bluuebunny/crossref_metadata_2025 huggingface dataset:
Cancer in Adolescents
Authors: Finkelstein Jordan W.
Published: December 2021

Cancer is the fourth leading cause of death in the adolescent age group, preceded only by accidents, homicide, and suicide. Table 1 lists by age, sex, and race cancer incidence rates (per million) for a three-year period (1969-1971) reported by the National Cancer Institute. Table 2 lists the most commonly involved sites. There are significant differences between the younger and the older age groups. With the advent of improved treatment, survival rates have increased. Table 3 lists the survival rates for the most common forms of cancer and includes all children under 15 years of age. Although survival rates are increasing, the majority of children with cancer still die. Table 4 lists cancer mortality rates for adolescents.

The issues involved in diagnosis, treatment, survival, and death present problems for all of those who care for the adolescent with cancer—the patient himself or herself, family and friends, the physician, and other health care professionals. The objectives of this article are: to increase awareness of the types of problems commonly encountered in caring for adolescents with cancer and to describe some of the ways of dealing with these problems. The problems are by no means clear-cut, and the suggested methods of dealing with them must be individualized to meet the needs of all involved.
DIFFERENTIAL DIAGNOSIS OF ARTHRITIS IN CHILDREN
Authors: BREWER EARL J.
Published: December 2021

Systemic onset juvenile rheumatoid arthritis (JRA)1 often follows a respiratory infection and has intermittent and persistent fever greater than 103 F (39 C) accompanied by classic rheumatoid rash. These children usually have multiple joint involvement (lasting more than six continuous weeks with the cervical spine often affected). Joint findings include swelling with thickening of the synovium with or without effusion, tenderness, pain on motion, and later limitation of motion (LOM) due to contracture. Early LOM can be a prominent and helpful finding. Girls are more commonly affected than boys (2/1) and onset can be at any age of childhood. Pericarditis, when present, almost always occurs in this group with hepatomegaly, splenomegaly, and lymphadenopathy.
Fetal Drug Syndromes: Effects of Ethanol and Hydantoins
Authors: Smith David W.
Published: December 2021

We are now into the era of fetal medicine.* Most of the handicapping disorders of infants and children that we care for today are the consequence of problems in prenatal development. Though the majority of these problems appear to have a genetic basis, it is extremely important to recognize those which have an environmental etiology since they are more readily preventable. When a chemical agent becomes recognized as causing problems in fetal development, ie, as being teratogenic, every attempt should be made to prevent the exposure of the fetus to dangerous levels of that chemical agent. This information should reach all women of reproductive age who are receiving the teratogen or who are liable to receive it after conception.

Mothering before birth is direct mothering. It is direct in the sense that most chemical agents that the mother takes during pregnancy are also "taken" by the fetus. This is graphically portrayed in Fig 1.

If we can simply foster the concept of mothering from conception, this will be a major philosophic advance toward prenatal preventive medicine. For example, every woman needs to know that her cigarette smoking or alcohol ingestion is cigarette smoking or alcohol ingestion by the fetus. Just as she would not wish her infant to smoke or drink after birth, it is even more important that the fetus not be exposed before birth, by her own smoking or drinking.
Management of Suicidal Drug Overdose
Authors: Marks Andrea
Published: December 2021

INCIDENCE AND EPIDEMIOLOGY

Suicide is the third leading cause of death among adolescents, and yet for each fatality it is estimated that between 50 to 200 adolescents survive a suicide attempt. Most of the survivors have taken overdoses of drugs commonly found at home.

The rate of suicide attempts that do not result in death peaks in adolescence. The male to female ratio is 1/2 and self-poisoning is usually the method. In contrast, suicide fatality rates generally increase with age. Overall, suicide is the ninth leading cause of death in the United States; the male to female ratio is 3/1; and the method used most often is fire-arms. Clearly, suicidal behavior by adolescents is a major health problem in the United States today. The usual challenge for the pediatrician is first managing an acute drug overdose and then facilitating subsequent psychosocial evaluation of the troubled youth. The key challenge is identification of disturbed individuals and their families prior to any suicidal acts.

DIAGNOSIS AND PHYSIOLOGIC MANAGEMENT

Most young people who present with a suicidal drug overdose are not comatose; many are asymptomatic. In such situations a careful history may be obtained from the patient to determine: the events surrounding the ingestion, which drug or drugs were taken, how much, and when the ingestion occurred.
Rashes with Ampicillin
Authors: Kraemer Michael J. , Smith Arnold L.
Published: December 2021

Ampicillin, first introduced in 1961, has probably become the most widely used penicillin in clinical pediatrics.

STRUCTURE ACTIVITY RELATIONSHIPS

All penicillins contain the 6-amino penicillanic acid moiety (Fig 1). Its structure includes a thiazolidine ring (A), a β-lactam ring (B), the source of antibacterial activity, and an acyl side chain (R), containing a variety of substitutions creating the family of semisynthetic penicillins. The only difference between ampicillin and penicillin G is the presence of an amino group in the acyl side chain (Fig 1).

