bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment Guidelines for Lead Exposure in Children
Authors:   Committee on Drugs
Published: December 2021

This Policy Statement was retired October 2007.

The recent introduction of an effective oral chelating agent for the reduction of a body burden of lead and the changing standards of care for children exposed to lead prompted the Committee on Drugs to review the therapy for lead intoxication. This statement reviews the pharmacology of available chelating agents. Screening standards and detailed discussions of environmental control and nutritional management have been previously published by the American Academy of Pediatrics.1

Lead intoxication has been a problem throughout history. In the early 1940s it was recognized that the amount of lead in the urban industrial environment had increased to the point at which a striking number of children demonstrated hematologic effects and clinical signs of acute lead intoxication. Blood lead levels in children in the United States on average have decreased, and rarely are children seen with blood lead levels of greater than 70 µg/dL. Even in patients with levels of greater than 50 µg/dL, "classic" laboratory and clinical findings of lead toxicity, such as basophilic stippling and encephalopathy, are rarely seen.2 In the past, therapy was based on the ability of chelators to reverse the hematologic effects of lead and halt the progression of lead encephalopathy. The efficacy of chelation therapy for children without the hematologic or neurologic findings has yet to be demonstrated; a decrease in blood lead concentration is the only discernible goal for chelation therapy in this setting. Eliminating the source of lead exposure also can accomplish this result. A recent study of moderately lead-exposed children receiving chelation therapy failed to demonstrate any additional benefit of CaNa2-ethylenediaminetetraacetic acid (EDTA) compared with abatement at improving cognitive function.3
Letters to the Editor
Authors: Wolke Dieter , Meyer Renate
Published: December 2021

We would like to thank Drs Hill and Hosking for their complimentary remarks. They believe that the statement by the accompanying comment to our paper1 by Carey,2 who considers cow milk allergy to affect only a small proportion of colicky infants, is far too dismissive of data published. Dr Carey, we assume, will answer himself. However, our own conclusions, drawn from published data available, are not so far removed from those of Carey.

The studies cited by Hill and Hosking3-5 in support of the thesis that cow milk protein intolerance (CMPI) is an important cause of colic have a number of methodologic problems.
Letters to the Editor
Authors: Emans S. Jean , Daniel Jessica Henderson , Vandeven Andrea
Published: December 2021

We are extremely concerned about the title and assumptions of the recent article entitled "The Association of Consensual Sexual Intercourse During Childhood With Adolescent Health Risk and Behaviors"by Resnick and Blum (Pediatrics 1994;94:907-913). The conclusions that a girl or boy having sexual intercourse at age 10 years or less was not the victim of sexual abuse and "consented" to the relationship is not supported by the current research or by our and others’ experiences in dealing with child abuse victims.
Emergency Medical Services for Chi in Rural and Frontier America: Diverse and Changing Environments
Authors: Hirschfeld Jerome A.
Published: December 2021

Rural emergency medical services for chi is challenged by timely access to professional care at all levels. Particular issues of communication, providers, equipment, transport, education, legislation, financing, prevention, public awareness, data collection, and research are addressed as they confront the rural physician, with some established and suggested methods of solution. The most sophisticated health care provider, pediatrician, family practitioner, or emergency department physician must accept responsibility for implementing and facilitating the many diverse elements of rural emergency medical service for children, for structuring a functional and progressive whole that is germane to the community, and for improving rural child morbidity and mortality.
Immunologic Response of Extremely Premature Infants to Tetanus, Haemophilus influenzae, and Polio Immunizations
Authors: D'Angio Carl T. , Maniscalco William M. , Pichichero Michael E.
Published: December 2021

Objective. To determine whether extremely premature infants have immunologic responses to tetanus toxoid, Haemophilus influenzae type b polysaccharide and polio vaccines similar to those of full-term infants.

Infants and Methods. Sixteen extremely premature (<29 weeks, <1000 g at birth) infants received separate diphtheria-tetanus-pertussis and H influenzae type b oligosaccharide-CRM,197-conjugated (HbOC) vaccines at 2, 4 and 6 months of chronologic age, enhanced potency inactivated polio vaccine at 2 months, and oral polio vaccine at 4 months. Serum was obtained for anti-tetanus toxoid (TT), anti-Haemophilus b polysaccharide (HbPs) and polio neutralizing antibody assays before the 2-month vaccination and 4 to 6 weeks after the 6-month vaccination. Comparison sera were obtained from full-term infants immunized with the same lots of diphtheria-tetanus-pertussis (n = 46) and HbOC (n 66) vaccines or the same sequence of polio vaccines (n = 10).

Results. Preterm and full-term infants had similar geometric mean titers of anti-TT antibodies, anti-HbPs antibodies, and neutralizing antibodies to polio serotypes 1, 2, and 3 after the completion of the primary series of vaccines. After vaccination, similar proportions of preterm and full-term infants had protective levels of antibody to TT (preterm 100% vs full-term 100% with levels >0.01 IU/mL), HbPS (82% vs 87%, >1.0 µg/mL), and polio serotypes 1 (85% vs 80%, ≥1:8) and 2 (100% vs 100%, ≥1:8). Preterm infants were less likely than full-term infants to have protective levels of neutralizing antibody to polio serotype 3 (31% vs 90%, ≥1:8).

