bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Ambient Temperature on Capillary Refill in Healthy Children
Authors: Gorelick Marc H. , Shaw Kathy N. , Baker M. Douglas
Published: December 2021

Objectives. To assess the effect of moderately decreased ambient temperature on capillary refill (CR) time in healthy children, and to measure the reliability of CR measurements between observers.

Design. Prospective interventional study with crossover design.

Setting. Urban pediatric emergency department.

Participants. 32 well-hydrated children aged 1 month to 12 years brought to the emergency department for care of minor illness or injury.

Interventions. Participants were assigned in random order to a 15-minute waiting period in each of two rooms, with and without air-conditioning (cool and warm rooms, respectively). At the end of each waiting period, fingertip CR was measured with a stopwatch, three times by each of one or more three trained observers.

Results. Mean CR time was 0.85 ± 0.45 seconds in the warm room (mean ambient temperature 25.7°C) vs 2.39 ± 0.76 seconds in the cool room (mean temperature 19.4°C). The mean overall difference in CR time between the two environments was 1.53 seconds (95% confidence interval [CI]: 1.31, 1.75; P < .001); the difference was significant regardless of age or sequence of exposure. 100% of patients were considered to have normal CR (less than 2 seconds) in the warm room, whereas only 31% were considered normal in the cool room. In the 16 patients with CR measured by three observers, interobserver reliability was fair, with an intraclass correlation coefficient of 0.70 (95% CI: 0.56, 0.85), and κ of 0.54 (95% CI: 0.33, 0.73).

Conclusions. Decreases in ambient temperature within a range found in typical office/emergency department settings may cause significant prolongation of CR time in children with normal circulatory status. There is marked interobserver variability in the measurement of CR even when performed by experienced observers. These findings suggest limitations to the use of CR in the assessment of ill or injured children.
Shunts in Patients With Respiratory Distress Syndrome
Authors: SKINNER JONATHAN R. , HEY EDMUND N.
Published: December 2021

To the Editor.—

We enjoyed this recent paper from Walther et al1 assessing pressure gradient across the arterial duct in neonates with respiratory distress syndrome. However, the initial statement that there have been no previous studies relating severity of respiratory distress syndrome to pulmonary artery pressure is incorrect. The conclusions of this study need to be related to the three earlier studies of Halliday et al,2 Evans and Archer,3 and Skinner et al,4 all of which studied the relationship of pulmonary artery pressure to disease severity.
Annual Summary of Vital Statistics—1992
Authors: Wegman Myron E.
Published: December 2021

A new low in the infant mortality rate was reached in 1992, at 848.7 deaths per 100 000 live births, a decline of 5% from 894.4 in 1991. Birth, death, and marriage rates were also lower, but the divorce rate inched up to 4.8 per 1000 population, the same level as in 1988. The age-adjusted death rate was 504.9 per 100 000 population, the lowest in US history. Natural increase in the population, excess of births over deaths, decreased from 1 941 389 to 1 907 000, from 7.7 to 7.5 per 1000 population. Births outside hospital were fewer, both in numbers and in proportion to all births. Birth rates increased at both ends of the age range but declined in the principal childbearing years. Births to unmarried mothers increased again, comprising more than one fifth of white births and two thirds of black births. A higher proportion of newborns weighed less than 2500 g than in 1989.

Life expectancy at birth increased again, to 75.7 years overall, paralleled in both sexes and white and black races. The age-adjusted death rate for cardiovascular diseases declined, but malignancies of the respiratory system increased again, to almost six times what it was in 1940. Chronic obstructive pulmonary diseases, despite slight improvement since 1991, caused death more than eight times as often as in 1940.

Black and white infant mortality rates both showed a decline, greater in the white neonatal component; the black/white discrepancy widened slightly. Infant mortality in those of Hispanic origin was slightly higher than non-Hispanic whites, but the National Center for Health Statistics warns that Hispanic rates may be understated. There was little change in causes of infant mortality, or in black to white ratios for the several causes.

On the world scene, most industrialized countries showed declines in infant mortality matching the US. In 1991, 21 countries, 15 in Europe, 3 in Asia, 2 in Oceania, and 1 in North America, had infant mortality rates less than the US. The decline in most other countries has been more rapid than in the US.
Randomized Trial of Silver Nitrate, Erythromycin, and No Eye Prophylaxis for the Prevention of Conjunctivitis Among Newborns Not at Risk for Gonococcal Ophthalmitis
Authors: Bell Thomas A. , Grayston J. Thomas , Krohn Marijane A. , Kronmal Richard A. ,   The Eye Prophylaxis Study Group
Published: December 2021

Objective. To compare the efficacy of commonly used forms of eye prophylaxis for newborns with no prophylaxis in the prevention of nongonococcal conjunctivitis.

Design. Randomized doubly masked clinical trial.

Setting. University of Washington Hospital and affiliated clinics, Seattle, between 1985 and 1990.

Subjects. The medical records of 8499 women were evaluated for possible participation; 2577 were eligible. Of the 758 enrolled, the infants of 630 were evaluable.

