are known to increase gastric acid secretion and to decrease lower esophageal sphincter pressure that, in turn, possibly increases gastroesophageal reflux (GER). Thirty babies were tested for GER before and during caffeine treatment. Eighteen were studied under the same conditions while undergoing theophylline treatment. All results of pH monitoring before treatment were within normal ranges. Episodes of GER increased significantly (P < .001) in about 50% of the group treated with caffeine and in 66% of the group treated with theophylline. These results were independent of plasma xanthine concentrations (within or below therapeutic ranges) and of the efficacy of the drug. In addition, an increase was noted for the number of episodes of GER in 24 hours (from 5.3 to 17.1 in the caffeine group and from 5.3 to 24.3 in the theophylline group) and for the time pH was < 4 (from 0.87% to 6% in the caffeine group and up to 13% in the theophylline group). Because GER is another known risk factor for sudden infant death syndrome, the administration xanthine derivatives in babies at risk for sudden infant death syndrome should be carefully considered in each case.
Use of Health Care Services by Children and Diagnoses Received During Presumably Stressful Life Transitions
Authors: Schor Edward L.
Published: December 2021

Transition periods in the lives of children are potentially stressful and might therefore be associated with adverse changes in children's physical or emotional health. The computerized medical records of 1,521 childern continuously enrolled in a prepaid health plan for 6 years were analyzed to identify if such a trend was present. The overall rates of children's health care use steadily decline with increasing age until early adolescence, at which time girls' rates modestly increase and boys' continue to decline. However, the prevalence of diagnoses for which an emotional basis may be presumed increases markedly during two major transitional periods: (1) early elementary school and (2) early adolescence. During both periods, there are notable differences between boys and girls with regard to rates and temporal patterns. Girls do not demonstrate the same increased rates during elementary school years as do boys. The study provides evidence from population-based data that for some children early school years and adolescence are times of increased stress. Children who are once diagnosed as having an emotional problem, presumably related to stressful life transitions, tend to continue having similar difficulties.
Day Care and Illness: Evidence, Costs, and Public Policy
Authors: Haskins Ron , Kotch Jonathan
Published: December 2021

Parents, pediatricians, social scientists, and policymakers have become increasingly concerned that infants and children in day care, especially those younger than 3 years of age, are at risk for morbidity associated with several types of acute illness. We have examined the empirical evidence on the impact of day-care attendance on frequency of respiratory illnesses, diarrhea, hepatitis A, meningitis, and cytomegalovirus disease in children, day-care staff, and household contacts. The short- and long-term costs of day-care-associated illnesses were assessed, wherever possible within a benefit-cost framework. Available evidence suggests that children in day care, and sometimes their teachers and household contacts, have higher rates of diarrhea, hepatitis A, meningitis, and possible otitis media than children not in day care. There is only weak or moderate evidence that children and their families are at risk for high rates of respiratory illness (other than otitis media) or cytomegalovirus infection. Taken together, the excess of these illnesses among children in day care may impose moderate net costs on families and on society. Revisions of state regulatory policy regarding health practices in day care and policy initiatives designed to provide parents with more information and authority are recommended to protect the health and development of children in day care.
Dominantly Inherited Unilateral Terminal Transverse Defects of the Hand (Adactylia) in Twin Sisters and One Daughter
Authors: Graham John M. , Brown Forst E. , Struckmeyer Carol L. , Hallowell Christian
Published: December 2021

Most previous cases of unilateral terminal transverse defects of the hand have not been familial. Several previously reported cases of apparent autosomal dominant inheritance of such defects have subsequently been reclassified as type B brachydactyly. We report a pair of adult twin women with unilateral terminal transverse defects affecting the left hand in one woman and the right hand in the other woman. The latter woman has one daughter with a unilateral terminal transverse defect affecting the left hand. The hand anomaly is characterized by absence of the terminal portions of digits 2 to 5 with a mildly hypoplastic thumb (adactylia). Tiny nail remnants are evident on the remaining digital stumps, and no soft tissue syndactyly is apparent. At 2 years of age, the daughter has hypoplastic first, fourth, and fifth metacarpals with no ossification of the second or third metacarpals or any of the phalanges. The affected mother has hypoplastic metacarpals for digits 2 to 4 and a vestigial fifth proximal phalanx on the affected hand, with no other phalanges evident by roentgenogram other than those of the thumb. The mother's twin sister has similar findings, except the ossified phalangeal remnant is on her second and third fingers rather than her fifth finger. Doppler flow arterial patterns appeared normal in each hand of affected family members. The other hand and both feet are clinically and radiologically normal in each case, and the family history is negative for any other individuals with limb anomalies. A review of the literature suggests that this family may very well be unique.
Views of Graham Challenged
Authors: CHRISTOFFEL KATHERINE K.
Published: December 2021