PHARMACOLOGY AND BACTERIOLOGY

Ampicillin is a semisynthetic penicillin, active against Streptococus pneumoniae and certain Gram-negative bacteria, including most Haemophilus influenzae, Escherichia coli, and certain Proteus species. Compared to penicillin G, it has increased stability in acid solutions: a property facilitating oral administration and absorption. It penetrates into most body tissues; effective entry into CSF, however, occurs only with inflamed meninges. The serum half-life with normal renal function varies from four hours in newborns1 to 1.3 hours in adults.2 Ampicillin can cause an allergic, or nonallergic skin rash (Fig 2).

ALLERGY

Allergy (for the purposes of this discussion) is defined as a specific immunologic interaction, between either antigen and antibody, or antigen with a sensitized lymphocyte, resulting in a clinically deleterious effect. Implicit is a prior contact with the antigen.
Splenic Trauma
Authors: Sinal Sara H.
Published: December 2021

Modern technology, specifically the splenic scan, aids in a quick and accurate diagnosis of splenic injury. Because children rarely exsanguinate from trauma to the spleen, splenectomy has been replaced by more conservative management as the treatment of choice in splenic trauma. Both nonoperative management and surgical repair of the spleen are alternatives. If splenectomy is necessary, the child is at greatly increased life time risk for an episode of overwhelming sepsis. Pneumococcal vaccine is indicated in children who must undergo splenectomy.
Children and Divorce
Authors: Wallerstein Judith S.
Published: December 2021

Children and adolescents experience severe stresses during the process of parental divorce. As a consequence, the pediatrician can expect to be called upon frequently to provide information and counsel to the divorcing parents, to the children, or to other family members directly, as well as to the physicians in other branches of medicine and concerned members of related disciplines whose professional work brings them into significant contact with these troubled families.

INCIDENCE

The number of children and adolescents who are caught in the process of marital dissolution has soared to more than 1 million new children each year since 1972. It has been estimated that between 32% and 46% of all children who grow up in the 1970s will experience either the separation or divorce of their parents.

Although research about the effects of divorce on children and adolescents is limited, some of the findings are worrisome. Our five-year study of the effects of divorce on a group of 131 California children and adolescents found a significant number at risk during the postdivorce years. Five years after the marital separation, 37% of these youngsters, who were drawn from a normal population, were considered to be suffering with various manifestations of moderate to severe depression, including learning below capacity in school, difficulties with peers, sexual acting out, minor delinquency, explosive anger, continued preoccupation with the divorce, and a general pervasive neediness.
Management of Status Epilepticus
Authors: Menkes John H.
Published: December 2021

Status epilepticus is one of the few neurologic emergencies in the practice of pediatrics. A patient is considered to be in status when seizures occur so frequently as to prevent emergence from the postictal phase induced by one attack before the occurrence of the next.

There are four sequential aspects to the management of the patient in status: maintenance of vital functions, drug therapy to control the convulsions, assigning a cause for the condition, and lastly, prevention of further convulsions.

MAINTENANCE OF VITAL FUNCTIONS

A significant percentage of patients die in the course of status epilepticus, or shortly thereafter. Fatalities have ranged from 23% in all ages to 4% in an exclusively pediatric series. The physician treating the child in status should act promptly to maintain an adequate airway, prevent aspiration of mucus, and secure the child from injury induced by the violence of the convulsions. Hyperthermia and hypotension should be vigorously corrected. Whenever there is cyanosis, oxygen should be administered.

From experimental work we have learned that convulsions lasting longer than 20 to 30 minutes may induce brain damage. Several systemic factors acting singly or in concert are believed to be responsible. Hyperpyrexia and arterial hypotension have been singled out as inducing damage to nerve cells, particularly within the cerebellum.
Editorial: Letters to the Editor
Authors: H. R. J.
Published: December 2021

I have received many, many letters from readers of PEDIATRICS IN REVIEW. To publish most, or even some of them, would take precious space from the cognitive material in PIR. I have decided not to publish a Letters to the Editor section, but to handle the letters in the following ways. They fall into three quite distinct categories and I believe that each should be dealt with in a different way. The first group, and by far the majority so far, is very complimentary. While I would always like to publish laudatory comments in the Journal, I cannot justify the space for adulation. I will keep them for my ego file.
COUGH AND WHEEZING
Authors: MASSIE F. STANFORD
Published: December 2021

An 8-year old boy complained of coughing, sputum production, and wheezing after exercise. Symptoms had been present for 18 months. There were occasional nasal symptoms of stuffiness and itchy nose with sneezing and spells of laryngotracheobronchitis with chest congestion; these occurred months apart. Symptoms improved on Dimetapp and an antibiotic. Sputum varied from one tablespoon to one cup and occurred shortly after reclining in the evening. The sputum was clear and colorless but contained bits of food. Recent direct laryngoscopy and allergy tests were negative. There was no past history of colic, eczema, recurrent colds, or otitis. Because of chronic "mucus production" the child was seen by a second pediatric allergist, who noted "a chronically ill-appearing child with rhonchi in the chest" on one examination and a clear chest a second time; there was no increased A-P diameter or overexpansion of the chest.
COMMENTARY ON ACHALASIA
Authors: RANDOLPH JUDSON G.
Published: December 2021

The symptoms and findings so nicely described in the accompanying clinical report of an 8-year-old boy are those of an obstructed distal esophagus which has led to chronic mucus production, nutritional deprivation with poor weight gain, and aspiration pneumonia. It is an extraordinary clinical paradox that these signs and symptoms are exactly the same for the obstructed gastroesophageal junction, and for the wide open reflux seen with pernicious gastroesophageal reflux.