Conclusions. Extremely premature infants have adequate antibody responses to tetanus and HbOC antigens but may have diminished responsiveness to serotype 3 polio vaccine.
Research in Emergency Medical Services for Chi
Authors: Jaffe David M.
Published: December 2021

Research is the key to future improvements in emergency medical services for chi (EMS-C). Ultimately these improvements should result in better prevention of childhood emergencies and better outcomes for children who experience emergency illness or injury. Research in EMS-C can be descriptive of the system and its users or focused on specific clinical or basic scientific questions. Descriptive research is needed to describe the EMS-C system, its users, the types of problems for which it is used, and the associated outcomes and costs. To facilitate the descriptive research, a uniform data set, a taxonomy of chief complaints, and a method of linkage among databases collected by different components of the system are needed.

Focused research efforts in clinical and basic sciences are also needed. The Institute of Medicine report identified seven research areas for highest priority: clinical aspects of emergencies and emergency care; indices of severity of injury and, especially, seventy of illness; patient outcomes and outcome measures; costs; system organization, configuration, and operation; and effective approaches to education and training, and prevention. Maturity of the subspecialty of emergency medicine will be indicated by the development of basic science research and epidemiology by physicians with clinical interests in emergency medicine. The most exciting discoveries are likely to come in areas that we have not yet imagined. Rapid development of meaningful research will require massively increased funding to support both the research itself and the training of future scientists to work in pediatric emergency medicine.
Anabolic-Steroid Use, Strength Training, and Multiple Drug Use Among Adolescents in the United States
Authors: DuRant Robert H. , Escobedo Luis G. , Heath Gregory W.
Published: December 2021

Objective. This study examined the relationships between anabolic-steroid use and the use of other drugs, sports participation, strength training, and school performance among a nationally representative sample of US high school students.

Design. Randomized survey data from the 1991 Centers for Disease Control and Prevention Youth Risk Behavior Survey.

Setting. Public and private schools in the 50 United States and District of Columbia.

Patients. A total of 12 272 9th through 12th grade students.

Main Outcome Measured. Prevalence of anabolicsteroid use.

Results. The frequency of anabolic-steroid use was significantly associated with the frequency of use of cocaine, the use of other drugs such as amphetamines and heroin, tobacco smoking, and alcohol use. The weighted prevalences of anabolic-steroid use were higher among male (4.08%) than female students (1.2%). Students living in the South (3.46%) reported higher prevalences than students in the Midwest (3.0%), West (2.02%), or Northeast (1.71%). Students with self-perceived below-average academic performances (5.10%) and students reporting injected drug use also reported higher anabolic-steroid use (51.57%). Based on a multiple logistic regression, the following variables were found to be significant predictors of anabolic-steroid use: injectable drug use (odds ratio [OR], 17.86), use of other drugs (OR, 4.19), male gender (OR, 2.79), alcohol use (OR, 1.38), and strength training (OR, 1.73). The variables that were significantly associated with anabolic-steroid use varied by gender and by region of the country.

Conclusion. These data suggest that adolescent anabolic-steroid users in this country are more likely to engage in strength training, injected drug use, and the use of multiple drugs, even after controlling for sports participation and poorer academic performance. These data confirm previous findings of an association between multiple drug use and anabolic-steroid use. Also, engaging in strength-training exercises continued to be associated with anabolic-steroid use after controlling for drug use and other predictors.
Evaluation of Perinatal Outcome Using Individualized Growth Assessment: Comparison With Conventional Methods
Authors: Ariyuki Yasuhide , Hata Toshiyuki , Kitao Manabu
Published: December 2021

Objective. To evaluate individualized growth assessment using the Rossavik growth model for detection of growth-retarded neonates with poor perinatal outcomes.

Methods. Rossavik growth models derived from second-trimester ultrasound measurements were used to predict birth characteristics of 154 singleton neonates. Individual fetal growth curve standards for head and abdominal circumference and weight were determined from the data of two scans obtained before 25 weeks' menstrual age and separated by an interval of at least 5 weeks. Comparisons between actual and predicted birth characteristics were expressed by the Growth Potential Realization Index and the Neonatal Growth Assessment Score (NGAS). The proportions of perinatal outcomes (mechanical delivery, low Apgar score, abnormal fetal heart rate [FHR] patterns, neonatal acidosis, meconium staining of amniotic fluid, neonatal intensive care unit admission, and maternal complications), using NGAS, were compared with those by the traditional birth weight-for-gestational age method and the ponderal index, respectively.