To the Editor.—

I am writing with a correction concerning the recently published Letter to the Editor,1 challenging George Graham's commentary on poverty and malnutrition.2 Readers may be confused by mention of Dr Lattimer in Dr Graham's reply,3 as Dr Lattimer's name is not among the signers whose names appear under the challenge letter. This is because the names of seven signers were somehow omitted. The omitted signatures were those of Agnes D. Lattimer, MD, Myrtis Sullivan, MD, Kinfe Gebeyehu, MD, Parviz Danesh, MD, Naomi Kistin, MD (all from Cook County Hospital), Frank K. Thorp, MD, PhD (University of Chicao/Wyler Child's Hospital), Yolanda Hall, RD (Rush-Presbyterian St. Luke's Medical Center).
Neonatal Polycythemia: Frequency of Clinical Manifestations and Other Associated Findings
Authors: Wiswell Thomas E. , Cornish J. Devn , Northam Ralph S.
Published: December 2021

We report the results of a two-part study examining the frequency of symptoms and other findings associated with neonatal polycythemia. In the first part of the investigation, we evaluated the occurrence and features of the disorder in a cohort of 3,768 infants born at our institution that had been screened for the disorder during a 4-year period. Fifty-five infants (1.46%) had neonatal polycythemia. Of these infants, 85% had features associated with the disorder. Frequent signs and symptoms included "feeding problems" (21.8%), plethora (20.0%), lethargy (14.5%), cyanosis (14.5%), respiratory distress (9.1%), jitteriness (7.3%), and hypotonia (7.3%). Other findings included hypoglycemia (40.0%) and hyperbilirubinemia (21.8%). Of the polycythemic infants, 14.5% had no clinical symptoms or associated laboratory abnormalities. In the second portion of the study, we reviewed the features of polycythemia in all infants so diagnosed who were born in United States Army hospitals, worldwide, during a 5-year period. There were 220,050 infants born during this period; 932 (0.42%) were diagnosed as having neonatal polycythemia. Frequent findings were hyperbilirubinemia (33.5%), hypoglycemia (13.0%), and respiratory distress (6.6%). In this large group, only 13 (1.4%) had necrotizing enterocolitis, and nine (1.0%) were thrombocytopenic. Several findings among the 932 infants were unexpected. Six of the infants (only one premature) had intracranial hemorrhages. Additionally, three of the 932 had gonadal dysgenesis and three had cystic fibrosis. We found that premature infants were not less prone to having polycythemia and that the overall frequency of the disorder was less than that which has been previously reported.
Paternal Hyperphenylalaninemia
Authors: Brown Eleanor S.
Published: December 2021

In an article published in 1981 that reported on semen studies in four men with phenylketonuria (PKU), it was concluded that semen volumes were significantly reduced. However, the index case should not have been included in the statistical analyses. In the other three cases, the men with PKU had smaller semen volumes than did the four control medical students. The significance of these data depends upon the subjects' reliability in accurately reporting abstinence from ejaculation during the preceding four days. Significant differences were not found in sperm count per milliliter, total sperm count, motility, viability, and abnormal forms of sperm. The 1981 article has aroused concerns about both the ability of men with PKU to father offspring and the outcome for children who are conceived. In the present article, the author reports on one case of paternal benign hyperphenylalaninemia from her clinic and eight cases of presumably classical PKU that were previously reported. The nine cases include a total offspring of 33. Of these 33, eight had PKU, two had milder to moderate hyperphenylalaninemia, and one undiagnosed retarded child died at the age of 8 years. The 22 other offspring seem to be normal or similar to their non-PKU mothers. Three of the fathers had no hyperphenylalaninemic offspring. Two PKU offspring were from a mating of two PKU parents. Hyperphenylalaninemic men can obviously father children, but abnormalities other than hyperphenylalaninemia have not been seen.
Discordance Between Male and Female Deaths Due to the Respiratory Distress Syndrome
Authors: Perelman Robert H. , Palta Mari , Kirby Russell , Farrell Philip M.
Published: December 2021

General neonatal mortality statistics and those for the respiratory distress syndrome (RDS) were examined for the State of Wisconsin from 1979 through 1982. The objectives were to ascertain whether there are differences in total neonatal mortality related to sex and birth weight, to determine the veracity of reported gender differences in deaths due to RDS, and to assess the contribution of other risk factors for neonatal mortality to overall and sex-specific deaths occurring secondary to RDS. Additionally, a prospective analysis was performed at one perinatal center during a 5-year period in attempts to determine whether gender remained a significant factor in deaths due to RDS after adjusting for incidence. Overall, the most frequent diagnoses in those who died were RDS (15.6%), deaths due to complications of pregnancy (8%), immaturity (4.2%), and asphyxia (3.4%). The majority of fatalities for both sexes occur in neonates weighing less than 1 kg and the percentage of deaths attributable to RDS is greatest between 1 and 1.5 kg. The difference between sexes is also maximal in the latter weight group. Deaths secondary to RDS are greater for males regardless of Apgar score at one and five minutes, mode of delivery, maternal age, or ancillary diagnosis. These data suggest that deaths secondary to RDS are consistently greater in male neonates and that delivery within a limited "window" of time during gestation increases male susceptibility to fatal RDS.
Cyanide Poisoning From Laetrile Ingestion: Role of Nitrite Therapy
Authors: Hall Alan H. , Linden Christopher H. , Kulig Kenneth W. , Rumack Barry H.
Published: December 2021