Achalasia is characterized by failure of the gastroesophageal junction to relax during swallowing. The term achalasia (A-without + chalasia-relaxation), means failure of relaxation. The defect is rare in children and has been seen in very few infants.
Prenatal Genetic Diagnosis
Authors: Milunsky Aubrey
Published: December 2021

The fundamental philosophy of prenatal genetic diagnosis is to enable prospective parents at risk to have children selectively, unaffected by a specific hereditary disorder.1 In practice, this new technology has allowed healthy children to be born to many couples who, without the reassurance that it is now possible to extend to them, would not have had any on any further children. Indeed, it is clear that the number of children born because of the opportunities provided by prenatal diagnosis exceeds the number of pregnancies terminated on account of fetal genetic disease.

Despite the availability of prenatal diagnosis for more than a decade, utilization has been slow. Even today, the vast majority of states provide studies for less than 10% of women aged 35 years or more. In Massachusetts, where strenuous efforts at professional and public education have been made, utilization in this age category is about 20%. In the United States, the remarkable tardiness in the application of this valuable technology may be related to earlier concerns about the risk and accuracy of second trimester amniocentesis. Today, however, the explanations are more likely to be a lack of awareness of the indications for prenatal genetic studies and antipathy to abortion. Virtually all states now have at least a single prenatal diagnostic facility or are able to use laboratories in an adjoining state.
School Failure
Authors: D Paul H.
Published: December 2021

Numerous factors may contribute to a child's failure to learn. Certain causes of school failure, such as specific learning disabilities, mental retardation, sensory impairment, and chronic illness may be regarded as intrinsic characteristics of the child. Other causes, such as family dysfunction, social problems, and ineffective schooling, are characteristics of the child's environment. Still other influences on school performance, such as temperamental dysfunction, attention deficits, and emotional illness, may be viewed as the consequence of the interaction between the child and his or her environment. The reasons for a child's school failure must not be considered in isolation but rather within the context of social and environmental circumstances.

Evaluation must consider the myriad of reasons for a child's school failure and attempt to identify "clusters" of adverse influences on school performance. Detailed information must be sought from the student, parents, and school system through the history and physical examination. Questionnaires are useful in data gathering. Ancillary methods of assessment that may be of value include neurodevelopmental screening and laboratory studies. Further investigations and referrals, particularly psychoeducational evaluation, are of major importance.

Traditional roles of the pediatrician in school failure include the treatment of underlying medical conditions, counseling, the coordination of further investigations and referrals, and the facilitation of communication with community services and resources.
Management of the Child With Multiple Injuries
Authors: Robertson William O.
Published: December 2021

Featured in this issue is a comprehensive update by Martha Bushore aimed at the practicing pediatrician confronted with a multiply injured child. It is not to be a quick referral piece available for consultation at the time of the disaster; rather, it is best consumed and digested slowly in one's favorite chair—far removed from the blare of the television set—and certainly not after a full dinner!

Dr Bushore has produced a particularly tightly written review with at least one telling idea in almost every sentence. Even though she has structured her message along traditional lines of organization logic (thus making the sequence easy to follow), the subject itself remains a conceptually difficult one to read through critically.
Sexual Behavior: Can the Pediatrician Counsel Adolescents?
Authors: Nazarian Lawrence F.
Published: December 2021

Dr Hardy has done the pediatrician a favor by delineating so clearly and sensibly the practitioner's role in counseling adolescents in the area of sexuality. She even addresses the problem of accomplishing this task in the context of a busy schedule, and those of us in practice appreciate her focusing on the practical aspects of this responsibility. But even more needs to be said about the real-world issues of counseling about sexuality.

Many adolescents, even those receiving regular care, see the pediatrician for 15 minutes every other year. How can we possibly influence their management of a life force as potent as sexuality with such brief contact? Does it even make sense to try?
Premature Sexual Activity, Pregnancy, and Sexually Transmitted Diseases: The Pediatrician's Role as a Counselor
Authors: Hardy Janet B.
Published: December 2021

Physicians providing preventive and primary health care for schoolaged patients are frequently confronted with difficult problems that stem from premature sexual activity among these young people. In this paper a brief description of the scope and potential costs, both human and societal, of these problems is given as background for discussion of the pediatrician's role as counselor and educator in their prevention and management.