Results. Of the 154 fetuses studied, 120 had normal growth outcomes at birth; 18 showed evidence of intrauterine growth retardation; and 16 had macrosomia, based on NGAS. According to birth weight-for-gestational age classification, 32 fetuses were small for gestational age; 118 were appropriate for gestational age; and only 4 were large for gestational age. According to the ponderal index, 55 fetuses had growth retardation, 99 showed appropriate growth and there was no macrosomia. There was a significant increase in mechanical deliveries in cases of growth-retarded neonates, determined using the NGAS classification, when compared with events related to normally grown or macrosomic neonates. However, there were no significant differences in mechanical deliveries among the groups by birth weight classification or ponderal index. Both birth weight classification and NGAS classification showed a significant increase in the low Apgar score, abnormal FHR patterns, and neonatal acidosis in infants classified as growth retarded when compared with appropriately grown or macrosomic infants. However, there were no significant differences in the low Apgar score, abnormal FHR patterns, and neonatal acidosis between growth-retarded and appropriately grown infants when they had been so classified by ponderal index. Three growth category classification methods failed to reveal significant differences in meconium staining of amniotic fluid, neonatal intensive care unit admission, and maternal complications among the groups.

Conclusion. We do cast doubt on the usefulness of the ponderal index for detection of growth-retarded neonates with poor perinatal outcomes, and individualized growth assessment seems to perform at least as well as the traditional birth weight-for-gestational age method.
Reduction in Obstructive Breathing Events During Body Rocking: A Controlled Polygraphic Study in Preterm and Full-Term Infants
Authors: Groswasser J. , Sottiaux M. , Rebuffat E. , Simon T. , Vandeweyer M. , Kelmanson I. , Blum D. , Kahn A.
Published: December 2021

Objective. To investigate the effect of body rocking on infant respiratory behavior during sleep.

Methods. Eighteen infants with documented obstructive sleep apneas were studied. There were eight premature infants with persistent bradycardias and 10 infants born full-term, admitted after an idiopathic apparent life-threatening event. No cause for the obstructive apneas was found. The infants were recorded with polygraphic techniques during two successive nights. They were randomly assigned to a rocking or a nonrocking mattress. The conditions were reversed the following night, in a crossover design.

Results. In both groups of infants, no significant difference was seen between the two consecutive nights for most of the variables studied: total sleep time, the proportion of non-rapid-eye-movement and rapid-eye-movement sleep, the number of arousals, the number and maximal duration of central apneas, the frequency of periodic breathing, the level of oxygen saturation, and heart rate. During the nonrocking nights, all infants had repeated obstructive breathing events. In seven of the eight preterm infants and in nine of the 10 full-term subjects, body rocking was associated with a significant decrease in the frequency of obstructive events. During rocking, in the preterm infants the obstructions fell from a median of 2.5 to 1.8 episodes per hour (P = .034). In the full-term infants, rocking reduced the obstructive events from a median of 1.5 obstructions per hour to 0.7 (P = .005). No difference was seen for the duration of the obstructive episodes.

Conclusion. In preterm and full-term infants prone to obstructive sleep apneas, gentle side-to-side body rocking is associated with a significant decrease in the frequency of upper-airway obstructions.
ABRAHAM JACOBI ON MASTURBATION IN CHILDREN
Authors: Combs S.
Published: December 2021

Recently while conducting research on the father of American pediatrics, Dr Abraham Jacobi, I came upon an entire chapter in his Collectanea Jacobi, entitled "Masturbation and Hysteria in Young Children." His concern with the subject and its profound affect on the youth of his day was revealing. Masturbation at the turn of the century was believed not only to promote physical and moral weakness, but also was believed to be a major cause of multiple neuroses. Today, we attribute masturbation to a normal precursor of object-related sexual behavior that occurs in nearly all men and three quarters of women.1 Self-stimulation is a common event in infancy and just as the infant explores the remainder of its body, so does it explore its genitalia. However today, even as in Jacobi's time, such experiences are often strewn with guilt and ridicule.

Jacobi wrote the following: "It is this habit of masturbation in the infant and child, to which I here desire to draw attention. To what extent it is practised (sic) in more advanced years, and how it interferes with a robust physical, mental and moral development of adolescence is but too well known to both physician and pedagogue. But it has often appeared to me that its frequent occurrence in the quite young is by no means fully appreciated ... The causes of masturbation, no matter whether considered as an acquired habit or disease, are very serious indeed. I have positive knowledge of cases in which the habit was contracted by the treatment of infants, both male and female, at the hands of nurses on servants" (sic).
Improving Pediatric Residents' Alcohol and Other Drug Use Clinical Skills: Use of an Experiential Curriculum
Authors: Kokotailo Patricia K. , Langhough Rebecca , Neary Elizabeth J. , Matson Steven C. , Fleming Michael F.
Published: December 2021

Objective. To evaluate the effectiveness of an experiential alcohol and other drug curriculum on pediatric residents' knowledge, attitudes, and skills in alcohol and other drug (AOD) issues.

Design. Nonrandomized control trial.

Setting. Two university pediatric residency programs.

Participants. Pediatric residents (n = 44).

Intervention. Intervention residents received an experiential AOD curriculum consisting of participation in an adolescent assessment program, interactive didactic sessions, role-playing practice, and interviewing skills sessions. The control group received no formal training.

Main Outcome Measures. Pretesting and posttesting each group using written and Objective Structured Clinical Examination evaluations using standardized patients. Evaluations were videotaped and scored by an expert panel using a standardized scoring process.