A 4-year-old child ingested laetrile and almost died of cyanide poisoning. Treatment with the Lilly cyanide antidote kit resulted in rapid, complete recovery. Extremely high whole blood cyanide levels were documented. The necessity for use of the antidote kit in serious cyanide poisoning has recently been questioned. This case demonstrates benefit from antidotal treatment.
Biochemical, Clinical, Epidemiologic, Genetic, and Pathologic Data in the Pediatric Age Group Relevant to the Cholesterol Hypothesis
Authors: KWITEROVICH PETER O.
Published: December 2021

The recent National Institutes of Health Concensus Conference on Lowering Blood Cholesterol to Prevent Heart Disease made several recommendations for healthy children older than 2 years of age.1 These recommendations are summarized in Table 1.

In a commentary in Pediatrics, A. M. Mauer2 outlined three major concerns regarding the proceedings and recommendations of this consensus conference. First, he concluded from the proceedings that "the significance of serum cholesterol levels as an independent variable could not be definitely assigned." Second, data from adults were being extrapolated to children; "there are no available data on children." Third, he questioned the safety, feasibility, and efficacy of the dietary recommendations for children and adolescents.
Home Phototherapy Recommendations Questioned
Authors: POLAND RONALD L.
Published: December 2021

In Reply.—

Dr Grabert provides me with an opportunity to relate some of the process that the Committee on Fetus and Newborn went through in constructing the statement on home phototherapy. Most statements start with the request of a practicing pediatrician who wants guidelines for a problem that is not well-defined in available texts and articles. In this case, guidelines were being sought for a procedure that had the potential of saving a substantial part of the costs of hospitalization or rehospitalization of neonates just for phototherapy.
Infants With Severe Respiratory Failure and Persistance of the Fetal Circulation, Without Hyperventilation
Authors: LEVIN DANIEL L.
Published: December 2021

To the Editor.—

I just finished reading the article by Wung et al Pediatrics 1985;76:488-494). I was quite surprised at the publication of this article. There are several problems that make it such that I question its appropriateness in the article section of Pediatrics. The most important objection is that it is a retrospective collection of patients who were treated by some general treatment plan with no prospective analysis or control group. The data collected are dubious at best; for example, the authors do not state where the O2 samples were drawn and they do not define what they mean by the patient's oxygenation being improved with tolazoline.
Otitis Media in Early Childhood and Its Relationship to Later Verbal and Academic Performance
Authors: Roberts Joanne Erwick , Sanyal Margaret A. , Burchinal Margaret R. , Collier Albert M. , Ramey Craig T. , Henderson Frederick W.
Published: December 2021

The relationship between the occurrence of otitis media with effusion during the first 3 years of life and subsequent verbal and academic performance was examined in 61 socioeconomically disadvantaged children who attended a research day-care program. Study children were participants in a longitudinal study of child development in which the number of episodes of otitis media and duration of each otitis episode were reported prospectively from infancy. The incidence of otitis media was highest during the first 2 years of life. Bilateral otitis media accounted for 66% of the days with otitis media with effusion. Standardized tests of intelligence and academic performance were administered to the children when they were 3½ to 6 years of age. No evidence of associations between measures of early childhood otitis media experience and these measures of verbal or academic functioning was found in this study population.
Energy Metabolism and Substrate Utilization in Low Birth Weight Neonates Under Radiant Warmers
Authors: Marks Keith H. , Nardis Elizabeth E. , Momin Malik N.
Published: December 2021