Intervention. Comparison of silver nitrate, erythromycin, and no eye prophylaxis given at birth for the prevention of conjunctivitis.

Main outcome measures. Conjunctivitis during the first 60 days of life and nasolacrimal duct patency in the first 2 days of life.

Results. The frequency of impatent tear ducts at the 30- to 48-hour examination did not differ significantly by prophylaxis group. Among the 630 infants randomized and observed, 109 (17%) developed mild conjunctivitis. Sixty-nine (63%) of the cases appeared during the first 2 weeks of life. After 2 months of observation, infants allocated to silver nitrate eye prophylaxis at birth had a 39% lower rate of conjunctivitis (hazard ratio = 0.61, 95% confidence interval = 0.39 to 0.97), and those allocated to erythromycin had a 31% lower rate of conjunctivitis (hazaid ratio = 0.69, 95% confidence interval = 0.44 to 1.07), than did those allocated to no prophylaxis.

Conclusion. Silver nitrate eye prophylaxis caused no sustained deleterious effects and even provided some benefit to infants born to women without Neisseria gonorrhoeae. However, the effect was modest and against microorganisms of low virulence. The results suggest that parental choice of a prophylaxis agent including no prophylaxis is reasonable for women receiving prenatal care and who are screened for sexually transmitted diseases during pregnancy.
Surfactant Therapy and Intracranial Hemorrhage: Review of the Literature and Results of New Analyses
Authors: Gunkel J. Harry , Banks Phillip L.C.
Published: December 2021

Background and objective. Surfactant replacement is a powerful therapy for newborns with respiratory distress syndrome, but limited observations suggest that alterations of cerebral blood flow can accompany the use of several available surfactants. An early European multicenter controlled study with beractant demonstrated an increased rate of intracranial hemorrhage in treated patients. Nine additional controlled studies were subsequently performed and included follow-up evaluations through 2 years adjusted age. This clinical experience provided a database of approximately 1700 infants to examine retrospectively for any relationship between surfactant therapy and intracranial hemorrhage.

Methods. Cumulative incidence rates, hazard ratios, and 95% confidence intervals for intracranial hemorrhage were computed for each study and for appropriately pooled studies of similar design. Where an association between surfactant and the risk of intracranial hemorrhage was found, additional analyses were performed to attempt to identify intermediate physiologic events that might link administration of surfactant to the occurrence of intracranial hemorrhage. These analyses were guided by literature reports of hemodynamic changes observed in association with surfactant therapy.

Results. During the controlled studies with beractant, treated newborns of 600 to 750 g birth weight were at higher risk for grades I and II intracranial hemorrhage than control newborns. There was no increased risk for grades III and IV hemorrhage among these newborns, nor was there increased risk of hemorrhage among any other patient groups. This finding did not result in increased morbidity for the affected patients; at 2 years adjusted age, they were not different from the control infants of 600 to 750 g birth weight. Retrospective examination of the database could not pinpoint the mechanism behind the finding, but it might have been related to changes in cerebral blood flow after surfactant uncompensated by ventilator management of oxygenation and ventilation.

Conclusion. Surfactant therapy may set in motion hemodynamic changes that could predispose to intracranial hemorrhage in certain circumstances, but this can probably be compensated by careful management of oxygenation and ventilation. A relationship between surfactant therapy and intracranial hemorrhage is probably not isolated to any particular surfactant preparation or method of delivery; studies comparing surfactants have shown no differences in rates of intracranial hemorrhage.
Neurodevelopmental Testing of Children Born to Human Immunodeficiency Virus Type 1 Seropositive and Seronegative Mothers: A Prospective Cohort Study in Kigali, Rwanda
Authors: Msellati Philippe , Lepage Philippe , Hitimana Deo-Gratias , Van Goethem Christiaan , Van de Perre Philippe , Dabis François
Published: December 2021

Objective. The results of developmental testing of 218 children born to human immunodeficiency virus (HIV)-seropositive mothers and infected or uninfected themselves were compared with those of 218 children born to HIV-seronegative mothers in an ongoing cohort study in Kigali, Rwanda.

Methods. When the children were 6, 12, 18, and 24 months of age, a specific neurodevelopmental examination was performed blindly by study physicians assessing gross motor development, fine motor development, language acquisition, and social contacts.

Results. Only one acute severe HIV-related encephalopathy was identified among the 50 infected children. The proportion of abnormal neurologic examinations in HIV-infected children varied from 15% to 40% according to age and was always higher than in HIV-uninfected children born to HIV-seropositive and seronegative mothers (≤5% or less of abnormal examinations at each time period). fter excluding those children with clinical ac-quired immunodeficiency syndrome (AIDS) from the analysis, the proportion of abnormal examinations in infected children was 12.5% at 6 months, 16% at 12 months, 20% at 18 months, and 9% at 24 months of age and was still more frequent than in HIV-uninfected children. The developmental delay was principally due to significantly lower gross motor scores.