Results. Pretest comparisons of written knowledge and clinical skills as assessed by the Objective Structured Clinical Evaluation showed no significant differences between the intervention and the control groups. Analysis of written test scores revealed that residents' general knowledge as well as knowledge of screening techniques and management resources related to AOD issues increased significantly more for the intervention group than for the control group from pretest to posttest (P < .001). Evaluation of the videotapes showed significant improvement for the intervention group compared with controls in overall score and in the use of specific screening techniques and interviewing skills (P < .05). Self-assessment of residents' interest, confidence, and competence in AOD issues improved significantly for intervention residents vs controls (P < .05).

Conclusions. Pediatric residents receiving an experiential AOD curriculum increased their knowledge and clinical skills in AOD issues significantly more than residents receiving no formal training. Similar curricula and evaluation could be used by other primary care residency programs and could be implemented in other areas of adolescent health risk behaviors.
Use of Dexamethasone in the Outpatient Management of Acute Laryngotracheitis
Authors: Cruz Minh N. , Stewart Gail , Rosenberg Norman
Published: December 2021

Objective. Recent studies have demonstrated that a single intramuscular injection of dexamethasone (0.6 mg/kg) shortens the duration and severity of illness in hospitalized patients with acute viral laryngotracheitis (croup). Our objective was to determine if dexamethasone has a role in the outpatient management of patients with acute viral croup of moderate severity.

Methods. Patients, 6 months to 5 years of age, who came to the emergency department (ED) with acute viral croup, a croup score of at least 2 (range 0 to 17), and a disposition of discharge were randomized in a double-blind fashion to receive a single intramuscular injection of dexamethasone, 0.6 mg/kg, or an equal volume of normal saline before discharge from the ED. Patients were excluded if they had any structural abnormalities, had received any steroids in the preceding 24 hours, or if they required β-agonist therapy, more than one racemic epinephrine treatment, or hospitalization. Patients were followed up by telephone 24 hours and 7 to 10 days after discharge to determine whether additional medical attention was sought for perceived lack of improvement or worsening of symptoms. Secondary outcome included the parents' perception of how the child was doing at 24 hours, based on a 4-point ordinal scale: worse (1), same (2), improved (3), symptoms resolved (4), and the number of days it took for complete recovery.

Results. Of the 38 patients comprising the study group, 19 received dexamethasone. The median age was 19 months (range 6 to 66 months), and median pretreatment croup score was 3 (range 2 to 5) for both groups. The number of patients requiring racemic epinephrine was similar in both groups. Five patients sought additional medical attention within 48 hours. Four of the five patients had received placebo (21% of the placebo group) and one had received dexamethasone (5% of the steroid group) (not statistically significant). At the 24-hour telephone follow-up, significantly more patients in the dexamethasone group had a score consistent with improvement compared with placebo (84% vs 42%, P = .003). There was no difference in the number of days for symptoms to completely resolve between the two groups.

Conclusion. The use of dexamethasone in the outpatient management of viral croup was associated with a reduction in severity of illness within 24 hours after treatment. Patients with viral croup of moderate severity should be considered as candidates for the use of dexamethasone before discharge from the ED.
A Phase I/II Evaluation of Stavudine (d4T) in Children With Human Immunodeficiency Virus Infection
Authors: Kline Mark W. , Dunkle Lisa M. , Church Joseph A. , Goldsmith Jonathan C. , Harris Alice T. , Federici Marianne E. , Schultze Mary E. , Woods Lin , Loewen Diane F. , Kaul Sanjeev , Cross Anne , Rutkiewicz Victoria L. , Rosenblatt Howard M. , Hanson I. Celine , Shearer William T.
Published: December 2021

Objectives. To determine the pharmacokinetic properties, tolerance, safety, and preliminary activity of stavudine in human immunodeficiency virus (HIV)-infected children.

Design. Phase I/II, open and dose-ranging (0.125 to 4 mg/kg/day in two divided doses).

Patients. Thirty-seven HIV-infected children (median age, 5.5 years; range, 7 months to 15 years) with a median CD4+ lymphocyte count at baseline of 242 cells/µL (range 2 to 2290 cells/µL). Thirty children had symptomatic HIV disease at entry; seven had HIV-related immunosuppression alone. Twenty-nine subjects had a history of prior zidovudine (ZDV) therapy.

Results. As compared with adults receiving the same weight-adjusted doses, the children we studied had lower maximum observed stavudine plasma concentrations (CMAX) and area under the plasma concentration versus time curves (AUC), and more rapid stavudine elimination. The absolute oral bioavailability of the drug ranged from 61% to 78%. There was no plasma accumulation of the drug between day 1 and week 12. Week 12 cerebrospinal fluid stavudine concentrations in seven subjects, obtained approximately 2 to 3 hours after oral doses, ranged from 16% to 97% of concomitant plasma concentrations.

Stavudine was well-tolerated and there were no dose-related clinical or laboratory adverse events. One subject with baseline neurologic abnormalities experienced a transient episode of apparent pain or discomfort in her fingers, possibly related to stavudine. All other adverse events were attributed to underlying disease. Stavudine activity, measured indirectly by CD4+ lymphocyte count and serum p24 antigen concentration changes, was observed in some subjects. Progression of HIV disease and survival correlated with prior ZDV therapy, HIV disease classification, baseline CD4+ lymphocyte count, and weight growth velocity.