We evaluated the metabolic response to the thermal demands of an open radiant warmer device, as distinct from convection incubator, in 13 healthy pre-mature infants (1,395 ± 169 g, 28 ± 12 days of age, mean ± SD). Metabolic rate was 10% higher for infants under the radiant warmer than in the incubator (2.60 ± 0.4 v 2.36 ± 0.3 kcal/kg/h; P < .05). The radiant warmer also induced a small (4%), but significant, increase in nonprotein respiratory quotient (0.94 ± 0.1 v 0.90 ± 0.1; P < .05) and a 13% increase in carbon dioxide production (8.26 ± 1.1 v 7.31 ± 1.1 mL/kg/min; P < .05). Subcutaneous fat accumulation (estimated from 60-second skin-fold thickness measurements) was greater under the radiant warmer than in the incubator (0.08 ± 0.05 v 0.04 ± 0.04 mm/d; P < .05). Under the warmer, the infant's mean skin temperatures and core temperatures were normal and similar to those found in the incubator, but the foot temperature was on average 0.6°C cooler. The average rate of weight gain (18 g/kg/d) was the same in the radiant environment. The pattern of the elevated metabolic rate, shift of respiratory quotient coupled with the accumulation of subcutaneous fat, and cool extremities of infants under the radiant warmer may represent a physiologic adaptive response to thermal stress. However, the reasons for the elevated metabolic rate are unclear, because activation of the sympathetic nervous system with the release of catecholamines is not apparently involved. We speculate that change in metabolic activity is more likely related to alterations in sleep and/or behavior patterns in the exposed environment. Given this relatively short-term study of healthy premature infants receiving an excellent caloric intake (120 kcal/kg/d), we conclude that radiant warmers produce no short-term metabolic complications or adverse effects on growth. Although the clinical importance of elevated metabolic rates in infants under radiant warmers is currently uncertain, our data suggest the need for caution in the long-term use of these devices.
Patterns of Walker Use and Walker Injury
Authors: Rieder M. J. , Schwartz C. , Newman J.
Published: December 2021

Infant walkers have been described as a cause of unexpected trauma in the first year of life. We conducted a prospective study to determine the mechanism and pattern of walker injuries presenting to an urban pediatric teaching hospital. We also studied the patterns of walker use. All injuries sustained by infants in baby walkers during a 1-year period were reviewed. The 139 injuries included 29 fractures. The most severe injuries were caused by falls down stairs; these falls accounted for 123 of the injuries. Stair gates were present in one third of all falls. At follow-up 2 months later, two thirds of the children had been in the walker subsequent to the injury. One third were still in the walker at 2 months after their initial injury. Less than half of the homes that had not had stair gates in place had acquired them at the time of follow-up. Baby walkers represent a cause of significant injury in the infant population; studies of warning labels and anticipatory guidance are needed.
Role of the Pediatrician in Prevocational and Vocational Education of Children and Adolescents With Developmental Disabilities
Authors:   Committee on Children With Disabilities
Published: December 2021

The majority of developmentally disabled adolescents who were once considered unemployable have now been demonstrated to have employment potential if appropriate educational support, family support, and medical services and planning are combined to encourage maximum independence.1,2 Concern for a child's eventual vocational placement may not traditionally be seen as part of the pediatrician's responsibility; however, pediatricians are in a unique position to be advocates for children with disabilities and for their families. Pediatricians are often the first to identify the disability for the family, and they assist in the family's adjustment to the child's special needs while providing ongoing care to both the child and family. With an enlightened eye to the child's eventual ability to function in society, the pediatrician can make a great contribution to the disabled child's future through the traditional functions of (1) diagnosis and management of medical problems, (2) education and counseling of parents, and (3) patient advocacy.

As part of health maintenance, pediatricians provide or coordinate the diagnosis and management of medical problems such as vision impairment, hearing loss, communication disorders, seizures, and motor disabilities. As members of interdisciplinary groups that generate a health services plan, pediatricians join in the evaluation and treatment planning for children. Pediatricians should also provide information for medical and therapeutic plans for these children and material for family discussions on long- and short-term personal goals for such children.

No matter how skillful the professional services, the family's culture has the strongest influence on patient behavior. For vocational planning, in addition to the ability to be trained in and to master specific technical skills, social behavior is a major variable in determining success.
Hazards of Baby Powder
Authors: MOFENSON HOWARD C. , CARACCIO THOMAS R. , OKUN SHARON , GREENSHER JOSEPH
Published: December 2021

To the Editor.—

In a recent letter to the editor, Cotton and Davidson1 have brought the hazards of baby powder aspiration to the attention of the medical community.

We have been monitoring episodes of possible powder inhalation and ingestion in our community (population 3 million) since 1980, when two infants were hospitalized

[See table in the PDF file]

for powder aspiration and one required ventilator therapy for two days. Our recent data (Table) shows a progressive decrease in the number of possible inhalations and ingestion episodes since 1981 when our article2 was published in Pediatrics and the American Academy of Pediatrics publicized the hazard of baby powder.
Normal Serum Bilirubin Levels in the Newborn and the Effect of Breast-Feeding
Authors: Maisels M. Jeffrey , Gifford Kathleen
Published: December 2021