The high frequency of sexual experience among school-aged girls and boys and the potential devastation that may result from the emerging epidemic of acquired immunodeficiency syndrome (AIDS), in combination with the pattern of multiple sex partners among adolescents, lend added urgency to the consideration of preventing these problems.

PROBLEMS ASSOCIATED WITH ADOLESCENT PREGNANCY, ABORTION, AND CHILDBEARING

The problems associated with pregnancy and childbirth among adolescents have attracted public concern and controversy since the middle 1970s when the number of births to American teenagers reached its peak. However, even though the number of births in this age group has declined as a result of the legalization of abortion and a decline in the number of teenagers in the population, the likelihood of pregnancy has declined much less, particularly among adolescents, younger than 18 years, and among the youngest teenagers. Among girls 15 years of age and younger, the pregnancy rate has been fairly stable and, among those who are white, it has continued to increase.
Substance Abuse
Authors: Macdonald Donald Ian
Published: December 2021

Following a decade during which drug use by adolescents was viewed by many parents and other adults as a normal phase of development, the 1980s have been marked by growing awareness of the risks and costs of illegal drug use. Yet, despite the many successes of a burgeoning parents' movement, stimulated by the active leadership and support of the President and Mrs Reagan, drug use persists as a significant threat to the health and well-being of American youth.

Physicians are in a powerful position to deliver health promotion messages to patients and their parents and have an obligation to do so whenever possible. Messages delivered on a routine basis can be influential in promoting smoking, alcohol, and drug abstinence. These messages should begin early and continue throughout childhood to reinforce and strengthen the development of healthy attitudes and behaviors. The pediatrician must never be reluctant to express his or her own views regarding the health consequences of drug and alcohol use to patients or their parents. Informed pediatricians represent formidable opposition to individuals who argue that "experimental" or "recreational" use of illicit substances during the developmental years is inevitable, normal, or harmless.
Do You Know These Patients? High-Risk Pediatric Encounters
Authors: Korsch Barbara M.
Published: December 2021

Who are the patients we come to identify as so troublesome that when we see their name on the day's schedule we hope they might cancel, or we feel tired before we get half way through the day at the thought that we have to face them? What is it about them that makes caring for them less gratifying and more difficult?

There has been a regrettable tendency to blame the patient for breakdowns in doctor-patient communication and to shift the burden of responsibility from the physician to the patients. We are all familiar with pejorative descriptions such as "the patient is a poor historian," "the patient is uncooperative," "this is a difficult patient," "this is a demanding patient," or "this is the patient I would most like to refer to my least favorite colleague." There are patients who are unpopular with all physicians, and then there are special sensitivities that make an individual physician react negatively to a particular group of patients.

Physicians may be insightful and perceptive of their own responses to other individuals and may have excellent communication skills, yet they are still only human. They are not perfect and not infrequently find themselves confronted by individual patients or families who annoy them, frustrate them, or disappoint them.
Exercise for Children
Authors: Risser William L.
Published: December 2021

It is important for the pediatrician to have knowledge about the impact of acute and chronic disease on sports participation; knowledge of up-to-date therapeutic and preventive strategies can help the clinician achieve the goal of safe, successful activity for almost all children. Other articles this year in Pediatrics in Review will discuss the preparticipation examination and physical fitness. These and the "Suggested Readings" are sources for further information about pediatric sports medicine.
Adoption: New Tasks for the Pediatrician
Authors: Haberkern Roy C.
Published: December 2021

Adoption involves an excess of 2,500,000 American children younger than 21 years of age and, thus, directly affects approximately 2% of American families. It profoundly touches the lives of those involved. For the pregnant, unmarried woman it offers hope for better nurture and security for her child than she may be able to provide. For the adopting couple, it offers an opportunity to love and care for a child as their own. For the adopted child, it offers a chance to have a family that is presumably able to meet his or her needs for love, guidance, and stability.

Pediatricians have provided services in different areas of the adoption process for many years. They may be asked for guidance by teenage patients who are pregnant but feel unable to care for the child themselves. Pediatricians are consulted by couples or adoption agencies to examine a child prior to adoption to assess specific problems and needs for services. They are asked for advice and assistance by families that include adopted children who find that they need help with difficulties that may or may not be specifically related to the adoption. Their help is sought by adoptees struggling with identity issues, problems in their relationships with members of their adoptive families or with others, concerns about obtaining medical information about themselves or their biologic families, or questions about attempting to establish contact with their families of origin.
Rheumatic Diseases of Childhood
Authors: Rennebohm Robert M.
Published: December 2021

The pediatrician frequently encounters children and adolescents with musculoskeletal complaints that raise the possibility of rheumatic disease. The purposes of this article are: to review an approach to the evaluation of "joint" symptoms and to review the pharmacology, use, and adverse effects of nonsteroidal anti-inflammatory drugs.

RHEUMATOLOGIC HISTORY

Systematic collection of the historical details is fundamental in the evaluation of "joint" complaints (Table 1).