Conclusions. Stavudine appears to hold promise for the treatment of HIV infection in children. Its pharmacokinetic properties are consistent and predictable, and it appears to be remarkably well-tolerated and safe. Although our study was not designed to assess the drug's efficacy, preliminary clinical and laboratory evidence of activity was observed.
Evaluation of a Subsidy Program to Increase Bicycle Helmet Use by Children of Low-Income Families
Authors: Parkin Patricia C. , Hu Xiaohan , Spence Laura J. , Kranz Katherine E. , Shortt Linda G. , Wesson David E.
Published: December 2021

Objective. We have previously shown that an educational program was not effective in increasing bicycle helmet use in children of low-income families. The objective of this study was to evaluate a combined educational and helmet subsidy program in the same population, while controlling for secular trends. The secondary objective was to complete a third year of surveying children's bicycle helmet use throughout the study community.

Design. A prospective, controlled, before-and-after study.

Subjects. Bicycling children 5 to 14 years of age from areas of low average family income.

Setting. A defined geographic community within a large urban Canadian city.

Intervention. In April 1992, students in three schools located in the area of lowest average family income were offered $10 helmets and an educational program; three other low-income areas served as control areas.

Main Outcome Measure. Helmet use was determined by direct observation of more than 1800 bicycling children.

Results. Nine hundred ten helmets were sold to a school population of 1415 (64%). Reported helmet ownership increased from 10% to 47%. However, observed helmet use in the low-income intervention area was no different from the rate in the three low-income control areas (18% versus 19%). There was no difference in the trend in helmet use during the period of 1990 through 1992 in the intervention area (4% to 18%) compared with the control areas (3% to 19%). Helmet use rates from all income areas have increased from 3.4% in 1990, to 16% in 1991, to 28% in 1992. In 1992, helmet use in the high-income areas was 48% and in the low-income areas was 20%.

Conclusions. There has been a trend toward increasing helmet use in all income areas during the 3-year period. Despite encouraging helmet sales and increases in reported helmet ownership, the results of the observational study do not support the efficacy of a helmet subsidy program in increasing helmet use in children residing in areas of low average family income. Strategies to increase helmet use in children of low average family income remain a priority.
Implementation of the Immunization Policy (S94-26)
Authors:   Committee on Practice and Ambulatory Medicine, 1994 to 1995
Published: December 2021

Prevention of disease through immunization always has been a priority for pediatricians and a major goal of comprehensive pediatric health care. Before 1994, the recommendation of the American Academy of Pediatrics (AAP) was that children should be completely immunized against diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b disease, measles, mumps, and rubella. Universal hepatitis B immunization of all infants and adolescents was recommended in the 1994 Red Book,1 adding a ninth disease to the previous list. Only those children with specific contraindications to one or more of the immunizations should be excluded. Childhood immunizations, per the AAP recommended schedule, must continue to be an essential component of continuous, comprehensive child health care. Furthermore, a child's immunization status warrants evaluation at every health care visit.

In recent years, inadequate immunization rates attributed to multiple causes have indicated that the Academy's original immunization policy (1977) calling for universal immunization of all children has not been fulfilled. From data collected in the National Health Interview Survey in 1993 and 1994, the Centers for Disease Control and Prevention (CDC)2 currently estimates that only about two thirds of 2-year-old children in the United States have received all appropriate immunizations. Vaccine coverage levels include the following ranges: 67% coverage for four doses of diphtheria, tetanus, and pertussis (DPT) vaccine; 76% for three doses of oral polio vaccine (OPV); 90% for one dose of measles, mumps, and rubella vaccine (MMR), and 71% for age-appropriate doses of H influenzae type b vaccine. Recent outbreaks of measles, particularly in preschool children but also in adolescents and young adults, attest to inadequate protection and demonstrate a continuing need for surveillance and modification of current immunization recommendations.
Hospital Pharmacists
Authors: Oddis Joseph A.
Published: December 2021

We noted with interest the report of the American Academy of Pediatrics' Committee on Hospital Care entitled "Staffing Patterns for Patient Care and Support Personnel in a General Pediatric Unit" that was published in Pediatrics.1 For the most part we found the document to be well-written and comprehensive, but we were surprised that it makes no mention of the role of pharmacists. We believe that pharmacists are integral to the care of patients in pediatric units.
Letters to the Editor
Authors: Lifshitz Fima , Smith Melanie
Published: December 2021

We thank Dr Lifschitz for recognizing that the combination of carbohydrates in fruit juice affects intestinal absorption as published in the March issue of Pediatrics. White grape juice, which contains equal amounts of fructose versus glucose and no sorbitol, was better absorbed than apple juice, which contains excess fructose and sorbitol. Furthermore, we agree that the generalization made by Dr Klish in his commentary regarding our article, namely that there is a difference among juices, was not supported by our data.
LINKAGE ANALYSIS OF IL-4 AND OTHER CHROMOSOME 5q31.1 MARKERS AND TOTAL SERUM IMMUNOGLOBULIN E (IgE) CONCENTRATIONS
Authors: Levy Arden
Published: December 2021