We measured the serum bilirubin concentrations in 2,416 consecutive infants admitted to our well-baby nursery. The maximum serum bilirubin concentration exceeded 12.9 mg/dL (221 µmol/L) in 147 infants (6.1%), and these infants were compared with 147 randomly selected control infants with maximum serum bilirubin levels ≤12.9 mg/dL. In 66 infants (44.9%), we identified an apparent cause for the jaundice, but in 81 (55%), no cause was found. Of infants for whom no cause for hyperbilirubinemia was found, 82.7% were breast-fed v 46.9% in the control group (P < .0001). Breast-feeding was significantly associated with hyperbilirubinemia, even in the first three days of life. The 95th percentile for bottle-fed infants is a serum bilirubin level of 11.4 mg/dL v 14.5 mg/dL for the breast-fed population, and the 97th percentiles are 12.4 and 14.8 mg/dL, respectively. Of the formula-fed infants, 2.24% had serum bilirubin levels >12.9 mg/dL v 8.97% of breast-fed infants (P < .000001). When compared with previous large studies, the incidence of "readily visibl" jundice (serum bilirubin level >8 mg/dL) appears to be increasing. The dramatic increase in breast-feeding in the United States in the last 25 years may explain this observation. There is a strong association between breast-feeding and jaundice in the healthy newborn infant. Investigations for the cause of hyperbilirubinemia in healthy breast-fed infants may not be indicated unless the serum bilirubin level exceeds approximately 15 mg/dL, whereas in the bottle-fed infant, such investigations may be indicated if the serum bilirubin exceeds approximately 12 mg/dL. If phototherapy is ever indicated in healthy term infants, the overwhelming majority of such infants are likely to be breast-fed; if breast-feeding is, indeed, the cause of such jaundice, a more appropriate approach to hyperbilirubinemia in the breast-fed infant might be to treat the cause (by temporary cessation of nursing) rather than (using phototherapy to treat) the effect.
Pulse Oximetry Advantages in Infants With Bronchopulmonary Dysplasia
Authors: Solimano Alfonso J. , Smyth John A. , Mann Tejinder K. , Albersheim Susan G. , Lockitch Gillian
Published: December 2021

We studied 12 infants with a clinical and radiologic diagnosis of bronchopulmonary dysplasia who were oxygen dependent and older than 30 days. Simultaneous readings of hemoglobin oxygen saturation (Sao2) determined by two pulse oximeters (Nellcor 100, BTI Biox III) and transcutaneous (tc) Po2 (Sensor Medics, Transend) were correlated with Sao2 (Radiometer, OSM 2 Hemoximeter) and Pao2 (Corning 178) measured on blood from an indwelling arterial catheter. For each infant, the fractional inspiratory oxygen (Fio2) was adjusted to obtain three to five sets of data in the range of 70% to 95% Sao2. Fifty-three data points were generated and pooled for analysis. The slope of the regression line generated for the Nellcor 100 was .86; for the BTI Biox III, it was .91; and for the Sensor Medics Transend, it was .55, resulting in average errors of +2.5%, +1.0%, and –29%, respectively, when comparing corresponding transcutaneous and arterial values. When Sao2 was equal to or less than 95%, no infants were hyperoxic. These data confirm reports by others that tcPO2 values do not accurately represent Pao2 values in older infants with bronchopulmonary dysplasia. Pulse oximeters do not require user calibration, and their sensor is unheated so they will not cause skin burns. We conclude that pulse oximetry offers major advantages over tcPo2 measurements in the management of infants with bronchopulmonary dysplasia.
Minoxidil for Control of Acute Blood Pressure Elevation in Chronically Hypertensive Children
Authors: Strife C. Frederic , Quinlan Monica , Waldo F. Bryson , Fryer Cheryl J. , Jackson Elizabeth C. , Welch Thomas R. , McEnery Paul T. , West Clark D.
Published: December 2021

Twenty-three episodes of acute elevation of BP related to renal disease in 13 chronically hypertensive children 2 to 18 years of age were treated with a single oral dose of minoxidil. All except one patient were receiving a diuretic and all but one a β-blocking agent at the time of minoxidil treatment. The goal of lowering BP to or below the 95th percentile for age within four hours of minoxidil administration was achieved in 14 of 23 treatment episodes. The goal was achieved in nine of 11 (82%) when the dose of minoxidil was ≥0.2 mg/kg and in five of 12 (42%) when the dose was <0.2 mg/kg (P < .05). In patients treated with ≥0.2 mg/kg of minoxidil, mean systolic and diastolic BP decreased significantly from pretreatment values within one hour. In patients receiving <0.2 mg/kg, mean systolic BP was never significantly reduced and mean diastolic BP did not change significantly for two hours. Adverse effects were minimal. The results indicate that minoxidil in a dose of 0.2 mg/kg in combination with a diuretic and β-blocking agent will lower BP to safe levels in most patients with severe hypertension related to renal disease within four hours with minimal side effects.
The Compelling Case for Seat Belts on School Buses
Authors: Spital Martha , Spital Aaron , Spital Robin
Published: December 2021

The ability of seat belts to reduce injuries and fatalities in vehicular accidents has been established beyond question. Nevertheless, most school buses are not equipped with seat belts. The available evidence shows that seat belts would provide added safety for our children in school buses, just as they do in the family car. Moreover, the use of seat belts on school buses would foster a lifelong habit of seat belt use. By exerting their considerable influence in the community, physicians can contribute a great deal to the nationwide campaign to require the use of seat belts on school buses. If this campaign is successful, not only will our children ride their school buses in greater safety, but a whole generation of young Americans will learn a habit that is known to reduce drastically the number of tragic highway injuries and deaths.
Pediatric Head Injury Resulting From All-Terrain Vehicle Accidents
Authors: KRIEL ROBERT L. , SHEEHAN MARIAN , KRACH LINDA E. , KRIEL HELENA D. , ROLEWICZ THOMAS F.
Published: December 2021