Conclusions. HIV-1-infected children are more frequently developmentally delayed than uninfected children during the first 2 years of life in this African population. This developmental delay is related to the AIDS stage of pediatric HIV infection.
Psychosocial Risks of Chronic Health Conditions in Childhood and Adolescence
Authors:   Committee on Children With Disabilities and Committee on Psychosocial Aspects of Child and Family Health
Published: December 2021

Chronic health conditions affect many children and adolescents. These conditions are illnesses or impairments that are expected to last for an extended period of time and require medical attention and care that is above and beyond what would normally be expected for a child or adolescent of the same age, extensive hospitalization, or in-home health services.1 These conditions include, among others, juvenile rheumatoid arthritis, asthma, cystic fibrosis, diabetes, spina bifida, hemophilia, seizure disorders, neuromuscular disease, acquired immunodeficiency syndrome, and congenital heart diseases. Although each specific condition may be relatively or extremely rare, when they are considered together, many children and adolescents are affected.

Health conditions may be characterized by their duration and their severity. Although these terms are often linked, they refer to different aspects of a health condition. A chronic condition is generally one that has lasted or is expected to last more than a defined period of time, usually 3 months or longer. Conditions vary widely in their onset, course, and duration.2 Severity refers to the impact a condition has on a child's physical, intellectual, psychological, or social functioning.3 This impact may occur as a result of persistent symptoms, required treatments, limitations of activity or mobility, or interference with school, recreation, work, and family activities.

Current estimates are that between 10 and 20 million American children and adolescents have some type of chronic health condition or impairment. Most of these conditions are relatively mild and interfere little with the children's ability to participate in usual childhood activities.4 However.
Statistics and Swedish `Sambos'
Authors: ALLEN STEVEN R.
Published: December 2021

To the Editor.—

I read with interest Myron E. Wegman's comments about infant mortality in Sweden in "Annual Summary of Vital Statistics—1991" (Pediatrics. 1992;90:835-845). It is necessary to understand a major difference between Sweden and the United States that renders Swedish statistics on out-of-wedlock birth irrelevant to the US statistics. The vast majority of children born out-of-wedlock in Sweden are nevertheless born into a stable two-parent family; many Sweden simply choose to live together without being married.
What Sunscreen Should I Use for My 3-Month-Old Baby?
Authors: MORELLI JOSEPH G. , WESTON WILLIAM L.
Published: December 2021

To the Editor.—

With the commercial availability of sunscreens for children, we are frequently asked by parents and by our colleagues in Pediatrics, "What sunscreen should be used on babies under 6 months?" Our answer is simple. "None." Although there is no evidence to suggest that sunscreens are harmful to infants, there is no compelling reason for infants less than 6 months to have sun exposure prolonged enough to require sunscreens. Babies younger than 6 months are not mobile and will not be exposed to the sun unless placed there.
Sleep, Feeding, and Opinions
Authors: WALKER MARSHA
Published: December 2021

To the Editor.—

I wish to express some concerns about the article by Pinilla and Birch which detailed how to teach young infants to sleep through the night.1As the authors stated in their introduction, making infants sleep through the night at an early age has become one of the major goals of parenting in the US. Parents are told that this is necessary so they can return to work and experience minimal disruption in their real lives.
Sleep, Feeding, and Opinions
Authors: PINILLA THERESA , BIRCH LEANN L.
Published: December 2021

In Reply.—

In our recent paper, we reported the results of a study using behavioral procedures that were successful in helping breast-fed infants to sleep through the night by 8 weeks postpartum.1 The caretaking techniques taught to parents included giving a feeding between 10 pm and midnight, and first using caretaking procedures other than feeding to sooth the distressed infant who awakened between midnight and 5 am In the newborn, feeding and sleeping patterns are tightly linked, and breast-fed newborns must wake and feed frequently in order for successful lactation to be established.
Think Globally; Act Locally
Authors: FISCHER PHILIP R.
Published: December 2021

To the Editor.—

Environmentalists use bumper stickers and other means to urge us to "think globally; act locally." The American Academy of Pediatrics could well make the same recommendations to authors who contribute to its publications. From one geographic location, we should not allow our writing to imply an ignorance of or disregard for the situations in which other child health care providers live.

Whether reporting and discussing research findings or proposing practice guidelines, we should be careful to clearly define the relevant populations.
Oral Immunoglobulins for Treatment of Acute Rotaviral Gastroenteritis
Authors: Guarino Alfredo , Canani Roberto Berni , Russo Stefania , Albano Fabio , Rubino Armido , Canani Mario Berni , Ruggeri Franco Maria , Donelli Gianfranco
Published: December 2021

Objective. Preliminary evidence has been reported on the antirotavirus effect of human serum immunoglobulin administered orally. The aim was to see whether such treatment might be effective in rotavirus acute gastroenteritis.

Methods. A prospective, double-blind, placebo-controlled study was performed. Ninety-eight children admitted with acute gastroenteritis were enrolled and randomly assigned to groups A (treated) and B (control). Children in group A received a single oral dose of 300 mg/kg body weight of human serum immunoglobulin. Parameters of efficacy were clinical condition, frequency and consistency of stools, duration of diarrhea, duration of viral excretion, and length of hospital stay. Antirotaviral activity was determined in the immunoglobulin preparation by a specific neutralization assay.