This group found evidence linking five markers in chromosome 5q31.1 with a gene modulating total serum IgE concentration in a sib-pair analysis of 170 individuals in 11 Amish families. Evidence was found for the linkage of 5q31. I and the IL-4 gene. Specific IgE concentrations were not linked to these markers. Thus, this study suggests that IL-4 or a nearby gene in 5q31.1 regulates overall IgE production.
SYNTHETIC FOOD COLORING AND BEHAVIOR: A DOSE-RESPONSE EFFECT IN A DOUBLE-BLIND, PLACEBO-CONTROLLED, REPEATED-MEASURES STUDY
Authors: Randolph Christopher
Published: December 2021

Behavioral changes in irritability, restlessness, and sleep disturbance are associated with the ingestion of tartrazine in some children. A dose-response effect was observed.
CLINICAL EXPERIENCE WITH PENICILLIN SKIN TESTING IN A LARGE INNER-CITY SEXUALLY TRANSMITTED DISEASE (STD) CLINIC
Authors: Oro Amy , Goldsobel Alan
Published: December 2021

The use of routine skin testing with both major and minor penicillin determinants is safe and can facilitate the safe use of penicillin in 90% of subjects with a previous history of penicillin allergy.
BIPHASIC SYSTEMIC ANAPHYLAXIS: AN INPATIENT AND OUTPATIENT STUDY
Authors: Sachs Martin I.
Published: December 2021

Outpatient anaphylaxis was evaluted in 35 patients who had had 44 reactions, all occurring after allergy immunotherapy administration. After resolution of anaphylaxis, patients were discharged home with instructions to return to the clinic or the hospital emergency room if symptoms recurred. None of these individuals were treated with oral corticosteroids after the initial phase of anaphylaxis. The inpatient group consisted of 59 patients who were admitted to the ward or intensive care unit for anaphylaxis.
ASSESSMENT OF PATIENTS WHO HAVE EXPERIENCED ANAPHYLAXIS: A 3-YEAR SURVEY
Authors: Sampson Hugh A.
Published: December 2021

The authors concluded that a minimal workup for anaphylaxis should include elicitation of a detailed history of allergic episodes, performance of prick skin tests or quantification of allergen-specific immunoglobulin E(IgE), further exploration of any positive test results, and regular follow-up of all patients to gauge the success of avoidance and emergency treatment.
INTRANASAL FLUNISOLIDE SPRAY AS AN ADJUNCT TO ORAL ANTIBIOTIC THERAPY FOR SINUSITIS
Authors: Segal Allen T.
Published: December 2021

The authors conclude that the major improvements occurred in both groups at the end of first 3 weeks. The addition of flunisolide was judged most effective in the global assessment and it tended to improve symptoms, to decrease nasal inflammatory cells, to normalize ultrasound scans, and to aid regression of radiographic abnormalities.
CHRONIC SINUSITIS AMONG PEDIATRIC PATIENTS WITH CHRONIC RESPIRATORY COMPLAINTS
Authors: Segal Allen T.
Published: December 2021

Chronic sinusitis is a common pediatric problem in patients with chronic respiratory symptoms. Because the clinical symptoms alone are not sensitive enough to make the diagnosis, imaging studies of the sinus (eg, a Water's view x-ray) should be considered as part of a allergy evaion, especially in those less than 10 years old.
ALBUTEROL DELIVERED VIA METERED-DOSE INHALER WITH SPACER FOR OUTPATIENT TREATMENT OF YOUNG CHILDREN WITH WHEEZING
Authors: Segal Allen T.
Published: December 2021

Albuterol delivered by MDI with spacer and mask to wheezing infants reduces the severity of wheezing and retractions.
A COMPARATIVE STUDY OF HUMAN IMMUNODEFICIENCY VIRUS CULTURE, POLYMERASE CHAIN REACTION AND ANTI-HUMAN IMMUNODEFICIENCY VIRUS IMMUNOGLOBULIN A ANTIBODY DETECTION IN THE DIAGNOSIS DURING EARLY INFANCY OF VERTICALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS INFECTION
Authors: Noroski Lenora M.
Published: December 2021

On the basis of this prospective study, HIV culture and PCR have been found to be useful diagnostic tests for HIV infection during the first 6 months of life. In the same population, HIV-specific IgA antibody assay was an insensitive diagnostic test. The authors recognize that test outcomes from a research laboratory may differ from those determined in a clinical laboratory, especially with the technique of PCR where minimal contamination can produce false positive results. Thus, in clinical practice, an infant within the first 6 months of life is considered HIV-infected by positive test results of any combination of two HIV culture on PCR tests performed on separate blood specimens.
ISOLATION OF A NOVEL GENE MUTATED IN WISKOTT-ALDRICH SYNDROME
Authors: Meer Sanober , Liu Andrew
Published: December 2021

Purpose of the Study. Wiskott-Aldrich syndrome (WAS) is an X-linked recessive disorder associated with severe thrombocytopenia, eczema, bloody diarrhea, B & T cell immunodeficiency and increased risk of malignancies. This study describes the isolation of a novel gene, WAS Protein (WASP) which is mutated in four WAS patients.