In our experience, accidents involving all-terrain vehicles are an increasingly frequent cause of brain injury in children. The risk associated with operation of these vehicles is not fully appreciated and should be better publicized. We believe that it is possible to delineate several steps that could significantly reduce the risk to the pediatric population without curtailing the recreation altogether. Although construction design has promised to produce safer vehicles, our experience has shown that extreme injury is still possible with the newer fourwheel machine.
Statistics and Sudden Infant Death Syndrome
Authors: ORAN JOSEPH , CARLEY DAVID , KELLY DOROTHY , SHANNON DANIEL
Published: December 2021

In Reply.—

Although the contingency tables noted by Dr LeBlanc each contain one cell with an expected frequency of less than 5, the Yates correction, which applies to all 2 by 2 tables irrespective of expected frequencies, does not address this issue. Furthermore, we agree with Grizzle1 that this correction produces an extremely conservative test and should not be used. Fisher exact test, however, is germane to the problem of small numbers. The results of this test are in good agreement with our published values.
Primary Care Pediatrics and Child Psychopathology: A Review of Diagnostic, Treatment, and Referral Practices
Authors: Costello Elizabeth J.
Published: December 2021

The quality of mental health care for children depends not only on specialist mental health services, but also on how effectively primary care providers identify, treat, and refer children with emotional and behavioral problems. Recent research has shown that primary care practitioners are the sole providers of mental health care to the majority of people with a mental disorder. For example, Regier et al1 calculated that in 1975 54.1% of persons with a mental disorder were treated only in a primary care or outpatient medical setting, with another 6% receiving care from both specialist mental health and primary care medical facilities. An additional 21.5% were not in treatment or received treatment from nonmedical agencies. If the data were extrapolated for all age groups, these rates would imply that only one child in five with a mental disorder is receiving specialist treatment, three are in the care of a pediatrician, and one is receiving no treatment. This would lead to the conclusion that pediatricians are, according to Regier et al,1 the de facto mental health service for most children in need of such care. It would lend support to the drive to increase pediatricians' awareness of, and training for, the mental health component of their work.2 In this paper, we review the published evidence as it applies to children.

SCOPE

This review includes the published studies of mental health problems diagnosed by primary care pediatricians, family practitioners, or pediatric nurse practitioners working in outpatient settings in the United States. These include private pediatric practices, group practices, health maintenance organizations (HMOs), and other types of prepaid group practices.

The questions addressed are: (1) What proportion of the children seen by primary care pediatricians and their colleagues are diagnosed by them as having a mental disorder? (2) What proportion of children are referred for specialist evaluation and treatment? (3) What risk factors are associated with a higher probability of receiving a diagnosis of psychopathology? (4) How accurate are primary care pediatricians' diagnoses of mental health problems?
Sudden Child Death and `Healthy' Affected Family Members With Medium-Chain Acyl-Coenzyme A Dehydrogenase Deficiency
Authors: Duran Marinus , Hofkamp Marchinus , Rhead William J. , Saudubray Jean-Marie , Wadman Sybe K.
Published: December 2021

A family is described in which the father and three (and probably all four) of his children had a decreased capacity for the oxidation of medium-chain fatty acids. One of the children suddenly died at the age of 16 months following an episode of a rapidly deteriorating Reye syndrome-like illness with hypoketotic hypoglycemia and dicarboxylic aciduria, but without any previous alarming symptoms. The eldest sibling had died at the age of 19 months under similar conditions. The other family members had always been healthy. On fasting, all affected family members accumulated in their plasma the medium-chain fatty acids octanoic, decanoic, and cis-4-decenoic acids. Their urinary organic acid excretion profile could be characterized as "dicarboxylic aciduria." A deficiency of medium-chain acyl-coenzyme A dehydrogenase was demonstrated in a postmortem liver sample of the index patient. Cultured fibroblasts from the father and the two healthy children had a decreased rate of [14C]octanoate oxidation. It is suggested that a deficiency of medium-chain acyl-coenzyme A dehydrogenase may lead to a life-threatening illness when other complicating factors such as diarrhea and vomiting result in an abnormal depletion of the body's glycogen stores. Careful monitoring of at-risk patients during a minor illness is necessary.
Child Restraint Law Effects on Motor Vehicle Accident Fatalities and Injuries: The New Mexico Experience
Authors: Sewell C. Mack , Hull Harry F. , Fenner John , Graff Howard , Pine Jeffrey
Published: December 2021