Results. Seventy-one of the 98 children enrolled had rotaviral gastroenteritis; 36 belonged to group A. Children who received immunoglobulin had significantly faster clinical improvement of clinical condition and stool pattern than control children. Mean total duration of rotaviral diarrhea was 76 hours in group A and 131 in group B (P < .01). Viral excretion lasted 114 and 180 hours, respectively (P < .01). Hospital stay was significantly reduced in children in group A. Neutralizing antibodies against rotavirus were detected in the immunoglobulin preparation.

Conclusion. Oral administration of immunoglobulin is associated with a faster recovery from acute gastroenteritis and should be given to children hospitalized with this illness.
The Transfer of Drugs and Other Chemicals Into Human Milk
Authors:   Committee on Drugs
Published: December 2021

This statement was first published in 1983,1 with a revision published in 1989.2 Information about the transfer of drugs and chemicals into human milk continues to become available. This current statement is intended to revise the lists of agents transferred into human milk and describe their possible effects on the infant or on lactation, if known (Tables I through 7). The fact that a pharmacologic or chemical agent does not appear on the lists is not meant to imply that it is not transferred into human milk or that it does not have an effect on the infant; it only indicates that there were no reports found in the literature. These tables should assist the physician in counseling a nursing mother regarding breast-feeding when the mother has a condition for which a drug is medically indicated.

The following question and options should be considered when prescribing drug therapy to lactating women. (1) Is the drug therapy really necessary? Consultation between the pediatrician and the mother's physician can be most useful. (2) Use the safest drug, for example, acetaminophen rather than aspirin for analgesia. (3) If there is a possibility that a drug may present a risk to the infant, consideration should be given to measurement of blood concentrations in the nursing infant. (4) Drug exposure to the nursing infant may be minimized by having the mother take the medication just after she has breast-fed the infant and/or just before the infant is due to have a lengthy sleep period.

Data have been obtained from a search of the medical literature.
Are There Serious Problems?
Authors: Sepkowitz Samuel
Published: December 2021

Blumberg et al1 have reported on a constellation of reactions characterized as "serious" reactions to diphtheria-tetanus-pertussis (DTP) vaccine. During 1986 through 1990 the authors were able to collect, with the assistance of the area physicians and nurses, 40 patients with seizures, 14 with hypotonic-hyporesponsive episodes, 8 patients with fever >40.5° C, and 6 patients with persistent crying. Some of the patients had more than one reaction. The patients were drawn from the Los Angeles area which has approximately 160 000 births per year.2
Bilirubin and Other Brain Cells
Authors: Aschner Michael
Published: December 2021

Drs Newman and Maisels1 agree that the current management of hyperbilirubinemia in the term newborn is based on assumptions searching for scientific validation. As I was reading these letters I could not help but think about another "hot" topic occupying the "Letters to the Editor" section of Pediatrics—lead. As with lead-induced neurotoxicity, children practitioners cannot wait until there are data to fully guide decision making. In their article Newman and Maisels2 indicate some areas in the treatment of newborn hyperbilirubinemia in which there are wide disparities about the preferred management approach, and they identify those aspects of treatment that require a revised consensus statement to help guide therapy.
Secretory Anti-Giardia lamblia Antibodies in Human Milk: Protective Effect Against Diarrhea
Authors: Walterspiel Juan N. , Morrow Ardythe L. , Pickering Larry K. , Ruiz-Palacios Guillermo M. , Guerrero M. Lourdes
Published: December 2021

Objective. To determine whether anti-Giardia lamblia secretory IgA (sIgA) antibodies in human milk protect infants from acquisition of or symptoms associated with Giardia infection.

Methods. One hundred ninety-seven Mexican mother/infant pairs were followed weekly from birth for diarrheal disease and feeding status. Infant stool specimens were collected weekly and were cultured for bacterial pathogens and tested for Giardia and rotavirus by enzyme-linked immunosorbent assay. Maternal milk samples were collected weekly for 1 month postpartum and monthly thereafter. To determine the protective effect of anti-Giardia sIgA in milk against infection and against diarrhea due to Giardia, milk samples from mothers of infected infants and appropriately matched controls were assayed for anti-Giardia sIgA by enzyme-linked immunosorbent assay.

Results. Asymptomatic, infected infants ingested significantly (P = .046) higher amounts of milk anti-Giardia sIgA compared with symptomatic, infected infants. However, milk anti-Giardia sIgA concentrations did not differ between Giardia-infected and noninfected infants.

Conclusion. The amount of anti-Giardia sIgA in human milk was associated with prevention of symptoms of diarrhea due to Giardia, but not with acquisition of the organism.
A Nationwide Study of the Risk of Injury Associated With Day Care Center Attendance
Authors: Briss Peter A. , Sacks Jeffrey J. , Kresnow Marcie-jo , O'Neil Joann , Addiss David G.
Published: December 2021

Objective. Because an increasing proportion of US children spends time in day care center environments, a national estimate of injury risks in day care centers is needed.