Methods. The WAS gene had been localized previously by linkage analyses to a >1 Megabase region in chromosome Xp11.22-p11.23. To isolate the WAS gene, a clone contig was constructed in this interval, followed by isolation of cDNA sequences.

Results. A novel gene, WASP, was isolated, which is believed to be the main genetic locus in WAS. This is supported by the following findings. First, the gene was isolated from the chromosome Xp11.22-p11.23 interval previously identified as containing the WAS gene. Second, lymphoblasts from two unrelated patients clinically diagnosed with WAS failed to express WASP on Northern blots. Two additional WAS patients were also found to have point substitution mutations of an arginine residue. Finally, WASP is expressed in lymphocytic and megakaryocytic cell lineages, indicating a close correlation between tissue-specific gene expression and the disease manifestations of WAS.

Reviewer's Comments. This paper succinctly describes a major breakthrough in the identification of the defective gene in WAS, which is found to be mutated in the four WAS patients studied. This finding brings direction and impetus to research on WAS, provides improved methods for detecting WAS, and brings the possibility of gene replacement therapy for WAS much closer.
The Value of Brain Imaging in Children With Headaches
Authors: Maytal Joseph , Bienkowski Robert S. , Patel Mahendra , Eviatar Lydia
Published: December 2021

Objective. To determine the value of performing computed tomography (CT) or magnetic resonance imaging (MRI) studies in children with chronic headaches.

Background. Headache is a common complaint in children, With the proliferation of brain imaging centers and the increasing patient demand for CT or MRI studies, brain imaging has become widely used to evaluate headaches.

Methods. A retrospective chart review was conducted of all children referred to the pediatric neurology clinic for evaluation of headaches over a 2-year period. Charts were reviewed for headache characteristics, clinical indications for performing CT and MRI studies, and imaging results. Particular attention was paid to evidence of brain tumors, vascular anomalies, or hydrocephalus.

Results. A total of 133 records were studied. Subjects ranged in age from 3 to 18 years. Most patients were diagnosed as having either vascular migrainous headaches (52%) or chronic tension headaches (21%). Other headache diagnoses were mixed tension-migraine, psychogenic, and post-traumatic. Headaches were unclassified in 25 patients (19%). Seventy-eight patients (59%) had brain imaging: 45 had MRI, 27 had CT, and 6 patients had both. In most cases, brain imaging studies were performed in patients with atypical headache pattern, presence of neurologic abnormalities during the headache, general symptoms (ie, weight loss or fatigue), or because of parents' or doctors' concerns about brain tumors. Cerebral abnormalities were found on brain imaging in four patients, but none indicated the presence of a treatable disease and all were deemed unrelated to the presenting complaint. Our findings of no relevant abnormalities in a series of 78 brain imaging studies indicate that the maximal rate at which such abnormalities might appear in this population is 3.8%.

Conclusions. These results indicate that brain imaging studies have very limited value in evaluating headaches in pediatric patients without clinical evidence of an underlying structural lesion.
ON SALE NOW AT YOUR HMO: ORGAN TRANSPLANTS DISCOUNT FEVER IS HITTING THE HIGH END OF MEDICINE: THE ORGAN-TRANSPLANT BUSINESS
Authors: L. J. F.
Published: December 2021

Renowned transplant centers such as the Cleveland Clinic, Duke University, and Johns Hopkins are cutting rates for procedures and follow-up treatments by 30% to 60%. The centers figure that cheaper prices will help them win big contracts with health-maintenance organizations (HMOs) and other powerful insurers that mandate where their millions of members can go for care.

Hospitals often discount their bills by about 20% for their biggest customers. But HMOs lately have been winning much steeper markdowns on fixed-price contracts that cover nearly all the expenses associated with organ transplants.

See Table in the PDF File
Silent Victims Revisited: The Special Case of Domestic Violence
Authors: Zuckerman Barry , Augustyn Marilyn , Groves Betsy McAlister , Parker Steven
Published: December 2021

In a commentary published previously, we communicated our concern regarding the plight of children who witness violence.1 Research suggests that children who witness violence suffer significant psychologic and behavioral problems that interfere with their ability to function in school, at home, and with peers. The primary focus of that commentary was children who witnessed community violence. Our ongoing clinical experience, heightened by media attention on domestic violence, including the O.J. Simpson case, leads us to revisit silent victims with a sole focus on those children who witness domestic violence. Domestic violence is a particularly devastating event for a child who, in the presence of danger, typically turns to a parent for protection and for whom there is no comfort or security if one parent is the perpetrator of violence, and the other is a terrified victim.
The Issues of Hyperbilirubinemia
Authors: Seidman Daniel S. , Stevenson David K.
Published: December 2021

"Tis with our judgments as our watches, none go just alike, yet each believes his own."

Alexander Pope

An Essay on Criticism, 1711.