The New Mexico State Legislature passed a child restraint law applicable to children less than 5 years of age that became effective in June 1983. To evaluate the effectiveness of this law, we analyzed traffic accident data for New Mexico from January 1981 through September 1984. During this period, there were 20,972 children younger than 5 years of age in motor vehicle accidents. Restraint usage increased for this age group from a low of about 10% in 1981 to more than 40% in 1984 (P < 10-6). Unrestrained children younger than 5 years of age were five times more likely to be killed and two times more likely to be injured than restrained children. Analysis of motor vehicle accident fatality and injury rates pre- and postlaw revealed a 33% reduction in motor vehicle accident fatality rates and a 12.6% reduction in nonfatal injury rates for children younger than 5 years. We conclude that (1) child restraint devices are effective in reducing motor vehicle accident fatalities and injuries in young children and (2) the child restraint law has been effective in increasing child restraint usage and in reducing childhood death and injury in New Mexico.
Ontogenic Development of Gastrointestinal Motility: IV. Duodenal Contractions in Preterm Infants
Authors: Morriss Frank H. , Moore Marylynn , Weisbrodt Norman W. , West M. Stewart
Published: December 2021

Duodenal motility was studied by intraluminal manometry in 27 healthy infants of 26 to 42 weeks, gestational age. The frequency of contractions, the number of contractions per burst, and the intraluminal peak pressure during contractions all increased during a narrow postconceptual period, 29 to 32 weeks, regardless of length of gestation before birth. Antenatal β-methasone administration to the mothers of 11 additional infants of 26 to 32 weeks gestational age was associated with creased duodenal contraction rate, number of contracintions per burst, and intraluminal peak pressure compared with infants of similar gestational age whose mothers did not receive β-methasone. The maturational effect of β-methasone on duodenal motility was most pronounced in infants whose gestational age at birth was 26 to 29 weeks. Seven infants of 31 weeks' or longer gestational duration who had a CNS abnormality or insult had fasting duodenal contraction rates that were less than one half of the rate for normal infants of similar gestational age. These observations suggest that neonatal duodenal motility undergoes marked maturational changes between 29 and 32 weeks after conception and that these changes may be inducible before 29 weeks by corticosteroid administration. An intact CNS appears to be required for full expression of the maturational changes.
Behavior Abnormalities and Poor School Performance Due to Oral Theophylline Use
Authors: Rachelefsky Gary S. , Wo Julie , Adelson Judith , Mickey M. Ray , Spector Sheldon L. , Katz Roger M. , Siegel Sheldon C. , Rohr Albert S.
Published: December 2021

Studies evaluating adverse effects of oral theophylline on learning and behavior have been performed on children with asthma receiving long-term theophylline therapy. To further differentiate the effects of asthma itself from the drugs used, we evaluated 20 asthmatic children (6 to 12 years of age) who had not received oral bronchodilators for at least 6 months. A double blind, placebo-controlled, parallel format was used with a 4-week theophylline or placebo period preceded by a 2-week baseline. Theophylline serum levels were maintained between 10 to 20 µg/mL. During baseline and treatment periods, the child's home and school behavior/performance were monitored independently by their parents and teachers using standardized report forms. A battery of psychologic tests was administered at the end of baseline and treatment periods. Seven children receiving theophylline were noted to have a change in school behavior and/or performance during their 4 weeks on drug compared to baseline, whereas none of the children receiving placebo were noted to be different (P = .004). Thus, the short-term administration of theophylline to asymptomatic asthmatic children not receiving oral bronchodilators can adversely affect school performance and behavior. Because this population represents the majority of asthmatic children, one needs to use theophylline cautiously in this age group, monitor school performance closely, or seek other treatment modalities.
Low Birth Weight, Vital Records, and Infant Mortality
Authors: WEGMAN MYRON E.
Published: December 2021

About one tenth of all infant deaths occur in babies weighing less than 500 g at birth, almost all of whom die very shortly thereafter. In 1983, when the United States reported 3,638,933 live births, 4,368 of them were less than 500 g; that year there were 26,507 neonatal deaths. This means that slightly more than 0.1% of all live births contributed to 17% of neonatal mortality. Given this order of magnitude, any change in the numbers relating to these tiny babies can have a disproportionate influence on reported infant mortality and on interstate comparisons. Two questions promptly arise. How accurate and meaningful are the data regarding babies born weighing less than 500 g? What can be done to decrease the deaths in this category?

Wilson et al1 call attention to how the number of very low birth weight infants reported by a state may be affected by the state's definition of a live birth.
Use and Abuse of the Apgar Score
Authors:   Committee on Fetus and Newborn
Published: December 2021

The Apgar score, devised in 1952 by Dr Virginia Apgar, is a quick method of assessing the state of the newborn infant.1,2 The ease of scoring has led to its use in many studies of outcome. However, its misuse, as in current International Classification of Diseases, revision 9, coding, has led to an erroneous definition of asphyxia.* Although the Apgar score continues to provide a convenient shorthand for reporting the state of the baby and the effectiveness of resuscitation, the purpose of this statement is to place the Apgar score in its proper perspective as a tool for assessing asphyxia and for prognostication of future neurologic deficit.