Methods. We interviewed directors of 1797 day care centers from every state and the District of Columbia from October to December 1990 and analyzed medically attended injuries and center characteristics reported by the directors.

Results. The centers were attended by 138 404 children. In the 2 months before the center directors were interviewed, 556 children sustained injuries requiring medical attention while attending the centers. The injury rate was 1.5 injuries per 100 000 child hours in day care. The most common injuries were cuts or lacerations (31%), bumps or bruises (15%), fractures (10%), and dental injuries (8%). Most injuries (51%) occurred on the play-ground. Many injuries (18%), and more than half of fractures and concussions (53%) were due to falls from climbing equipment.

Conclusions. Day care center injury rates estimated by this study were relatively low. Many injuries that occur in this setting are probably minor. However, lowering the height of playground equipment and providing more resilient playground surfaces could further reduce injury risks in day care centers.
Prevalence and Health Impact of Developmental Disabilities in US Children
Authors: Boyle Coleen A. , Decouflé P. , Yeargin-Allsopp M.
Published: December 2021

Objective. Data from the 1988 National Health Interview Survey—Child Health Supplement were used to examine the prevalence of selected developmental disabilities and their impact among children ages 0 through 17 years.

Design. The following conditions, identified through a structured in-person interview with a parent or other adult household member, were examined: deafness or trouble hearing, blindness, epilepsy or seizures, stammering and stuttering, other speech defects, cerebral palsy, delay in growth or development, learning disabilities, and emotional or behavioral problems. The impact was defined by measures of perceived health status, school performance and attendance, and health care utilization.

Results. Seventeen percent of children in the United States were reported to have ever had a developmental disability. The prevalence of the individual disabilities ranged from 0.2% for cerebral palsy to 6.5% for learning disabilities. These conditions taken together had a substantial impact on the health and educational functioning of affected children: 1.5 times more doctor visits, 3.5 times more hospital-days, twice the number of school-days lost, and a 2.5-fold increase in the likelihood of repeating a grade in school compared with children without these conditions. The extent of this impact was much greater among children with multiple disabilities or with either cerebral palsy, epilepsy or seizures, delays in growth and development, or emotional or behavioral problems. The impact on school performance was most pronounced for children reported to have learning disabilities.

Conclusions. Future research efforts should be focused on ways to reduce the impact of these developmental disabilities on quality of life.
Cortical Hyperostosis: A Complication of Prolonged Prostaglandin Infusion in Infants Awaiting Cardiac Transplantation
Authors: Woo Karen , Emery Janet , Peabody Joyce
Published: December 2021

Background. Infants awaiting heart transplantation for congenital heart disease frequently require prostaglandin E1 (PGE1) infusion for prolonged periods. As a result, complications of prolonged PGE1 infusion, such as cortical hyperostosis, are being encountered more commonly.

Objective. To determine the incidence and severity of cortical hyperostosis in newborns requiring prolonged PGE1 infusion.

Methods. Chest radiographs of 86 infants receiving PGE1 infusion awaiting heart transplantation were reviewed. The chest radiographs were graded for the severity of cortical hyperostosis (no bony changes, minimal hyperostosis, or severe hyperostosis). Duration of PGE1 infusion, total PGE1 dose, and highest alkaline phosphatase were recorded for each patient. Infants were arbitrarily divided into three groups according to the duration of PGE1 infusion (<30 days, 30 to 60 days, >60 days).

Results. Fifty-three of the 86 infants (62%) had radiologic evidence of cortical hyperostosis. Forty-two of 80 infants (53%) had elevated alkaline phosphatase. The percentage of infants with hyperostosis increased with increasing duration of PGE1 infusion (42% at <30 days; 87% at 30 to 60 days; 100% at >60 days). The incidence and severity of cortical hyperostosis were related (by Kruskal-Wallis) to the duration of PGE1 infusion (P < .0001) and the total dose of PGE1 received (P < .0001). The highest alkaline phosphatase levels were observed in infants with the most severe grades of hyperostosis (P < .0001). The percentage of infants with elevated alkaline phosphatase increased with greater severity of hyperostosis (26% of infants with no bony changes, 59% with minimal changes, and 85% with severe changes). Two infants had symptomatic bone tenderness or swelling mimicking osteomyelitis.

Conclusion. It is concluded that cortical hyperostosis is a frequent, often asymptomatic, side effect of prolonged PGE1 infusion that should be evaluated in any infant on long-term PGE1 therapy. When symptoms occur in infants awaiting transplantation, osteomyelitis must be excluded rapidly to avoid an unnecessary delay in transplantation.
SINGAPORE TO LIMIT PHYSICIANS
Authors: L. J. F.
Published: December 2021

Singapore imposed curbs on new physicians to prevent excessive demand for medical services that could inflate health costs and undermine rapid economic growth. The government reduced to 15 from 40 a year the maximum registrations of foreign doctors, said it would freeze at 150 a year the admissions of National University medical students, and slashed to 28 from 176 the foreign medical schools Singaporeans may attend if they want to return to practice medicine.
Monitoring for Anthracycline Cardiotoxicity
Authors: Lipshultz Steven E. , Sanders Stephen P. , Colan Steven D. , Goorin Allen M. , Sallan Stephen E. , Krischer Jeffrey P.
Published: December 2021

Objective. To review the basis for recommendations of the Cardiology Committee of the Children's Cancer Study Group, published in Pediatrics, for serial cardiac monitoring of cancer patients during anthracycline therapy and reduction of therapy should cardiac studies show abnormalities.