The practice parameter published recently by the American Academy of Pediatrics Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia1 introduces clearly the major points for which a consensus exists between experts:

1. "Factors influencing bilirubin toxicity to the brain cells of newborn infants are complex and incompletely understood."

2. "It is not known at what bilirubin concentration or under what circumstances significant risk of brain damage occurs or when the risk of damage exceeds the risk of treatment."
Letters to the Editor
Authors: Schechter Neil L. , Bernstein Bruce , Weisman Steven , Rosenblum Martin , Conard Patti Lynn
Published: December 2021

We appreciate Dr Brenn's careful reading of our article and his identification of an apparent discrepancy in the sample size in Table 2. While in the text and in all other tables in the article, we had a sample size of 48, in Table 2, we had a sample size of 50. This was due to the inclusion of side effects data on two additional children who received oral transmucosal fentanyl citrate (OTFC) but were excluded from the pain data analyses because no self-report pain scores were available for them.
Comparison of 13 Acellular Pertussis Vaccines: Overview and Serologic Response
Authors: Edwards Kathryn M. , Meade Bruce D. , Decker Michael D. , Reed George F. , Rennels Margaret B. , Steinhoff Mark C. , Anderson Edwin L. , Englund Janet A. , Pichichero Michael E. , Deloria Maria A. , Deforest Adamadia
Published: December 2021

Objective. To compare the immunogenicity of a licensed conventional whole-cell (WCL) and 13 diphtheria-tetanus-acellular pertussis (DTaP) vaccines that differed in source, method of manufacture, and included antigens; all vaccines included diphtheria and tetanus toxoids.

Methods. Healthy infants were enrolled through six university-based vaccine and treatment evaluation units and were randomized to receive one of the study vaccines at 2, 4, and 6 months of age. Sera were obtained before the first immunization and 1 month after the third immunization and were analyzed for antibody to pertussis toxin (PT), filamentous hemagglutinin, fimbriae, pertactin, and diphtheria and tetanus toxins. Chinese hamster ovary cell toxin neutralization assays were performed, and levels of agglutinating antibodies were determined.

Results. Of 2342 infants enrolled, 1942 contributed usable preimmunization and postimmunization serum specimens. Each vaccine produced significant increases in antibodies directed against the included antigens; postimmunization antibody titers differed significantly among the DTaP vaccines. For each evaluated antigen, the majority of DTaP vaccines produced antibody responses that equaled or exceeded those produced by WCL. For some antigens (eg, PT), mean antibody levels by vaccine correlated poorly with the quantity of antigen included in each vaccine; for others (eg, fimbriae), there was a close correlation.

Conclusion. Although serologic correlates of pertussis immunity are not defined, it is clear that DTaP vaccines can stimulate immune responses that exceed those of licensed whole-cell vaccine with respect to the measured antibodies. Particularly for PT, immunogenicity seems to depend on factors in addition to antigen concentration, possibly including antigen derivation and formulation. No DTaP was most or least immunogenic with respect to all included antigens.
A Randomized Comparison of Reactogenicity and Immunogenicity of Two Whole-Cell Pertussis Vaccines
Authors: Steinhoff Mark C. , Reed George F. , Decker Michael D. , Edwards Kathryn M. , Englund Janet A. , Pichichero Michael E. , Rennels Margaret B. , Anderson Edwin L. , Deloria Maria A. , Meade Bruce D.
Published: December 2021

Objective. To compare prospectively the reactogenicity and immunogenicity of two licensed whole-cell pertussis vaccines.

Methods. We conducted a prospective, randomized, double-blinded assessment of two licensed whole-cell pertussis vaccines with diphtheria and tetanus toxoids that were included in a multicenter trial evaluating 13 acellular pertussis vaccines. Infants were immunized at 2, 4, and 6 months of age with a single lot of Lederle (309 infants) or Massachusetts Public Health Biologic Laboratories (MPHBL; 94 infants) vaccine.

Results. The group receiving the Lederle vaccine demonstrated significantly higher antibody titers to pertussis toxin by enzyme-linked immunosorbent assay (ELISA) and by the Chinese hamster ovary cell pertussis toxin neutralization assay, and to fimbrial antigens by ELISA, as well as higher mean agglutinin titers. In contrast, the group receiving the MPHBL vaccine demonstrated higher ELISA antibody levels to filamentous hemagglutinin and pertactin. Similar differences were observed in the proportions of vaccinees seroconverting to these antigens. Rates of systemic and local reactions were relatively low for both vaccines. Although the Lederle product had substantially lower reactogenicity in this study than previously reported for that vaccine, the MPHBL vaccine was significantly less reactogenic in nearly all clinical categories.

Conclusion. The two whole-cell vaccines demonstrated statistically significant differences in postimmunization antibody levels to all six evaluated pertussis antigens. Whether these statistically significant differences in antibody levels have clinical relevance is not clear. Rates of nearly all local and systemic reactions were significantly lower among the MPHBL group than the Lederle group. Licensed whole-cell diphtheria-tetanus-pertussis vaccines produced by different manufacturers cannot be assumed to be similar in reactogenicity or immunogenecity.