Age and Sex

The child's age and sex provide initial clues. For example, suspicion that a young girl (less than 5 years of age) with knee swelling might have monoarticular juvenile rheumatoid arthritis is heightened simply because of her age and sex. (At onset of their disease, almost 20% of all patients with juvenile rheumatoid arthritis are young girls with pauciarthritis, most commonly involving the knee.) Suspicion that an older boy (10 years of age or older) with axioskeletal complaints might have an enthesopathy syndrome is increased, in part, because of his age and sex. of the age and sex predilections of various rheumatic conditions is, therefore, helpful.

Chief Complaint

The chief complaint is often directive. For example, the complaint "his knees hurt every night" or "his legs hurt at night" is not characteristic of children who have juvenile rheumatoid arthritis or other well-defined inflammatory arthritides.
Childhood Asthma: Overview
Authors: Goldenhersh M. J. , Rachelefsky Gary S.
Published: December 2021

DEFINITION

Asthma is a syndrome characterized by increased responsiveness of the trachea and bronchi to various stimuli and is manifested by widespread reversible narrowing of the airways that changes in severity either spontaneously or as a result of therapy.1 The hyperresponsiveness ("twitchiness") of airways is a fundamental abnormality and is dynamic in nature. Asthma is a disease of persistent or recurrent airway inflammation characterized by the presence of inflammatory cells (eosinophils and polymorphonuclear cells), edema of the wall, and changes in epithelial cells. Airway response to allergens and certain irritants may be acute (occurring within minutes to one hour following exposure), delayed or late (occurring within four to eight hours following exposure), or dual (combination of acute and late phase). Some reactions are only delayed. The late phase reaction is largely attributed to ongoing inflammation. Because of the variability of its presentation (complete v partial reversibility of airways obstruction, hyperreactivity accompanying other respiratory disease, chronic cough, or recurrent pneumonia with or without wheeze), children have often been denied appropriate antiasthmatic medications and their symptoms have been attributed instead to "wheezy bronchitis," "recurrent bronchiolitis," "spastic bronchitis," or "wheezy baby syndrome." For years pediatricians have been schooled to approach the wheezing child skeptically ("all that wheezes is not asthma").
Problem Behavior of Adolescents
Authors: Irwin Charles E. , Ryan Sheryl A.
Published: December 2021

The health problems of adolescents have recently become the focus of new and unprecedented attention by public health officials and physician organizations. By traditional outcome measures of morbidity and mortality, the health status of adolescents in the United States is excellent. Outpatient physician use and hospital discharge rates for the age group 11 to 20 years remain the lowest of any age cohort.1 Because of these low frequency utilization rates and apparent excellent health status, the pediatrician has a major challenge: how to identify emergent problems in his or her preadolescent and adolescent patients.

These data concern primarily short-term, medical outcomes and provide little information about rates of chronic medical and psychologic disability, rates of change of behaviors during the second decade of life, and, most important, behavior-related problems, which often have their onset during adolescence. A different picture of adolescent health emerges when the causes of mortality are assessed. In 1986, 80% of the deaths in this age group were from accidents, homicides, and suicides—an increase from 51% in 1950. Furthermore, when the rate of change of mortality is evaluated during the second decade, there is a 200% increase, the largest in any single decade of the lifespan.2 Although hospitalization rates are low in this age group, leading discharge diagnoses, excluding pregnancy-related causes, are injuries and poisonings.
Childhood Asthma: Management
Authors: Goldenhersh M. J. , Rachelefsky Gary S.
Published: December 2021

The goals of childhood asthma treatment are straightforward: facilitation of parent/patient understanding and acceptance of the disease prevention of patient physical and emotional disability. Patient/family education should be instituted at the time diagnosis is made, such that the patient and involved family members are familiarized with the short-term and long-term care that will be necessary. Setting realistic goals for asthmatic children that allow for a normal life-style (regular school attendance, participation in physical activities, etc) is helpful.

Successful management of childhood asthma requires knowledge, experience, and time. The demands on the physician can be tremendous. Patient management will be dictated by the age of the patient, the severity of the disease, and the social and financial resources of the involved family. The pediatrician with extra effort can provide appropriate care for the child with mild asthma. The moderate to severe asthmatic child (particularly those with evidence of chronic obstruction) are probably best managed by a team approach. Referral to a subspecialist who has the experience, updated knowledge, and time to institute both an educational and treatment program will benefit the patient with moderate to severe asthma (Table 1). The subspecialist assists in appropriate alteration of treatment plans in accordance with patient progress and may serve as a useful advisor to the pediatrician.
Child Care and the Pediatrician
Authors: Aronson Susan S.
Published: December 2021

Working parents and child care programs are here to stay. The pediatrician has many opportunities to advocate for children concerning child care, both in encounters with parents in the office and in roles played in the community. By focusing attention on the determinants of the quality of child care, the pediatrician can minimize the risks and enhance the potential benefits of child care program participation.
Reader's Comments and Questions
Authors: H R. J.
Published: December 2021