Design. Because the effects of overall morbidity and mortality should be considered when a recommendation is made to withhold potentially lifesaving chemotherapy based on abnormal cardiac findings of patients without clinical evidence of cardiac dysfunction, supporting studies referenced in the published recommendations were reviewed. Specifically, studies were evaluated to determine whether a reduction in anthracycline dose, as a result of abnormal cardiac findings by monitoring, reduced cardiac morbidity and related mortality compared with a prospectively followed control population without dose modification. In addition, the effects of cardiac monitoring and subsequent anthracycline dose modification on oncologic morbidity and mortality were reviewed in these studies. Finally, the contributions of the cardiac and oncologic effects of dose modification were examined to determine the effect of this change in therapy on overall morbidity and mortality.

Results. None of the studies cited in developing these recommendations prospectively determined, with controls, the effects of cardiac monitoring and anthracycline dose modification on cardiac, oncologic, or overall morbidity and mortality. Therefore, none of the studies cited in support of cardiac monitoring and subsequent dose reduction demonstrated the efficacy of such an approach. In the absence of such data, concerns are raised as to whether such a monitoring program with subsequent dose modification might do more harm than good. In addition, none of the methods of screening for anthracycline cardiotoxicity has been shown to be adequately predictive of early or late cardiac outcomes. Finally, adoption of these recommendations would inhibit the investigation of the efficacy of the proposed plan.

Conclusion. Given the absence of supportive data and the potential to do harm, no recommendation for dose modification based on abnormal cardiac findings in patients without clinical evidence of cardiotoxicity can be endorsed, including those of the Cardiology Committee of the Children's Cancer Study Group. When clinical evidence of cardiotoxicity is present, anthracycline dose modification is recommended. A prospective controlled study to determine the effects of dose modification based on cardiac test results is indicated.
Reading Ability of Parents Compared With Reading Level of Pediatric Patient Education Materials
Authors: Davis Terry C. , Mayeaux E. J. , Fredrickson Doren , Bocchini Joseph A. , Jackson Robert H. , Murphy Peggy W.
Published: December 2021

Objectives. To test the reading ability of parents of pediatric outpatients and to compare their reading ability with the ability necessary to read commonly used educational materials; to compare individual reading grade levels with the levels of the last grade completed in school; and to further validate a new literacy screening test designed specifically for medical settings.

Design. Prospective survey.

Setting. Pediatrics outpatient clinic in a large, public university, teaching hospital.

Participants. Three hundred ninety-six parents or other caretakers accompanying pediatric outpatients.

Measurements. Demographics and educational status were assessed using a structured interview. Reading ability was tested using the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Wide Range Achievement Test-Revised2. Written educational materials were assessed for readability levels with a computer program (Grammatik IV).

Results. The mean score on the REALM for all parents placed them in the seventh to eighth grade reading range, despite the mean self-reported last grade completed in school being 11th grade 5th month. Wide Range Achievement Test-Revised2 scores correlated well with REALM scores (0.82). Eighty percent of 129 written materials from the American Academy of Pediatrics, the Centers for Disease Control, the March of Dimes, pharmaceutical companies, and commercially available baby books required at least a 10th grade reading level. Only 25% of 60 American Academy of Pediatrics items and 19% of all materials tested were written at less than a ninth grade level, and only 2% of all materials were written at less than a seventh grade level.

Conclusion. This study demonstrates that parents' self-reported education level will not accurately indicate their reading ability. Testing is needed to screen at-risk parents for low reading levels. In a public health setting, a significant amount of available parent education materials and instructions require a higher reading level than most parents have achieved. In such settings, all materials probably should be written at less than a high school level if most parents are to be expected to read them. The REALM can easily be used in busy public health clinics to screen parents for reading ability.
The Congenital Isolated Apical Ventricular Septal Defect
Authors: Sapin Samuel O. , Junkel Paul A. , Wong Ah Lin , Simandle Karen G.
Published: December 2021

Congenital isolated apical VSDS can be found from early infancy through adolescence. Spontaneous closure is common in the first year of life. The defects are almost always small and rarely cause symptoms or require surgery. Antibiotic prophylaxis for infectious endocarditis is indicated. The auscultatory findings are characteristic and distinctive, and when present, referral for an echocardiogram or to a pediatric cardiologist is not necessary. The most cost-effective approach to the diagnosis is the use of the stethoscope and an educated ear.
Life-Threatening Reaction to Trimethoprim/Sulfamethoxazole in Pediatric Human Immunodeficiency Virus Infection
Authors: Chanock Stephen J. , Luginbuhl Lynn M. , McIntosh Kenneth , Lipshultz Steven E.
Published: December 2021

Trimethoprim/sulfamethoxazole (TMP/SMX) is frequently administered to children with human immunodeficiency virus (HIV) infection for treatment or prevention of bacterial and opportunistic infections.1 The incidence of adverse reactions to this drug combination in HIV-infected individuals seems to be higher than in those without HIV infection.2-6 Severe life-threatening reactions to TMP/SMX are rare and have been reported in adult patients with and without HIV infection.