The Apgar score is comprised of five components: heart rate, respiratory effort, tone, reflex irritability, and color, each of which can be given a score of 0, 1, or 2 (Table).

FACTORS THAT MAY AFFECT THE APGAR SCORE

Although rarely stated, it is important to recognize that elements of the score such as tone, color, and reflex irritability are partially dependent on the physiologic maturity of the infant. The normal premature infant may thus receive a low score purely because of immaturity with no evidence of anoxic insult or cerebral depression.

Maternal sedation or analgesia may decrease tone and responsiveness. Neurologic conditions such as muscle disease or cerebral malformations may decrease tone and interfere with respiration. Cardiorespiratory conditions may interfere with heart rate, respiration, and tone. Thus, to equate the presence of a low Apgar score solely with asphyxia represents a misuse of the score.
Maternal Depression: A Concern for Pediatricians
Authors: Zuckerman Barry S. , Beardslee William R.
Published: December 2021

Maternal depression is common in clinical experience but has not been fully addressed in the pediatric literature. Depression can refer to either depressive symptoms or a diagnosable depression. Depression among mothers occurs frequently, is persistent, and is related to other factors such as low social class and marital disharmony. Studies demonstrate an association between a mother's depression and adverse outcomes for her child including low birth weight, behavior problems, somatic complaints, poor growth, accidents, and affective illness. Affect and child-rearing characteristics of depressed mothers seem to be important factors in mediating these poor outcomes. Pediatricians have a special role in helping depressed mothers and their children.
Health Care Needs of Indochinese Refugee Teenagers
Authors: Fitzpatrick S. , Johnson Jennifer , Shragg Paul , Felice Marianne E.
Published: December 2021

Although 50% of Indochinese refugees are under 18 years of age, previous studies have emphasized the prevalence of parasites, anemia, tuberculosis, and hepatitis, with few addressing age-related health care needs. In this study the specific health care needs of 80 Indochinese refugee teenagers, evaluated during a 4-year period, were determined. The Centers for Disease Control's suggested screening measures were used, and it was found that 52% had positive purified protein derivative skin tests, 38% lacked immunizations, 35% had stool specimens positive for parasites (prevalence and number of parasites greatest among Cambodians), 14% had blood tests positive for hepatitis B surface antigen, and 10% were anemic. Additional evaluations showed that 19% had hemoglobinopathies, 14% were in or below the fifth percentile for height and weight, 12% had goiters, 12% had skin disorders, 8% had positive hepatitis B surface antigen, 5% had visual defects, 5% had hearing loss, 5% had psychosomatic illness, and 4% had idiopathic scoliosis. Although suggested Centers for Disease Control screening measures may be adequate for younger Indochinese children, these data suggest that additional studies are necessary for teenagers. For the sexually active adolescent, identification of and counseling for hepatitis antigenemia and hemoglobinopathies are crucial. In addition, early identification of emotional and physical problems during screening may enhance assimilation into a new society and facilitate completion of the psychosocial tasks of adolescence.
Genitalia in Children's Drawings: An Association With Sexual Abuse
Authors: Hibbard Roberta A. , Roghmann Klaus , Hoekelman Robert A.
Published: December 2021

Many sexual abuse victims have been observed to draw genitalia on human figures. To test the hypothesis that sexually abused children draw genitalia on human figures more often than do nonabused children, drawings from 57 children, 3 through 7 years of age, who were referred to child protective services as alleged sexual abuse victims, were compared with drawings from an age-, sex-, race-, and socioeconomically matched group of 55 nonabused children receiving well-child care in medical settings. A standardized procedure to obtain drawings was followed by a structured interview to collect demographic, past medical, and developmental information. Five evaluators unaware of the children's backgrounds independently examined drawings for the presence or absence of five body parts; there was 94% agreement for all body parts and 93% agreement for genitalia. Eight children were excluded from the analysis because they only scribbled (n = 5) or because evaluators could not agree on whether genitalia were present in their drawings (n = 3). Ten percent (5/52) of the alleged sexual abuse victims and 2% (1/52) of the comparison children drew genitalia (P = .10, one-tailed Fisher exact test). The estimated relative risk was 5.4; that is, alleged sexual abuse victims were 5.4 times more likely to draw genitalia than were comparison children. Children known to have been sexually abused were 6.8 times more likely to draw genitalia than were comparison children (P = .07, one-tailed Fisher exact test). It must be cautioned that, although the presence of genitalia in a child's drawing should alert one to consider the possibility of sexual abuse, it does not prove it, just as the absence of genitalia does not exclude abuse. The drawing of genitalia should sensitize providers and influence the effort directed toward exploring the possibility of sexual abuse.