I treasure comments such as these which readers send with their self-assessment sheets, because it is one of the few ways we have of knowing how well we serve them. I will be grateful if even more of you will send in your responses. But let me answer a few of the questions raised by readers:

Are the articles in Pediatrics in Review too long, too short, too complicated, too simple? Such questions are not easy to answer. We seek to provide a mixture of articles. Abstracts, which some readers believe are too short and simple because they do not explain the complexities of most of modern medicine, are used to address specific educational objectives, usually developed as part of the Recent Advances objectives.
Diabetic Ketoacidosis in Children and the Role of Outpatient Management
Authors: Chase H. Peter , Garg Satish K. , Jelley David H.
Published: December 2021

Diabetic ketoacidosis (DKA) is a common complication among children with diabetes, accounting for 14% to 31% of all diabetes-related hospital admissions.1,2 Extrapolation of data from the National Commission on Diabetes3 suggests that there are approximately 160 000 admissions to private hospitals each year in the United States for DKA. The cost of hospitalizations for DKA is over one billion dollars annually. Sixty-five percent of all patients admitted are less than 19 years of age. The incidence of DKA is believed to be declining. However, because the numbers of subjects with insulin-dependent diabetes mellitus is increasing, the absolute number of hospitalizations for DKA is still increasing. It is the single most common cause of death in diabetic patients under 24 years of age.2

The treatment of DKA has changed in recent years, particularly with the use of low-dose continuous intravenous insulin infusion and with the availability of blood pH levels. Severe DKA has been defined as "a state of ketoacidosis with serum bicarbonate decreased to 10 mmol/L or less," or more recently, as a "pH of 7.1 or less."4 The mortality from DKA has been reported to be in the range of 0.5 to 15.4%.3,5 Previous mortality figures were as high as 38%.2
Hypospadias
Authors: Duckett John W.
Published: December 2021

Hypospadias results in various degrees of deficiency of the urethra, corpus spongiosum, and corpora cavernosa. The fibrous tissue that causes ventral curvature replaces Buck fascia and dartos fascia. The skin on the ventral surface may be thin; the prepuce is deficient ventrally and forms a dorsal hood over the glans.

As a rule, the location of the meatus does not cause significant obstructive urinary symptoms, although ventral deflection of the stream of urine commonly occurs. When the meatus is more proximal, the stream flows straight downward or backward, requiring the patients to urinate ad modum feminarum. Uncorrected, the curvature of the penis is likely to cause painful erections and result in severe psychologic consequences.

INCIDENCE/GENETICS

The incidence of hypospadias is about 1 in every 300 male children. If minor degrees of hypospadias are included, this incidence may be as high as 1 in 125 male births. If 1 848 500 male births occur in the United States, we should see 6200 hypospadias cases each year.

The risk of occurrence in an infant is 8% if his father has hypospadias and 14% if a sibling has the condition; if two members of the same family have hypospadias, the risk is about 21%.

The cause of hypospadias is still unknown.
Obesity in Childhood
Authors: Rosenbaum Michael , Leibel Rudolph L.
Published: December 2021

It is estimated that as many as 25% of children and 30% of adults in the United States are obese. Clinicians need little reminding of the intractable nature of this disorder and the need for more effective and long-lasting therapies, Obesity in childhood may lay the foundation of the degenerative cardiovascular diseases that may or may not be grossly evident until adulthood. Obese children manifest many of the same disturbances (eg, hyperinsulism, hyperlipidemia, and hypertension) as obese adults. Tracking studies of obesity, hypertension, and serum lipid values from childhood to adulthood have indicated that these variables track well, ie, that the obese, hypertensive, hyperlipidemic child is likely to remain obese, hypertensive, and hyperlipidemic throughout many years. The observation that hyperlipidemia, obesity, and other factors associated with an increased risk of subsequent cardiovascular disease that are noted in childhood tend to persist into adulthood emphasizes the importance of screening in selected children to identify those at risk for subsequent morbidity. Pediatricians should recognize obesity as a significant disease entity with both immediate and long-term consequences.

DIAGNOSTIC CRITERIA FOR OBESITY IN CHILDREN

Obesity is a maladaptive increase in the amount of energy stored as fat. "Optimal" body fat stores for a given individual depend upon factors such as age, intercurrent health, genotype, and environment.
Biliary Atresia
Authors: Wanek Elizabeth A. , Karrer Frederick M. , Brandt Carlos T. , Lilly John R.
Published: December 2021

Biliary atresia is a pathologic entity in which there is obliteration of some portion of the extrahepatic bile ducts. In the past, occlusion of the proximal ducts (at the liver hilus) was referred to as "noncorrectable" (Fig 1). If only the distal duct is occluded (and the proximal duct is patent), the lesion was referred to as "correctable." The distinction is academic because current treatment and prognosis are identical. The disease is panductular, ie, both extrahepatic and intrahepatic ducts are involved. Early in the disease, however, occlusion is complete only in the extrahepatic system. Without intervention, intrahepatic biliary obstruction and, subsequently, cirrhosis supervene.