Two HIV-infected children with life-threatening reactions after rechallenge with TMP/SMX are described. In each case, the patient survived, but only after intensive care management. With the expected increase in the number of HIV-infected children and the need to administer prophylaxis against Pneumocystis carinii pneumonia, pediatric care providers should be aware of this dangerous, adverse reaction to TMP/ SMX.
Precocious Puberty in Girls With Myelodysplasia
Authors: Elias Ellen Roy , Sadeghi-Nejad Ab
Published: December 2021

Myelodysplasia is a relatively common anomaly occurring in 1 to 5 per thousand live births. It is seen more frequently in girls. The severity of developmental defect and the resultant neurological impairment is variable; however, hydrocephalus is a common finding.1 True precocious puberty, premature activation of the hypothalamic-pituitary-gonadal axis, also occurs more frequently in girls.2,3 It has been our clinical impression that sexual precocity is more common in girls with myelodysplasia than in otherwise healthy children. To assess the degree and nature of this association, if any, we retrospectively studied 62 girls with myelodysplasia.

MATERIALS AND METHODS

All female patients with myelomeningocele attending our multidisciplinary myelodysplasia clinic at the New England Medical Center (Floating Hospital for Children) between September 1989 and May 1991 were studied.
Fatal Child Abuse and Sudden Infant Death Syndrome (SIDS): A Critical Diagnostic Decision
Authors: Beeber Bruce , Cunningham Nicholas
Published: December 2021

We read with interest Dr Robert Reece's thorough article on "Fatal Child Abuse and Sudden Infant Death Syndrome: A Critical Diagnostic Decision," in the February issue of Pediatrics.1 Ever timely is this issue of the interplay between abuse and SIDS, as Reece and those at the Cleveland Child Protection Program have reported. A decade ago, we presented a paper entitled "SIDS—Child Abuse: Diagnostic Interface."2 The findings were based on both written surveys and follow-up telephone contacts.
Neurologic Manifestations of Cocaine Exposure in Childhood
Authors: Mott Stephen H. , Packer Roger J. , Soldin Steven J.
Published: December 2021

Objective. To describe the neurologic manifestations of cocaine exposure in children and adolescents as the neurologic effects of cocaine have been described in adults and neonates.

Methods. During 1-year period, 41 children between the ages of 2 months and 18 years who had been exposed to cocaine, were examined in the emergency department at the Children's National Medical Center. Cocaine exposure was documented on urine samples; all were confirmed by urine gas chromatographic/mass spectrometric analysis.

Results. Nineteen (46%) of 41 had neurologic abnormalities, including seizures (7), obtundation (6), delirium (4), dizziness (1), drooling (1), and ataxia (1). In 14 others, the neurologic effects of cocaine were difficult to determine because of other concomitant medical conditions, including head injuries and severe abdominal or chest trauma. Two major age-related patterns were seen: (a) in each child <5 years of age, seizures and obtundation; and (b) in 11 older children, delirium (3), dizziness (1), drooling (2), and lethargy (4). Seizures, occurring at ages 12 months to 8 years, were focal with secondary generalization in three and generalized in four. They were associated with fever in two children. Six children had no further seizures, and one developed a mixed-seizure disorder. Passive intoxication while being in a room in which "crack" was smoked was the most likely cause of exposure for young victims. Multiple drug abuse was not documented in any child with neurologic impairment.

Conclusions. 1) Cocaine exposure is common in children in our urban setting; 2) neurologic manifestations frequently occur; 3) in children 8 years of age or younger, "passive" ingestion/inhalation is associated with focal and generalized seizures without evidence of structural brain injury; 4) cocaine may lower seizure threshold in children predisposed to seizures; 5) in children >8 years of age, manifestations are similar to those in adults; 6) trauma and motor vehicle accidents were seen in the adolescent age group exposed to cocaine; and 7) urine toxicological study in cocaine exposure is recommended in all first-time seizures as well as first-time febrile seizures.
CANADA'S FAILURE
Authors: L. J. F.
Published: December 2021

The direct costs of Canada's national health insurance are not as troublesome as the distortive effect they have on health care delivery. Health care facilities have been forced to cut back severely on their capital expenditures, thus depleting the availability of advanced medical equipment. As a result, many patients must seek advanced treatment elsewhere. According to a recent study reported in the New England Journal of Medicine, nearly one-third of Canada's doctors have sent patients outside the country for treatment during the past five years. About 10% of all British Columbia residents requiring cancer therapy have been sent to the U.S. In Toronto, because the government doesn't provide enough money for personnel, 3,000 beds have been removed from service, while thousands of patients are on waiting lists for admission.

Even where advanced equipment is available, bureaucratic absurdities prevent proper use. According to the April issue of "Fraser Forum," dogs at York Central Hospital in metropolitan Toronto were able to get CAT scans immediately while humans were put on a waiting list. The reason? Canadian patients are not allowed to pay for CAT scans, and the procedure costs too much to operate more than a few hours a day for nonpaying customers. Dog owners, on the other hand, were permitted to pay to use it. The user fees paid by the dog owners allowed the machine to operate longer, thus more human patients could be scanned. When this information was released, instead of considering user fees for humans, the Canadian government banned the tests for dogs!
COST-EFFICIENCY MODEL
Authors: L. J. F.
Published: December 2021

In an interview, Dr. Thier said he hopes to turn Massachusetts General into another kind of model: one that increases cost-efficiency without compromising basic research or patient care.

"A way of life is changing," Dr. Thier asserted. Academic medical centers are being forced to rein in costs quickly, he contended, because of growing price- pressure from insurers, as well as the movement in Washington to enact healthcare legislation.

Top teaching hospitals haven't conducted much cost-oriented research involving patients. Instead, the hospitals have concentrated on discovering fundamental medical techniques, often working at the molecular level. Research on treatment costs and effectiveness has been carried out mostly by schools of public health and by such think tanks as Rand Corp...

Other big teaching hospitals are starting research on treatment costs and effectiveness, said George Lundberg, editor of the Journal of the American Medical Association. "I expect such research to flourish with the pressures of health-system reform," he said.

"Now that it's so much in the best interests of the largest health-delivery groups to discover the best ways to deliver maximum services for minimum cost," Dr. Lundberg added, "it's not at all surprising that such institutions will enter health-services research in a big way."
Acetaminophen Analgesia in Neonatal Circumcision: The Effect on Pain
Authors: Howard Cynthia R. , Weitzman Michael L. , Howard Fred M.
Published: December 2021

Objective. Recognizing the concerns about the use of local anesthesia in neonatal circumcision, a painful procedure usually performed without analgesia or anesthesia, we undertook a study of acetaminophen for pain management of this procedure.

Design. A prospective, randomized, double-blind, placebo-controlled, clinical trial of acetaminophen analgesia in 44 healthy full-term neonates undergoing circumcision was conducted. Beginning 2 hours before Gomco circumcision, neonates received either acetaminophen (15 mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15 mL/kg per dose) every 6 hours for 24 hours. Neonates were monitored intraoperatively for changes in heart rate, respiratory rate, and crying time. Postoperative pain was assessed at 30, 60, 90, 120, 360 minutes, and 24 hours using a standardized postoperative comfort scoring system. Feeding behavior was also assessed before and after circumcision by nursing observation.

Results. Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences observed between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores (P < .05). Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acetaminophen did not seem to influence this deterioration.

Conclusions. This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the immediate postoperative period.
Carbamate Poisoning and Oxime Treatment in Children: A Clinical and Laboratory Study
Authors: Lifshitz Matitiahu , Sofer Shaul , Shahak Eliezer , Rotenberg Michal , Almog Shlomo , Tamiri Tsippy
Published: December 2021

Objective. (1) Retrospective evaluation of the clinical course of carbamate poisoning and the effect of oxime therapy in children. (2) In vitro study of the effect of oximes on the reactivation of carbamylated cholinesterase.

Design. (1) Clinical survey: The records of 26 children intoxicated with carbamates were examined retro-spectively. The poisoning agents in all cases were positively identified as methomyl or aldicarb by gas chromatography-mass spectrometry. (2) Laboratory study: The direct effect of obidoxime and of pralidoxime on acetylcholinesterase activity in vitro was investigated in normal human packed red blood cells pretreated with an organophosphate (paraoxon) or a carbamate (aldicarb or methomyl).

Clinical setting. Pediatric intensive care unit of a teaching hospital.

Patients. Twenty-six infants and young children (aged 1 to 8 years) admitted to the pediatric intensive care unit with severe carbamate intoxication.

Interventions. All cases had been treated with repeated doses of atropine sulfate (0.05 mg/kg) administered every 5 to 10 minutes until muscarinic symptoms disappeared. Obidoxime chloride (Toxogonin, 6 mg/kg) was administered on admission, and again after 4 to 5 hours.

Results. Predominant symptoms were related to central nervous system and nicotinic effects. All the patients showed marked improvement within several hours and recovered completely within 24 hours. None of the children deteriorated and none showed exacerbation of cholinergic symptoms after obidoxime treatment. In vitro, oximes reactivated acetylcholinesterase inhibited with paraoxon, whereas no significant effect of oximes on carbamylated enzyme activity was observed.

Conclusions. Based on the recovery of all cases, as compared with other reports of carbamate poisoning treated with atropine alone, it is concluded that, in the case of aldicarb or methomyl poisoning, oxime therapy apparently does not contribute to the recovery of poisoned patients. In cases of poisoning by an unknown pesticide or of mixed poisoning, oxime therapy can prove beneficial because no negative effects of the therapy can be discerned.