In the past, except for a few cases of the correctable variant, surgical procedures were unsuccessful until Morio Kasai performed a hepatic portoenterostomy, which was first reported in English in 1968. Bile flow was effectively reestablished in both correctable and noncorrectable forms of biliary atresia. The operation was only successful when done before the patient was 4 months of age. Subsequent confirmation of Kasai's results were reported throughout the world.

ETIOLOGY/PATHOLOGY

Biliary atresia was originally thought to be a congenital malformation. Careful histopathologic examination of excised surgical specimens indicate that this is not the case; instead, the disease is a dynamic, progressive panductular sclerotic process that may continue in the intrahepatic ducts even after surgical relief of biliary obstruction.
Urinary Tract Infections in Infants and Children
Authors: Feld Leonard G. , Greenfield Saul P. , Ogra Pearay L.
Published: December 2021

CASE HISTORY AND OFFICE DIAGNOSIS

A 7-month-old uncircumcised male infant had vomiting, diarrhea, and low grade fever (38.4°C) 2 days before coming to the pediatrician's office. One day before seeing the baby, the physician prescribed Pedialyte and acetaminophen elixir. The child appeared active to the pediatrician. Mucous membranes were slightly dry and tears were present. His blood pressure was 98/62 mm Hg, pulse rate 92 beats per minute, and temperature 38°C. Laboratory evaluation included an analysis and culture of catheterized urine sample: specific gravity, 1.025; pH, 6.0; protein, trace; blood, negative; sugar and ketones, negative; sediment—0 to 1 red blood cells per high-power field; 6 to 8 white blood cells per high-power-field and no bacteria. Based on the differential diagnosis of viral gastroenteritis vs urinary tract infection, the patient was sent home with a prescription for Pedialyte and acetaminophen and the parents were told to call the office in 24 hours for test results.

The urine culture was positive for greater than 100 000 colonies per milliliter of a single organism which was later identified as Escherichia coli and sensitive to all antibiotics. The child was started on a regimen of amoxicillin. Two weeks later, a repeat urine culture was negative for bacteria.
Jaundice in Infancy
Authors: Rosenthal Philip , Sinatra Frank
Published: December 2021

Jaundice in infancy may be physiologic or due to a pathologic cause. Fractionation of the serum bilirubin level is the first step in the evaluation. Unconjugated hyperbilirubinemia if left untreated may reach toxic levels. Primary hepatobiliary disorders, as well as infectious, toxic, genetic, and metabolic diseases, may manifest with conjugated hyperbilirubinemia. A carefully organized diagnostic evaluation in a timely fashion allows early identification of treatable disorders. Medical management of the complications of cholestatic liver disease remains a major challenge. Early surgical intervention for biliary atresia and significant advances in hepatic transplantation offer the opportunity for long-term survival for infants with previously fatal liver disorders.
Evaluation of Hematuria in Children and Adolescents
Authors: Boineau Frank G. , Lewy John E.
Published: December 2021

Hematuria is a frequent abnormal clinical finding in the genitourinary system, second only to urinary tract infection. The pediatrician needs to have an appropriate and organized approach to the examination of children with hematuria, to identify common causes or diseases and to identify those who need a more extensive evaluation of their problem and those who need urologic evaluation. The prevalence of microscopic hematuria among school-aged children ranges from 0.4% to 2.1%. Despite this frequency, it would appear that the presence of hematuria alone is rarely indicative of serious illness.

DEFINITIONS

The literature concerning hematuria is inconsistent in the various methods used to detect it and in the differing criteria for diagnosing hematuria. The most sensitive test for detecting the presence of blood in the urine is a reagent strip impregnated with orthotolodine-peroxide and enhanced with 6-methoxyquinolone. The commonly used dipsticks (Chemstrip-Boehringer Mannheim; Multistix or Labstix, Ames Division of Miles Laboratories) are sensitive. In the presence of hemoglobin (or another oxidizing agent), a blue coloration of the strip occurs. False-negative results are unusual but have been reported in the presence of high urinary concentrations of ascorbic acid. False-positive results (also unusual) are occasionally demonstrated in heavily infected urine where bacterial peroxidase is being liberated in high quantity.
Hypoglycemia in Children
Authors: Gruppuso Philip A. , Schwartz Robert
Published: December 2021

Hypoglycemia, although rare in childhood beyond the newborn period, remains a vexing problem for the pediatrician. First, the symptoms may be vague and nonspecific, thus making diagnosis particularly dependent on a high index of suspicion. Second, the pathogenic mechanisms that result in hypoglycemia are as numerous and complicated as the physiologic mechanisms that maintain euglycemia. Finally, although most patients have no permanent sequelae, a catastrophic episode of hypoglycemia can cause neurologic deficit and mental retardation. In this brief review, the most common cause for hypoglycemia, namely, insulin-dependent type I diabetes mellitus, will not be considered. Instead, we will focus on those metabolic disorders that result directly in a loss of the ability to maintain normal serum glucose concentrations.

SYMPTOMS

In the older infant (older than 2 months), child, and adult, a rapid decrease in blood glucose to levels less than 40 mg/dL (2.2 mmol/L) may produce hunger and trigger an excessive release of epinephrine, causing weakness, anxiety, cold sweat, inward trembling and tachycardia. These adrenergic symptoms tend to occur in persons with postprandial hypoglycemia. In contrast, fasting hypoglycemia generally is progressive and gradual and produces neuroglycopenic symptoms which include headache, mental dullness, fatigue, confusion, abnormal behavior or psychosis, amnesia or other neurologic deficit, seizures, or frank coma.
Dehydration in Infancy: Hospital Treatment
Authors: Harrison Harold E.
Published: December 2021

Dehydration of a degree severe enough to require intravenous replacement of water and electrolytes indicates (1) depletion of extracellular fluid sodium and water to such an extent that reduction of plasma volume results or (2) distortion of the composition of extracellular fluid with consequent disturbance of physiologic function. Such distortion may be marked hypernatremia, severe depletion of extracellular bicarbonate, or disturbances of potassium concentration resulting in either hyperkalemia or hypokalemia. In addition, hypocalcemia or hypomagnesemia may require specific replacement of these ions.

EXTRACELLULAR FLUID DEPLETION WITH HYPOVOLEMIA

The most important cause of extracellular fluid depletion in terms of frequency is loss of gastrointestinal secretions through either diarrhea or vomiting. In persons with lower intestinal obstruction, sequestration of gastrointestinal secretions in dilated loops of intestine may be sufficient to cause dehydration in the absence of vomiting. In infants with diarrhea, the onset of vomiting usually is an indication for intravenous replacement of electrolyte and water deficits. Oliguria is also an important item of information, indicating that dehydration is severe enough to require parenteral fluids. It has been estimated that hypovolemia and reduced glomerular filtration with oliguria results when about one third of extracellular fluid volume has been lost. In an infant, the normal extracellular fluid volume is 25% of body weight; therefore, a loss of 8% of body weight as extracellular fluid would result in the manifestation of severe dehydration with reduction of plasma volume.
Chest Wall Deformities
Authors: Ellis Dick G.
Published: December 2021

Chest wall deformities are principally depression deformities, the most common being pectus excavatum (funnel chest). The most common protrusion deformity is pectus carinatum (pigeon breast). Pectus carinatum is a cosmetic problem, but its presence can be psychologically devastating to the patient. Pectus excavatum is definitely a physiologic problem, the effects of which may be reversible by surgical correction. Surgery is safe, complications are minimal, and results are usually satisfactory.
Pre- and Postoperative Fluid Management in Infancy
Authors: Chesney Russell W. , Zelikovic Israel
Published: December 2021

The fluid and electrolyte management of the infant either before or following surgery is not difficult if the several principles are carefully followed: (1) Fluid requirements include maintenance therapy, correction of ongoing losses, and replacement of deficit losses. (2) Calculation for fluid requirements in the postoperative period will include maintenance therapy, correction of ongoing losses, and provision of fluid lost by internal shifts. (3) Maintenance needs for fluid in infants equals 100 to 120 mL/kg per 24 hours, and Na+ at 3 mEq/kg per 24 hours and K+ at 2 to 3 mEq/kg per 24 hours are needed. (4) Infants with pyloric stenosis should be anticipated to have hypokalemic, hypochloremic metabolic alkalosis, and dehydration. These electrolyte abnormalities should be corrected before surgery is performed. A pyloromyotomy is not an emergency procedure. (5) Ileostomy losses can equal 90 mEq/L of Na+ and up to 110 mEq/L of HCO3. Thus, adequate fluid replacement results in volume depletion and metabolic acidosis. (6) Children whose nutritional status is marginal and whose bowels cannot be used for nutrient absorption should receive their fluid and electrolyte needs as part of a total parenteral nutrition program.
Children of Divorce: Recent Findings Regarding Long-Term Effects and Recent Studies of Joint and Sole Custody
Authors: Wallerstein Judith S. , Johnston Janet R.
Published: December 2021

The 10-year study revealed that the effects of divorce on children are often long lasting. Children are especially affected because divorce occurs within their formative years. What they see and experience during the failing marriage becomes a part of their view of themselves and of society. Although the findings from the study are, in some respects, dismaying, what emerges clearly is that a successfully reestablished family or a successful remarriage can improve the quality of life for both adults and children. The divorce may resolve the family conflict and allow the children to preserve a relationship with both parents. Divorce may also be useful in putting some distance between a child and a disturbed parent. Under these conditions, children may show accelerated maturity and independence. They may also bring to young adulthood a morality that places high value on sustaining relationships and on love, fidelity, and compassion.

The results of the longitudinal study, as well as those of the two joint custody studies, indicate that ongoing conflict between divorced parents has especially detrimental effects on the children and that children are particularly at risk when they have frequent and continuing access to both parents who are hostile and uncooperative with each other.